Psoriatic arthritis (PsA) is a chronic autoimmune disease that causes a variety of musculoskeletal abnormalities. Musculoskeletal ultrasound in PsA is becoming increasingly popular, both in clinical practice and research. This narrative reviews recent literature on the utility of ultrasound in PsA.A search of PubMed was used to identify publications written in English, with titles containing the term psoriatic arthritis and either ultrasound, ultrasonography, or sonographic. A total of 178 publications were identified; those that were not relevant (n = 59), were not original research (n = 45), or that had small (<30) sample sizes (n = 34) were excluded, leaving 40 studies for review of the use of ultrasound in various aspects of PsA. Publications with similar findings were grouped into seven domains: (1) the use of ultrasound findings compared to clinical assessment; (2) the use of ultrasound in the assessment of enthesitis; (3) the use of ultrasound in the assessment of nails; (4) the use of ultrasound as a screening tool in patients with psoriasis at risk for PsA; (5) the use of ultrasound in differentiating PsA from other similar conditions; (6) the use of ultrasound as a measure of disease activity; and (7) the use of ultrasound compared to MRI.In recent studies, ultrasound measures of inflammation tended to agree with objective clinical findings of disease, such as swollen joint counts, while being less influenced by subjective measures, such as pain. Ultrasound has utility in the assessment of enthesitis and psoriatic nail disease in PsA, and as an overall measure of disease activity. Ultrasound-based outcomes measures have been used in observational studies and in clinical trials involving PsA, and may have utility as a measure of treatment response. The findings from recent studies suggest that ultrasound may have utility in improving the accuracy and precision of screening programs designed to identify subclinical PsA in cohorts of patients with psoriasis; however, cost-efficacy remains to be determined. Beyond screening, ultrasound may have utility in the diagnosis of PsA in patients with suspected inflammatory arthritis, and ultrasound measures of inflammation agree with MRI measures of inflammation, meaning that incorporating ultrasound into clinical practice might help to overcome the barriers associated with MRI.As ultrasound technology continues to advance, and associated costs decrease, it is likely that ultrasound will become more integrated into the clinical journeys of patients with PsA. 

Utility of Musculoskeletal Ultrasound in Psoriatic Arthritis.

AIMS
To investigate the prevalence and distribution of bone erosions in an early psoriatic arthritis (PsA) population using conventional radiography (CR) and to explore the agreement between CR and ultrasound (US) detected bone erosions.


METHODS
Newly diagnosed, treatment naïve PsA patients fulfilling the ClASsification for Psoriatic Arthritis (CASPAR) classification criteria of ≤5 years symptom duration were recruited as part of the Leeds Spondyloarthropathy Register for Research and Observation and underwent CR and US examination of hands and feet.


RESULTS
Overall, 4655 hand and feet joints were assessed in 122 patients. CR erosions were detected in 24.6% (n=30) with lowest prevalence seen below 8 months of symptoms (17.5% vs 24.3%>24 months). The number of erosions was higher on CR (1.55% (63/4,655); US 1.04% (34/3,270)), with 5th metatarsophalangeal (MTP) joint being the most affected site in both CR (5.21% (11/211)) and US (7.14% (15/210)). Erosions in CR were more evenly distributed compared with US where three-quarters of the total number of bone erosions were detected in wrists, second metacarpophalangeal (MCP) and fifth MTP joints. Most joints had almost perfect prevalence-adjusted bias-adjusted kappa values ranging from 0.91 to 1.


CONCLUSIONS
Erosions were seen in a quarter of patients with newly diagnosed, untreated PsA with a declining trend around the 8-month symptom duration cut-off. High levels of agreement between CR and US were seen with CR detecting more erosions. A focused US assessment of the wrist, second MCP and fifth MTP joints may be useful to detect bone erosions in early PsA.

High prevalence of radiographic erosions in early, untreated PsA: results from the SpARRO cohort.

Nail unit (anatomy)

Abstract Rheumatoid and psoriatic arthritis (RA and PsA, respectively) are common types of inflammatory arthritis. Differentiating between the two diseases in their early stages is challenging, especially in the absence of diagnostic biomarkers and specific psoriatic lesions. Our aim was to evaluate the role of musculoskeletal ultrasonography (MSUS) and dermoscopy in the diagnosis of PsA and RA. Sixty patients with early hand arthritis diagnosed as seronegative RA, seropositive RA, or PsA were enrolled in this case-control study. All patients underwent rheumatological and dermatological clinical assessments and MSUS and dermoscopic examinations. All patients were followed up after one year of recommended treatment. Wrist and metacarpophalangeal joint (MCP) synovitis and erosions were higher in patients with RA than in those with PsA. The MSUS features of PsA, including distal interphalangeal joint (DIP) synovitis, flexor tenosynovitis, central slip enthesitis, and DIP enthesitis, were significantly higher in the PsA group than in the RA group. In addition, dermoscopic scalp, nail, and elbow findings of psoriasis are more commonly found in PsA than in RA. Similar MSUS and dermoscopic differences were detected after one year of follow-up. The sensitivity and specificity of at least one MSUS feature for PsA diagnosis were 90% and 62%, respectively, whereas those of combined MSUS and nail dermoscopy were 42% and 100%, respectively. We concluded that Both MSUS and dermoscopy could differentiate patients with PsA from those with RA, and combining both modalities may increase the likelihood of accurate diagnosis. 

Use of Ultrasonography Combined with Dermoscopy for Diagnosis of Early Psoriatic Arthritis and Early Seronegative Rheumatoid Arthritis

Psoriatic arthritis (PsA) is a chronic immunoinflammatory disease of the enthesis and adjacent synovium, skin, and nail, which early diagnosis may be crucial for starting a prompt therapeutic intervention. Theoretically, early treatment offers the advantage of acting on the reduction of the articular damage progression since initial phases of the disease. 

Early psoriatic arthritis: clinical and therapeutic challenges.

Objective: Despite recent advances, early diagnosis of psoriatic arthritis (PsA) remains a challenge in clinical practice. Ultrasound (US) could be a useful tool for the diagnosis and management of PsA. The objective of this review was to determine the role of US in early diagnosis of PsA. Methods: We have performed a literature review aiming to evaluate studies on US findings in psoriasis and their predictive value of progression to PsA, as well as studies on US features specific for PsA in comparison with other conditions. Results: A total of 40 studies were included. Sixteen studies assessed US findings in psoriasis, of which only 3 prospectively evaluated the role of US in predicting progression to PsA. Patients with PsA had a greater frequency of US abnormalities, in particular enthesitis and Power Doppler(PD) signal compared to patients with psoriasis only. In the longitudinal studies, psoriatic patients with higher enthesopathy scores at baseline were more likely to progress to PsA. Twenty-four studies evaluated US abnormalities in PsA and compared them to other conditions. Most specific US features that distinguish PsA from psoriasis were PD signal and erosions in joints and entheses. Extra-synovial changes, including peri-tendinous dermal soft tissue oedema with associated PD signal and flexor tendon enthesopathy, as well as thickening of the pulleys in the flexor tendons were highly characteristic for PsA, as they were frequently found in PsA patients, but in none of the RA patients. US-detected entheseal abnormalities in particular erosions and PD signal were more frequent in patients with PsA compared to fibromyalgia. Conclusion: Despite the wide use of US in PsA, more research is needed to identify predictive factors of progression to PsA in patients with psoriasis, as well as to determine most specific US features that differentiate PsA from other conditions.

Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis

<h3>Introduction</h3> Admissions with decompensated cirrhosis are demonstrably increasing nationally.<sup>1</sup> A GIRFT audit of our Trust’s data from 2017–2018 revealed a 30-day readmission rate from liver disease of 30.43%. Demand for Consultant Gastroenterology appointments is rapidly rising with waiting times extending beyond several months, and increasingly limited space for face-to-face appointments. Novel methods are required to manage complex patients. Specialist nurse-led early post-discharge clinics have shown reductions in admissions, length of stay and complications.<sup>2</sup> We present the implementation of a hybrid virtual and face-to-face clinic delivered by gastroenterology senior house officers familiar with the patients, from a ward-adjacent location, advised by registrars and consultants. <h3>Methods</h3> Patients were followed up 1 week post-discharge in an SHO-led clinic, with senior guidance. Appointments were carried out to monitor ascites, weight, renal function, liver function, diuretic dosing and ensure timely review of pending results on discharge, e.g. non-invasive liver screens. Retrospective analysis of data over a 6-month period from 20/07/22 to 20/01/23 was carried out. <h3>Results</h3> From 20/07/22 to 20/01/23, a total of 112 reviews on 58 patients were booked, with progressing numbers as the service developed. 70% of reviews were virtual. The 30-day mortality for patients discharged from the ward with decompensated cirrhosis to the SHO clinic was 0%. Over the period evaluated, 21 patients with cirrhosis were re-admitted; of these 12 patients had DNA’d their SHO clinic and thus did not have optimisation of their liver disease. <h3>Conclusions</h3> Our model has ensured pending results on discharge are acted on promptly, and has aimed to reduce re-admission and complication rates, particularly secondary to unsuitable diuretic dosing. Analysis shows a 30-day mortality of 0% in the cohort followed up by our clinic, and over half of patients re-admitted had not been optimised through our outpatient model. The model avoids issues with the lack of direct access to specialty advice through units such as ambulatory care. It is one that can be adapted by other trusts to utilise the efficiency and competence of middle grade doctors to manage patients on a pre-defined pathway with consultant direction and tackle issues with long clinic waiting lists. <h3>References</h3> British Liver Trust (2019) The alarming impact of liver disease in the UK Facts and statistics. Giles B, <i>et al.</i> (2021) ‘O03 A novel nurse-led early post-discharge clinic is associated with fewer readmissions and lower mortality following an index hospitalisation with decompensated cirrhosis,’ <i>Oral</i> [Preprint]. Available at: https://doi.org/10.1136/gutjnl-2021-basl.3. 

P302 A novel SHO-led early post-discharge hepatology clinic is associated with high attendance and low mortality

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Improving Imaging Modalities in Early Psoriatic Arthritis: The Role of Ultrasound in Early Diagnosis of Psoriatic Arthritis

P302 A novel SHO-led early post-discharge hepatology clinic is associated with high attendance and low mortality