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Dactylitis is a hallmark feature of psoriatic arthritis (PsA) and other spondyloarthritis, although it can also be present in other conditions such as sarcoidosis, gout or infections. Regarding PsA, dactylitis, which occurs in 30% to 50% of patients, is a highly discriminative feature for PsA diagnosis in early disease as well as a predictor factor for structural damage development. On ultrasound, dactylitis is a complex and heterogeneous “imaging syndrome” that includes a variey of elementary lesions, i.e. enthesitis (finger extensor tendon, collateral ligaments, flexor fibrous sheaths, flexor pulleys, functional entheses), tenosynovitis, paratenonitis, synovitis, subcutaneous/peritendon tissue inflammation, and proliferative and erosive bone changes. High resolution B-mode ultrasound offers a detailed anatomical imaging of the different lesions present in dactylitis as well as Doppler ultrasound provides information on the inflammatory activity of the involved structures and tissues.Disclosure of InterestNone declared

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9–9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.

Over the last two decades, an increasing number of rheumatologists have progressively incorporated musculoskeletal ultrasound (MSUS) as a valuable diagnostic and monitoring tool in their clinical practice and research. US is also expanding its applications to new anatomic regions of importance in rheumatologic practice such as large vessels, salivary glands, ligaments, and peripheral nerves. In the first decade of the 21st century, the increasing utility of MSUS in rheumatology has led to a great demand for appropriate education in this imaging modality among rheumatologists worldwide. The European League Against Rheumatism (EULAR) has promoted for many years education in MSUS among rheumatologists in Europe and other continents. The EULAR has supported many educational projects in MSUS such as the development of the content and conduct of a high-quality multi-level MSUS training programme that culminates with a competency assessment systems for rheumatologic MSUS. In addition, EULAR qualifies European centres to become part of a network of Imaging training centres which includes MSUS. Currently EULAR is developing an Imaging Library that will offer images from the wide spectrum of imaging modalities used in rheumatology for the purpose of learning or teaching.Disclosure of InterestNone declared

Background:Rheumatoid arthritis (RA) is a chronic autoimmune disorder associated with significant pain and subsequent poor quality of life. Due to the conventional belief that the primary pain mechanism in Rheumatoid Arthritis (RA) is nociceptive and related to joint inflammation, physicians have long considered pain an indicator of ongoing inflammation. However, even with the effective use of anti-inflammatory drugs, up to 50% of patients in remission continue to experience pain. Thus, alternative pain mechanisms may exist. Musculoskeletal ultrasound (MSUS) is a sensitive tool to identify joint inflammatory changes.Objectives:In this study, MSUS was employed as a measure of nociceptive pain to investigate the relationship between joint inflammation and pain in RA. The goal was to quantify the contribution of inflammatory nociceptive mechanisms in explaining the totality of pain in RA.Methods:This study was a secondary analysis of a prospective study (Naredo et al., 2008) of RA patients who met the 1987 American College of Rheumatology criteria. The study was conducted on 367 participants starting treatment with a tumour necrosis factor-alpha (TNFα) blocking agent. The participants underwent assessments, including clinical, laboratory, MSUS, pain VAS 100mm, and DAS28 at baseline and after 12 months of treatment. MSUS examination included 86 sites in 28 joints, and synovial fluid (SF), synovial hypertrophy (SH), and Power Doppler (PD) signals were scored. MSUS metrics scores were graded semi-quantitatively on a scale of 0–3 (0 “ absent; 1 “ mild; 2 “ moderate; 3 “ marked). The relationship between pain VAS and MSUS metrics in RA was examined using appropriate correlations and linear regression models cross-sectionally at baseline and longitudinally. In a linear regression model, the longitudinal analysis assessed the change between baseline and 12 months in the MSUS metrics as explanatory variables for change in pain VAS.Results:A moderate significant correlation with a minor effect size was observed between pain VAS and MSUS metrics, namely PD, SF and SH at baseline (r = 0.154, p = 0.003; r = 0.123, p = 0.018; r = 0.111, p = 0.034, respectively). Furthermore, a strong statistically significant correlation with a small effect size was observed between longitudinal changes in pain VAS and MSUS metrics, namely PD, SF and SH (r = 0.197, p < 0.001; r= 0.254, p < 0.001; r = 0.241, p < 0.001, respectively). Moreover, MSUS metrics were mildly associated with the progression of pain in RA in the regression model. The MSUS metrics accounted for 6.7 % of the variance in Pain VAS (R Square = 0.067).Conclusion:The findings indicate that the MSUS metrics of joint inflammation only accounted for a minor portion of pain experienced by patients with RA. These findings suggest that nociceptive pain mechanisms do not predominate as classically considered and that other pain mechanisms, such as nociplastic pain, require elucidation.REFERENCES:[1] Naredo, E., Möller, I., Cruz, A., Carmona, L. and Garrido, J., 2008. Power Doppler ultrasonographic monitoring of response to anti–tumor necrosis factor therapy in patients with rheumatoid arthritis. Arthritis & Rheumatism: Official Journal of the American College of Rheumatology, 58(8), pp.2248-2256.Acknowledgements:NIL.Disclosure of Interests:None declared.

To develop evidence based points to consider the use of imaging in the diagnosis and management of juvenile idiopathic arthritis (JIA) in clinical practice. The task force comprised a group of paediatric rheumatologists, rheumatologists experienced in imaging, radiologists, methodologists and patients from nine countries. Eleven questions on imaging in JIA were generated using a process of discussion and consensus. Research evidence was searched systematically for each question using MEDLINE, EMBASE and Cochrane CENTRAL. Imaging modalities included were conventional radiography, ultrasound, MRI, CT, scintigraphy and positron emission tomography. The experts used the evidence obtained from the relevant studies to develop a set of points to consider. The level of agreement with each point to consider was assessed using a numerical rating scale. A total of 13 277 references were identified from the search process, from which 204 studies were included in the systematic review. Nine points to consider were produced, taking into account the heterogeneity of JIA, the lack of normative data and consequent difficulty identifying pathology. These encompassed the role of imaging in making a diagnosis of JIA, detecting and monitoring inflammation and damage, predicting outcome and response to treatment, use of guided therapies, progression and remission. Level of agreement for each proposition varied according to the research evidence and expert opinion. Nine points to consider and a related research agenda for the role of imaging in the management of JIA were developed using published evidence and expert opinion.

Psoriasis is a common chronic immune mediated skin disease. Psoriatic arthritis occurs in a variable, albeit considerable percentage of psoriatic patients which ranges from 10 to 30% depending on the studied population. Psoriatic arthritis may be present in different clinical forms whose major features are synovitis and/or enthesitis. In most patients, psoriasis precedes the clinical onset of the joint inflammatory disease. A number of studies have reported the presence of subclinical synovitis and enthesopathy detected by imaging techniques (e.g. MRI, ultrasound) in a higher percentage of psoriatic patients without musculoskeletal symptoms compared to controls. Some preliminary data on the predictive value of these imaging findings in relation to psoriatic arthritis development have been reported. This lecture offers an update of imaging modalities as biomarkers in psoriasis and psoriatic arthritis. Disclosure of Interest E. Naredo Grant/Research support from: UCB and MSD, Consultant for: Abbvie, Roche Farma, Bristol-Myers Squibb, Pfizer, UCB, General Electric Healthcare, and Esaote DOI 10.1136/annrheumdis-2014-eular.6110

The aims of the EULAR Standing Committee on Musculoskeletal Imaging (SCMI) committee are to promote Education and research in imaging modalities as well as improve patient care through the appropriate use of imaging modalities. The committee is composed by delegates coming from member countries of EULAR, a representative of EUMEUNET and several co-opted members with particular interest in imaging both for research and education purposes. This lecture offers an overview of future EULAR projects in musculosketal imaging under the umbrella of the committee. Disclosure of Interest E. Naredo Grant/Research support from: UCB and MSD, Consultant for: Abbvie, Roche Farma, Bristol-Myers Squibb, Pfizer, UCB, General Electric Healthcare, and Esaote DOI 10.1136/annrheumdis-2014-eular.6147

Objectives:To develop an ultrasound enthesis score and to assess its validity in the diagnostic classification of the spondyloarthropathies (SpAs).Methods:Twenty-five patients with SpA and 29 healthy controls participated in a blinded, gender-matched, cross-sectional study involving ultrasound assessment. The following entheses were explored bilaterally: proximal plantar fascia, distal Achilles tendon, distal and proximal patellar ligament, distal quadriceps and brachial triceps tendons. The ultrasound score evaluated enthesis thickness, structure, calcifications, erosions, bursae and power Doppler signal. The value of each elemental lesion was calculated using a three-model analysis. Validity was analysed by receiver operating characteristic (ROC) curves. Inter-reader and interexplorer intraclass correlation coefficients (ICCs) were calculated.Results:The logistic regression model overestimated the score of three elemental lesions: calcification (0–3), Doppler (0 or 3) and erosion (0 or 3), while scoring tendon structure, tendon thickness and bursa as 0 or 1. ROC curves established an ultrasound score of ⩾18 as the best cut-off point for differentiation between cases and controls. This cut-off point was exceeded by 5/29 controls (17%) and by 21/25 patients with SpA (84%). The sensitivity, specificity, positive and negative likelihood ratios (LR+, LR−) were 83.3%, 82.8%, 4.8% and 0.2%, respectively. The inter-reader and interexplorer ICCs were 0.60 and 0.86, respectively.Conclusion:The findings suggest that the ultrasound enthesis score could be a valid tool in the diagnosis of SpA.

Modern imaging modalities have become increasingly implemented in rheumatology practice thanks to the growing evidence body regarding their role in optimizing diagnosis and management of rheumatologic patients. There are new publications that support the clinical added value of imaging techniques in the diagnosis, therapy monitoring and prognostication of inflammatory arthritis in both adults and children. In addition, some new published papers deals with promising applications of imaging techniques in osteoarthritis, microcrystalline arthritis, connective tissue diseases and vasculitidis. This lecture offers an update of current and emerging applications and research of imaging techniques in Rheumatology. Disclosure of Interest None Declared

Background:The achievement of inactive disease (ID) is the goal of contemporary treatment strategies in all patients with juvenile idiopathic arthritis (JIA). Complete disease quiescence is regarded as the ideal therapeutic goal as its attainment helps to minimize pain and disability associated with active disease, prevent articular and extra-articular damage, and improve the quality of life of children and their families. Artificial intelligence is a powerful tool that is well suited to identify the variables that are of foremost relevance to predict a desired outcome.Objectives:The aim of our study is to seek for the disease parameters that have the best ability to predict the achievement of the state of ID at 24 months using artificial intelligence methods.Methods:The clinical charts of all consecutive patients with JIA by ILAR criteria who were first seen at study centre within 6 months after disease onset between 2007 and 2019 and had follow-up visits at 6, 12, 18, and 24 months after initial evaluation were reviewed retrospectively. Demographic parameters, clinical features (including physician-centred and parent-reported outcomes), laboratory tests and prescribed therapy were collected at all visits and entered into an excel dataset. ID was defined by 2004 Wallace criteria. The Last Observation Carried Forward (LOCF) and posteriorly Baseline Observation Carried Forward (BOCF) methods were used to impute missing values. Patients in whom imputation could not be performed with these computational techniques were excluded. Data recorded at baseline and at 0-, 6- and 12-month follow-up visits were included in the analysis of prediction of achievement of ID at 24 months. The study cohort was divided into two subsets: a training set (50%) and a test set (50%). Multivariate time series forecasting was applied to the longitudinal data through the Light Gradient Boosting Machine (LightGBM) method using the Scikit-learn with mlforecast to train and test the predictive model. Features were ranked by importance to determine their relative impact on achievement of ID. Hyperparameter tuning was carried out using the optuna package. Matthews correlation coefficient (MCC) was used as a metric to assess model performance. The entire analysis procedure was implemented in Python.Results:Of the 449 patients who had their initial evaluation within 6 months after disease onset at study centre in the study period, 294 had longitudinal assessments available. 147 patients were randomly allocated to the training set and 147 to the test set. For each follow up visit 74 features were collected. By applying the mlforecast method coupled with LightGBM algorithm, we obtained 71% of MCC in the training set and 69% in the test set, which indicated a strong ability of our artificial intelligence model to predict the state of ID from the identified clinical variables at 0, 6 and 12 months. The ranking of features which proved relevant in predicting ID is shown in Figure 1. The best predictor of ID was the physician’s global assessment of disease activity (PhGA), followed by the age at onset and count of active joints. Other relevant features were acute phase reactants (erythrocyte sedimentation rate and C-reactive protein).Conclusion:The PhGA over time was the strongest predictor of achievement of ID at 24 months, which highlights the importance of its regular scoring and its key role in guiding treatment decisions. The prominent importance of physician-centred outcome measures (PhGA and active joint count) and acute phase reactants in ID prediction supports the use of the Juvenile Arthritis Disease Activity Score (JADAS), which includes all these variables, in deciding treatment adaptations within treat-to-target strategies aimed to attain complete disease control.REFERENCES: NIL.Figure 1.Feature importance derived from the LGBM model for predicting ID.Acknowledgements:Ana Isabel Rebollo-Giménez is holding a fellowship supported by the Sociedad Española de Reumatología.Disclosure of Interests:Ana Isabel Rebollo Giménez: None declared, Davide Cangelosi: None declared, Francesca Ridella: None declared, Silvia Orsi: None declared, Elena Aldera: None declared, Valentina Natoli: None declared, Silvia Rosina: None declared, Esperanza Naredo: None declared, Angelo Ravelli AbbVie, Novartis, Pfizer,Reckitt Benckiser, Alexion, Galapagos, Sobi.