Bowel Ultrasound: a Non-invasive, Easy to Use Method to Predict the Need to Intensify Therapy in Inflammatory Bowel Disease Patients

Background and Aims: Bowel ultrasound (BU) is a non-invasive, inexpensive, widely available tool, valuable for inflammatory bowel disease (IBD) assessment. The aim of the present study was to investigate the clinical utility of BU to predict the need to intensify therapy in IBD patients. Methods: One hundred seventeen IBD patients (89 Crohn’s disease, and 28 ulcerative colitis) diagnosis established at least 6 months before enrolment, undergoing maintenance therapy were prospectively included in the study. Bowel ultrasound investigated the following parameters: the bowel wall thickness (BWT), loss of wall stratification, the presence of the bowel wall Doppler signal, the visible lymph nodes, the mucosal hyperechoic spots, and the irregular external bowel wall. The patients were followed-up for 6 months, registering the need to escalate the treatment regimen. Subgroup analyses were conducted for patients requiring immediate treatment intensification (37 subjects), due to active disease at baseline and patients with subsequent treatment intensification, in the 6 months follow-up period (21 cases) in comparison to patients that required no therapeutic optimization (59). Results: During the follow-up, 49.6% of patients needed treatment escalation. All the investigated BU variables were significantly associated with the main outcome. In the multivariate analysis, the mean BWT (p<0.0001), and the presence of the bowel wall Doppler signal (p=0.007) were independent predictors of the main outcome. For the subgroup analyses: mean BWT (p=0.0001) and the presence of the bowel wall Doppler signal (p=0.01) were independent predictors for immediate treatment intensification (active disease at baseline) and mean BWT (p=0.0003) and the lack of bowel wall stratification (p=0.05) were independent predictors for the need of subsequent therapeutic optimization. Logistic regression prediction models and prediction scores (BU score) had the best AUROC values (>0.91) when compared to traditional biomarkers of active inflammation, such as C reactive protein or fecal calprotectin. Conclusion: Bowel ultrasound could be used as a non-invasive, easy to use diagnostic tool to predict the need to intensify therapy in patients with IBD.

Rotor UAV’s Micro-Doppler Signal Detection and Parameter Estimation Based on FRFT-FSST

The micro-Doppler signal generated by the rotors of an Unmanned Aerial Vehicle (UAV) contains the structural features and motion information of the target, which can be used for detection and classification of the target, however, the standard STFT has the problems such as the lower time-frequency resolution and larger error in rotor parameter estimation, an FRFT (Fractional Fourier Transform)-FSST(STFT based synchrosqueezing)-based method for micro-Doppler signal detection and parameter estimation is proposed in this paper. Firstly, the FRFT is used in the proposed method to eliminate the influence of the velocity and acceleration of the target on the time-frequency features of the echo signal from the rotors. Secondly, the higher time-frequency resolution of FSST is used to extract the time-frequency features of micro-Doppler signals. Moreover, the specific solution methodologies for the selection of window length in STFT and the estimation of rotor parameters are given in the proposed method. Finally, the effectiveness and accuracy of the proposed method for target detection and rotor parameter estimation are verified through simulation and measured data.

Moving object detection and tracking based on Doppler ultrasound

Fetal health monitoring during pregnancy has become a necessary procedure. Fetal heart rate (FHR) monitoring can determine fetal development or presence of heart disease and evaluate fetal well-being. The FHR measurement uses typically an acoustic probe-based Doppler ultrasound. Doppler ultrasound method transmits a continuous wave signal to the abdomen of a pregnant woman to receive a reflected signal from the fetal heart. Periodic displacement of the heart tissue produces the Doppler effect and the phase change of the reflected wave is proportional to the velocity of the fetal heart. The reflected signal is modulated into a phase signal and the received signal is demodulated to detect the heart rate. The current clinician system consists of a single probe and requires the probe to be manipulated to the optimal position to measure FHR. The system is highly dependent on trained diagnostic experts. The movement of the pregnant woman and the fetus leads to the misaligned acoustic beam which degrades the reliability of the measurement. This work presents a detection and tracking system using a Doppler signal to compensate for the target's movement. The system is implemented by integrating multi-channel probes interfaced to a Doppler signal converter with a 2-degree of freedom (DOF) motor device. This work describes the characteristics of two key components: Doppler signals of multi-channel probes according to the direction of the acoustic beam and the algorithm with a 2-DOF tracking system.

POS0258 REAL-TIME VERSUS STATIC SCORING IN MUSCULOSKELETAL ULTRASONOGRAPHY IN PATIENTS WITH INFLAMMATORY HAND OSTEOARTHRITIS

Background:Ultrasound (US) is used in rheumatic musculoskeletal diseases (RMDs) such as hand osteoarthritis (OA) as outcome measure. Traditionally scoring is performed real-time, but central reading of static US images could avoid issues of inter-rater reliability. However, agreement between real-time and static assessment has not been studiedObjectives:To study the agreement between real-time and static scoring of US in inflammatory hand OA.Methods:Ultrasound was performed of 30 joints obtained in 75 patients with hand osteoarthritis, treated with prednisolone or placebo in a randomized double-blind trial. Hand joints were assessed for synovial thickening, effusion, Doppler signal and osteophytes by ultrasound (score 0-3 per joint) at baseline and after treatment. Two ultrasonographers blinded for clinical data scored the live images together (simultaneously) in real-time. A consensus score for each joint was recorded. Representative images stored during scanning were scored by one ultrasonographer minimally 6 months after real-time scoring. For each patient, images of each visit were scored paired, with known chronological order.Agreement between scoring methods was studied at joint level with quadratic weighted kappa. At patient level, intra-class correlations (ICC; mixed effect model, absolute agreement, with clustering taken into account) were calculated at both timepoints. ICCs were also calculated for the delta of sum scores. Responsiveness of scoring methods was analyzed with generalized estimating equations (GEE) with treatment as independent and ultrasonography findings as dependent variable.Results:Thirty-nine patients (52%) were treated with prednisolone and 36 (48%) were treated with placebo. Patient characteristics were well-balanced between treatment groups.All patients had signs of synovial thickening and osteophytes as assessed by real-time ultrasonography, and almost all signs of effusion (99%) or a positive Doppler signal (95%) in at least one joint. Total ultrasonography sum score for osteophytes was high (mean 45 ±SD 12), whereas sum score was low for positive Doppler signal (mean 5.9 ±SD 4.4), with intermediate sum scores for synovial thickening and effusion (mean 16 ±SD 6.3 and 11 ±SD 6.0 respectively). Static sum scores were overall slightly higher (osteophytes mean 48 ±SD 10; Doppler mean 6.9 S±D 5.0; synovial thickening mean 20 ±SD 7.0 and effusion 13 ±SD 6.5)Agreement at baseline was good to excellent at joint level (kappa 0.72-0.88) and moderate to excellent at patient level (ICC 0.59-0.86). Agreement for delta sum scores was poor to fair for synovial thickening and effusion (ICC 0.18 and 0.34 respectively), but excellent for Doppler signal (ICC 0.80) (Table 1).Real-time ultrasonography showed responsiveness to prednisolone with a mean between-group difference of synovial thickening sum score of -2.5 (CI:-4.7 to-0.3). Static ultrasonography did not show a decrease in synovial thickening (Figure 1). No difference in ultrasonography scores was seen for the other ultrasonography features, neither with real-time nor static scoring.Conclusion:While cross-sectional agreement between real-time and static ultrasonography was good, agreement of delta sum scores was not and paired static ultrasonography measurement of synovial thickening did not show responsiveness to prednisone therapy where real-time ultrasonography did. Therefore, when using ultrasonography in clinical trials, real-time dynamic scoring should remain the standard.Table 1.Agreement on patient levelBaselineWeek 6Delta W6-BLICC (95% CI)ICC (95% CI)ICC (95% CI)Synovitis0.59 (0.26-0.76)0.58 (0.24-0.77)0.18 (0 - 0.40)Effusion0.84 (0.66-0.92)0.84 (0.75-0.89)0.34 (0.12-0.53)Osteophytes0.82 (0.50-0.92)0.78 (0.56-0.88)NDDoppler0.86 (0.75-0.92)0.91 (0.85-0.94)0.80 (0.70 -0.87)ICC: intra-class correlation coefficient linear mixed model (random patient, fixed rating), absolute agreement. ND: Not DerterminedDisclosure of Interests:Lotte van de Stadt: None declared, Féline Kroon: None declared, Monique Reijnierse Grant/research support from: Dutch Arthritis Foundation, Désirée van der Heijde Consultant of: bbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Frits Rosendaal: None declared, Naghmeh Riyazi: None declared, R. de Slegte: None declared, Jende van Zeben: None declared, Cornelia Allaart: None declared, Margreet Kloppenburg Consultant of: Abbvie, Pfizer, Levicept, GlaxoSmithKline, Merck-Serono, Kiniksa, Flexion, Galapagos, Jansen, CHDR, Grant/research support from: MI-APPROACH, Marion Kortekaas: None declared

AB0158 COMPARISON OF CLINICAL EXAMINATION AND ULTRASOUND OF HAND AND WRIST JOINTS IN RHEUMATOID ARTHRITIS

Background:Ultrasound (US) is an accessible and non-invasive tool to assess joint involvement in rheumatoid arthritis (RA). It is used for diagnostic and prognosis purposes and for following of RA patients by evaluating the disease activity and therefore the response to treatment.Objectives:This study investigates agreement between US of hand and wrist findings and the clinical examination and biological inflammatory parameters in RA patients.Methods:We performed a cross sectional study including patients responding to the ACR/EULAR 2010 criteria for RA diagnosis. We collected US findings assessing synovitis and doppler signal in wrist, metacarpophalangeal (MCP) and proximal interphalangeal (PIP) articulations, and concomitant clinical examination assessing synovitis and pain in the same joints along with C reactive protein (CRP) levels and disease activity score (DAS28). The power Doppler US score (PDUS) from 6 simplified synovial sites (wrists, bilateral second and third MCP joints) was calculated [1].Results:Forty-three patients were included with 91.7% of women. The mean age was 62±12.95 years old. The mean age at diagnosis was 52±14.79 years with a mean disease evolution of 8±8.57 years. Rheumatoid factor and anti-citrullinated antibodies were positive in respectively 78% and 83.9% of cases.The mean disease activity (DAS28) was 1,52 with levels ranging from 1.5 to 7.33.Right wrist was the articulation in which US synovitis was most frequently detected (60.5% of patients), followed by the left wrist (53.5%). Power doppler signal was detected as frequently in the right as in the left wrist articulations (41.9%). Subsequently, clinical synovitis was most frequently detected in right and left wrist with 39,5% and 41,5% respectively. These joints were the most frequently painful, in 51.2% and 48.8% at right and left respectively.US synovitis of the first interphalangeal joint was found in only 2.3% and 4.7% in the right and left hand respectively, with positive power doppler signal in 2.3% of the patients in the same articulations.The overall agreement between US and clinical examination in detecting synovitis of wrist, MCP and PIP joints was of 67.3%. It was of 71.4% in wrists, 54.7% in MCP joints and 87% in PIP joints. This suggests the presence of infra-clinical synovitis. All sites combined, US synovitis were correlated to clinical synovitis (p=0.03).A positive correlation was found between PDUS from 6 simplified joint sites and CRP levels (p value of 0.02). No correlation was found with disease activity score (DAS28).Conclusion:US of hands and wrist articulations is more performant than clinical examination in detecting synovitis. The most frequently involved joints with clinical and US synovitis, pain and positive power doppler signal were the wrist joints. CRP level is predictive of the presence of a high simplified power doppler score which is related to clinical activity of the disease as reported by Kawashiri et al. [1].References:[1]Kawashiri S, Kawakami A, Iwamoto N, Fujikawa K, Satoh K, Tamai M, et al. The power Doppler ultrasonography score from 24 synovial sites or 6 simplified synovial sites, including the metacarpophalangeal joints, reflects the clinical disease activity and level of serum biomarkers in patients with rheumatoid arthritis. Rheumatology (Oxford). mai 2011;50(5):962-5.Disclosure of Interests:None declared

AB0578 SUBCLINICAL ENTHESITIS IN PSORIASIS patiEntS AS prediCtor OF ARTHRITIS (EPESCA STUDY): PRELIMINARY RESULTS

Background:Enthesitis is one of the typical pathological signs of spondyloarthritis such as psoriatic arthritis (PsA) and it seems to be the Primum movens of the disease. Clinical assessment of enthesitis showed to be less sensitive, compared to ultrasound (US) evaluation, in identifying enthesitis in patients with PsA [1].OMERACT defined US enthesitis as: “hypoechoic and/or thickened insertion of the tendon close to the bone (within 2 mm from the bony cortex), which exhibits Doppler signal if active and that may show erosions, enthesophytes/calcifications as a sign of structural damage” [3]The reported prevalence of subclinical enthesitis in psoriasis (PsO) patients in different countries ranges between 7% and 20% [2].Objectives:The main objective of this study was to estimate, by US evaluation, the prevalence of subclinical enthesitis in PsO patients without any clinical signs of enthesitis. Secondary objectives were to analyze differences, in terms of age, sex, BMI, PsO onset and diagnosis, among patients with enthesitis (active or not active), enthesopathy and without any alteration of enthesis.According to the OMERACT definition of ultrasound enthesitis, patients were divided into 4 groups: patients with active enthesitis (AE) defined as the presence of power-Doppler signal in a hypoechoic and/or thickened insertion of the tendon close to the bone; patient with enthesitis (En) defined as hypoechoic and/or thickened insertion of the tendon close to the bone without PD signal; patients with enthesopathy (Ep) defined as the presence of structural damage (erosions, enthesophytes/calcifications); patients without any alteration of enthesis (WE).Methods:Patients with at least 18 years and a diagnosis of PsO made by a Dermatologist were included. Exclusion criteria were the presence of clinical symptoms or signs of articular or entheseal involvement, diagnosis of arthritis and therapy with bDMARDs or tsDMARDs.All patients underwent US examination on grey scale and Power Doppler (PD) ultrasonography of 6 sites (Achilles, quadriceps, distal and proximal patellar, plantar fascia and triceps enthesis) bilaterally. Ultrasound was performed by an experienced sonographer, using a Logiq P9 equipped with 6-12 MHz broad band linear transducer. Data were reported as frequencies and median with interquartile range. To check differences among these four groups, we used chi-square test or Kruskall-Wallis test. P-value ≤ 0.05 is considered statistically significant.Results:We enrolled 124 consecutive psoriasis patients (47 [37.9%] female) with median age 57.7 (45.3-66.5) years, median disease duration 20.4 (10.1-30.8) years, median BMI 27 [24-29]. Patients with AE, En, Ep were 20.2% (25/124), 49.2% (61/124) and 18.5% (23/124), respectively.Patients WE (12.1%, 15/124) showed significantly lower BMI, younger age and shorter diagnostic delay compared to the other patients.All signs of enthesopathy/enthesitis were more frequently observed at Achilles (33.1%, 41/124), triceps (23.4%, 29/124), quadriceps (20.2%, 25/124), distal patellar (18.5%, 23/124) and proximal patellar (4.8%, 6/124) enthesis.Conclusion:Subclinical enthesitis is quite common in PsO patients, and about 20% showed active enthesitis. The enthesopathy seems to be more frequent in patients with increased delay in PsO diagnosis, older age and higher BMI.References:[1]Bandinelli F. et al. Ultrasound detects occult entheseal involvement in early psoriatic arthritis independently of clinical features and psoriasis severity. Clin Exp Rheumatology. Mar-Apr 2013;31(2):219-24.[2]Zuliani F. et al. Ultrasonographic detection of subclinical enthesitis and synovitis: a possible stratification of psoriatic patients without clinical musculoskeletal involvement. Clin Exp Rheumatol Jul-Aug 2019;37(4):593-599.[3]Balint P. V. et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: an OMERACT US initiative. Ann Rheum Dis 2018 Dec;77(12):1730-1735.Disclosure of Interests:None declared.

POS1066 IS ENTHESITIS A SONOGRAPHIC BIOMARKER OF DISEASE SEVERITY IN PSORIATIC ARTHRITIS? THE LINK BETWEEN ULTRASOUND ENTHESEAL ABNORMALITIES AND PERIPHERAL JOINT EROSIVE DAMAGE

Background:Enthesitis is one of the hallmark of psoriatic arthritis (PsA). Ultrasound (US) accurately detects morphostructural abnormalities indicative of entheseal inflammation and structural damage. Interestingly, in a recent study, US-detected entheseal pathology appeared to be a potential marker of disease severity, being associated with higher radiographic score of structural damage at peripheral joint level. (1) However, a sub-analysis of the impact of each elementary finding of US enthesitis was not performed. Moreover, some US entheseal abnormalities (hypoechogenicity, thickening and calcification/enthesophyte) have been described as frequent findings in healthy subjects and patients with dysmetabolic conditions, undermining their specificity. (2) Thus, we hypothesized that their role as a sonographic biomarker of joint disease severity could be questioned.Objectives:The main aim of the present study was to explore the association between the US elementary findings of enthesitis defined by OMERACT [i.e. hypoechogenicity, thickening, Doppler signal, calcification/enthesophyte and bone erosion at enthesis] (3) and the presence of US-detected joint bone erosions in patients with PsA.Methods:Consecutive patients with PsA (CASPAR criteria) were included in this cross-sectional single-centre study. The scanning protocol included bilateral assessment of the main entheses of the lower limbs [plantar fascia, quadriceps, patellar (proximal and distal) and Achilles tendons]. The presence of US joint bone erosions was investigated in the following areas: 2nd and 5th metacarpophalangeal (MCP) joints, ulnar head and 5th metatarsophalangeal (MTP) joint, bilaterally, as well as the most inflamed joint at the physical examination. The US examination was carried out with a 6-18 MHz probe. Univariate and multivariate logistic analysis were performed to identify predictors of US joint bone erosions.Results:A total of 74 PsA patients were enrolled. The mean disease duration was 7.9±8.0 years. Joint bone erosions were found in 36/75 patients (48.0%), and in 71/600 joints (11.8%), most frequently in the 5th MTP joint (in 26/75 patients, 34.7%). The univariate analysis showed that entheseal bone erosions [odds ratio (OR) 27.1, 95% confidence interval (CI) 3.3-220.2, p value <0.01] and Doppler signal (OR 3.5, 95% CI 1.3 - 9.4, p value 0.01) were associated with joint bone erosions. Only entheseal bone erosions remained significantly associated with joint bone erosions in the multivariate analysis (Table 1).Table 1.Multivariate regression analysis: predictive value of the entheseal US findings for the presence of joint bone erosions.OR (95% CI)P valueHypoechogenicity0.5 (0.1-3.4)0.45Thickening2.2 (0.6-8.3)0.27Doppler signal3.2 (0.9-10.8)0.06Calcification/enthesophyte1.1 (0.1-11.2)0.99Entheseal bone erosion24.2 (2.7-216.2)<0.01Conclusion:Entheseal bone erosion and, to a lesser extent, Doppler signal, were the only entheseal abnormalities correlated with the presence of US-detected joint bone erosions, representing potential sonographic biomarkers of disease severity in PsA.References:[1]Polachek A, Cook R, Chandran V, Gladman DD, Eder L. The association between sonographic enthesitis and radiographic damage in psoriatic arthritis. Arthritis Res Ther 2017; 15;19:189.[2]Balint PV, Terslev L, Aegerter P, Bruyn GAW, Chary-Valckenaere I, Gandjbakhch F, et al. Reliability of a consensus-based ultrasound definition and scoring for enthesitis in spondyloarthritis and psoriatic arthritis: An OMERACT US initiative. Ann Rheum Dis 2018; 77(12):1730-5.[3]Di Matteo A, Filippucci E, Cipolletta E, Martire V, Jesus D, Musca A, et al. How normal is the enthesis by ultrasound in healthy subjects? Clin Exp Rheumatol 2020;38:472-8.Disclosure of Interests:Gianluca Smerilli: None declared, Edoardo Cipolletta: None declared, Giulia Maria Destro Castaniti: None declared, Andrea Di Matteo: None declared, Marco Di Carlo: None declared, Erica Moscioni: None declared, Francesca Francioso: None declared, Walter Grassi Speakers bureau: W.G. has received speaking fees from AbbVie, Celgene, Grünenthal, Pfizer and UCB Pharma., Emilio Filippucci Speakers bureau: E.F. has received speaking fees from Abbvie, BMS, Janssen, Lilly, MSD, Novartis, Roche, Pfizer, UCB Pharma.