Ultrasound Enthesitis Research Articles

Ultrasound Doppler enthesitis shows sensitivity to change after biological therapy in spondyloarthritis and psoriatic arthritis patients

Objective To explore the sensitivity to change in power Doppler (PD) enthesitis in active spondyloarthritis (SpA) and psoriatic arthritis (PsA) patients. Method This was a longitudinal study in patients with SpA and PsA with active disease [patients starting or switching to biological disease-modifying anti-rheumatic drugs (bDMARDs)]. The MAdrid Sonographic Enthesitis Index (MASEI) was performed at baseline and at 3 and 6 month visits. The MASEI and Outcome Measures in Rheumatology (OMERACT) PD enthesitis definitions were checked. Reliability analysis among three readers was performed with ultrasound (US)-recorded videos. Results US examinations of 25 patients were included; 16 (64%) had SpA and nine (36%) PsA. The median (interquartile range, IQR) age was 49 (41–61) years, and 13 patients (52%) were female. The median (IQR) 28-joint Disease Activity Score of 3.6 (2.3–4.2), Bath Ankylosing Spondylitis Disease Activity Index of 6.7 (6.1–7.4), and C-reactive protein value of 8.2 (1.6–20) reflected moderate to high disease activity at baseline. Both MASEI and OMERACT PD enthesitis improved significantly at 3 and 6 month follow-up (p < 0.05) and showed sensitivity to change (standard error of measurement = 0.47 and 0.61, respectively). Improvement in clinical activity outcomes was significantly associated with decreases in MASEI and OMERACT PD enthesitis counts (p < 0.05). The MASEI and OMERACT PD definitions had excellent reliability (kappa = 0.918 and 0.865, respectively). Conclusion PD enthesitis significantly improved at 3 and 6 month follow-up in patients undergoing bDMARD therapy. Both MASEI and OMERACT PD US enthesitis reflect response to treatment.

Enthesis lesions are associated with X-ray progression in psoriatic arthritis.

To analyze the relationship among enthesis ultrasound (US) lesions and radiological structural damage in psoriatic arthritis (PsA) patients. Consecutive PsA patients with swelling of at least 1 of the 2nd to 5th metacarpophalangeal joints were included. Clinical and demographic data were collected. The Madrid Sonographic Enthesitis Index (MASEI) was selected to evaluate the enthesis, with its total score and MASEI-activity and MASEI-structural damage subscores. The modified Sharp van der Heijde method for PsA and the New York criteria for sacroiliitis were selected to evaluate cumulative bone damage on X-rays. Twenty-seven patients were included. Male gender, older age, longer PsA duration and acute reactant factors were associated with greater bone cumulative damage. Enthesis tendon thickening, enthesophytes, total MASEI and the MASEI-structural damage subscore showed significant correlations with radiographic peripheral and sacroiliac damage scores. Tendon thickening and enthesophytes were the enthesis lesions more frequently associated with radiographic damage in PsA. The enthesis MASEI score was associated with axial and articular radiographic structural damage in PsA patients. The MASEI-structural damage subscore correlated better with cumulative bone damage in PsA than the MASEI-activity subscore.

O12 Dactylitis is associated with greater disease severity, CRP, ultrasound determined synovitis, and erosive damage in DMARD-naïve early PsA

Abstract Background/Aims Dactylitis, a hallmark feature of psoriatic arthritis (PsA), is defined as uniform swelling of a finger or toe ('sausage digit'). Understanding of the phenotypical significance of dactylitis and association with PsA disease activity/severity is still lacking. The aim of this study was to characterise and evaluate a DMARD-naïve early PsA cohort based on the clinical presence or absence of dactylitis. Methods Early PsA patients achieving CASPAR criteria, were recruited into a prospective observational study; the Leeds Spondyloarthritis Register for Research and Observation (SpARRO). The cohort was evaluated based on presence/absence of dactylitis. Dactylitis was recorded per digit; tender (hot)/ non-tender (cold). Synovitis was graded via the semiquantitative method (0-3) for grayscale (GS) and power Doppler (PD) at 50 joints: wrists, MCP1-5, PIP1-5, DIP2-5, MTP1-5, elbows, knees, ankles, subtalar and talonavicular joints. Bone erosions were determined by US if cortical bone discontinuity was present in two perpendicular planes (longitudinal/transverse). Enthesitis was determined via OMERACT definitions/ modified Glasgow Ultrasound Enthesitis Severity Score (GUESS). Statistical calculations (STATA/SPSS): student’s t-test, quantile regression, one-sample tests, Pearson Chi-squared test and Fischer’s exact test. Results Of the 177 PsA patients recruited, PsA with dactylitis recorded significantly higher median difference in TJC (p &amp;lt; 0.01), SJC (p &amp;lt; 0.001), and CRP (p &amp;lt; 0.01) compared to PsA without dactylitis. Dactylitis was present in 81/177 (46%) patients and 214 digits. Multiple digits (&amp;gt;1) were involved in 51/81 (63%) patients, asymmetrical in 52/81 (64%). Dactylitis was more prevalent in toes (146/214; 68.2%) than fingers (68/214; 31.8%). Hot dactylitis was more prevalent (179/214; 83.6%) than cold dactylitis (35/214; 16.4%). The most frequent sites for hot dactylitis were 2nd finger (23/179; 12.8%), 4th toe (40/179; 22.3%) and for cold dactylitis, 3rd finger (2/35; 8.5%), 4th toe (10/35; 28.5%). Significantly greater US synovitis was identified in PsA with dactylitis (p &amp;lt; 0.01). PsA with dactylitis recorded more patients in high DAPSA state and greater DAPSA scores (median 24.4 vs 20.8; p = 0.07). Joints affected by dactylitis had a high prevalence of US synovitis; 190/255 (74.5%). Synovitis was more prevalent in hot dactylitis than cold dactylitis; 180/227 (79.3%) versus 10/28 (35.7%). Ultrasound erosions were significantly greater in joints in PsA with dactylitis (p &amp;lt; 0.001) and identified in significantly greater PsA patients with dactylitis [22/69 (31.9%) versus 11/86 (12.8%) patients (p = 0.004)]. The sites most prone to erosive damage were MCP2 (9/33, 27.3%), MTP5 (11/33, 33.3%). No significant differences were found for enthesitis determined by OMERACT/ modified GUESS. Conclusion This study identifies dactylitis as a clinical indicator for an aggressive phenotype with significantly greater TJC, SJC, CRP, US synovitis and US defined erosions in DMARD-naïve early PsA. Longitudinal follow-up will determine if dactylitis represents poor prognosis. Dactylitis may be a useful discriminator for risk stratification in future PsA management strategies and clinical trials. Disclosure S. Dubash: None. O.A. Alabas: None. X. Michelena: None. L. Garcia-Montoya: None. R. Wakefield: None. A. Tan: None. P. Helliwell: None. P. Emery: None. D. McGonagle: None. H. Marzo-Ortega: None.

The Role of Clinical and Ultrasound Enthesitis Scores in Ankylosing Spondylitis.

Introduction: Ankylosing spondylitis (AS) is a chronic inflammatory disease, part of the spondyloarthritis (SpA) group, characterized by axial (spine and sacroiliac joints), entheseal, and peripheral joint involvement, which is frequently associated with extra-articular manifestations. Material and Methods: The study included a number of 30 patients diagnosed with AS according to the New York modified criteria, with history of entheseal pain, hospitalized between 2016–2018 in the Department of Rheumatology of the Emergency County Hospital of Craiova. Results: Regarding the Belgrade Ultrasound Enthesitis Score (BUSES) score and the disease activity calculated using the Ankylosing Spondylitis Disease Activity Score (ASDAS), they did not show a statistically significant association (p = 0.738). Additionally, BUSES did not have a statistically significant association with the disease activity quantified by the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score (p = 0.094). The Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC) clinical score was not statistically associated with ASDAS (p = 0.434) nor with BASDAI (p = 0.130). The SPARCC clinical score and the BUSES ultrasound score were statistically significantly associated, registering a value of p = 0.018. Conclusions: Our study proved a significant correlation between SPARCC and BUSES, although in literature the evidence is contrasting.

Early detection of subclinical lower limb enthesopathy by ultrasonography in patients with psoriasis: Relation to disease severity

BackgroundEntheseal involvement is a frequent and distinctive feature of psoriatic arthritis (PsA). It is detected clinically but lacks sensitivity and reliability. Musculoskeletal ultrasound (MSUS) is an important tool for accurate detection of enthesitis. Aim of the workTo determine the frequency and distribution of subclinical entheseal abnormalities at lower limbs using MSUS in patients with psoriasis for early detection of PsA, and to evaluate its relation to disease severity. Patients and methods80 patients with psoriasis were studied. Psoriasis Area and Severity Index (PASI) was assessed. High-resolution MSUS assessment of quadriceps, patellar and Achilles tendons, and plantar fascia entheses was performed. Glasgow Ultrasound Enthesitis Scoring System (GUESS) was assessed. ResultsThe median (interquartile range; difference between 75th and 25th quartile) age of the patients was 46(26.3) years and were 42 males. The disease duration was 9(12) years, PASI was 10.9(18.9), and GUESS 6(4). Nail dystrophy was found in 48(60%). Clinical enthesitis was found in 15(18.8%) patients; MSUS revealed lower limb enthesopathy in at least one enthesis in 76(95%) patients, and abnormality in 421 of 800 entheses (52.6%). Distal insertion of the patellar tendon was the most frequently involved (68.8%). GUESS significantly correlated with the age, body mass index (BMI), and PASI. ConclusionPsoriasis is associated with a relevant frequency of asymptomatic entheseal abnormalities. MSUS is a valuable, simple, and noninvasive tool in early detection of enthesopathy in psoriatic patients, especially in the presence of older age, high BMI, and high PASI as potential parameters for detection of psoriatic enthesitis.

A comparison of clinical examination and ultrasound enthesitis indices in patients with psoriatic arthritis, adjusted for concomitant fibromyalgia.

Objectives:To: (a) determine the extent of ultrasound (US)-detected peripheral enthesitis in a cohort of patients with psoriatic arthritis (PsA); (b) compare this with three clinical examination (CE) enthesitis indices; and (c) determine the effect of concurrent fibromyalgia on the evaluation of enthesitis.Methods:A prospective single-centre cross-sectional study of consecutive outpatients with established PsA undergoing clinical examination for enthesitis and US examination for inflammatory and structural lesions of enthesitis. Multivariable analyses tested for association between US scores, CE enthesitis indices and influence of concurrent fibromyalgia.Results:A total of 106 patients were assessed. Of these, 91/106 (85.8%) had CE enthesitis and 105/106 (99.1%) had ⩾1 US feature of enthesitis. There was a moderate correlation between US entheseal inflammation and both the Leeds Enthesitis Index (LEI) (Spearman rank, r = 0.36) and Spondyloarthritis Research Consortium of Canada Enthesitis Index (SPARCC) (r = 0.44). US entheseal damage did not correlate with CE enthesitis indices. Twenty-eight (26.4%) patients were classified as having concurrent fibromyalgia, in whom multivariable regression analyses demonstrated no correlation between US scores and CE enthesitis indices. PsA patients without fibromyalgia demonstrated a statistically significant association between both LEI (r = 0.48, p < 0.0001) and SPARCC (r = 0.62, p < 0.0001) and US entheseal inflammation.Conclusion:There is a moderate association between US entheseal inflammation, but not damage, and CE enthesitis indices in patients with PsA. The presence of concurrent fibromyalgia is linked with higher CE enthesitis scores, without an increase in US inflammation, suggesting that CE enthesitis indices should be used/interpreted with caution in these patients. Imaging, including US, should be the preferred modality to detect enthesitis in PsA patients with concurrent fibromyalgia.

Evaluación ecográfica del compromiso de entesis en pacientes con espondiloartritis

Introduction: The enthesis is the target organ of inflammation in spondyloarthritis (SpA), being key in its physiopathology. Ultrasound is becoming the preferable technique to de- tect enthesitis. This study was done to describe the ultrasonographic characteristics of enthesis involvement in patients with spondyloarthritis Materials and methods: We evaluated 20 patients with diagnosis of SpA who presented to Hospital de Clinicas. We investigated clinical and demographic variables and later perfor- med ultrasound evaluation of 12 enthesis areas, calculating the GUESS (Glasgow Enthesitis Scoring System) and MASEI (Madrid Sonographic Enthesitis Index) scores with susequent correlation between ultrasonographic and clinical variables. Results: The BASDAI, ASDAS and BASFI scores were 4.05, 2.35, and 3.56 respectively. Out of the 240 evaluated enthesis, 35 (14.5%) had pain during clinical evaluation. Thickening of the tendon or ligament was found in 42.5% of all enthesis, 24.1% showed calcification, 10.8% showed erosions, and PD signal was seen in 1.25%. The average GUESS score was 8.45 and the average MASEI score was 15.2. No relation between sonographic scores and BASDAI, ASDAS or BASFI scores were found. There was no significant difference between GUESS and MASEI scores with different types of SpA, age, disease duration or type of treatment. Male gender and axial involvement was associated with higher GUESS and MASEI scores. Conclusion: We found poor correlation between the presence of enthesitis symptoms and the ultrasonographic findings. The MASEI and GUESS scores did not correlate with disease activity scores. The values of MASEI and GUESS scores were related to male gender and predominantly axial involment in patients with SpA. There was very low acute inflammatory findings with Power Doppler signal detection.

Lower limb entheseal involvement in systemic lupus erythematosus patients: Relation to disease activity

BackgroundMusculoskeletal involvement is extremely common in patients with systemic lupus erythematosus (SLE). Musculoskeletal ultrasound (MSUS) is an important tool for evaluation of patients with inflammatory arthritis as well as early detection of subclinical inflammation at the joint, tendon and entheseal level. Aim of the workTo investigate the frequency and distribution of lower limb entheseal abnormalities detected by MSUS in SLE patients and to evaluate its relation to disease activity. Patients and methods50 adult SLE patients were studied. SLE Disease Activity Index-2000 (SLEDAI-2K) was assessed. High-resolution MSUS assessment of quadriceps, patellar and Achilles tendons, and plantar fascia entheses was performed. Glasgow Ultrasound Enthesitis Scoring System (GUESS) was assessed. ResultsThe median age of the patients was 30 (interquartile range 23–36.3 years) and were 49 females. The median disease duration was 4 (2–8.3 years), SLEDAI-2K was 4 (2–8) and GUESS score 3 (1–5.3). Clinical enthesitis was found in 22 (44%) patients; 58% of the patients had evident MSUS features of enthesitis and 32% had minimal or isolated entheseal abnormalities. The age and SLEDAI-2K were significantly increased in those with clinical enthesitis compared to those without (p = 0.007 and p = 0.03 respectively). GUESS significantly correlated with the age (r = 0.39, p = 0.005) and SLEDAI-2K (r = 0.29, p = 0.04). ConclusionClinical and ultrasound-proved enthesitis are prevalent in SLE patients. Quadriceps tendon insertion is the most affected enthesis. Clinical enthesitis tends to occur in older SLE patients. Enthesitis has positive correlations with; age, and SLEDAI-2K score. The presence of enthesitis may represent a potential marker for SLE disease activity.

Clinical evaluation of foot disability in patients with axial spondyloarthritis

Objective: To evaluate foot disability both ultrasonographically and by using the Foot Function Index (FFI) in patients with axial spondyloarthritis (SpA) and to investigate its effects on patients' quality of life and functional capacity by determining the factors that may affect the level of disability.Patients and methods. A total of 100 patients were included in the study. Enthesis sites in the feet were assessed for tenderness and swelling. Ultrasonographic examination of the Achilles tendon and plantar fascia was made and the findings were scored according to Glasgow Ultrasound Enthesitis Scoring System (GUESS). The Foot Function Index (FFI) was used to investigate the effects of foot disorders on disability and activity limitation. The correlation between GUESS and FFI scores, and relationship of GUESS and FFI scores with age, disease duration, body mass index (BMI), smoking and disease activity parameters were investigated.Results and discussion. Physical examination revealed signs of enthesitis in 13 (13%) patients, while ultrasonographic (USG) evaluation – in 36 (36%) patients. A statistically significant correlation was found between all FFI and GUESS scores except between FFI for the right foot and GUESS for right Achilles tendon enthesitis. A positive correlation was found between age and BMI and FFI (p&lt;0.05). There was no correlation between disease duration and smoking and FFI scores. While there was a statistically significant correlation between all scores of GUESS and age, disease duration, and BMI, no correlation was found between smoking and GUESS scores. No significant difference was found in either FFI or GUESS scores between patients with or without / diabetes and patients who were smokers or non-smokers. All FFI and GUESS scores significantly correlated with BASDAI, ASDAS, BASFI, and ASQoL (p&lt;0.05).Conclusion. Enthesitis may lead to decreased functional capacity and loss of quality of life in ax-SpA patients. Subclinical enthesitis in the feet of patients with SpA is not rare and may be detected by USG.

Doppler enthesitis: a potential useful outcome in the assessment of axial spondyloarthritis and psoriatic arthritis.

To analyse the frequency of power Doppler (PD) enthesitis in active axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients and its potential usefulness in clinical practice. A prospective multicentre cross-sectional study in patients with axSpA and PsA with active disease was undertaken. Patients underwent bilateral ultrasound (US) examination of the peripheral entheses according to the Madrid Sonographic Enthesis Index (MASEI). The MASEI and Outcome Measures in Rheumatology (OMERACT) PD enthesitis definitions were checked. An inter-reader analysis of recorded videos was performed to determine reliability. Sixty-four consecutive patients were included. The mean DAS28 (3.9 ± 1.3) for peripheral involvement, mean BASDAI (5.6 ± 2.2) for axial involvement, and CRP values (10 ± 10.9) reflected moderate-high disease activity at baseline. The mean global MASEI score was 29.4 (± 11.4), and 55 patients (86%) scored ≥ 18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing a PD signal were observed in 52 (81.3%) patients using the MASEI PD definition and 48 (75%) using the OMERACT PD definition, without significant variation between axSpA and PsA. The inter-reader reliability was excellent (kappa = 0.92 for MASEI PD and 0.86 for OMERACT PD). PD enthesitis was found in the majority of patients with active axSpA and PsA, independent of axial or peripheral affectation. Both MASEI and OMERACT PD definitions were useful in detecting active enthesitis. These findings support the usefulness of a PD US evaluation of entheses in the assessment of axSpA and PsA. Key Points • PD enthesitis is a very common finding in patients with active axSpA and PsA • Both MASEI and OMERACT PD definitions are useful to detect active enthesitis • US enthesitis may reveal information in axSpA and PsA.

Psoriatic arthritis: clinical and ultrasound parallels

Objective: to assess the relationship of the clinical characteristics and laboratory inflammatory markers to the ultrasound signs of synovitis and enthesitis in patients with psoriatic arthritis (PsA).Patients and methods. Examinations were made in 63 patients diagnosed with PsA according to the 2006 Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Among the patients, the majority were females (54.2%); the mean age was 42.9±10.3 years; the median (Me) PsA duration was 7 [3; 10] years; Me Disease Activity in Psoriatic Arthritis (DAPSA) was 16.5 [11.6; 25] years.All the patients underwent estimation of tender joint count, swollen joint count, tender entheseal count, inter alia using the Leeds Enthesitis Index (LEI), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), and Spondyloarthritis Research Consortium of Canada (SPARCC). The investigators determined PsA activity by DAPSA and the prevalence and severity of psoriasis by the Psoriasis Area and Severity Index (PASI) and also estimated erythrocyte sedimentation rate (ESR) and high-sensitivity CRP (hs-CRP) levels. Ultrasonography was used to assess bilateral upper and lower limb joints, by calculating joint counts (JC) with synovitis signs (SJC), as well as tendon and ligament entheses (a total number of 54 in one patient), by determining the presence of vascularized enthesis count (VEC) and structurally changed enthesis count (SCEC) and using the ultrasound indices (Glasgow Ultrasound Enthesitis Scoring System (GUESS), Belgrade Ultrasound Enthesitis Score (BUSES), Madrid Sonography Enthesitis Index (MASEI), Sonographic Enthesitis Index (SEI)).Results and discussion. There were no significant differences in the frequency of damage to the upper (15.7%) and lower (19.3%) limb joints (p&gt;0.05), whereas inflammation in the entheses of the lower limbs (23.2%) was significantly more common than that in the upper limbs (15.3%) (p&lt;0.01). A weak relationship was established between SPARCC and SEI (r=0.276; p&lt;0.05). A positive correlation was found between VEC and hs-CRP levels (r=0.323, p=0.01), ESR (r=0.332, p&lt;0.01). Ultrasound imaging showed that SJC (p&lt;0.01), enthesitis count (p&lt;0.01), and SCEC (p&lt;0.05) increased with age. The relationship between SCEC and GUESS (r=0.724; p&lt;0.01) and that between the VEC and BUSES (r=0.562, p&lt;0.01) proved to be more pronounced.Conclusion. Ultrasound imaging indicates that the entheses of the lower limbs are more frequently affected in patients with PsA. There is no relationship between DAPSA and ultrasound inflammatory changes in the joints and extra-articular structures. A strong relationship is established between enthesiseal structural and inflammatory changes and GUESS and BUSES, respectively, which allows one to recommend the use of these indices for assessing enthesitis in PsA. Entheseal vascularization associated with inflammatory markers (hs-CRP, ESR) (p&lt;0.05) is a manifestation of PsA activity regardless of age and DAPSA.

Musculoskeletal Ultrasound Assessment of Enthesopathy in Fibromyalgia Patients

Background: Fibromyalgia (FM) is a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and unrefreshing sleep, and cognitive difficulties, often accompanied by multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living Objectives: To assess the frequency and pattern of enthesopathy in primary FM using musculoskeletal ultrasound with Glasgow Ultrasound Enthesitis Scoring System (GUESS) and Correlate these findings with clinical and laboratory parameters of FM. Patients and Methods: A cross-sectional study includes 100 persons divided into two groups as follows: Group (1): 50 patients with primary fibromyalgia syndrome (FM) were diagnosed. Group (2): 50 apparently healthy controls with comparable age and sex. Patients were selected from those attending the outpatient clinic of the Rheumatology & Rehabilitation Department of Al-Azhar University Hospital, Assiut. Results: There is no statistically significant difference between cases and control groups regarding age, gender, and BMI (P>0.05 for each), there were no statistically significant correlations between the GUESS scores and any of the clinical characteristics of FM patients. Although non-significant, these correlations were negative between the GUESS score and the tender point number, the Widespread Pain Index as well as the Fibromyalgia Impact Questionnaire. The total GUESS score of the FM group ranged between 0-12 with a mean ±SD of 5.3 ± 2.8. The total GUESS score of control group ranged between 0-6 with a mean ±SD of 0.97± 1.58, with a significant difference between the two groups (P<0.05) Conclusion: There were significant enthesopathic changes detected among FM patients especially affecting the Achilles, quadriceps, and proximal patellar tendons.

Musculoskeletal Ultrasound Assessment of Enthesopathy in Fibromyalgia Patients

Background: Fibromyalgia (FM) is a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and unrefreshing sleep, and cognitive difficulties, often accompanied by multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living Objectives: To assess the frequency and pattern of enthesopathy in primary FM using musculoskeletal ultrasound with Glasgow Ultrasound Enthesitis Scoring System (GUESS) and Correlate these findings with clinical and laboratory parameters of FM. Patients and Methods: A cross-sectional study includes 100 persons divided into two groups as follows: Group (1): 50 patients with primary fibromyalgia syndrome (FM) were diagnosed. Group (2): 50 apparently healthy controls with comparable age and sex. Patients were selected from those attending the outpatient clinic of the Rheumatology & Rehabilitation Department of Al-Azhar University Hospital, Assiut. Results: There is no statistically significant difference between cases and control groups regarding age, gender, and BMI (P>0.05 for each), there were no statistically significant correlations between the GUESS scores and any of the clinical characteristics of FM patients. Although non-significant, these correlations were negative between the GUESS score and the tender point number, the Widespread Pain Index as well as the Fibromyalgia Impact Questionnaire. The total GUESS score of the FM group ranged between 0-12 with a mean ±SD of 5.3 ± 2.8. The total GUESS score of control group ranged between 0-6 with a mean ±SD of 0.97± 1.58, with a significant difference between the two groups (P<0.05) Conclusion: There were significant enthesopathic changes detected among FM patients especially affecting the Achilles, quadriceps, and proximal patellar tendons.

Prologue: 2019 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA).

The 2019 Annual Meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) was held in Paris, France, and was attended by rheumatologists, dermatologists, representatives of biopharmaceutical companies, and patients. As in previous years, GRAPPA members held a symposium for trainees to discuss their research in psoriatic disease with experts in the field. Other subjects featured during the annual meeting included a composites workshop to review continuous composite measures; the GRAPPA-Collaborative Research Network's third annual meeting; the need for a precision medicine approach to the treatment of psoriatic disease; updates from working groups in International Dermatology Outcome Measures and Outcome Measures in Rheumatology; a debate on the effectiveness of methotrexate in the treatment of psoriatic arthritis (PsA); updating recommendations for optimal treatment approaches for patients with PsA; an update on GRAPPA's research and educational projects; and the GRAPPA ultrasound (US) working group's goal to optimize the evaluation of enthesitis in patients with PsA using US through the development of a diagnostic US enthesitis tool. In this Prologue, we introduce the papers that summarize that meeting.

Development and Validation of a Sonographic Enthesitis Instrument in Psoriatic Arthritis: The GRAPPA Diagnostic Ultrasound Enthesitis Tool (DUET) Project.

Enthesitis is a key feature in psoriatic arthritis (PsA) and may be the initial site of musculoskeletal inflammation in patients with PsA. Ultrasound (US) optimizes the detection of enthesitis, but the lack of a validated sonographic enthesitis scoring system for PsA limits the ability to conduct US-based studies of approaches to improve the early diagnosis of PsA. Creating a sonographic enthesitis scoring system that reliably identifies PsA at early stages is an important step in optimizing early diagnosis and encouraging timely interventions that will ultimately improve longterm outcomes for patients with PsA. The Group for Research and Assessment of Psoriasis and PsA (GRAPPA) US working group has set a goal of improving the evaluation of enthesitis in patients with PsA by using US through the development of a Diagnostic Ultrasound Enthesitis Tool (DUET). This article summarizes the proposed DUET study design and methodology as discussed during the 2019 GRAPPA annual meeting in Paris, France.

GRAPPA 2019 Project Report.

At the 2019 annual meeting of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA), members received updates on several ongoing efforts. Among them were updates on research, including the trainee symposium, pilot research grants, and the Collaborative Research Network; GRAPPA's patient research partners; education, including the slide collection; treatment recommendations; and additional work related to advancing the understanding of disease aspects, including the Outcome Measures in Rheumatology (OMERACT)-GRAPPA outcome measure, axial involvement, and ultrasound enthesitis projects; as well as the early psoriatic disease systematic literature review and magnetic resonance imaging.

Assessment of enthesitis in patients with psoriasis: Relationships with clinical features, screening questionnaries results, and quality of life: An ultrasound study

Background/Aim. Often asymptomatic, enthesitis can be an integral feature of the wide clinical spectrum in psoriasis as well as an early sign of development of psoriatic arthritis (PsA). It may be difficult to clinically recognize enthesitis in patients with psoriasis or distinguish it from other causes of extraarticular pain. Ultrasound (US) expanding use with the development of accurate assessments through standardized US algorithms as the Glasgow Ultrasound Enthesis Scoring System (GUESS) and the Madrid Sonographic Enthesitis Index Scoring System (MASEI) scores made the US the dominant imaging technique in diagnosing enthesitis. The aims of this study were to establish the prevalence of US signs of en-thesitis, compare it with screening questionnaires results, and estimate possible connections of US verified enthesitis with quality of life (QOL) of patients with psoriasis without PsA diagnosis. Methods. A cross-sectional study was performed on 67 patients with psoriasis who were without systemic therapy. The clinical presence of enthesitis was examined by an experienced rheumatologist, and systemic inflammation was estimated through serum level of C-reactive protein (CRP). The Psoriasis Area Severity Index (PASI) and Body Surface Area- Psoriasis (BSA-PsO) were calculated by a dermatologist. Visual analogue scale (VAS) for pain, screening questionnaires ? the Toronto Psoriatic Arthritis Screening (ToPAS), Psoriasis Ep-idemiology Screening Tool (PEST), Psoriatic Arthritis Screening and Evaluation (PASE), Early Psoriatic Arthritis Screening Questionnaire (EARP), and Psoriasis and Arthrosis Screening Questionnaire (PASQ) ? were filled by patients. GUESS and MASEI scores were determined by US. The QOL was estimated by the Dermatology Life Quality Index (DLQI). Results. The presence of clinical enthesitis was recorded in 8.7% of patients. According to US signs of enthesitis using GUESS and MASEI scores, only 7% and 2% of patients, respectively, had no sign of enthesitis. Duration of psoriasis and age of subjects were in a significant correlation with GUESS and MASEI scores, while systemic inflammation, V AS v alue, PASI, and BSA-PsO scores were not. GUESS and MASEI scores significantly correlated with scores of all screening questionnaires as well as with DLQI. Conclusion. US can detect subclinical enthesitis better than clinical examination and widely used screening questionnaires, even though the correlations between MASEI and/or GUESS scores and results of screening questionnaires were positive. US examination is important in the multidisciplinary approach in diagnosing and managing psoriasis.

Ultrasound assessment, unlike clinical assessment, reflects enthesitis in patients with psoriatic arthritis.

Enthesitis is a major musculoskeletal manifestation of psoriatic arthritis (PsA). It is conventionally assessed clinically, by the presence of tenderness, despite its low reliability. However, ultrasound (US) provides a sensitive and feasible method for evaluating enthesitis. We investigated enthesitis as assessed clinically and by US in patients with PsA. Forty-seven patients with PsA underwent US examination of the bilateral humeral medial epicondyles and insertions of the triceps, distal quadriceps, proximal/distal patellae, Achilles tendons, and plantar fascia. These 14 entheses were also clinically evaluated by tenderness. The correspondence between US and clinical enthesitis was evaluated, as well as their associations with inflammatory markers (C-reactive protein [CRP], matrix metalloproteinase-3 [MMP-3]), disease activity indices (Disease Activity in Psoriatic Arthritis [DAPSA], Disease Activity Score 28 joints [DAS28-CRP], Psoriatic Arthritis Screening and Evaluation [PASE], Psoriasis Area Severity Index [PASI]), radiographic damage (modified Total Sharp Score [mTSS]), and functional status (health assessment questionnaire [HAQ]), and axial involvement. Among 47 patients with PsA, 37 and 23 had US and clinical enthesitis, respectively. US and clinical enthesitis had very low concordance (kappa coefficient 0.04), with no correlation between enthesitis counts (r=0.15, p=0.30). The US enthesitis count correlated only with the MMP-3 level (r=0.41, p=0.007), whereas the clinical enthesitis count correlated with the DAPSA, DAS28-CRP, HAQ, and PASE (r=0.50, p<0.001; r=0.44, p=0.002; r=0.41, p=0.008; r=0.54, p<0.001, respectively). US and clinical enthesitis are completely different entities. US enthesitis, but not clinical enthesitis, reflects inflammatory conditions.

Cutaneous immunohistochemical expression of interleukin-23 receptor (IL-23R) in psoriasis and psoriatic arthritis patients: Relation to musculoskeletal ultrasound findings

Aim of the workTo assess the immunohistochemical expression of cutaneous interleukin-23 receptor (IL-23R) in psoriasis and psoriatic arthritis (PsA) patients and study its relation to musculoskeletal ultrasound (MSUS) findings. Patients and methodsThe study was conducted on 40 patients: 20 with PsA and 20 with psoriasis only. The psoriasis area severity index (PASI) was estimated. Synovitis was assessed by Power Doppler ultrasound and enthesitis by Glasgow Ultrasound Enthesitis Scoring System (GUESS). ResultsThe mean age of PsA and psoriasis only patients (49.9 ± 11.6 and 44.9 ± 13 years) and gender (12 males and 8 females each) were comparable. IL-23R expression in the epidermal keratinocytes and dermal inflammatory cells of PsA patients scored 5 in 40% and 4 in 45% respectively while in psoriasis only the highest frequency of cases (40%) scored 2 in both. In psoriasis only, dermal and epidermal IL-23R were significantly associated to effusion (5 ± 0 vs 2.2 ± 0.7 and 4 ± 0 vs 1.5 ± 0.5, p < 0.001 respectively) and synovitis (5 ± 0 vs 2.4 ± 1 and 4 ± 0 vs 1.7 ± 0.8, p < 0.001 respectively) (p < 0.001) and both significantly correlated with erosions (r = 0.64, p = 0.002 and r = 0.64, p = 0.003) and GUESS (r = 0.68, p = 0.001 and r = 0.61, p = 0.005). Dermal IL-23R was significantly associated with the PASI score in PsA patients (r = 0.59, p = 0.01). On regression, IL-23R significantly predicted PsA (epidermal: p = 0.001 and dermal: p = 0.018). ConclusionIL-23R is highly expressed in psoriatic skin and strongly associated with psoriatic skin, joints and entheses findings. MSUS is valuable in the detection of subclinical arthritis. Cutaneous IL-23R expression may refer to early joint affection and with MSUS may allow early prediction and management.

Sonographic Evaluation of Subclinical Enthesopathy in Patients of Chronic Plaque Psoriasis.

Background:Psoriasis is associated with spondyloarthropathy in 10%–30% of cases. Enthesitis is major feature of psoriatic arthritis. Ultrasonography can detect subclinical entheseal abnormalities in psoriasis patients.Objectives:To determine the prevalence of subclinical enthesopathy in psoriasis vulgaris using ultrasonography and evaluating its correlation with severity and duration of psoriasis.Materials and Methods:This study included 50 patients of psoriasis vulgaris and 50 healthy controls. Sonographic evaluation of six sites bilaterally (proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligaments, distal quadriceps, and brachial triceps tendons) were done in each subject. All Ultrasonographic findings were identified according to MASEI (Madrid sonography enthesitis index). Enthesopathy scores of patients and controls were compared and receiver operating characteristic curve was used to determine cut off value of MASEI, above which ultrasound enthesitis of clinical significance could be diagnosed.Results:31 (62%) psoriasis patients had subclinical enthesopathy of clinical significance as compared to only 5 (10%) of controls. Mean MASEI score between psoriasis cases and control was statistically different, 12.72 ± 7.55 (Mean ± SD) and (5.14 ± 4.69), respectively (P value 0.000001).The receiver operating characteristic curve established an ultrasound score of >11 as the best cut-off to differentiate between subject with enthesopathy of clinical significance from those with enthesopathy of unknown significance. No statistically significant correlation was found between the degree of enthesopathy (MASEI score) and duration and severity of the psoriasis.Conclusion:Ultrasonography can effectively screen subclinical entheseal abnormalities in psoriasis patients.