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Objectives To define chronic ultrasound lesions of the axillary artery (AA) in long-standing giant cell arteritis (GCA) and to evaluate the reliability of the new ultrasound definition in a web-based exercise. Methods A structured Delphi, involving an expert panel of the Large Vessel Vasculitis subgroup of the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group was carried out. The reliability of the new definition was tested in a 2-round web-based exercise involving 23 experts and using 50 still images each from AA of long-standing and acute GCA patients, as well as 50 images from healthy individuals. Results The final OMERACT ultrasound definition of chronic changes was based on measurement and appearance of the intima-media complex. The overall reliability of the new definition for chronic ultrasound changes in longstanding GCA of the AA was good to excellent with Light's kappa values of 0.79-0.80 for inter-reader reliability and mean Light's-kappa of 0.88 for intra-reader reliability. The mean inter-rater and intra-rater agreements were 86-87% and 92%, respectively. Good reliabilities were observed comparing the vessels with longstanding versus acute GCA with a mean agreement and kappa values of 81% and 0.63, respectively. Conclusion The new OMERACT ultrasound definition for chronic vasculitis of the AA in GCA revealed a good to excellent inter- and intra-reader reliability in a web-based exercise of experts.

Zusammenfassung. In diesem CME konzentrieren wir uns auf die Ultraschallanatomie der Enthese. Im Weiteren beschreiben wir Enthesopathien und Enthesitiden und diskutieren damit verbundene differenzialdiagnostische Überlegungen. Es ist wichtig, sämtliche Erkrankungen zu kennen, welche sich an der Enthese manifestieren können, damit Diagnosen korrekt gestellt werden können. Dabei kann der Ultraschall die Differenzialdiagnose massgebend eingrenzen. An dieser Stelle sei erwähnt, dass der Befund einer Enthesitis nicht zwingend mit einer Spondylarthritis assoziiert sein muss.

Objective.Major salivary gland ultrasonography (SGUS) is a widely used imaging technique to evaluate salivary gland involvement in primary Sjögren syndrome (pSS). The aim of this study was to evaluate the relationship between SGUS, salivary flow rate (SFR) as an objective measure of the gland function, and oral health-related quality of life (OHRQOL) as a patient-reported outcome measure (PROM) in a pSS cohort.Methods.Sixty-six patients with pSS were examined by SGUS according to Hocevar and Milic scoring systems. Patients with inhomogeneity/hypoechoic areas with scores ≥ 2 in parotid and submandibular glands were classified separately as “severe glandular involvement.” Further, oral health, SFR, and Oral Health Impact Profile-14 (OHIP-14) for OHRQOL were assessed.ResultsBoth total Hocevar and Milic scores were higher in 21 pSS patients with low unstimulated whole salivary flow rate (U-WSFR) than 45 pSS patients without low U-WSFR (P = 0.001 and P < 0.0001, respectively). Increased scores of homogeneity, hypoechoic areas and glandular border visibility were observed in patients with low U-WSFR (P < 0.05). Among these variables, homogeneity score was found to be an independent risk factor for low U-WSFR in pSS according to logistic regression analysis (OR 1.586, P = 0.001). Moreover, a higher OHIP-14 score was observed in severe parotid involvement compared to nonsevere cases (23.26 ± 21.19 vs 8.32 ± 13.82, P = 0.004).Conclusion.High Milic and Hocevar SGUS scores are associated with reduced SFR and poor OHRQOL as a PROM. The inhomogeneity component of the SGUS score is associated with low U-WSFR and is an indicator of severely affected gland function.

ObjectivesTo develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties.MethodsThe OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima–media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24.ResultsAgreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72–0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from −1.19 to −2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff0.37–0.48).ConclusionWe developed a provisional OGUS for potential use in clinical trials.

ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range.MethodsAdult HS (age 18–80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1–5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort.Results939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference in the proportion of TSH and TPD involvement between HS and subjects with RA (HS vs RA pConclusionsUltrasound-detected TSH and TPD abnormalities are rare in HS and can be regarded as markers of active inflammatory disease, especially in newly presenting RA.

Objectives U-Act-Early was a 2-year, randomized placebo controlled, double-blind trial, in which DMARD-naïve early RA patients were treated to the target of sustained remission (SR). Two strategies initiating tocilizumab (TCZ), with and without methotrexate (MTX), were more effective than a strategy initiating MTX. The aim of the current study was to determine longer-term effectiveness in daily clinical practice. Methods At the end of U-Act-Early, patients were included in a 3-year post-trial follow-up (PTFU), in which treatment was according to standard care and data were collected every 3 months during the first year and every 6 months thereafter. Primary end point was disease activity score assessing 28 joints (DAS28) over time. Mixed effects models were used to compare effectiveness between initial strategy groups, correcting for relevant confounders. Between the groups as randomized, proportions of patients were tested for DMARD use, SR and radiographic progression of joint damage. Results Of patients starting U-Act-Early, 226/317 (71%) participated in the PTFU. Over the total 5 years, mean DAS28 was similar between groups (P > 0.20). During U-Act-Early, biologic DMARD use decreased in both TCZ initiation groups and increased in the MTX initiation group, but during follow-up this trend did not continue. SR was achieved at least once in 99% of patients. Of the 226 patients, only 30% had any radiographic progression over 5 years, without significant differences between the groups. Conclusion Although in the short-term the strategies initiating TCZ yielded the most clinical benefit, in the longer-term differences in important clinical outcomes between the strategies disappeared, probably due to continuation of the treat-to-target principle.

ObjectiveTo produce European League Against Rheumatism (EULAR) recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs).MethodsBased on the literature reviews and expert opinion (through Delphi surveys), a taskforce of 23 members (12 experts in ultrasound in RMDs, 9 in methodology and biostatistics together with a patient research partner and a health professional in rheumatology) developed a checklist of items to be reported in every RMD study using ultrasound. This checklist was further refined by involving a panel of 79 external experts (musculoskeletal imaging experts, methodologists, journal editors), who evaluated its comprehensibility, feasibility and comprehensiveness. Agreement on each proposed item was assessed with an 11-point Likert scale, grading from 0 (total disagreement) to 10 (full agreement).ResultsTwo face-to-face meetings, as well as two Delphi rounds of voting, resulted in a final checklist of 23 items, including a glossary of terminology. Twenty-one of these were considered ‘mandatory’ items to be reported in every study (such as blinding, development of scoring systems, definition of target pathologies) and 2 ‘optional’ to be reported only if applicable, such as possible confounding factors (ie, ambient conditions) or experience of the sonographers.ConclusionAn EULAR taskforce developed a checklist to ensure transparent and comprehensive reporting of aspects concerning research and procedures that need to be presented in studies using ultrasound in RMDs. This checklist, if widely adopted by authors and editors, will greatly improve the interpretability of study development and results, including the assessment of validity, generalisability and applicability.

International audience; Aims: To analyze whether there is sufficient data from published literature to demonstrate that ultrasound, including elastography, present good metric properties (truth, discrimination and feasibility) in autoimmune myositis (AIM). Methods: A population, intervention, comparator and outcome-structured (PICO) search was performed in Medline, Cochrane Library and Embase database from 01/01/1973 to 08/05/2019. The inclusion criteria required original research involving adult humans, reported in English, assessing ultrasound and elastography in patients with an AIM. Conference abstracts and computer-assisted diagnostics that focused on technique and not ultrasound domains were excluded. Results: Approximately 2670 articles were identified. Forty-one full-text articles were included in the final analysis. There were 551 AIM patients studied. Eighteen studies (43.9%) had a control group, of which 15 (63.3%) were healthy controls. The age of participants (including controls) varied from 18 to 86 years, and most were females (59%). Diagnosis of AIM was largely biopsy-proven, although some were derived through clinical presentation, positive clinical imaging (ultrasound or otherwise) and/or electromyography and steroid responsiveness. The features examined with ultrasound in the 41 included articles consisted of: muscle echogenicity, bulk, atrophy, architecture, power Doppler, perfusion characteristics, shear wave modulus, shear wave velocity, elasticity index and fasciculations. Twelve studies (29.2%) used quantitative methods to assess these characteristics, whilst others used semi-quantitative, dichotomous/binary and descriptive scoring systems. Criterion validity was met in 14 studies (12/14, 85.7%) and construct validity in 22 studies (22/25, 88.0%). Most published articles reported Level 3b to Level 5 evidence with varying degrees of bias. There was only one longitudinal study examining discrimination. Reliability and feasibility were under-reported. Conclusion: This is the first systematic review studying the utility of ultrasound, including elastography, in AIM. There is some evidence for criterion and construct validity, suggesting that ultrasound may be a promising outcome measurement instrument in AIM. Agreement on the standardization of acquisition, and the definitions of target domains, is required. Additionally, further validation studies are required to determine discrimination, reliability and feasibility.

Objective.To describe the Outcome Measures in Rheumatology (OMERACT) stepwise approach to select and develop an imaging instrument with musculoskeletal ultrasound (US) as an example.Methods.The OMERACT US Working Group (WG) developed a 4-step process to select instruments based on imaging. Step 1 applies the OMERACT Framework Instrument Selection Algorithm (OFISA) to existing US outcome measurement instruments for a specific indication. This step requires a literature review focused on the truth, discrimination, and feasibility aspects of the instrument for the target pathology. When the evidence is completely unsatisfactory, Step 2 is a consensus process to define the US characteristics of the target pathology including one or more so-called “elementary lesions”. Step 3 applies the agreed definitions to the image, evaluates their reliability, develops a severity grading of the lesion(s) at a given anatomical site, and evaluates the effect of the acquisition technique on feasibility and lesion(s) detection. Step 4 applies and assesses the definition(s) and scoring system(s) in cross-sectional studies and multicenter trials. The imaging instrument is now ready to pass a final OFISA check.Results.With this process in place, the US WG now has 18 subgroups developing US instruments in 10 different diseases. Half of them have passed Step 3, and the groups for enthesitis (spondyloarthritis, psoriatic arthritis), synovitis, and tenosynovitis (rheumatoid arthritis) have finished Step 4.Conclusion.The US WG approach to select and develop outcome measurement instruments based on imaging has been repeatedly and successfully applied in US, but is generic for imaging and fits with OMERACT Filter 2.1.

Objectives Suboptimal medication adherence is a serious problem in the treatment of chronic inflammatory diseases. To measure medication adherence, electronic monitoring is regarded as superior to pill count. GLORIA is an ongoing two-year trial on the addition of low-dose (5 mg/d) prednisolone or placebo to standard care in older people (65+ years) with RA. During the entire trial, adherence is measured with electronic caps, and with pill counts. The objective is to describe medication adherence patterns, and to compare the adherence results of the two methods. Methods The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. The cutoff for good adherence was set at 80% of prescribed pills taken. Results Trial inclusion closed in 2018 at 451 patients, but trial follow-up is ongoing; the current dataset contains adherence data of 371 patients. Mean number of recorded 90-day periods per patient was 4 (range 1–8). Based on pill count over all periods, 90% of the patients had good adherence; based on cap data, only 20%. Cap data classified 30% of patients as non-user ( Conclusion In our trial of older people with RA, the majority appeared to be adherent to medication according to pill count. Results from caps conflicted with those of pill counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so. Trial registration NCT02585258. ClinicalTrials.gov (https://www.clinicaltrials.gov/)

International audience; Objective: This study aimed to develop (1) a new ultrasound definition for aggregates and (2) a semi-quantitative ultrasound scoring system (0–3) for tophus, double contour and aggregates. Furthermore, the intra- and inter-reader reliabilities of both the re-defined aggregates and the semi-quantitative scoring system were assessed using static image exercises. Methods: Thirty-seven rheumatologists were invited. A Delphi process was used for re-defining aggregates and for selecting a semi-quantitative scoring system with >75% agreement obligate for reaching consensus. Subsequently, a web-based exercise on static ultrasound images was conducted in order to assess the reliability of both the re-defined aggregates and the semi-quantitative scoring system. Results: Twenty rheumatologists contributed to all rounds of the Delphi and image exercises. A consensual re-definition of aggregates was obtained after three Delphi rounds but needed an overarching principle for scoring aggregates in patients. A consensus-based semi-quantitative ultrasound scoring system for gout lesions was developed after two Delphi rounds. The re-definition of aggregates showed good intra- and inter-reader reliability (κ-values 0.71 and 0.61). The reliabilities of the scoring system were good for all lesions with slightly higher intra-reader (κ-values 0.74–0.80) than inter-reader reliabilities (κ-values 0.61–0.67). Conclusion: A re-definition of aggregates was obtained with a good reliability when assessing static images. The first consensus-based semi-quantitative ultrasound scoring system for gout-specific lesions was developed with good inter- and intra-reader reliability for all lesions when tested in static images. The next step is to assess the reliabilities when scoring lesions in patients.

ObjectiveTo evaluate the discriminatory ability of ultrasound in calcium pyrophosphate deposition disease (CPPD), using microscopic analysis of menisci and knee hyaline cartilage (HC) as reference standard.MethodsConsecutive patients scheduled for knee replacement surgery, due to osteoarthritis (OA), were enrolled. Each patient underwent ultrasound examination of the menisci and HC of the knee, scoring each site for presence/absence of CPPD. Ultrasound signs of inflammation (effusion, synovial proliferation and power Doppler) were assessed semiquantitatively (0–3). The menisci and condyles, retrieved during surgery, were examined microscopically by optical light microscopy and by compensated polarised microscopy. CPPs were scored as present/absent in six different samples from the surface and from the internal part of menisci and cartilage. Ultrasound and microscopic analysis were performed by different operators, blinded to each other’s findings.Results11 researchers from seven countries participated in the study. Of 101 enrolled patients, 68 were included in the analysis. In 38 patients, the surgical specimens were insufficient. The overall diagnostic accuracy of ultrasound for CPPD was of 75%—sensitivity of 91% (range 71%–87% in single sites) and specificity of 59% (range 68%–92%). The best sensitivity and specificity were obtained by assessing in combination by ultrasound the medial meniscus and the medial condyle HC (88% and 76%, respectively). No differences were found between patients with and without CPPD regarding ultrasound signs of inflammation.ConclusionUltrasound demonstrated to be an accurate tool for discriminating CPPD. No differences were found between patents with OA alone and CPPD plus OA regarding inflammation.

Background To assess the reliability of the consensually agreed US definitions of major salivary gland lesions and the US scoring system for salivary gland assessment in patients with SS. Methods Nine experienced sonographers scanned and read the US images of both parotid glands (PGs) and submandibular glands (SMGs) in eight patients with primary and secondary SS in two rounds. A consensually agreed four-grade semi-quantitative scoring was applied in B-mode for morphological lesions: grade 0, normal; grade 1, mild inhomogeneity without anechoic or hypoechoic areas; grade 2, moderate inhomogeneity with focal anechoic or hypoechoic areas; grade 3, severe inhomogeneity with diffuse an- or hypoechoic areas occupying the entire gland or fibrous gland. The presence or absence of typical SS lesions, i.e. the Sjögren’s signature, was scored binary. Intra- and interreader reliabilities were computed using weighted and unweighted Cohen’s and Light’s κ coefficients. Results The mean prevalence of grades 0–3 in PG were 43, 17, 23 and 31% and 28, 14, 33 and 32% for the SMGs, respectively. The weighted κ for intrareader reliability ranged from 0.44 to 1 for grading and 0.64 to 1 for the Sjögren’s signature of PG and 0.59 to 1 and −0.09 to 0.6 for SMGs, respectively. The interreader reliability κ for grading in PG was 0.62 (95% CI 0.47, 0.74) and for Sjögren’s signature it was 0.36 (95% CI 0, 0.43); in SMG it was 0.62 (95% CI 0.47, 0.72) and 0.03 (95% CI 0, 0.07) respectively. Conclusions The consensually agreed novel US scoring system for major salivary gland lesions showed substantial intra- and interreader reliability in patients with SS. The reliability of the Sjögren’s signature was moderate.

Objective To determine the intra- and inter-observer reliability of ultrasound (US)-detected age-related joint vascularization and ossification grading in healthy children. Methods Following standardized image acquisition and machine setting protocols, 10 international US experts examined four joints (wrist, second metacarpophalangeal joint, knee, and ankle) in 12 healthy children (divided into four age groups: 2–4, 5–8, 9–12, and 13–16 years). Grey-scale was used to detect the ossification grade, and power Doppler (PD) US was used to detect physiological vascularization. Ossification was graded from grade 0 (no ossification) to grade 3 (complete ossification). A positive PD signal was defined as any PD signal inside the joint. Kappa statistics were applied for intra- and inter-observer reliability. Results According to the specific joint and age, up to four solitary PD signals (mean, 1.5) were detected within each joint area with predominant localization of the physiological vascularization in specific anatomic positions: fat pad, epiphysis, physis, and short bone cartilage. The kappa values for ossification grading were 0.87 (range, 0.85–0.91) and 0.58 for intra- and inter-observer reliability, respectively. The bias-adjusted kappa values for intra- and inter-observer reliability were 0.71 (range, 0.44–1.00) and 0.69, respectively. Conclusion Detection of normal findings (i.e., grading of physiological ossification during skeletal maturation and identification of physiological vessels) can be highly reliable by using clear definitions and a standardized acquisition protocol. These data will permit development of a reliable and standardized US approach for evaluating paediatric joint pathologies. This article is protected by copyright. All rights reserved.

ObjectivesTo evaluate the sensitivity to change of ultrasound structural gout lesions, as defined by the Outcome Measures in Rheumatology (OMERACT) ultrasound group, in patients with gout during urate-lowering therapy (ULT).MethodsUltrasound (28 joints, 26 tendons) was performed in patients with microscopically verified gout initiating or increasing ULT and repeated after 3 and 6 months. Joints and tendons were evaluated by ultrasound for presence of the OMERACT structural gout lesions—double contour sign (DC), tophus, aggregates and erosion—scored binarily. A sum score was calculated at patient and lesion level. Changes at 3 and 6 months in patient sum scores and lesion scores at different locations were evaluated.Results50 patients (48 men), mean age 68.9 (range, 30–88) years, were included. Ultrasound showed a statistically significant decrease in DC and tophus sum scores from 0 months (3.16 and 2.68, respectively) to 3 months (2.33 and 2.43) and 6 months (1.34 and 1.83) (all p1 lesions bilaterally), and furthermore MTP2–4 and knee joints were common sites especially for DC. Likewise, these regions were the locations with most pronounced changes in scores.ConclusionUltrasound assessment of the OMERACT structural gout lesions scored binarily seems to be a useful tool for monitoring urate depositions during ULT. Particularly DC and tophus showed sensitivity to change after only 3 months of treatment.

Introduction: Surgical biopsy of minor salivary glands is routinely performed for the diagnosis of Sjogren syndrome. However, surgical biopsies of the minor labial glands may result in various complications in up to 6% of patients. On the other hand, adverse events following core needle biopsies of the parotid gland in non-rheumatological settings have been reported as very rare. Aim: The objective of this study was to assess the feasibility and determine the presence of parotid gland tissue in ultrasound-guided parotid gland biopsies performed by rheumatologists in cadavers. Material and method: Two senior rheumatologists obtained, under direct ultrasound visualization in in-plane technique, biopsies of 8 parotid glands from 4 different cadavers using a core biopsy needle. One biopsy per gland was taken. Results: All histological exams showed typical parotid gland tissue without any neuronal or vascular tissue. Conclusion: In conclusion, we demonstrated that minimally invasive, ultrasound-guided core needle biopsy of the parotid gland is a highly precise and easy method to obtain salivary gland tissue. Introduction: Surgical biopsy of minor salivary glands is routinely performed for the diagnosis of Sjogren syndrome. However, surgical biopsies of the minor labial glands may result in various complications in up to 6% of patients. On the other hand, adverse events following core needle biopsies of the parotid gland in non-rheumatological settings have been reported as very rare. Aim: The objective of this study was to assess the feasibility and determine the presence of parotid gland tissue in ultrasound-guided parotid gland biopsies performed by rheumatologists in cadavers. Material and method: Two senior rheumatologists obtained, under direct ultrasound visualization in in-plane technique, biopsies of 8 parotid glands from 4 different cadavers using a core biopsy needle. One biopsy per gland was taken. Results: All histological exams showed typical parotid gland tissue without any neuronal or vascular tissue. Conclusion: In conclusion, we demonstrated that minimally invasive, ultrasound-guided core needle biopsy of the parotid gland is a highly precise and easy method to obtain salivary gland tissue.

Objective.To assess structural and inflammatory ultrasound (US) lesions of entheses in ankylosing spondylitis (AS) patients with active disease and to evaluate inflammatory lesions after 6 months of tumor necrosis factor (TNF-α) blocking therapy, in daily clinical practice.Methods.Consecutive patients with AS were clinically evaluated and underwent US examination of 9 bilateral entheses before and after 6 months of TNF-α blocking therapy. US examination included the following as inflammatory lesions: bone erosions/cortical irregularities, enthesophytes, calcifications as structural lesions; adjacent bursitis, effusion, increased tendon hypoechogenicity or thickness; and positive power Doppler (PD) signal.Results.At baseline, 105 (95%) of 111 included patients showed US abnormalities. Structural lesions were seen in 74 patients (67%) and inflammatory lesions in 88 (79%). Enthesophytes and positive PD signal were the most prevalent structural and inflammatory lesions, respectively. Most lesions were found at the lower extremities. Additionally, inflammatory lesions occurred at the lateral epicondyle of the elbow. Patients with structural lesions at baseline were significantly older, had longer disease duration, higher modified Stoke AS Spine score, and higher C-reactive protein. Individually, there was a great diversity in changes of inflammatory entheseal lesions during treatment, but on the group level no significant decrease was found.Conclusion.This prospective observational cohort study in daily clinical practice shows a high prevalence of structural and inflammatory US lesions in AS patients with longstanding and active disease. Positive PD signal was the most common inflammatory feature. No significant change in inflammatory US lesions was found after 6 months of TNF-α blocking therapy.

Homer’s Iliad tells the epic story of the Trojan War, a 10-year siege of the city of Troy, conducted by an alliance of Greek kings1. According to Homer, the reason for the Trojan war was the abduction of the most beautiful of women, Helen, by the Trojan prince Paris. Since the excavation works of the German archeologist Heinrich Schliemann, we know that the city indeed existed on the northwestern coast of Turkey. The Iliad gives an account of only the 10th year of the siege, in which the Greek warrior Achilles slays Hector, the commander of the Trojan army, and drags him for 9 days behind his chariot around the city. According to Greek mythology, Achilles was unbeatable, yet vulnerable for a single spot of his body where his mother held him as a baby while dipping him in the river Styx. Following the death of Hector, Paris shot an arrow guided by the god Apollo at Achilles. The arrow struck Achilles right at the enthesis of the tendon in the heel, presumably leaving him defenseless on the battlefield and leading to his death. Homer’s poems clearly illustrate the mechanical vulnerability of the entheses, although the poet could not be aware of the mechanoinflammatory entheseal concepts 2800 years ago. In their report entitled “Entheseal changes in response to age, body mass index, and physical activity: an ultrasound study in healthy … Address correspondence to Dr. G. Bruyn, MC Groep Hospitals, Department of Rheumatology, Lelystad 8333 AA, the Netherlands. E-mail: gawbruyn{at}wxs.nl

We thank Dr Coiffier and colleagues for their interesting letter in which they suggest that damages of major salivary glands (SG) might be associated with cryoglobulinemic vasculitis and lymphoma in primary Sjogren’s syndrome. The authors raise the question whether the ultrasonographic (US) features of the salivary glands [our proposed novel ultrasound scoring system] could be used as the new prognostic markers for cryoglobulinemic vasculitis and lymphoma in patients with Sjogren’s syndrome.1 In their recent study of different US scoring systems in 97 sicca syndrome patients, Coiffier et al found three B-cell lymphomas in the primary Sjogren’s syndrome (pSS) group and three, two, and one patient with …

ObjectiveTo develop ultrasound (US) definitions and a US novel scoring system for major salivary gland (SG) lesions in patients with primary Sjögren’s syndrome (pSS) and to test their intrareader and inter-reader reliability using US video clips.MethodsTwenty-five rheumatologists were subjected to a three-round, web-based Delphi process in order to agree on (1) definitions and scanning procedure of salivary gland ultrasonography (SGUS): parotid, submandibular and sublingual glands (PG, SMG and SLG); (2) definitions for the elementary SGUS lesions in patients with Sjögren’s syndrome; (3) scoring system for grading changes. The experts rated the statements on a 1–5 Likert scale. In the second step, SGUS video clips of patients with pSS and non-pSS sicca cases were collected containing various spectrums of disease severity followed by an intrareader and inter-reader reliability exercise. Each video clip was evaluated according to the agreed definitions.ResultsConsensual definitions were developed after three Delphi rounds. Among the three selected SGs, US assessment of PGs and SMGs was agreed on. Agreement was reached to score only greyscale lesions and to focus on anechoic/hypoechoic foci in a semiquantitative matter or, if not possible on a qualitatively (present/absent) evaluation of fatty or fibrous lesions. Intrareader reliability for detecting and scoring these lesions was excellent (Cohen’s kappa 0.81) and inter-reader reliability was good (Light’s kappa 0.66).ConclusionNew definitions for developing a novel semiquantitative US score in patients with pSS were developed and tested on video clips. Inter-reader and intrareader reliabilities were good and excellent, respectively.

Objectives: To assess the prevalence of clinical, US and radiographic hip involvement in AS patients with active disease and to explore the associations between these assessments. Furthermore, to evaluate the effect of 6 months of TNF-α blocking therapy on tender and inflammatory power Doppler US lesions of hip joints.Methods: Consecutive AS patients starting TNF-α blocking therapy were evaluated for hip joint involvement. At baseline, patient-reported history of hip involvement was assessed and radiographic evaluation (BASRI-hip) was performed. Clinical examination (tender hip joints) and US examination took place before and after 6 months of treatment.Results: Of the 111 included patients, 20% reported a history of hip involvement. At baseline, tender hip joints were present in 23% of patients. US examination showed inflammatory lesions in 17% of patients, of which 74% had positive power Doppler. Structural lesions were present in 20% of patients, of which 55% had osteophytes. Structural radiographic damage was seen in 10% of patients. Highest concordance was found between history of hip involvement and radiographic hip involvement (phi coefficient 0.333). After 6 months of TNF-α blocking therapy, significant decrease was found in tender hip joints (from 29 to 11), total number of inflammatory US lesions (from 29 to 9) and positive power Doppler (from 22 to 6).Conclusion: The prevalence rate of hip involvement in AS patients varies from 10 to 23%, depending on the type of hip assessment. TNF-α blocking therapy significantly improved tender hip joints, and inflammatory US lesions including positive power Doppler.

Background: Tenosynovitis (TS) is a common, often clinically undetectable finding in Rheumatoid Arthritis (RA). Recent data showed TS on ultrasound (US) has a role in predicting outcome in early disease and flare in clinical remission. However data is limited on US measured TS in healthy subjects (HS), none specifically encompassing the older age range when RA commonly presents. Objectives: This OMERACT study aimed to determine prevalence of US measured tendon abnormalities in HS throughout the age range. Methods: Adult HS without: joint pain (VAS A comparison cohort of DMARD-naive patients with RA (ACR-EULAR 2010 and/or 1987 criteria) at presentation was taken from the Birmingham Early Arthritis (BEACON) inception cohort, who underwent identical tendon US assessment. They were grouped into ≤12 and > 12 weeks from symptom onset. Results: Data from 899 HS and 144 RA patients were included. Prevalence of TSH and particularly PD abnormalities in HS was very low at all ages, and was all grade 1 except in one individual ECU tendon. ECU TSH grade≥1 was more common than DF grade≥1 in the older HS groups, and less common in the 18-39 age group (p=0.011). TSH and PD of grade ≥1 were common in RA patients, with DF PD abnormalities more common in early disease (p=0.02). Conclusion: Low prevalence of TSH or PD abnormalities in tendons of HS even in old age suggests US determined TS will be a robust tool in clinically managing RA. References: [1] Naredo E, D’Agostino MA, et al. Reliability consensus-based US score TS RA. ARD.2013;72(8):1328-34 Disclosure of Interests: Jeanette Trickey: None declared, Ilfita Sahbudin: None declared, Alessandra Bortoluzzi: None declared, Annamaria Iagnocco: None declared, Carlos Pineda: None declared, Cesar Sifuentes-Cantu: None declared, Coziana Ciurtin: None declared, Cristina Reategui Sokolova: None declared, Daniela Fodor: None declared, Ellen-Margrethe Hauge: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, Florentin Ananu Vreju Consultant for: abbvie and novartis, Speakers bureau: abbvie, novartis, pfizer, sandoz, eli lilly, ucb pharma, Garifallia Sakellariou: None declared, George Bruyn : None declared, Georgios Filippou Speakers bureau: Laborest, Abbvie, BMS, Sanofi, Giuliana M.C. La Paglia : None declared, Gustavo Leon: None declared, Helen Keen: None declared, Hilde Berner Hammer Grant/research support from: AbbVie, Pfizer and Roche, Paid instructor for: AbbVie, Pfizer, UCB, Novartis, Roche, Speakers bureau: AbbVie, Pfizer, UCB, Novartis, Roche, Ilaria Tinazzi: None declared, Irene Azzolin: None declared, Jacek Flicinski: None declared, James Wilton: None declared, Kei Ikeda: None declared, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, Mads Ammitzboll-Danielsen: None declared, Mads Nyhuus Bendix Rasch: None declared, Marcin Milchert: None declared, Maria Stoenoiu Grant/research support from: Abbvie, Roche, Wyeth, Marion Kortekaas: None declared, Marwin Gutierrez: None declared, Mihaela Maruseac: None declared, Mohammed A Mortada: None declared, Philippe Carron: None declared, Rositsa Karalilova: None declared, Ruth Wittoek: None declared, Sarah Ohrndorf: None declared, Takeshi Suzuki: None declared, Teodora Serban: None declared, Maria-Antonietta d’Agostino: None declared, Andrew Filer: None declared

Background Tendon involvement is common in patients with juvenile idiopathic arthritis (JIA). Differentiating tenosynovitis and underlying arthritis may be challenging on the basis of clinical examination (CE) alone. In daily clinical practice, ultrasound (US) imaging with Doppler information can be more versatile as it allows a dynamic assessment of joint inflammation and can be done quickly at the bedside. US can reliably evaluate the location of inflammation and provide direct visualization when local steroid injection is considered as treatment for children with JIA. Objectives To present the published data concerning the US assessment of tenosynovitis and the US metric properties investigated in JIA. Methods A systematic literature review (SLR) was conducted comprising PubMed, Embase and the Cochrane Library (before June 2018). Search terms: “arthritis, juvenile” AND, “tenosynovitis OR tendinopathy” AND “ultrasonography” OR “Doppler” AND “diagnosis OR therapy management”. Selection criteria: Original articles published in English reporting US, tenosynovitis and tendinopathy in the paediatric population (up to18 years old) with JIA. Data were extracted from manuscripts meeting the selection criteria, with particular focus on the definition used, scoring system applied and the US metric properties investigated. The quality of the studies was assessed using the same methodology developed for the SLR on paediatric synovitis [1]. Results After selection, 11 articles were analysed. The tibialis posterior tendon group and peroneal tendons were the most commonly evaluated. Most authors applied the OMERACT definition proposed to rheumatoid arthritis (RA) [2] for evaluating paediatric tenosynovitis. Binary scoring system on both grey scale and Doppler was applied in most of studies. Doppler function was commonly included, with only five specifying the Doppler parameters that were used. Construct validity was reported in roughly 50% of articles, including the CE as the main comparator. However, some of those articles have shown that clinical evaluation underestimates tendon involvement. US reliability and responsiveness for tenosynovitis in JIA was rarely included. Conclusion Although US seems a promising image modality to assess tenosynovitis in JIA, this SLR emphasizes the definitions of US elementary lesions of RA are frequently used in children. Moreover, there is insufficient evidence of studies exploring the construct validity of the US-determined tenosynovitis in JIA. Further validation studies are needed for implementation in clinical practice and trials. References [1] Collado P. Arthritis Care Res2012; 64:1011 [2] Wakefield R. J Rheumatol. 2005;32:2485 Disclosure of Interests PAZ COLLADO: None declared, Silvia Magni-Manzoni Consultant for: Abbvie, Speakers bureau: Abbvie, MARTINA STEINER: None declared, Tracy Ting : None declared, Patricia Vega Fernandez: None declared, Clara Malattia: None declared, Ana Rodriguez: None declared, George Bruyn : None declared, Helen Keen: None declared, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene

Background Interstitial lung disease (ILD) evaluation is challenging, given the low sensitivity of X-ray and pulmonary function tests, and limited accessibility and radiation linked to repetitive HRCT. Lung Ultrasound (US) has shown potential in the evaluation of ILD of autoimmune diseases including systemic sclerosis. Objectives To define and asses the reliability of definitions of US-detected findings in ILD. Methods A taskforce (TF) within the OMERACT US WG performed a literature review (LR) to identify US lesions in ILD, a Delphi exercise to define these lesions and a web-based exercise to test the reliability of these definitions by using either intraclass correlation coefficient (ICC) or kappa statistics. Prior to the Delphi exercise all participants received training files and were subsequently asked to provide clips on BL, PLI and normal findings. Based on the results of the LR, which identified B-lines (BL) and pleural line irregularity (PLI) as main US findings in ILD, the Delphi exercise contained statements on US definitions on BL and PLI. After reaching agreement (> 75%) on the above mentioned items, a set of 80 high-quality clips (30 for PLI, 50 for BL), was selected and distributed to the TF members in order to score them (semiquantitatively, 0-2 for PLI and total number for BL) Results The 3 Delphi rounds and the web-based exercise were completed by 24 and 22 sonographers, respectively. Final definitions are reported in Table I. The web-based exercise showed moderate inter-reader reliability for both BL (ICC=0.61) and PLI (kappa=0.69). Table I: definitions of PLI and BL Pleural line irregularity (PLI): a loss of regularity that may be associated with an increase in thickness, focal, diffuse, or nodular B-line (BL): a vertical hyperechoic reverberation artifacts that arise from the pleural line, extend to the bottom of the screen without fading, and move synchronously with lung sliding Conclusion US is a candidate imaging modality to identify and monitor ILD in rheumatic diseases; US consensus based definitions of main US findings were defined and endorsed. Further development is planned for validating US as an outcome measurement instrument for ILD. Disclosure of Interests Andrea Delle Sedie Speakers bureau: Abbvie, UCB, Celgene, MSD, Lene Terslev Speakers bureau: Speakers fee from : Roche, Novartis, Pfizer, MSD, BMS, Celgene, George Bruyn : None declared, Tomas Cazenave: None declared, stavros chrysidis: None declared, Mario Diaz: None declared, Marco Di Carlo: None declared, Marilena Frigato: None declared, Luna Gargani: None declared, Marwin Gutierrez: None declared, ALOJZIJA HOCEVAR: None declared, Annamaria Iagnocco: None declared, Aaron Juche: None declared, Peter Mandl: None declared, Esperanza Naredo Consultant for: Abbvie, Speakers bureau: AbbVie, Roche, Bristol-Myers Squibb, Pfizer, UCB, Lilly, Novartis, Janssen, and Celgene GmbH, Mohammed A Mortada: None declared, Carlos Pineda: None declared, Francesco Porta: None declared, Viviana Ravagnani: None declared, Carlo Alberto Scire: None declared, Teodora Serban: None declared, Kate Smith: None declared, Maria Stoenoiu Grant/research support from: Abbvie, Roche, Wyeth, Marika Tardella: None declared, Karina Torralba: None declared, Richard Wakefield: None declared, Maria-Antonietta d’Agostino: None declared

Objectives To develop and test the reliability of a new semiquantitative scoring system for the assessment of cartilage changes by ultrasound in a web-based exercise as well as a patient exercise of patients with RA. Methods A taskforce of the Outcome Measures in Rheumatology Ultrasound Working Group performed a systematic literature review on the US assessment of cartilage in RA, followed by a Delphi survey on cartilage changes and a new semiquantitative US scoring system, and finally a web-based exercise as well as a patient exercise. For the web-based exercise, taskforce members scored a dataset of anonymized static images of MCP joints in RA patients and healthy controls, which also contained duplicate images. Subsequently, 12 taskforce members used the same US to score cartilage in MCP and proximal interphalangeal joints of six patients with RA in in a patient reliability exercise. Percentage agreement and prevalence of lesions were calculated, as intrareader reliability was assessed by weighted kappa and interreader reliability by Light’s kappa. Results The three-grade semiquantitative scoring system demonstrated excellent intrareader reliability (kappa: 0.87 and 0.83) in the web-based exercise and the patient exercise, respectively. Interreader reliability was good in the web-based exercise (kappa: 0.64) and moderate (kappa: 0.48) in the patient exercise. Conclusion Our study demonstrates that ultrasound is a reliable tool for evaluating cartilage changes in the MCP joints of patients with RA and supports further development of a new reliable semiquantitative ultrasound scoring system for evaluating cartilage involvement in RA.

Objective.To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA).Methods.Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen’s and Light’s κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal.Results.Mean weighted Cohen’s κ for SH, PD, and JE were 0.80 (95% CI 0.62–0.98), 0.61 (95% CI 0.48–0.73), and 0.52 (95% CI 0.36–0.67), respectively. Weighted Cohen’s κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were −0.04 to 0.79, 0.42–0.95, and 0.28–0.77; 0.31–1, −0.05 to 0.65, and −0.2 to 0.69; 0.66–1, 0.52–1, and 0.42–0.88, respectively. Weighted Light’s κ for SH was 0.67 (95% CI 0.58–0.74), 0.46 (95% CI 0.35–0.59) for PD, and 0.16 (95% CI 0.08–0.27) for JE. Weighted Light’s κ for SH, PD, and JE were 0.63 (95% CI 0.45–0.82), 0.33 (95% CI 0.19–0.42), and 0.09 (95% CI −0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27–0.64), 0.35 (95% CI 0.27–0.4), and 0.04 (95% CI −0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75–0.89), 0.66 (95% CI 0.56–0.8), and 0.18 (95% CI 0.04–0.34) for posterolateral STJ, respectively.Conclusion.Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Objective.To identify and synthesize the best available evidence on the application of musculoskeletal (MSK) ultrasound (US) in patients with systemic lupus erythematosus (SLE) and to present the measurement properties of US in different elementary lesions and pathologies.Methods.A systematic literature search of PubMed, Embase, and the Cochrane Library was performed. Original articles were included that were published in English between August 1, 2014, and December 31, 2018, reporting US, Doppler, synovitis, joint effusion, bone erosion, tenosynovitis, and enthesitis in patients with SLE. Data extraction focused on the definition and quantification of US-detected synovitis, joint effusion, bone erosion, tenosynovitis, enthesitis, and the measurement properties of US according to the OMERACT Filter 2.1 instruments selection.Results.Of the 143 identified articles, 15 were included. Most articles were cross-sectional studies (14/15, 93%). The majority of the studies used the OMERACT definitions for ultrasonographic pathology. Regarding the measurement properties of US in different elementary lesions and pathologies, all studies dealt with face validity, content validity, and feasibility. Most studies achieved construct validity. Concerning the reliability of image reading, 1 study (1/15, 7%) assessed both intraobserver and interobserver reliability. For image acquisition, 4 studies (4/15, 27%) evaluated interobserver reliability and none had evaluated intraobserver reliability. Criterion validity was assessed in 1 study (1/15, 7%). Responsiveness was not considered in any of the studies.Conclusion.This literature review demonstrates the need for further research and validation work to define the involvement of US as an outcome measurement instrument for the MSK manifestations in patients with SLE.

Objective. Musculoskeletal (MS) ultrasound (US) is increasingly being used as an extension of paediatric clinical practice, particularly in the clinical management of children with juvenile idiopathic arthritis (JIA). MSUS is most commonly used in the assessment of effusion and synovial hypertrophy and detection of soft tissue disorders. It can also be used to visualise other structures, such as hyaline cartilage and bone surfaces. Given the unique anatomy of the growing skeleton, many of the difficulties encountered in its use result from misinterpretation of MSUS images. Thus, a detailed knowledge of anatomy in healthy children, both in B-mode and Doppler mode, is mandatory. Additionally, as US is the most operator-dependent imaging modality, the experience and expertise of the examiner will determine the value of the diagnostic information obtained from this technique. Incorrect acquisition and interpretation of images may result in inappropriate disease management. Thus, a systematic scanning method and a standardised evaluation procedure are essential in children.

Objective.Bone erosions in rheumatoid arthritis (RA) have been studied in an increasing amount of research. Both earlier and present classification criteria of RA contain erosions as a significant classification component. Ultrasound (US) can detect bone changes in accessible surfaces. Therefore, the study group performed a systematic literature review of assessment of RA bone erosions with US.Methods.A systematic search of PubMed and Embase was performed. Data on the definitions of RA bone erosions, their size, scoring, relation to synovitis, comparators, and elements of the OMERACT (Outcome Measures in Rheumatology Clinical Trials) filter were collected and analyzed.Results.The selection process identified 58 original research papers. The assessed joints were most frequently metacarpophalangeal (MCP; 41 papers), proximal interphalangeal (19 papers), and metatarsophalangeal joints (MTP; 18 papers). The OMERACT definition of RA bone erosion on US was used most often (17 papers). Second and fifth MCP and fifth MTP were recommended as target joints. Conventional radiography was the most frequently used comparator (27 papers), then magnetic resonance imaging (17 papers) and computed tomography (5 papers). Reliability of assessment was presented in 20 papers and sensitivity to change in 11 papers.Conclusion.This paper presents results of a systematic literature review of bone erosion assessment in RA with US. The survey suggests that US can be a helpful adjunct to the existing methods of imaging bone erosions in RA. It analyzes definitions, scoring systems, used comparators, and elements of the OMERACT filter. It also presents recommendations for a future research agenda based on the results of the review.

Background:Medication adherence in the GLORIA trial, among elderly patients with rheumatoid arthritis, is measured with caps that register openings of the medication bottle. At each study visit, one or two medication bottles with cap (kits) are dispensed, each containing 90 capsules. Multiple steps are needed to come to a workable dataset to describe adherence.Objectives:To describe the steps that are needed to come from raw data to a workable dataset to analyze adherence data that are recorded by electronic caps.Methods:The medication bottle contains a cap with the ability to register cap openings. The raw dataset from the caps consist of an excel file with one opening event per row, recorded as date and time. One cap yields approximately 90 rows. First, the kit numbers were matched to the corresponding patient numbers, that are recorded in another excel file. Instances where two kits were dispensed were recorded with two kit numbers in one cell and need to be copied to two cells with one kit number. Second, the VLOOKUP function was used to combine dates and kit numbers. One row now contains all openings from one kit. Then, the number of days between first opening and each next opening date was calculated. A range of 90 days was made to calculate how many times the bottle was opened on each day of the 90-days period. The results were color-coded to visualize instances of zero, one or ≥two openings on a day.Results:The colored calendar matrix (Figure 1) can now be used to categorize adherence patterns.Conclusion:A monitoring cap seems a simple instrument to measure adherence. However, multiple steps and a lot of time are needed to come to a workable dataset for the study of adherence patterns.Acknowledgments:The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‟Personalizing Health and Care’’, grant agreement No 634886.Disclosure of Interests:Linda Hartman: None declared, Elisa Alessandri: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

Background:Adherence is a serious problem in treatment of inflammatory diseases. To measure adherence, caps that record medication bottle openings may be superior to capsule counts (1). In the ongoing two-year GLORIA trial on the addition of low-dose (5 mg) prednisolone or placebo to standard of care in elderly patients (65+ years) with rheumatoid arthritis, adherence was measured in both ways during the whole trial.Objectives:To describe adherence patterns, and to compare adherence as assessed with adherence caps and with capsule counts in the GLORIA trial.Methods:The recorded adherence patterns of patients (blinded for treatment group) were classified according to descriptive categories. Overall adherence according to number of bottle openings was compared with adherence according to the capsule count. Good adherence was defined as 80%: i.e. for caps 80% of days one opening recorded, and for counts less than 20% of prescribed tablets returned at the subsequent visit. Each patient has a maximum of 8 periods of 90 days.Results:Trial inclusion has closed in 2018 at 452 patients; the current dataset contains adherence data of 385 patients. Mean number of recorded 90-day periods per patient was 4 (range 1-8). Based on capsule counts over all periods, 90% of the patients met the 80% threshold of adherence; based on cap data only 31% met this criterion.The four adherence patterns are shown in a calendar matrix, with yellow for zero, green for one and blue for ≥two openings on a day (Figure 1). Bottles were supposed to be opened once a day.Patients were categorized according to the opening pattern seen in at least 50% of assessed periods:32% non-use(26% stable use(≥80% of the days 1 opening);40% irregular use(different adherence patterns, in or between periods);2% weekly use(1 opening per week).Conclusion:In our trial of elderly rheumatoid arthritis patients, patients appeared to be mostly adherent according to conventional capsule counts. Results from adherence caps were highly discrepant with the capsule counts, with patterns suggesting patients did not use the bottle for daily dispensing, despite specific advice to do so.References:[1] El Alili M, Vrijens B, Demonceau J, Evers SM, Hiligsmann M. A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence. Br J Clin Pharmacol 2016;82:268-79.Acknowledgments:The GLORIA project is funded by the European Union’s Horizon 2020 research and innovation programme under the topic ‘’Personalizing Health and Care’’, grant agreement No 634886.Disclosure of Interests:Linda Hartman: None declared, Sabrina Paolino: None declared, Reinhard Bos: None declared, Daniela Opris-Belinski Speakers bureau: as declared, Marc R Kok Grant/research support from: BMS and Novartis, Consultant of: Novartis and Galapagos, Hanneke Griep-Wentink: None declared, Ruth Klaasen: None declared, Cornelia Allaart: None declared, George Bruyn: None declared, Hennie Raterman Grant/research support from: UCB, Consultant of: Abbvie, Amgen, Bristol-Myers Sqibb, Cellgene and Sanofi Genzyme, Marieke Voshaar Grant/research support from: part of phd research, Speakers bureau: conducting a workshop (Pfizer), Nuno Gomes: None declared, Rui Pinto: None declared, Thomas Klausch: None declared, WIllem Lems Grant/research support from: Pfizer, Consultant of: Lilly, Pfizer, Maarten Boers: None declared

Background: The incidence of subtalar joint (STJ) disease in patients with rheumatoid arthritis (RA) is greatly increased between five and ten years of disease duration and regularly precedes changes in the tibiotalar joint [1]. The joint is notoriously difficult to assess clinically and frequently overlooked in favour of the more accessible tibiotalar joint. We hypothesized that US might be used as a reliable outcome measure to evaluate synovitis of the STJ in patients with RA. The objectives of this study were first, to develop an expert consensus derived definition of synovitis and scanning protocol for the STJ and second, to test the reliability of the definitions and protocol. Objectives: To evaluate the intra- and interobserver reliability of the US assessment of STJ synovitis in patients with RA. Methods: Following a Delphi process, twelve sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis (synovial hypertrophy (SH) and power Doppler (PD) signal) and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen and Light kappa (k). Weighted k coefficients with absolute weighting were computed for B-mode and PD signal. Results: Mean weighted Cohen’s kappa for SH, PD, and JE, was 0.80 (0.62–0.98), 0.61 (0.48–0.73), and 0.52 (0.36–0.67), respectively. Weighted Cohen’s kappa for SH, PD, and JE in the anteromedial, posteromedial and posterolateral STJ was -0.04–0.79, 0.42–0.95, and 0.28–0.77; 0.31–1, -0.05–0.65, and -0.2–0.69; 0.66–1, 0.52–1, and 0.42–0.88, respectively. Weigthed Light kappa for SH was 0.67 (95%CI 0.58–0.74), 0.46 (0.35–0.59) for PD, and 0.16 (0.08–0.27) for JE. Weighted Light kappa for SH, PD, and JE was 0.63 (0.45–0.82),0.33 (0.19–0.42) and 0.09 (-0.01–0.19), for the anteromedial; 0.49 (0.27–0.64), 0.35 (0.27–0.4), and 0.04 (-0.06–0.1) for posteromedial, and 0.82 (0.75–0.89), 0.66 (0.56–0.8), and 0.18 (0.04–0.34) for posterolateral STJ, respectively. Conclusions: Ultrasound is a feasible and reliable tool for assessing synovitis of the posterolateral STJ in RA, but not for the anteromedial and posteromedial STJ. SH can be reliably detected in B-mode and PD mode, but this is not true for JE. Reference 1. Van der Leeden M, Steultjens MP, Van Ursem J, et al. Prevalence and course of forefoot impairments and walking disability in the first eight years of rheumatoid arthritis. Arthritis Rheum2008;59:1596–1602. Disclosure of Interest: None declared

Background In daily practice, surgical biopsy of minor salivary glands is routinely performed for the diagnosis of Sjogren’s syndrome. The classification criteria for Sjogren’s syndrome imply specific positive labial salivary gland biopsy findings. Surgical biopsies of the minor labial glands may result in up to 6% of patients in various complications, e.g. numbness of the lower lip. On the other hand, adverse events following core needle biopsies of the parotid gland in non-rheumatological settings were reported as very rare. Even so parotid gland biopsies require a more demanding surgical expertise mainly to protect the facial nerve. Objectives The objective of this study was to assess the feasibility and to determine the presence of parotid gland tissue in minimally invasive ultrasound-guided parotid gland biopsies in cadavers performed by rheumatologists using histology as a gold standard. Methods Two senior rheumatologists obtained under direct ultrasound visualisation in in-plane technique biopsies of 8 parotid glands from 4 different cadavers using a core biopsy needle (core biopsy needle 18G). One biopsy per gland was taken and was subsequently stored. The direction of the bioptic access is shown in Figure 1. The specimen underwent histological examination by an experienced pathologist. Results All histological exams showed typical parotid gland tissue. Notably, no facial nerve tissue or major vessels could be detected in the biopsy material. Conclusions In this cadaveric feasibility study, we demonstrated that minimally invasive ultrasound guided parotid core biopsy is a highly precise and easy method to obtain salivary gland tissue. References [1] Shiboski C. H. et al, 2016American College of Rheumatology/European League Against Rheumatism Classification Criteria for Primary Sjogren’s Syndrome. Arthritis Rheumatol. 2017 Jan;69(1):35–45. [2] Kim H.Jet al, Ultrasound-Guided Core Needle Biopsy in Salivary Glands: A Meta-analysis, Laryngoscope, 00:000–000, 2017. Disclosure of Interest None declared

Background Musculoskeletal ultrasound (US) is increasingly used in rheumatology clinical practice and research. Standardisation of US scanning techniques and definitions of pathologies is driven forward by the EULAR and OMERACT (Outcome measures in rheumatology) definitions and guidelines. However, no international consensus on a globally accepted US score system on patient level has been achieved so far. The US7 score, first published in 2009, assesses soft tissue lesions (synovitis, tenosynovitis/paratenonitis) as well as bone erosions of 7 preselected joints in one score.1 Objectives The aim of this retrospective analysis was to further validate the US7 score by a detailed analysis of affected joint regions in patients with different RA disease stages. Methods The US7 score1 examines the most commonly affected joints in RA, including the wrist, MCP2,3, PIP2,3 and MTP2,5 joints, for synovitis and tenosynovitis/paratenonitis and bone erosions from dorsal, palmar, ulnar (wrist), radial (only MCP2) and lateral (only MTP5) by greyscale (GS) and power Doppler (PD) US. In this retrospective analysis, our population of 524 patients with RA was divided into 3 subgroups – 69 patients (13.2%) with very early RA (max. 6 months disease duration), 98 patients with early RA (>6 month,≤2 years of disease duration), and 343 patients (65.5%) with established RA (>2 years disease duration). Patients were examined at baseline, 3, 6 and 12 months after starting or changing therapy (csDMARD/bDMARD). Results MCP2 and the wrist (especially from dorsal) were most frequently affected by GS/PDUS synovitis in all groups. PDUS showed a slight tendency towards the dorsal versus the palmar joint side being more often affected in all groups. The group of established RA was more often affected by synovitis, while tenosynovitis/paratenonitis appeared more frequently in very early RA. Significant sensitivity to change within 12 months was detected by GSUS in the group of very early RA in all hand joint regions (for synovitis: p Conclusions Based on these results, we recommend to include wrist and MCP2 joints in a global US score on the patient level to monitor RA, independent of the disease stage, since they are1 most commonly affected by synovitis and2 most responsive to therapy. Tenosynovitis/paratenonitis is frequent in very early RA and should therefore be implemented in an US score monitoring early disease stages. Reference [1] Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Rheum2009;61(9):1194–201. Disclosure of Interest None declared

Objectives To assess the reliability of the OMERACT ultrasound (US) definitions for the identification of calcium pyrophosphate deposition disease (CPPD) at the metacarpal-phalangeal, triangular fibrocartilage of the wrist (TFC), acromioclavicular (AC) and hip joints. Methods A web-based exercise and subsequent patient-based exercise were carried out. A panel of 30 OMERACT members, participated at the web-based exercise by evaluating twice a set of US images for the presence/absence of CPPD. Afterwards, 19 members of the panel met in Siena, Italy, for the patient-based exercise. During the exercise, all sonographers examined twice eight patients for the presence/absence of CPPD at the same joints. Intraoberserver and interobserver kappa values were calculated for both exercises. Results The web-based exercise yielded high kappa values both in intraobserver and interobserver evaluation for all sites, while in the patient-based exercise, inter-reader agreement was acceptable for the TFC and the AC. TFC reached high interobserver and intraobserver k values in both exercises, ranging from 0.75 to 0.87 (good to excellent agreement). AC reached moderate kappa values, from 0.51 to 0.85 (moderate to excellent agreement) and can readily be used for US CPPD identification. Conclusions Based on the results of our exercise, the OMERACT US definitions for the identification of CPPD demonstrated to be reliable when applied to the TFC and AC. Other sites reached good kappa values in the web-based exercise but failed to achieve good reproducibility at the patient-based exercise, meaning the scanning method must be further refined.

Objectives: To define the elementary ultrasound (US) lesions in giant cell arteritis (GCA) and to evaluate the reliability of the assessment of US lesions according to these definitions in a web-based reliability exercise.Methods: Potential definitions of normal and abnormal US findings of temporal and extracranial large arteries were retrieved by a systematic literature review. As a subsequent step, a structured Delphi exercise was conducted involving an expert panel of the Outcome Measures in Rheumatology (OMERACT) US Large Vessel Vasculitis Group to agree definitions of normal US appearance and key elementary US lesions of vasculitis of temporal and extracranial large arteries. The reliability of these definitions on normal and abnormal blood vessels was tested on 150 still images and videos in a web-based reliability exercise.Results: Twenty-four experts participated in both Delphi rounds. From originally 25 statements, nine definitions were obtained for normal appearance, vasculitis and arteriosclerosis of cranial and extracranial vessels. The 'halo' and 'compression' signs were the key US lesions in GCA. The reliability of the definitions for normal temporal and axillary arteries, the 'halo' sign and the 'compression' sign was excellent with inter-rater agreements of 91-99% and mean kappa values of 0.83-0.98 for both inter-rater and intra-rater reliabilities of all 25 experts.Conclusions: The 'halo' and the 'compression' signs are regarded as the most important US abnormalities for GCA. The inter-rater and intra-rater agreement of the new OMERACT definitions for US lesions in GCA was excellent.

BackgroundIn 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines.ObjectivesTo update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology.MethodsThe project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures).ResultsStructures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts.ConclusionsThis task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Objective.To provide an update from the Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group on the progress for defining ultrasound (US) minimal disease activity threshold at joint level in rheumatoid arthritis (RA) and for standardization of US application in juvenile idiopathic arthritis (JIA).Methods.For minimal disease activity, healthy controls (HC) and patients with early arthritis (EA) who were naive to disease-modifying antirheumatic drugs were recruited from 2 centers. US was performed of the hands and feet, and scored semiquantitatively (0–3) for synovial hypertrophy (SH) and power Doppler (PD). Synovial effusion (SE) was scored a binary variable. For JIA, a Delphi approach and subsequent validation in static images and patient-based exercises were used to developed preliminary definitions for synovitis and a scoring system.Results.For minimal disease activity, 7% HC had at least 1 joint abnormality versus 30% in the EA group. In HC, the findings of SH and PD were predominantly grade 1 whereas all grades were seen in the EA cohort, but SE was rare. In JIA, synovitis can be diagnosed based on B-mode findings alone because of the presence of physiological vascularization. A semiquantitative scoring system (0–3) for synovitis for both B-mode and Doppler were developed in which the cutoff between Doppler grade 2 and grade 3 was 30%.Conclusion.The first step has been taken to define the threshold for minimal disease activity in RA by US and to define and develop a scoring system for synovitis in JIA. Further steps are planned for the continuous validation of US in these areas.

Objectives Musculoskeletal ultrasonography (US) has the potential to be an important tool in the assessment of disease activity in childhood arthritides. To assess pathology, clear definitions for synovitis need to be developed first. The aim of this study was to develop and validate these definitions through an international consensus process. Methods The decision on which US techniques to use, the components to be included in the definitions as well as the final wording were developed by 31 ultrasound experts in a consensus process. A Likert scale of 1-5 with 1 indicating complete disagreement and 5 complete agreement was used. A minimum of 80% of the experts scoring 4 or 5 was required for final approval. The definitions were then validated on 120 standardized US images of the wrist, MCP and tibiotalar joints displaying various degrees of synovitis at various ages. Results B-Mode and Doppler should be used for assessing synovitis in children. A US definition of the various components (i.e. synovial hypertrophy, effusion and Doppler signal within the synovium) was developed. The definition was validated on still images with a median of 89% (range 80-100) of participants scoring it as 4 or 5 on a Likert scale. Conclusions US definitions of synovitis and its elementary components covering the entire pediatric age range were successfully developed through a Delphi process and validated in a web-based still images exercise. These results provide the basis for the standardized US assessment of synovitis in clinical practice and research. This article is protected by copyright. All rights reserved.

Background Ultrasound (US) was found to have face and content validity for detecting synovitis in juvenile idiopathic arthritis (JIA) with higher sensitivity than clinical examination. In order to test validity and improve the applicability of US in JIA, the OMERACT US pediatric subtask force recently published preliminary definitions for the sonographic features of synovitis in children. Objectives Aim of this study was to confirm and improve B-mode and color power/Doppler (PD) US definitions for synovial components and grading in children, by using an image and patient based exercise. Methods The definitions were confirmed and modified in a multi-step process. In the 1st step, definitions were developed in multi-round Delphi web based consensus process were ≥80% of participants would need to reach ≥80% of agreement on a Likert scale from 1–5 (1 strongly disagree, 2 disagree, 3 neutral, 4 agree, 5 strongly agree). In the 2nd step, in a face to face meeting, a subgroup of these experts revised the definitions for final wording and performed intra- and inter-observer reliability exercise study in JIA patients as the final 3rd phase of the process. The definitions were tested in four joints (wrist, 2nd MCP, knee and ankle) of JIA patients divided in four age groups following standardized image acquisition and machine setting protocol. Statistics program R (version 3.3.0) was used for the statistical analyses. For intra-rater agreement Cohen kappa and for inter-rater agreement prevalence and bias adjusted kappa (PABAK) were calculated if needed. Results Reliability exercise included 20 JIA patients (distributed in equal numbers by age groups), 14 observers, 4 joints/observer, 3 observers/joint, 360 intra- and 360 inter-observer tests. A 0–3 semi-quantitative B-mode and color power/Doppler US definitions for synovial components and grading, were agreed (presented in Figure 1). Conclusions The proposed synovitis grading for children showed to be reliable why the next step should be to test sensitivity to change in order to possibly be used as an outcome tool in JIA. Disclosure of Interest None declared

Background Joint destruction in rheumatoid arthritis (RA) is comprised of hyaline cartilage and bone damage, with the former more clearly associated with irreversible physical disability than bony damage. Objectives To test the reliability of a semiquantitative scoring system for the assessment of cartilage by musculoskeletal ultrasound (US) in a web-based exercise as well as a patient-based reliability study of patients with RA. Methods Static images of metacarpophalangeal (MCP) joints 2–5 in RA patients and healthy controls were acquired and a dataset of 123 anonymized images including 25 duplicate images was circulated among an international EULAR-OMERACT taskforce of 25 rheumatologist experts in US who independently scored the images using a semiquantitative scoring system. Subsequently 12 taskforce members participated in a patient-based reliability study. During this meeting MCP joints 2–5 of 6 patients with RA were assessed twice on the same day by all experts using US machines (GE) equipped with high-frequency transducers (18–22MHz) with presets calibrated for the appropriate assessment of cartilage. Participants assessed metacarpal cartilage both in the standardized longitudinal midline scan as well as by freehand technique utilizing multiple planes and scored by the semiquantitative scoring system. Intraobserver reliability was assessed by Cohen9s kappa and interobserver reliability by Fleiss9 kappa. Results The three-grade semiquantitative (Grade 0, normal cartilage; Grade 1, minimal change; Grade 2, severe change) scoring system demonstrated excellent (kappa: 0.87) to good (kappa: 0.73) intraobserver reliability in the web-based exercise and the patient-based reliability study respectively. Interobserver reliability was good in the web-based exercise (kappa: 0.64) and moderate (kappa: 0.49) in the patient-based reliability study. The dynamic technique performed slightly better than the longitudinal midline scan alone. Conclusions A semiquantitative scoring system demonstrated good intra- and moderate to good inter-observer reliability in a web-based exercise and patient-based reliability study. Our study demonstrates that US is a reliable tool for evaluating cartilage and supports the use of a new semiquantitative US scoring system for evaluating cartilage change in RA. Acknowledgements The patient-based reliability study was supported by a research grant from UCB. Disclosure of Interest None declared

Background Ultrasonography (US) of salivary glands (USSG) may support diagnosis and evaluation of disease activity in primary Sjogren9s syndrome pSS. In order to extent the use of USSG in daily practice, consensus definitions of normal and abnormal USSG findings are needed. Objectives To obtain consensual definitions of normal and abnormal USSG findings using a Delphi process. Methods Twenty-seven experts participated in the Delphi process. A Likert scale from 1–5 was used in which 1 indicated complete disagreement and 5 complete agreement. Three core items were proposed: 1. Consensus of assessment of SG (parotid gland (PG), submandibular glands (SMG), sublingual glands SLG)). 2. Consensus for elementary lesions of PG, SMG, and SLG changes in PSS patients. 3. Consensus on grading of PG, SM, and SLG in pSS. Results The consensus of definitions between experts was reached after three rounds.The results (table 1) showed agreement with more than 75% of agreement in normal and abnormal definitions in SG and concluded to not evaluate SLG in pSS patients as well as to score pSS SG patients with at least two abnormal glands out of 4 (2 PG and 2 SMG) with a scoring system >2 for each abnormal gland. Conclusions We developed a consensual US definition of normal and abnormal USGS findings through a Delphi exercise process. This finding will be used as a basis to further proceed with the validation of USGS for clinical application. Disclosure of Interest None declared

Background The OMERACT US subtask force “US in CPPD” recently created the definitions for US identification of crystal deposits in joints and tested the reliability at the knee [1]. Objectives To assess the inter/intra-observer reliability of US on detecting CPPD at triangular fibrocartilage complex (TFCC) of the wrists, fibrocartilage of the AC joint, hip labrum (HL), hyaline cartilage (HC) of the metacarpal (MC) and femoral head. Methods The OMERACT criteria for CPPD were used for the exercise [1] using a 2 steps approach. First, the panel of experts gave a dichotomous score (presence/absence of CPPD) of 120 images of the sites included, using a web platform. The images were evaluated twice to assess the inter/intra-observer reliability. Then, the experts met in Siena for a patient based exercise. Bilateral evaluation of TFCC, AC, HL /HC of the hip and HC of the II-III MCP of 8 patients was carried out twice in a day, using a dichotomous score for CPPD. 8 US machines (3 GE, 1 Samsung and 4 Esaote) equipped with high resolution linear probes were used. Results Reliability values of static exercise were high for all sites, demonstrating that definitions were clear. The results of the second step are presented in table 1. On live scanning, the TFCC resulted the most reliable site for CPPD assessment, followed by AC. Other sites demonstrated lower kappa values and thus are not reliable for CPPD assessment. Conclusions TFCC of the wrist is the most reliable site for CPPD. By adding these results to the previous [2], we confirm that the OMERACT definitions for CPPD can be applied reliably at the knee (meniscus and HC), TFCC and AC, usually the most involved sites in CPPD. The next step of the OMERACT subtask force will be to test these findings in a longitudinal observational study. References Filippou G, Scire CA, Damjanov N et al. Definition and reliability assessment of elementary US findings in CPPD. Results of an international multi-observer study by the OMERACT sub-task force “US in CPPD”. J Rheumatol, in press. Disclosure of Interest None declared

Objective.To define the ultrasonographic characteristics of calcium pyrophosphate crystal (CPP) deposits in joints and periarticular tissues and to evaluate the intra- and interobserver reliability of expert ultrasonographers in the assessment of CPP deposition disease (CPPD) according to the new definitions.Methods.After a systematic literature review, a Delphi survey was circulated among a group of expert ultrasonographers, who were members of the CPPD Ultrasound (US) Outcome Measures in Rheumatology (OMERACT) subtask force, to obtain definitions of the US characteristics of CPPD at the level of fibrocartilage (FC), hyaline cartilage (HC), tendon, and synovial fluid (SF). Subsequently, the reliability of US in assessing CPPD at knee and wrist levels according to the agreed definitions was tested in static images and in patients with CPPD. Cohen’s κ was used for statistical analysis.Results.HC and FC of the knee yielded the highest interobserver κ values among all the structures examined, in both the Web-based (0.73 for HC and 0.58 for FC) and patient-based exercises (0.55 for the HC and 0.64 for the FC). Kappa values for the other structures were lower, ranging from 0.28 in tendons to 0.50 in SF in the static exercise and from 0.09 (proximal patellar tendon) to 0.27 (triangular FC of the wrist) in the patient-based exercise.Conclusion.The new OMERACT definitions for the US identification of CPPD proved to be reliable at the level of the HC and FC of the knee. Further studies are needed to better define the US characteristics of CPPD and optimize the scanning technique in other anatomical sites.