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The use of ultrasound (US) has increased over the past 20 years for clinical decision making and for optimised patient care. The utility of US for correctly diagnosing the cause of musculoskeletal symptoms is known by many clinicians but little published data exist in this area. However, the value of US for diagnosing and handling treatment decisions especially in patients with rheumatoid arthritis (RA) has been well documented. US has been proven to be more sensitive than clinical joint evaluation.1 2 This has resulted in the acknowledgement of US as an addition to the clinical joint evaluation in suspected RA patients for assessing a more elaborate joint involvement helping the clinician to correctly classify the patients according to the new RA classification criteria.3 Likewise, in early undifferentiated inflammatory arthritis the use of US may assist in pinpointing those patients who will develop persistent inflammatory arthritis over time.4 US may also impact diagnosis and treatment decisions. This has been shown both in situations with regional pain such as the painful foot in chronic inflammatory diseases and the possible need for corticosteroid injections but also in global disease activity assessment in RA patients where US provides additional disease activity information leading to altered treatment decisions as compared to regularly DAS28 assessment.5,6 Also, in remission US may – by assessing subclinical inflammation – detect those patients with the highest risk of flare.7 US is a valuable part of future decision making in rheumatology.References[1] Wakefield RJ, Green MJ, Marzo-Ortega H, Conaghan PG, Gibbon WW, McGonagle D, et al. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis2004;63:382–5.[2] Salaffi F, Filippucci E, Carotti M. Naredo E, Meenagh G, Ciapetti A, et al. Inter-observer agreement of standard joint counts in early rheumatoid arthritis: A comparison with grey scale ultrasonography–a preliminary study. Rheumatology (Oxford)2008;47:54–8.[3] Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO 3rd, Birnbaum NS, Burmester GR, Bykerk VP, Cohen MD, Combe B, Costenbader KH, Dougados M, Emery P, Ferraccioli G, Hazes JM, Hobbs K, Huizinga TW, Kavanaugh A, Kay J, Kvien TK, Laing T, Mease P, Ménard HA, Moreland LW, Naden RL, Pincus T, Smolen JS, Stanislawska-Biernat E, Symmons D, Tak PP, Upchurch KS, Vencovský J, Wolfe F, Hawker G. Rheumatoid arthritis classification criteria: An American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis Rheum2010Sep;62(9):2569–81.[4] Freeston JE, Wakefield RJ, Conaghan PG, Hensor EM, Stewart SP, Emery P. A diagnostic algorithm for persistence of very early inflammatory arthritis: The utility of power Doppler ultrasound when added to conventional assessment tools. Ann Rheum Dis2010Feb;69(2):417–9.[5] d’Agostino MA, Ayral X, Baron G, Ravaud P, Breban M, Dougados M. Impact of ultrasound imaging on local corticosteroid injections of symptomatic ankle, hind-, and mid-foot in chronic inflammatory diseases. Arthritis Rheum2005Apr 15;53(2):284–92.[6] Dale J, Purves D, McConnachie A, McInnes I, Porter D. Tightening up? Impact of musculoskeletal ultrasound disease activity assessment on early rheumatoid arthritis patients treated using a treat to target strategy. Arthritis Care Res (Hoboken)2014Jan;66(1):19–26.[7] Saleem B, Brown AK, Quinn M, Karim Z, Hensor EM, Conaghan P, Peterfy C, Wakefield RJ, Emery P. Can flare be predicted in DMARD treated RA patients in remission, and is it important? A cohort study. Ann Rheum Dis2012Aug;71(8):1316–21.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.

Doppler ultrasound allows the visualization of perfusion in the inflamed synovium and therefore allows the diagnosis and quantification of inflammatory activity in a joint, tendon or enthesis. The issue when choosing Doppler modality in a rheumatological setting is the sensitivity for slow flow. This may be colour of power Doppler depending on the machine. Always choose the Doppler modality that provides the most flow information. The preset on the ultrasound machines are not per se set optimally for slow flow. The most important parameters to adjust are frequency, gain, PRF and thereby the filters, focus and colour priority. Doppler frequency behaves as the grey-scale frequency. High Doppler frequency gives better resolution on the expense of penetration. Gain determines the sensitivity of the system to slow flow and is adjusted by increasing the gain until noise pixels are present in the image and then gradually lowering the gain until only very few noise pixels are seen in the image. By lowering the gain further noise and motion artefacts may be prevented but also loss of slow flow information. The PRF is the pulse repetition frequency and determines the sensitivity to slow flow. The PRF must be kept as low as possible (around 500 Hz) because linked with the PRF adjustments are the filters. The higher the PRF the higher the filters are and high filters will eliminate slow flow. Focus in Doppler is like focus in grey-scale. It must be palce in the region of interest to get optimal resolution. Colour priority may not be adjusted easily in all machine but is a function that determines what is the most important in the image: the colours or the greys. Also adjust to a 100% to ensure maximal flow information. Adjusting the many parameters of the Doppler should not be done at every examination. Fortunately, there is little difference from patient to patient and from joint to joint with respect to Doppler settings. An exception is the hip joint because of its deep location. Once the sensitivity of the Doppler has been maximised, the settings may be saved as a set-up, which the machine reverts to at every new exam. It is possible to have many different set-ups, which can be named to our liking such as knee, obese knee, wrist etc. Using the same settings from patient to patient and from visit to visit is important if we wish to gauge the treatment response longitudinally or compare patients. Therefore it is also important that the same make and model of ultrasound machine are used from visit to visit. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6258

Doppler ultrasound allows the visualization of perfusion in the inflamed synovium and therefore allows the diagnosis and quantification of inflammatory activity in a joint, tendon or enthesis. The issue when choosing Doppler modality in a rheumatological setting is the sensitivity for slow flow. This may be colour of power Doppler depending on the machine. Always choose the Doppler modality that provides the most flow information. The preset on the ultrasound machines are not per se set optimally for slow flow. The most important parameters to adjust are frequency, gain, PRF and thereby the filters, focus and colour priority. Doppler frequency behaves as the grey-scale frequency. High Doppler frequency gives better resolution on the expense of penetration. Gain determines the sensitivity of the system to slow flow and is adjusted by increasing the gain until noise pixels are present in the image and then gradually lowering the gain until only very few noise pixels are seen in the image. By lowering the gain further noise and motion artefacts may be prevented but also loss of slow flow information. The PRF is the pulse repetition frequency and determines the sensitivity to slow flow. The PRF must be kept as low as possible (around 500 Hz) because linked with the PRF adjustments are the filters. The higher the PRF the higher the filters are and high filters will eliminate slow flow. Focus in Doppler is like focus in grey-scale. It must be palce in the region of interest to get optimal resolution. Colour priority may not be adjusted easily in all machine but is a function that determines what is the most important in the image: the colours or the greys. Also adjust to a 100% to ensure maximal flow information. Adjusting the many parameters of the Doppler should not be done at every examination. Fortunately, there is little difference from patient to patient and from joint to joint with respect to Doppler settings. An exception is the hip joint because of its deep location. Once the sensitivity of the Doppler has been maximised, the settings may be saved as a set-up, which the machine reverts to at every new exam. It is possible to have many different set-ups, which can be named to our liking such as knee, obese knee, wrist etc. Using the same settings from patient to patient and from visit to visit is important if we wish to gauge the treatment response longitudinally or compare patients. Therefore it is also important that the same make and model of ultrasound machine are used from visit to visit. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6259

A task force convened by the European League Against Rheumatism (EULAR) comprising rheumatologists, radiologists and methodologists from 11 countries developed 10 recommendations, based on both evidence obtained through systemic literature reviews as well as expert opinion. The recommendations encompass the role of imaging in making a diagnosis of axial or peripheral spondyloarthritis (SpA), monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis (OP). Selected aspects of the recommendations are given below (NOT all recommendations and NOT the exact wording, due to space constraints): conventional radiography (CR) of the sacroiliac joint (SIJ) is recommended as the first imaging method to diagnose sacroiliitis as part of axial SpA, while magnetic resonance imaging (MRI) is an alternative first imaging method in certain cases. Ultrasound (US) or MRI may be used to detect peripheral arthritis, tenosynovitis, bursitis and particularly peripheral enthesitis, which may support the diagnosis of SpA. MRI of the SIJ and/or spine may be used to assess and monitor disease activity, while CR of the SIJ and/or spine may be used for long-term monitoring of structural damage, particularly new bone formation in axial SpA. In patients with anklyosing spondylitis (AS) (not nonradiographic axial SpA), initial CRs of the lumbar and cervical spine are recommended to detect syndesmophytes, which are predictive of development of new syndesmophytes. MRI (vertebral corner inflammatory lesion) may also be used to predict development of new radiographic syndesmophytes. When spinal fracture in axial SpA is suspected, CR is the recommended initial imaging method. In axial SpA without radiographic syndesmophytes in the lumbar spine, OP should be assessed by dual-emission x-ray absorptiometry of the hip and spine. The SOR for each recommendation varied, but was generally very high (mean 8.9-9.5). Recommendations for future research were agreed by consensus following the presentation of the evidence obtained from the literature reviews. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.6279

Ultrasound is used increasingly for diagnosing large vessel vasculitis (LVV). The application of Doppler in LVV is very different from in arthritic conditions. This paper aims to explain the most important Doppler parameters, including spectral Doppler, and how the settings differ from those used in arthritic conditions and provide recommendations for optimal adjustments. This is addressed through relevant Doppler physics, focusing, for example, on the Doppler shift equation and how angle correction ensures correctly displayed blood velocity. Recommendations for optimal settings are given, focusing especially on pulse repetition frequency (PRF), gain and Doppler frequency and how they impact on detection of flow. Doppler artefacts are inherent and may be affected by the adjustment of settings. The most important artefacts to be aware of, and to be able to eliminate or minimize, are random noise and blooming, aliasing and motion artefacts. Random noise and blooming artefacts can be eliminated by lowering the Doppler gain. Aliasing and motion artefacts occur when the PRF is set too low, and correct adjustment of the PRF is crucial. Some artefacts, like mirror and reverberation artefacts, cannot be eliminated and should therefore be recognised when they occur. The commonly encountered artefacts, their importance for image interpretation and how to adjust Doppler setting in order to eliminate or minimize them are explained thoroughly with imaging examples in this review.

Background:Ultrasound (US) is sensitive for detecting monosodium urate (MSU) crystal depositions in gout, described as double contour (DC), tophi and aggregates. Depositions decreased during the first year of serum urate lowering treatment (ULT) in the NOR-Gout study [1].Objectives:As part of the NOR-Gout study to explore the US changes in depositions after 2 and 5 years on ULT.Methods:Patients with crystal-proven gout and a recent gout flare with serum uric acid (sUA) level >360 μmol/L were consecutively included in the NOR-Gout study [1,2]. During the first year they had frequent visits for ULT adjustment to achieve sUA <360 μmol/L (or <300 μmol/L if clinical tophus) and US was performed at baseline and after 3, 6 and 12 months. Patients were then followed by their general practitioner to keep the ULT target, and met for study visits at year 2 and 5. The US assessment (General Electric E9) included a semi-quantitative scoring of MSU crystal depositions using the OMERACT scoring system [3], with bilateral examination of radiocarpal, metacarpophalangeal2, knee, ankle and metatarsophalangeal1 joints as well as triceps, quadriceps, patellar (proximal and distal) and Achilles tendons and insertions. Sum scores of US depositions (DC, tophi, and aggregates, respectively) were calculated, and changes from baseline were explored by paired samples T-test.Results:209 patients were included (mean (SD) age 56.4 (13.8) years, time since first flare (disease duration) 7.9 (7.7) years, 95.5% men). Mean (SD) sUA (µmol/L) during the study were 500 (77) at baseline, 341 (61) at 3 months, 327 (60) at 6months, 312 (49) at 12 months, 325 (70) at 2 years and 337 (83) at 5 years. The US sum scores (DC, tophi, and aggregates, respectively) decreased during the study (p<0.001 for all lesions) shown in the Table 1 and Figure 1. At 2 (n=172) and 5 (n=161) years, a sum score of zero was found in 70.9% and 83.2% respectively, for DC, with corresponding percentages of 33.1 and 62.7 for tophi, and 7.6 and 23.6 for aggregates. At least one flare was described by 26.6% between year 1 and 2, and 15.4% had ≥ 1 flare between year 2 and 5.Conclusion:The amount of crystal depositions decreased not only during treat to target ULT the first year of the study, but also when the patients were followed by their general practitioner between year 1 and 5. Patients and clinicians should be encouraged to comply to ULT to remove the depositions in joints and tendons and thereby reduce the burden of gout.REFERENCES:[1] Hammer HB et al. Ann Rheum Dis 2020[2] Uhlig T et al. RMD Open 2021[3] Christiansen SN et al. Semin Arthritis Rheum 2021Table 1.Figure 1.Acknowledgements:NIL.Disclosure of Interests:Hilde Berner Hammer AbbVie, Lilly, Novartis, UCB, Lars Karoliussen: None declared, Lene Terslev: None declared, Espen A. Haavardsholm Pfizer, AbbVie, Celgene, Novartis, Janssen, Gilead, Lilly, and UCB, Till Uhlig Novartis, SOBI.

Background:Ultrasound (US) is sensitive for detecting monosodium urate (MSU) crystal depositions in gout, described as double contour (DC), tophi and aggregates. After persistent urate lowering treatment (ULT) we had at 1 year seen a significant decrease of the US depositions of MSU, and 85.3% of patients achieved the serum uric acid (sUA) target of <360 µmol/L (i.e. < 6 mg/dL) and 96.2% had <400 µmol/L [1]. The patients were after the first year followed on ULT by their general practitioner and had follow-up study visits at year 2 and 5.Objectives:To explore whether the amount of US detected depositions at 2 and 5 years after initiation of ULT were related to achievement of the sUA target.Methods:Patients had clinical, laboratory and US assessments at baseline, 1, 2 and 5 years. The US examination (General Electric E9) included a semi-quantitative scoring of MSU depositions using the OMERACT scoring system [2] with bilateral examination of radiocarpal, metacarpophalangeal2, knee, ankle, and metatarsophalangeal1 joints as well as triceps, quadriceps, patellar (proximal and distal) and Achilles tendons and insertions. Total sum scores of US depositions (DC, tophi and aggregates, respectively) were calculated. Changes from baseline were explored by separate paired samples T-test for patients with sUA levels < or > 360 µmol/L. Differences between US depositions dependent on sUA was assessed by independent sample T-test.Results:209 patients were included at baseline (mean (SD) age 56.4 (13.8) years, time since first flare (disease duration) 7.9 (7.7) years, 95.5% men). Mean sUA (µmol/L) during the study were 500 at baseline, 312 (n=184) at 1 year, 325 (n=173) at 2 years and 337 (n=161) at 5 years. At 2 years, 78.6% had sUA <360 µmol/L and 89% <400 µmol/L, and the corresponding percentages were 71.4 and 82.6 at 5 years. From 1 to 5 years, the sum scores of US (DC, tophi, and aggregates) decreased for patients with sUA <360 µmol/L (p<0.001) (Figure 1), but for patients having >360 µmol/L at the visits, significant decreases were only found for tophi between year 1 and 2 (p=0.001) and for aggregates between year 2 and 5 (p=0.02). Patients with sUA >360 µmol/L versus <360 µmol/L at 2 years (n=37 vs 136) had higher scores of DC (p=0.02) and at 5 years (n= 46 vs 115) the patients with sUA >360 µmol/L had higher scores of DC (p<0.001), tophi (p=0.008) and aggregates (p=0.046). Figure 2 shows the US depositions at 5 years according to sUA levels, and highest scores were found in patients with sUA levels > 400 µmol/L (p<0.001).Conclusion:After treat-to-target ULT in the first year, 5-year reductions in US depositions were most favourable in patients who had a sUA levels <360 µmol/L. Our findings support the recommendation to keep a low sUA level over time.REFERENCES:[1] Hammer HB et al. Ann Rheum Dis 2020.[2] Christiansen SN et al. Semin Arthritis Rheum 2021.Figure 1.Figure 2.Acknowledgements:NIL.Disclosure of Interests:Hilde Berner Hammer AbbVie, Lilly, Novartis, UCB, Lars Karoliussen: None declared, Lene Terslev: None declared, Espen A. Haavardsholm Pfizer, AbbVie, Celgene, Novartis, Janssen, Gilead, Lilly, and UCB, Till Uhlig Novartis, SOBI.

Tenosynovitis is a common feature in rheumatoid arthritis (RA) patients in both hands and feet. The extensor carpi ulnaris (ECU) was seen by Magnetic Resonance Imaging (MRI) to be very commonly involved in RA and in one MRI study ECU involvement in early RA was associated with erosive disease [1,2]. ECU has also been shown by ultrasound (US) to be a frequently involved tendon in RA together with the tibialis posterior (TP) tendon and finger flexors tendons of 2.-4. fingers [3,4]. Though both modalities may be used for detecting tenosynovitis US appear to be more feasible than MRI. The US definition of tenosynovitis was already proposed in 2005 by the OMERACT group [5] and a recent US study assessed the reliability of detecting inflammatory and destructive tendon abnormalities in patients with RA using an anatomy-based or a free scanning, and independent of scanning technique the overall interobserver reliability for tenosynovitis and tendon damage was found to be excellent both for GS and PD [6]. However, in order to monitor tenosynovitis changes in RA a scoring system is needed and several different systems have been proposed using either descriptive grading, binary grading or semi-quantitative scoring from 0-3 (0=normal, 1=minor, 2=moderate and 3=major amount of tenosynovitis/degree of PD). A recent study explored the reliability of a proposed semi-quantitative scoring system of both grey scale and Doppler and found good reproducibility [7] which is mandatory for clinical trials. So far there is no consensus on how many tendons that should be included in a US joint/tendon score for follow-up of RA patients, and this issue needs to be explored together with further studies on the predictive value of tenosynovitis in early RA. References McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N. Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years. Arthritis Rheum 2005; 52: 744-51. Lillegraven S, Bøyesen P, Hammer HB, et al. Tenosynovitis of the extensor carpi ulnaris tendon predicts erosive progression in early rheumatoid arthritis. Ann Rheum Dis 2011; 70: 2049-50. Filippucci E, Gabba A, Di Geso L, Girolimetti R, Salaffi F, Grassi W. Hand Tendon Involvement in Rheumatoid Arthritis: An Ultrasound Study. Semin Arthritis Rheum. 2012 Jun;41(6):752-60 Hammer HB, Kvien TK. Ultrasonography shows significant improvement of wrist and ankle tenosynovitis in rheumatoid arthritis patients treated with adalimumab. Scand J Rheumatol 2011; 40: 178-82. Wakefield RJ, Balint PV, Szkudlarek M, Filippucci E, Backhaus M, D’Agostino MA, Sanchez EN, Iagnocco A, Schmidt WA, Bruyn GA, Kane D, O’Connor PJ, Manger B, Joshua F, Koski J, Grassi W, Lassere MN, Swen N, Kainberger F, Klauser A, Ostergaard M, Brown AK, Machold KP, Conaghan PG; OMERACT 7 Special Interest Group. Musculoskeletal ultrasound including definitions for ultrasonographic pathology. J Rheumatol. 2005 Dec;32(12):2485-7. Bruyn GAW, Möller I, Bong D, et al. Reliability testing of tendon disease using two different scanning methods in patients with rheumatoid arthritis. First step towards an ultrasonography scoring index. Rheumatology (Oxford). 2012;51(9):1655-61. Naredo E, D’Agostino MA, Wakefield RJ, Möller I, Balint PV, Filippucci E, Iagnocco A, Karim Z, Terslev L, Bong DA, Garrido J, Martínez-Hernández D, Bruyn GA; on behalf of the OMERACT Ultrasound Task Force* Reliability of a consensus-based ultrasound score for tenosynovitis in rheumatoid arthritis. Ann Rheum Dis. 2012 Sep 14. [Epub ahead of print] Disclosure of Interest None Declared

Background:Musculoskeletal ultrasound (MSUS) is widely regarded as a valuable tool for assessing the full extent of synovitis in patients with rheumatoid arthritis (RA). In recent decades, numerous global ultrasound scores have been developed, however the number of joints, and choice of MSUS modality or elementary lesion (e.g. grey-scale [GS]and/or Doppler [D], synovial effusion [SE] and/or synovial hypertrophy [SH], etc.) to be included remained questionable. Following a systematic literature review (SLR) published in 2010 [1] which highlighted the heterogeneity of MSUS definitions, scoring systems and number of joints scanned to evaluate synovitis burden in RA, the OMERACT US Working Group (WG) developed a global synovitis scoring system (GLOESS) at joint and patient level (joint set), with standardized and validated definitions and grading of synovitis which advocates the use of a combined GS and D score, and synovial hypertrophy, but not synovial effusion as the elementary lesions denoting synovitis [2].Objectives:To analyze the implementation and metric properties of the proposed GLOESS as scoring system to evaluate synovitis burden in RA.Methods:A SLR of Central, Embase and Medline databases was performed (31.3.2010 to 15.9.2023) by two independent reviewers updating our previous SLR [2]. Original research reports written in English which assessed the reliability, validity and sensitivity of global MSUS scoring systems in RA were included and data extracted using a predefined extraction sheet.Results:Of 1564 reports identified, 99 articles were included in the final review. The majority of global scoring systems were composed of semiquantitative grades of individual joints, quantitative grades were utilized in only 6/99 (6%) of studies, while a global score based on joints graded in binary fashion was investigated in 28/99 (28%) The joint set most commonly used was the 7-joint (wrist, metacarpophalangeal [MCP]2, MCP3, proximal interphalangeal [PIP]2, PIP3, metatarsophalangeal [MTP]2, MTP5 of the clinically more affected side) (15/99, 15%), and 12-joint (bilateral elbow, wrist, MCP2, MCP3, knee, ankle) (15/99, 15%), 22-joint (bilateral wrist, MCP1-5, PIP 1-5) (12/99, 12%) and 28-joint (bilateral shoulder, elbow, wrist, MCP 1-5, IP1, PIP 2-5, knee) sets (9/99, 9%), while more extensive sets were investigated more rarely. Regarding the consideration of SE or SH as signs of synovitis 40/99 (40%) considered only SH as proposed by the GLOESS, while 38/99 (38%) articles considered both – studies in the latter group were generally older as compared to the former. Regarding the use of a composite score (GS+D) this was evaluated in 22/99 (22%) studies, with the majority of studies evaluating the domains separately. All included studies assessed face and content validity, while 73/99 (73%) also assessed construct validity by comparison to clinical examination, laboratory findings or other imaging modalities. 34/99 (37%) evaluated responsiveness and 42/99 (42%) evaluated reliability. With regard to feasibility, time of evaluation varied from 15 to 60 min and tended to increase with the number of joints involved in the examination.Conclusion:MSUS can be regarded as a valuable tool for globally examining the extent of synovitis in RA. The adoption of GLOESS has a validated scoring system was clearly denoted in the more recently published articles, as well as the use of SH solely to define synovitis. Reduced joint counts are utilized more frequently than more extensive joint sets, especially for evaluating responsiveness.REFERENCES:[1] Mandl P et al. A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter. J Rheumatol. 2011;38(9):2055-62.[2] D’Agostino MA et al. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 1: definition and development of a standardised, consensus-based scoring system. RMD Open. 2017;3(1):e000428.Acknowledgements:NIL.Disclosure of Interests:Peter Mandl Abbvie, Janssen, Abbvie, Janssen, Novartis, Clara Watschinger: None declared, Irina Gessl: None declared, Lene Terslev Janssen, Novartis and GE, Helen Keen: None declared, Carlos Pineda: None declared, Brigitte Wildner: None declared, Maria-Antonietta D’Agostino: None declared.