Doppler Activity Research Articles

Normative data on lower extremity entheseal tendon thicknesses in healthy children: an ultrasound study correlating age, sex, and anthropometry

Abstract Objectives This study aims to establish normative data on lower extremity entheseal tendon thicknesses in healthy children and examine correlations with age, gender, and anthropometric measures using musculoskeletal ultrasound. The secondary objective of the study is to investigate the power Doppler properties of entheseal tendons. Methods A total of 192 healthy children, aged 5–18 years, participated in this cross-sectional study. Participants underwent detailed physical and ultrasonographic examinations. Entheseal tendon thickness measurements were taken from five specific regions: distal quadriceps tendon (DQT), proximal patellar ligament (PPL), distal patellar ligament (DPL), Achilles tendon (AT), and plantar fascia (PF). Correlations between thicknesses and age, weight, height, and BMI were analysed. Intra-tendinous vascularity was evaluated using power Doppler. Interobserver and intraobserver agreements were assessed using intraclass correlation coefficients (ICC). Results Normative data on lower extremity entheseal tendon thicknesses according to age, weight, height, and BMI have been established. Significant positive correlations were found between thicknesses and age, weight, height, and BMI. Weight was identified as the most influential factor, particularly for the DPL and AT. Right side tendons (AT and PF) are statistically thicker. Minimal Doppler activity was detected in 10.6% of the entheseal DQTs in the group of children aged 5–9 years. The study achieved high to excellent interobserver and intraobserver agreement. Conclusion This study examined the ultrasonographic characteristics of lower extremity entheseal tendons in healthy children using B-mode and power Doppler, provided normative data on their thicknesses, and demonstrated significant correlations between tendon thicknesses and both age and anthropometric measures.

Intestinal ultrasound for follow-up after 24 weeks of biological therapy in inflammatory bowel disease patients: an Egyptian center experience during the COVID-19 pandemic

BackgroundInflammatory bowel disease is a chronic inflammatory condition of the gut. It has two major subtypes Crohn’s disease and ulcerative colitis. The follow-up consists of radiologic, molecular, endoscopic, and histological assessments. Intestinal ultrasound (IUS) is a noninvasive measure that provides future hope in guiding the management of IBD patients. This study is to assess the effectiveness of IUS in IBD patients’ follow-up in our tertiary center during the pandemic. This is a prospective observational study during the COVID-19 pandemic. We used IUS to assess activity of IBD at baseline and at 6-month follow-up of patients on maintenance biological therapy using the following parameters: bowel haustrations, stratification, bowel wall thickness (BWT), Doppler sign (Limberg classification), presence of lymph nodes, or fibrofatty infiltration, echogenicity of the bowel, and presence of fistulae or abscesses. We compared the IUS with other radiologic parameters, histologic, and endoscopic scores at baseline before therapy, while we compared IUS with clinical scores and laboratory parameters before and after 24 weeks of biological treatment.ResultsThe cohort included 50 known IBD patients from June 2021 to January 2022. The laboratory studies showed a significant improvement in the hemoglobin indices, CRP, and fecal calprotectin from baseline and after 24 weeks. BWT, lumen diameter, lymph node presence, inflammatory signs, and Doppler activity signs were the most significant parameters in detecting improvement. However, there was no significant correlation between fecal calprotectin levels and ultrasound parameters. There was a positive correlation between MR and CT enterography, endoscopic parameters, and IUS parameters at baseline.ConclusionsIUS is an effective tool for follow-up of IBD patients especially during the pandemic periods.

Reflection of power DOPPLER activity in the subacromial space on nocturnal pain in patients with rotator cuff tears: a cross-sectional study

BackgroundNocturnal shoulder pain is seen in patients with rotator cuff tears. The purpose of the present study was to determine whether Doppler ultrasound parameters predict the intensity of nocturnal pain in patients with rotator cuff tears. MethodsA total of 60 patients with rotator cuff tears were included. Doppler ultrasound parameters (peak systolic velocity in the anterior humeral circumflex artery, Doppler activity in the glenohumeral joint and subacromial space) and clinical parameters were examined. For the presence of nocturnal pain, the clinical parameters were compared with and without nocturnal pain. For the intensity of the nocturnal pain, a multivariate analysis of clinical parameters and nocturnal pain intensity was performed. ResultsIn all, 39 patients (65%) reported nocturnal pain, and the mean pain intensity was 47.0 (standard deviation, 26.0) on the visual analogue scale. In nocturnal pain presence analysis, Doppler activity in the subacromial space showed significant associations (p < 0.001). In nocturnal pain intensity analysis, Doppler activity in the subacromial space and diabetes showed significant associations (p < 0.001, p = 0.01, respectively). ConclusionDoppler activity in the subacromial space emerges as an independent factor associated with the presence and intensity of nocturnal pain in patients with rotator cuff tears. Our findings may provide a basis for further exploration and refinement of treatment strategies.

Simplified vs modified (reduced) ultrasound 6 joint score in assessing disease activity in rheumatoid arthritis patients

Introduction and aim. With increasing ultrasound US assessment opportunities for tight rheumatoid arthritis (RA) management, more simplified accurate US-assessment is desired in clinical practice. Aim of the work is assessing modified vs simplified ultrasound 6-joint scores relevance in assessing rheumatoid arthritis disease activity. Material and methods. Fifty-five RA patients were subjected to detailed history, clinical, and musculoskeletal examination with disease activity assessment by clinical disease activity index, simple disease activity index and disease activity score in 28 joints. Com plete blood count, erythrocyte sedimentation rate, C-reactive protein, rheumatoid factor, anti-cyclic citrullinated peptide antibodies were done. Patients underwent US examination (gray-scale and power Doppler) for wrist, 2nd and 3rd metacarpophalangeal and knee joints bilaterally. Synovitis composite score was added. Two US indices were constructed: simplified S6 and modified M6 joint scores. Results. Statistical significant positive correlations were high between S6/M6 score parameters (total, grey-scale (GS), power doppler (PD), Composite) and disease activity markers. Both M6 and S6 scores differentiated mild-moderate and moderate-severe disease activity patients. However, only S6 score differentiated remission from mild disease activity patients. Conclusion. Ultrasound 6-joint scores (especially simplified S6) were rapid, easy and sensitive ultrasound tools assessing rheu matoid arthritis disease activity in clinical practice.

Determination of differences in ultrasound parameters for patellar tendons in males with unilateral patellar tendinopathy-An ancillary analysis of data from two randomized controlled trials.

To investigate power Doppler (PD) activity and tendon structure (between the injured and contralateral limb) in patients with unilateral patellar tendinopathy (PT) using ultrasonography (US). Secondly, the aim was to determine the intra-rater reliability of the PD activity and tendon structure. This study analyzed US baseline data from 57 male participants with symptomatic unilateral PT who had been enrolled in one of two randomized clinical trials. Data were analyzed to examine if systematic differences existed between injured and contralateral limbs using Fiji ImageJ. The PD activity of the symptomatic tendon was larger 25.6 (Q1 = 14.9; Q3 = 41.6) mm2 than the asymptomatic 0 (Q1 = 0.0; Q3 = 0.0) mm2 (p < 0.001). There was a significantly greater tendon thickness at the proximal (2.5 mm 95% CI [2.0; 3.0]), mid (0.8 mm 95% CI [0.5; 1.1]), and distal (0.2 mm 95% CI [0.1; 0.4]) part of the tendon for the symptomatic compared to the asymptomatic tendon. Intra-rater reliability for PD activity and tendon structure ranged from moderate-to-excellent (0.74; 0.99). These results provide mean estimates for tendon thickness of symptomatic and asymptomatic tendons, that can be used for clinicians to reliably estimate pathological tendon thickness.

Tendon Elongation and Function After Delayed or Standard Loading of Surgically Repaired Achilles Tendon Ruptures: A Randomized Controlled Trial

Background: Achilles tendon ruptures often result in long-term functional deficits despite accelerated (standard) rehabilitation. Purpose/Hypothesis: The purpose of this study was to investigate if delayed loading would influence functional, clinical, and structural outcomes of the muscles and tendon 1 year after a surgical repair. It was hypothesized that delaying the loading would reduce the heel-rise height deficit 1 year after Achilles tendon rupture. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In total, 48 patients with a surgically repaired Achilles tendon rupture were randomized to 2 groups: the standard group received the currently accepted rehabilitation, and the delayed group received the same rehabilitation except that initial loading was delayed by 6 weeks. The primary outcome was the heel-rise height difference between the injured and uninjured sides at 1 year. The secondary outcomes were (1) tendon length measured with magnetic resonance imaging, (2) muscle fascicle length and pennation angle of the gastrocnemius medialis muscle, (3) Doppler activity measured with ultrasonography, (4) Achilles tendon Total Rupture Score (ATRS), and (5) isometric muscle strength. Results: The mean heel-rise height deficits for the standard and delayed groups were −2.2 cm and −2.1 cm, respectively (P = .719). The soleus part of the tendon was already elongated 1 week after surgery in both groups without a between-group difference (side-to-side difference: standard, 16.3 mm; delayed, 17.5 mm; P = .997) and did not change over 52 weeks. The gastrocnemius tendon length was unchanged at 1 week but elongated over time without a between-group difference (side-to-side difference at 52 weeks: standard, 10.5 mm; delayed, 13.0 mm; P = .899). The delayed group had less Doppler activity at 12 weeks (P = .006) and a better ATRS (standard, 60 points; delayed, 72 points; P = .032) at 52 weeks. Conclusion: Delayed loading was not superior to standard loading in reducing the heel-rise height difference at 1 year. The data indirectly suggested reduced inflammation in the initial months and a better patient-reported outcome at 1 year in the delayed group. The soleus part of the tendon was already markedly elongated (35%) 1 week after surgery, while the length of the gastrocnemius tendon was unchanged at 1 week but was 6% elongated at 1 year. Together, these data indirectly suggest that the delayed group fared better, although this finding needs to be confirmed in future investigations. Registration: NCT04263493 (ClinicalTrials.gov identifier).

CLINICAL, BIOCHEMICAL, AND INTESTINAL ULTRASONOGRAPHY RESPONSE TO CURCUMIN-QINGDAI (CURQD) COMBINATION IN PEDIATRIC PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A CASE SERIES

Abstract BACKGROUND There are few FDA-approved therapies for pediatric patients with inflammatory bowel disease (IBD). Clinical remission rates plateau at 60%, even with the currently available biologic therapies. Nutraceuticals are novel alternative treatments that can be used as adjunct treatments. AIM In this case series of 8 patients, we aim to present the clinical and radiological response to a novel nutraceutical agent, CurQD, composed of QingDai (Indigo Naturalis) and Curcumin. METHODS Patients included required a baseline pre-treatment clinical assessment and at least a single follow-up examination. Clinical status was evaluated based on the Physician General Assessment (PGA, determined independently from the clinical scoring systems) and the pediatric Crohn’s disease activity index (PCDAI) or the pediatric ulcerative colitis activity index (PUCAI), as appropriate. Baseline biomarkers (Hgb, ESR, CRP, albumin, and calprotectin(FC)) were collected pre and post-treatment when available. When available, intestinal ultrasound (IUS) features were also noted. On the IUS, bowel wall thickness (BWT, in mm) and color Doppler signaling (measured by the modified Limberg score graded 0,1,2, or 3 based on severity) were collected. The longitudinal changes were demonstrated on the most inflamed segment. Considering the small sample size, only descriptive statistics were applied. RESULTS Primary therapies received included anti-TNFα for 3 patients, ustekinumab in 3 patients, 1 on vedolizumab, and mesalamine in 1. Baseline assessment was done at a median time of 1.8 weeks (IQR 0.9-3.6 weeks) before starting the supplement, and the follow-up was 3.9 weeks (IQR 2.8-5.4 weeks) after starting the supplement. Two patients were in clinical remission at baseline but had active disease based on Doppler activity on IUS, 3 patients had mild active disease, and 3 patients had either moderate or severe disease activity. At follow-up, all patients but one were in clinical remission. (Table 1) Median baseline FC decreased from 1047.4 ug/g (IQR 532.4-1107) to 27.1 (IQR 27.5-341.3). Five patients had complete IUS information. When isolating the most inflamed segment on IUS, all patients demonstrated a response to treatment, noted by a decrease in BWT and/or a decrease in Doppler signaling. (Figure 1) No patient had a baseline therapy change after their follow-up. One patient reported abdominal bloating after starting CurQD and discontinued the product after five weeks. CONCLUSION CurQD is a promising nutraceutical that may assist in breaking the therapeutic ceiling of biological therapies in IBD. Based on this small experience, a larger randomized controlled trial in children would be needed to assess the safety and efficacy of this product in this vulnerable patient group. Furthermore, IUS is a practical tool for evaluating response to therapy in a pragmatic clinical setting. Table 1 Change in clinical disease scores in patients receiving CurQD Figure 1 Description of changes in a) bowel wall thickness (BWT) and b) color Doppler signaling (measured by the modified Limberg score) in patients treated with CurQD.

Blood flow velocity in the anterior humeral circumflex artery and tear size can predict synovitis severity in patients with rotator cuff tears.

Rotator cuff tears are often associated with synovitis, but the ability of noninvasive ultrasonography to predict the severity of synovitis remains unclear. We investigated whether ultrasound parameters, namely peak systolic velocity in the anterior humeral circumflex artery and Doppler activity in the glenohumeral joint and subacromial space, reflect synovitis severity. A total of 54 patients undergoing arthroscopic rotator cuff repair were selected. Doppler ultrasound was used to measure peak systolic velocity in the anterior humeral circumflex artery and Doppler activity in the glenohumeral joint and subacromial space, and these values were compared with the intraoperative synovitis score in univariate and multivariate analyses. Univariate analyses revealed that tear size, peak systolic velocity in the anterior humeral circumflex artery, and Doppler activity in the glenohumeral joint were associated with synovitis in the glenohumeral joint (P=0.02, P<0.001, P=0.02, respectively). In the subacromial space, tear size, peak systolic velocity in the anterior humeral circumflex artery, and Doppler activity in the subacromial space were associated with synovitis severity (P=0.02, P<0.001, P=0.02, respectively). Multivariate analyses indicated that tear size and peak systolic velocity in the anterior humeral circumflex artery were independently associated with synovitis scores in both the glenohumeral joint and the subacromial space (all P<0.05). These findings demonstrate that tear size and peak systolic velocity in the anterior humeral circumflex artery, which can both be measured noninvasively, are useful indicators of synovitis severity. Level of evidence: IV.

P945 Crohn´s disease response to ustekinumab measured by bowel ultrasound

Abstract Background After the STRIDE-II update for patients with Crohn’s disease (CD) one of the new possible adjunct treatment goals was transmural healing, yet its assessment is still not fully cost/risk-benefit proven. A valuable tool to assess this adjunct goal is bowel ultrasound. For this reason, our aim was to evaluate the bowel ultrasonographic response to ustekinumab at one year. Methods Retrospective, observational, single center study was designed. All adult patients with CD who were treated with ustekinumab and had a bowel ultrasound just before the induction dose with ustekinumab and who repeated the bowel ultrasound one year after it were included. Examination was done by ultrasound machine (Hitachi Avius) with low frequency curved-array (1-5 MHz) and high-frequency linear-array (5-13 MHz) transducers. The measured bowel ultrasonographic variables were: wall thickness, Doppler activity (Limberg index) and fatty striation. Ultrasonographic response was defined as a reduction in wall thickness of at least 25%, 2mm or 1mm plus 1 Doppler sign. Remission was defined as wall thickness less than 3mm plus absent Doppler sign. Patient demographics and disease characteristics were also collected: age, sex, extension of CD, previous biologic treatments and ustekinumab trough levels. Demographic and clinical characteristics were compared using χ2 analysis (or Fisher’s exact test), Student’s t test or Spearman correlation. All statistical analyses were performed using the STATA Statistical Software. Results A total of 41 patients (56.1% female) with a mean age of 57.9 years (SD ±2.7) were included. 63.4% had ileal disease and 36.6% ileocolonic involvement. Ustekinumab was first line of biologic treatment in 7.3%, second line in 61.0%, third line in 29.3% and fourth line in 2.4% of patients. 63.4% of patients were on ustekinumab 90mg subcutaneous every 4 weeks at one year with a median trough level of 8.6 (range 7.9-10.6). The median wall thickness measured by bowel ultrasound before induction was 5.5 mm (range 5.0-6.4) and after one year it was 5.0 mm (4.1-5.7) (p=0.47) Figure 1. Before treatment Limberg index was 3 in 26.8% and after treatment it was 3 in 4.9% (p=0.052). Fatty striation was present in 90.2% of patients at the beginning of treatment and in 63.4% at one year (p=0.013). Ultrasound response was achieved in 36.6% of patients while transmural remission was achieved in 12.2% of patients in the first year. No association between ustekinumab trough levels and response/remission were found (p=0.70/p=0.83) Conclusion Treatment with USK was related with an ultrasonographic response in one third of patients with refractory CD at one year. No association between ustekinumab trough levels and ultrasonographic response/remission were found

DOP07 Monitoring disease activity by intestinal ultrasound predicts biologic treatment persistence in patients with Inflammatory Bowel Disease

Abstract Background Current biomarker-based monitoring strategies have limited efficacy in predicting risk of biologic treatment failure in inflammatory bowel disease (IBD). Endoscopic assessment identifies patients at risk of disease progression but is expensive and poorly accepted by patients. Therefore, we examined how intestinal ultrasound (IUS) performed as part of a monitoring program to predict treatment persistence to biologics in IBD patients. Methods Data were generated as part of a 1-year prospective, observational, cohort study of patients on biologics comparing tight monitoring to a historic cohort (‘Time It´ study). Data used in the present analysis included Harvey Bradshaw index (HBI), simple clinical colitis activity score (SCCAI), CRP, f-calprotectin (FC), IUS, and ileocolonoscopy all done at inclusion. The following definitions were used: Treatment persistence: no need for dose escalation or switching to another biologic or small molecule; IUS transmural remission (TR): bowel wall thickness ≤3mm in all bowel segments and zero color Doppler activity; endoscopic remission (ER): simple endoscopic score (SES)-CD≤2 or Mayo endoscopic score 0; clinical remission (CR): HBI≤4 or SCCAI≤2; FC remission (FCR): FC≤250; CRP remission (CRPR): CRP≤10 mg/L. Chi-square tests and Kaplan-Meier statistics were used to compare baseline measures in treatment persistent and non-persistent patients. Results Of the 91 patients included in 'Time It’, 77 had IUS performed and 69 ileocolonoscopy. Of the 77 patients, 61% were on maintenance treatment at inclusion and 39% were included during induction (Table 1). COVID-19 restrictions were the main reason for missing IUS or endoscopy. As expected, more patients with ER had 1-year treatment persistence (87% vs. 41%; p&amp;lt;0.001). However, patients with IUS TR also had better treatment persistence (78% vs. 38%; p&amp;lt;0.001). CR or FCR were associated with treatment persistence (p&amp;lt;0.05 and p&amp;lt;0.01, respectively), but not CRPR. Combining TR and FCR performed numerically as well as ER (treatment persistence 85% vs. 41%, p=0.002). Survival analysis of TR showed a mean treatment persistence of 318 days vs. 221 days without TR (p&amp;lt;0.001); corresponding treatment persistence data were 327 days vs. 230 days for combined TR and FCR; and 338 days vs. 226 days for ER (both p&amp;lt;0.001; Figure 1). There was no difference in mean treatment persistence between TR and ER (318 vs. 338 days; p=0.36). Conclusion IUS alone or combined with FCR was comparable to endoscopy to identify patients with high biologic treatment persistence. Being a non-invasive, patient friendly, cost-effective modality, IUS monitoring may improve current disease monitoring programs aiming to increase treatment persistence.

Effects of extracorporeal shockwave therapy for mild knee osteoarthritis: A pilot study.

Extracorporeal shockwave therapy (ESWT) has been widely used for various musculoskeletal disorders, including knee osteoarthritis (OA), and has been shown in several studies to be a safe treatment. Although some studies have confirmed the pain-relieving effect of ESWT for knee OA, research on objectivity for structural changes in knee OA is lacking. The aim of this study was to evaluate the ESWT treatment mechanisms in patients with knee OA by means of clinical symptoms and ultrasound techniques as objective measures. Eighteen patients with mild knee OA were enrolled and randomized to 1 of 2 treatment groups: active or sham. Patients in the experimental group received 0.05 mJ/mm² total energy with 1000 pulses weekly for 3 weeks. We then assessed them before, immediately after, and 1-month after the last treatment using the following measurements: pain on a visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index, Lequesne index, knee joint range of motion, and ultrasonographic features (articular cartilage thickness, Doppler activity, and joint effusion height). All 18 patients completed the 3 treatment sessions without any complication. Both the experimental and control groups improved in terms of OA symptoms, as measured by the visual analog scale, Western Ontario and McMaster Universities Osteoarthritis Index score, and Lequesne index (P < .05). The height of the suprapatellar effusion decreased with time course in the experimental group (P < .05) and showed significant differences with control group at 1-month follow-up (P < .05). The experimental group showed an increase in knee flexion range of motion and Doppler activity immediately following the last treatment session (P < .05), but the effect was not sustained at the 1-month follow-up. Although the therapeutic activity itself could improve OA symptoms, objective improvements were only observed after ESWT. Suprapatellar effusion height was reduced after ESWT and the effect was maintained after 1-month. Our results suggest that ESWT may be effective in reducing suprapatellar effusion and improving symptoms in mild knee OA. However, studies with a larger sample size are required.

Rheumatoid arthritis with concomitant fibromyalgia: The role of ultrasound in assessing disease activity.

Fibromyalgia (FM) is a chronic painful condition frequently associated with rheumatoid arthritis (RA), which may falsely increase RA activity. The aim of our study was to compare clinical scoring and ultrasound (US) assessment in RA patients with concomitant FM with those without FM. A cross-sectional study including patients with RA according to the ACR/EULAR 2010 criteria was conducted. Patients were divided into two groups: RA patients meeting ACR 2016 FM criteria (cases) and RA patients not meeting FM criteria (controls). Clinico-biological and US assessments of RA activity were performed on the same day for each patient. Eighty patients distributed into 40 patients in each group were recruited. Biologic DMARD prescription was more frequent in RA with FM patients than the control group (p=0.04). DAS28 was significantly greater than DAS28 V3 in RA with FM group (p=0.002). FM group had significantly less US synovitis (p=0.035) and less Power Doppler (PD) activity (p=0.035). Grey scale US score (p=0.87) and DP US score (p=0.162) were similar in the two groups. The correlation between the clinical and the ultrasonographic scores was strong to very strong in both groups with the strongest correlation found between DAS28 V3 and US DAS28 V3 (r=0.95) in RA+FM group. Our study confirms the overestimation of disease activity by the clinical scores in RA with concomitant FM. DAS28 V3 score and US assessment would represent a better alternative.

E064 A rare hereditary haemochromatosis type three (3) related arthritis

Abstract Background/Aims Arthritis is a common manifestation in hereditary haemochromatosis (HHC). Haemochromatosis arthropathy frequently involves small joint of hands especially the metacarpo-phalangeal joints (MCPJs) and hence is one of the differentials when assessing for rheumatoid arthritis, psoriatic arthritis along with osteoarthritis but requires a high index of suspicion. We report a case of Haemochromatosis arthropathy where the arthropathy was due to type 3 hereditary haemochromatosis (HHC) which is a much rarer form and requires specialist genetic testing. Methods A 38-year-old lady was referred with abnormal iron profile and ten-month history of small joint arthralgia mainly affecting the index and middle finger in right hand with occasional swelling. She had a normal body mass index with minimal alcohol intake. Clinical examination showed low grade synovitis in index finger metacarpo-phalangeal joint (MCPJ). Blood investigations for Rheumatoid arthritis and connective tissue diseases were negative with normal CRP &amp; ESR, Ferritin was slightly raised at 236 and transferrin saturation was 100% on two successive occasions, LFTs were normal. Xray of hands showed slight narrowing of 2nd MCPJ and US hands showed thickened synovium but no erosions or Doppler activity in 2nd MCPJ. Results Based on these, possible hereditary haemochromatosis (HHC) arthropathy was considered. By that time, she had been seen by the hepatology service where no evidence of iron deposition in other organs was found. Surprisingly her genetic testing for hereditary haemochromatosis (HHC) (Cys282Y/H63D in HFE gene) was negative resulting in most common HFE-related HHC excluded. Iron studies were repeated which were still raised, hence after discussion with hepatologist and biochemist the plan was made to investigate for rarer form of hereditary haemochromatosis (HHC), genetic tests showed that she had TFR2 variant mutation which would be consistent with type 3 hereditary haemochromatosis (HHC), which is inherited in autosomal recessive pattern. Venesections were started with ferritin levels improving to less than 50 with plans to monitor arthralgia to see if there is any improvement over time. Conclusion Metacarpo-phalangeal joints (MCPJs) involvement is common in various arthropathies. This case highlights the importance of considering other, much rarer forms of hereditary haemochromatosis (HHC) as treatment will help in preventing iron deposition in other organs like liver, heart, pancreas etc. These conditions are very rare and there is need to create awareness of genetic testing as hereditary haemochromatosis (HHC) arthropathy does present not uncommonly to rheumatology services and requires dedicated non-HFE molecular panel. Disclosure H. Umair: None. M. Kazmi: None.

P614 Reduction of bowel wall thickness and doppler signals as early as 36 hours predicts corticosteroid response in a multi-centre prospective cohort of Acute Severe Ulcerative Colitis: USUC Study including the GENIUS cohort

Abstract Background Gastrointestinal ultrasound (GIUS) can accurately assess disease activity in atients with ulcerative colitis (UC). The aim of this study was to determine the accuracy of GIUS in predicting IV corticosteroid (CS) failure in patients with Acute Severe Ulcerative Colitis (ASUC) and the requirement for rescue therapy. Methods We conducted a multi-centre prospective observational cohort study of adult ASUC admitted to hospital between November 2019 to July 2022. GIUS was performed at six time points for each patient: at hospital admission (SV1), day 3 (SV2), at discharge (SV3), and thereafter during outpatient review in the 10 months of follow-up. Medical rescue therapy was given at the discretion of treating physician according to best clinical practice. Results A total of 32 consecutive patients with ASUC were recruited with a median follow-up duration of 8.9 months: median age 32 years, 38% male and median duration of disease 19 months. Seven patients had newly diagnosed UC and six patients (19%) were biologic experienced. Sixteen patients (50%) were CS responders and the remainder required medical rescue therapy; two patients required colectomy. The median time to rescue therapy and colectomy was 3.5 and 11 days from admission, respectively. At SV1, the median BWT of the worst affected segment was similar between CS responders and non-responders (5.50mm vs 5.85mm, p=0.66), however at SV2, responders had a significantly lower BWT (3.85mm vs 5.05mm, p=0.02). CS responders demonstrated a significant reduction in width of the muscularis propria (p=0.02) and submucosal (p=0.006) layer, but not the mucosal (p=0.61) layer (Figure 1). CS non-responders had a smaller absolute and relative reduction in median BWT at SV2. Receiver operating characteristic curve analysis showed that an absolute reduction of &amp;lt;1.40mm (Sn 63%, Sp 75%, AUROC 0.76) or a relative BWT reduction of &amp;lt;20% (Sn 81%, Sp 75%, AUROC 0.78) predicted CS non-response and need for rescue therapy well. A reduction in BWT and the absence of doppler activity at SV2 further enhanced the predictive capability of GIUS (Sn 81.3%, Sp 87.5%, AUROC 0.91) (Figure 2). Conclusion This study demonstrates the predictive utility of early GIUS in the management of ASUC. A reduction in absolute BWT of &amp;lt;1.40mm or relative BWT of &amp;lt;20% at 36-48 hours of admission identifies CS non-responders with good sensitivity and specificity. BWT reduction at SV2 in responders was driven mainly by decreased muscularis propria and submucosal thickness. Accuracy is further augmented when reduction in BWT and resolution of doppler signal are combined. This study suggests GIUS may allow clinicians to expedite initiation of rescue therapy for patients requiring salvage treatment.

The frequency and characteristics of ultrasonographic ankle joint involvement in systemic lupus erythematosus: A prospective cross-sectional single-center study.

The involvement of ankles in systemic lupus erythematosus (SLE) has not been widely studied. The aim of our prospective study was to determine the characteristics of the ankle joint and tendon involvement in SLE using ultrasound (US) as an imaging modality. Sixty consecutive patients with SLE underwent a detailed clinical evaluation and US examination. Gray-scale and power Doppler US of the bilateral tibiotalar (TT) joints, subtalar (ST) joints, and ankle tendons were performed using a multiplanar scanning technique. Joint effusion, synovitis, tenosynovitis, enthesitis, and vascularization were assessed according to the OMERACT recommendations. The Total Ankle Ultrasound Score (TAUSS) was calculated as the sum of the grades of joint effusion and synovial hypertrophy for both TT and ST joints bilaterally (ranging from 0–24) and power Doppler activity was assessed separately. Finally, US findings were correlated with physical evaluation, laboratory parameters, and SLE activity scores. US ankle joint involvement was present in 32/60 (53.3%) patients. TT joints were affected in 26 (43.3%) and ST joints in 16 (26.7%) patients. Thirteen (21.7%) patients had US tendons and/or enthesal involvement. TT joint effusion was the most frequent finding, present in 55/240 (22.9%) examined joints, followed by synovial hypertrophy detected in 18/240 (7.5%) joints. The median (interquartile range; range) TAUSS of the US-affected joints was 1 (0–2; range 1–10). There were no significant correlations between US findings and inflammatory parameters or serological parameters of disease activity, but we found a weak positive correlation between TAUSS and the European Consensus Lupus Activity Measurement (r = 0.281, P = .029). This study revealed a high prevalence of pathological US ankle changes in patients with SLE and a positive correlation between ankle US involvement and disease activity score (European Consensus Lupus Activity Measurement).

Ultrasound of the Heel Improves Diagnosis-Tender Entheses in the Heel Region Rarely Corresponds to Inflammatory Enthesitis in Patients with Peripheral Spondyloarthritis.

Enthesitis is a key pathology in spondyloarthritis (SpA), but diagnosis may be clinically challenging. The objective of this study was to investigate the prevalence of ultrasound enthesitis lesions in tender entheses in the heel region in patients with peripheral SpA. In 27 patients with tenderness upon palpation at the Achilles tendon or the plantar fascia insertion, ultrasound assessment of the affected enthesis was performed using greyscale and color Doppler mode. Images were evaluated using the Outcome Measures in Rheumatology (OMERACT) scoring system for enthesitis, scoring presence/absence of hypoechogenicity, thickening, calcifications/enthesophytes, and erosions, and color Doppler activity semi quantitatively from 0 to 3. A total enthesitis sum score was calculated. A second examiner scanned 10 patients for inter-reader reliability. Ultrasound signs of inflammatory enthesitis (thickening/hypoechogenicity and/or Doppler activity) were found in 48%, and 19% showed Doppler activity—all in the Achilles enthesis. Inflammatory pathologies other than enthesitis (e.g., tendinitis, arthritis, bursitis) were identified in 26% of tender heels. The ultrasound OMERACT scoring system for enthesitis lesions showed excellent intra- and inter-reader agreement in a clinical setting. In conclusion, less than 50% of clinically tender entheses are related to inflammatory enthesitis when assessed by ultrasound. Ultrasound is useful for diagnosing other pathologies that may explain tenderness in the area.

Associations between joint pathologies and central sensitization in persons with hand osteoarthritis: results from the Nor-Hand study.

ObjectivePain sensitization is associated with pain severity in persons with hand OA. What contributes to pain sensitization is unclear. This study explores whether hand OA pathologies and symptom duration are related to central sensitization.MethodParticipants with hand OA in the Nor-Hand study underwent bilateral hand radiography and US examination. Central sensitization was assessed with pressure pain thresholds (PPT) at remote sites (wrist, trapezius and tibialis anterior muscles) and temporal summation. We examined whether hand OA pathologies, independent of each other, including structural severity (Kellgren–Lawrence sum score, presence of erosive hand OA), inflammatory severity (greyscale synovitis and power Doppler activity sum scores) and symptom duration, were related to central sensitization, adjusting for age, sex, BMI, comorbidities and OA-severity of knee/hip.ResultsIn 291 participants (88% women, median age 61 years, interquartile range 57–66 years) Kellgren–Lawrence, greyscale synovitis and power Doppler activity sum scores were not associated with lower PPTs at remote sites. Persons with erosive hand OA had lower PPTs at the wrist (adjusted beta −0.75, 95% CI −1.32, −0.19) and tibialis anterior (adjusted beta −0.82, 95% CI −1.54, −0.09) and had greater temporal summation (adjusted beta 0.56, 95% CI 0.12, 1.01) compared with persons with non-erosive disease. No associations were found for symptom duration.ConclusionsA person’s overall amount of structural or inflammatory hand OA pathologies was not associated with central sensitization. Although persons with erosive hand OA showed greater signs of central sensitization, the small differences suggest that central sensitization is mainly explained by factors other than joint pathologies.

No Treatment Benefits of Local Administration of Insulin-like Growth Factor-1 in Addition to Heavy Slow Resistance Training in Tendinopathic Human Patellar Tendons: A Randomized, Double-Blind, Placebo-Controlled Trial With 1-Year Follow-up

Background: Heavy slow resistance (HSR) training is currently recommended as part of the treatment of patellar tendon tendinopathy. However, treatment success is not reached in all patients, and combinations of different treatments could be beneficial. Local administration of insulin-like growth factor-1 (IGF-1) in humans has been shown to quickly stimulate tendon collagen synthesis. Purpose: To study whether IGF-1 injections combined with HSR training enhance tendon synthesis, tissue structure, and patient satisfaction versus saline injection combined with HSR training in patients with patellar tendinopathy. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Forty patients (age 18-50 years) with unilateral patellar tendinopathy undertook HSR training (3 times a week for 12 weeks) and received intratendinous IGF-1 injections (1 mg IGF-1 per dose) or isotonic saline injections (sham injections) at baseline and after 1 and 2 weeks of training. The primary outcome was collagen synthesis parameters after 12 weeks (primary endpoint). The secondary outcomes were patient-reported outcomes (scores on the Victorian Institute of Sport Assessment–Patella [VISA-P] and visual analog scale [VAS] for pain) and structural changes before the initiation of treatment and at week 3, week 12, and 1 year after the initiation of treatment. Results: Analysis of the patellar tendon biopsy specimens at 12 weeks showed that collagen mRNA and total RNA were increased in the tendinopathic tendons compared with the contralateral healthy tendons regardless of treatment with IGF-1 or saline. Similarly, no difference between the groups was seen in tendon thickness and Doppler activity at week 12 or at 1-year follow-up. The combination of HSR training and IGF-1 injections significantly improved VISA-P and VAS pain scores after 3 weeks, whereas the overall responses after 12 weeks and at 1-year follow-up were identical in the 2 groups. Conclusion: Although a small, immediate clinical response to IGF-1 injections was seen when combined with training, no additional long-term effect of intratendinous IGF-1 was observed on structural and clinical outcomes in patients with patellar tendinopathy. Registration: NCT01834989 (ClinicalTrials.gov identifier)

Rheumatoid arthritis patients with predominantly tender joints rarely achieve clinical remission despite being in ultrasound remission.

ObjectivesGiven that subjective variables might reduce remission by composite DAS (CDAS), the main objectives were to explore whether RA patients with mainly tender vs mainly swollen joints had differences in patient-reported outcome measures (PROMs), clinical or US assessments or in achieving remission defined by CDAS or US.MethodsIn a Nordic multicentre study, RA patients initiating tocilizumab were assessed by PROMs, clinical, laboratory and US assessments (36 joints and 4 tendons) at baseline, 4, 12 and 24 weeks. Remission was defined according to clinical disease activity index (CDAI)/Boolean or no Doppler activity present. Tender–swollen joint differences (TSJDs) were calculated. Statistics exploring changes over time/differences between groups included Wilcoxon, Mann–Whitney, Kruskal–Wallis and Spearman tests.ResultsOne hundred and ten patients were included [mean (s.d.) age 55.6 (12.1) years, RA duration 8.7 (9.5) years]. All PROMs, clinical, laboratory and US scores decreased during follow-up (P < 0.001). During follow-up, tender joint counts were correlated primarily with PROMs [r = 0.24–0.56 (P < 0.05–0.001)] and swollen joint counts with US synovitis scores [r = 0.33–0.72 (P < 0.05–0.001)]. At 24 weeks, patients with TSJD > 0 had higher PROMs and CDAI (P < 0.05–0.001) but lower US synovitis scores (P < 0.05). Remission by CDAI/Boolean was seen in 26–34% and by Doppler 53%, but only 2–3% of patients with TSJD > 0 achieved CDAI/Boolean remission.ConclusionPatients with more tender than swollen joints scored higher on subjective assessments but had less US synovitis. They seldom achieved CDAS remission despite many being in Doppler remission. If patients with predominantly tender joints do not reach CDAS remission, objective assessments of inflammation should be performed.Trial registrationClinicalTrials.gov, https://clinicaltrials.gov/, NCT02046616.

A standardized sonographic analysis of nails in psoriatic arthritis and healthy controls: Feasibility, reliability, diagnostic performance, and demographic and clinical associations.

Subunits of the nail can be evaluated by nail ultrasonography (NUSG). The purposes of this study are to document NUSG properties (both nail-based and participant-based evaluations) in patients with psoriatic arthritis (PsA) and healthy controls and to explore the final scorings. After the literature review and a pilot study, a consensus was reached to evaluate 12 nails and 5 parameters by NUSG: nail plate impairment (NPI), nail plate thickness (NPT), nail bed thickness (NBT), nail thickness (NT), and Doppler activity (DA); further, scorings for each parameter (NPIs, NPTs, NBTs, NTs, and DAs) were calculated. Group comparisons and diagnostic performances (with ROC curve analysis) were applied to both parameters and scorings. Final scorings to predict PsA diagnosis among the NUSG scorings were reached by regression analysis. Feasibility, reliability, and clinical associations of the scores were also performed. Sixty-four patients with PsA and 26 controls (3240 baseline images) were assessed. The most affected nails, PsA/control comparisons, and the ROC analysis varied among the nails, within the higher values of PsA; therefore, 12 nails remained in the scorings. Participant-based scorings showed better content and diagnostic performances than the nail-based. Diagnostic performances, feasibility, reliability, and regression analysis of the scorings documented that NPIs, NTs, and DAs were the best. Some demographics, employee status, hemoglobin, and disease activity of the participants were associated with them. The NUSG Index (NUSGI) including NPIs, NTs, and DAs is a feasible, reliable, and discriminative method to predict PsA diagnosis, with its rich content. Clinicaltrials.gov-ID: NCT04718428.