Nurses step up to the challenge of working during the pandemic

Chief Nursing Officers for Northern Ireland, Scotland, Wales and England Jean White, Charlotte McArdle, Fiona McQueen and Ruth May all agree that, although plans to mark International Nurses' Day are on hold, we must still find time to celebrate nurses across all specialties who have responded with speed and flexibility.

Leaders in health for everyone

The chief nursing officers for England, Northern Ireland, Scotland and Wales celebrate nurses' essential role in ensuring high-quality care for all.

Healthcare is a human right

In celebration of International Nurses Day, Jane Cummings, Jean White, Fiona McQueen and Charlotte McArdle, Chief Nursing Officers (CNOs) for England, Wales, Scotland and Northern Ireland, share their thoughts on this important day in the nursing calendar.

Advanced Imaging in the Diagnosis of Gout and Other Crystal Arthropathies

In recent years significant advances have been made in imaging techniques. Dual-energy computed tomography has revolutionized the ability to detect and quantify gout. The key ultrasound features of gout have been defined. Magnetic resonance imaging is an excellent modality for demonstrating the extent and severity of crystal arthropathies, but the findings may be nonspecific. This article summarizes the use of advanced imaging techniques in the diagnosis and assessment of gout and other crystal arthropathies.

UK Chief Nursing Officers: shaping the future of the profession

In celebration of International Nurses Day, Jane Cummings, Charlotte McArdle, Fiona McQueen and Jean White, Chief Nursing Officers (CNOs) for England, Northern Ireland, Scotland and Wales.

Chief Nursing Officers: the past, present and future of nursing

In celebration of International Nurses Day, Jane Cummings, Charlotte McArdle, Fiona McQueen and Jean White, Chief Nursing Officers (CNOs) for England, Northern Ireland, Scotland and Wales, reflect on the state of nursing in their respective countries, and what the future might hold for this rapidly evolving profession

Comprehensive appraisal of magnetic resonance imaging findings in sustained rheumatoid arthritis remission: a substudy

OBJECTIVE

To evaluate the effect of sustained American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission on residual joint inflammation assessed by magnetic resonance imaging (MRI) and to secondarily evaluate other clinical definitions of remission, within an early seropositive rheumatoid arthritis (RA) cohort.

METHODS

A subcohort of 118 RA patients was enrolled from patients who completed the 2-year, double-blind randomized Treatment of Early Aggressive Rheumatoid Arthritis (TEAR) trial. Patients received a single contrast-enhanced 1.5T MRI of their most involved wrist. Two readers scored MRIs for synovitis, osteitis, tenosynovitis, and erosions. Clinical assessments were performed every 3 months during the trial and at time of MRI.

RESULTS

The subcohort was 92% seropositive with mean age 51 years, duration 4.1 months, and Disease Activity Score in 28 joints using the erythrocyte sedimentation rate 5.8 at TEAR entry. Total MRI inflammatory scores (tenosynovitis + synovitis + osteitis) were lower among patients in clinical remission. Lower MRI scores were correlated with longer duration of Clinical Disease Activity Index (CDAI) remission (ρ = 0.22, P = 0.03). At the time of MRI, 89 patients had no wrist pain/tenderness/swelling; however, all 118 patients had MRI evidence of residual joint inflammation after 2 years. No statistically significant differences in damage or MRI inflammatory scores were observed across treatment groups.

CONCLUSION

This is the first detailed appraisal describing the relationship between clinical remission cut points and MRI inflammatory scores within an RA randomized controlled trial. The most stringent remission criteria (2011 ACR/EULAR and CDAI) best differentiate the total MRI inflammatory scores. These results document that 2 years of triple therapy or tumor necrosis factor plus methotrexate treatment in early RA does not eliminate MRI evidence of joint inflammation.

OMERACT endorsement of measures of outcome for studies of acute gout

OBJECTIVE

To determine the extent to which participants at the Outcome Measures in Rheumatology (OMERACT) 11 meeting agree that instruments used in clinical trials to measure OMERACT core outcome domains in acute gout fulfill OMERACT filter requirements of truth, discrimination, and feasibility; and where future research efforts need to be directed.

METHODS

Results of a systematic literature review and analysis of individual-level data from recent clinical studies of acute gout were presented to OMERACT participants. The information was discussed in breakout groups, and opinion was defined by subsequent voting in a plenary session. Endorsement was defined as at least 70% of participants voting in agreement with the proposition (where the denominator excluded those participants who did not vote or who voted "don't know").

RESULTS

The following measures were endorsed for use in clinical trials of acute gout: (1) 5-point Likert scale and/or visual analog scale (0 to 100 mm) to measure pain; (2) 4-point Likert scale for joint swelling; (3) 4-point Likert scale for joint tenderness; and (4) 5-point Likert scale for patient global assessment of response to treatment. Measures for the activity limitations domain were not endorsed.

CONCLUSION

Measures of pain, joint swelling, joint tenderness, and patient global assessment in acute gout were endorsed at OMERACT 11. These measures should now be used in clinical trials of acute gout.

The impact of illness perceptions on sexual functioning in patients with systemic lupus erythematosus

OBJECTIVE

Sexual problems are common in patients with chronic illnesses. However, few studies have investigated problems with sexual functioning in patients with systemic lupus erythematosus (SLE). The present cross-sectional study assessed the influence of SLE on sexual functioning and its associations with illness perceptions and medical and socio-demographic characteristics.

METHOD

The study included 106 SLE patients who used at least one immunosuppressive agent to control their SLE. Sexual functioning was measured using the Physical Disability Sexual and Body Esteem and the Medical Impact Scale from the Sexual Functioning Questionnaire. Patients' illness perceptions were assessed using the Brief Illness Perception Questionnaire.

RESULTS

49.1% of patients agreed that their SLE had a negative influence on their sexual functioning. In addition, treatment for SLE seemed to play an important role in the negative impact on sexual functioning. Patients' illness perceptions were more important predictors of sexual functioning than medical and socio-demographic characteristics. SLE patients appear to report a lower sexual functioning than patients with other chronic illnesses.

CONCLUSION

SLE in general and immunosuppressive treatment for SLE specifically have a negative influence on sexual functioning. Patients' illness perceptions appear to play a more important role in the negative impact on sexual functioning than medical characteristics such as disease activity. The high prevalence of sexual problems highlights the need to more frequently address and aim to improve sexual functioning in patients with SLE. Patients may benefit from methods such as illness perception modification and coping style interventions to reduce their sexual problems.

Effect of glacial acetic acid pre-treatment of cervical liquid-based cytology specimens on the molecular detection of human papillomavirus

OBJECTIVE

Cytology laboratories routinely treat cervical liquid-based cytology (LBC) specimens that are heavily contaminated with blood with glacial acetic acid (GAA) in order to lyse red blood cells and facilitate assessment. However, the impact on downstream human papillomavirus (HPV) detection is not well understood. This study examines the effect of GAA pre-treatment of ThinPrep(®) Preservcyt(®) specimens on the molecular detection of HPV.

METHODS

A panel of 150 routinely collected cervical LBC specimens was tested with two commercial HPV tests, the Abbott RealTime High Risk HPV test (rtHPV) and the Qiagen Hybrid Capture 2 High Risk HPV DNA test (HC2), as aliquots before and after GAA treatment. Statistical analysis was performed using McNemars test and Bland and Altman plots.

RESULTS

Agreement between the results of the rtHPV test on GAA-untreated and GAA-treated specimens was 95.7%, with no evidence of a significant difference in the distribution of the discrepant results (P = 0.414). HC2 test agreement on GAA-untreated and GAA-treated specimens was 91% at a cut-off of 1 relative light unit index (RLUI) and 92% at a cut-off of 2 RLUI. There was no evidence of a difference in the distribution of discordant results at a cut-off of 1 (P = 0.405) and 2 RLUI (P = 0.564).

CONCLUSIONS

GAA pre-treatment of cervical ThinPrep Preservcyt LBC specimens had little effect on the two commercial HPV tests used in this study. The impact of GAA treatment on HPV testing should, however, be validated for all HPV tests and all LBC collection media used in each particular diagnostic setting.

Valproate-induced hyperammonaemia superimposed upon severe neuropsychiatric lupus: a case report and review of the literature

This paper presents a case of systemic lupus erythematosus (SLE) with neuropsychiatric features, where the outcome was influenced by the development of hyperammonaemia, probably induced by sodium valproate. A case of severe SLE occurring in a 20-year-old Maori girl is described. Her disease had been characterised by neuropsychiatric features for several years, culminating in persistent seizure activity at the time of her final presentation. Her management with anticonvulsants was complicated by the development of intractable hyperammonaemia which contributed to irreversible clinical deterioration. We have reviewed the English literature for reports of valproate-related hyperammonaemia which has often been described in the setting of seizure and mood disorders. This is the first case where it has been reported, superimposed upon severe neuropsychiatric SLE (NP-SLE). The mechanism by which valproate induces hyperammonaemia remains incompletely understood but is likely to relate to the urea cycle. Under normal metabolic conditions, acyl-CoA is transported into the mitochondria via a carnitine transport system. It is then converted to acetyl-CoA via β-oxidation and eventually to N-acetyl glutamate. This pathway can be interrupted by the introduction of sodium valproate, leading to a reduction of free coenzyme A, acetyl-CoA and carnitine, and resulting in the decreased availability of cofactors necessary for the function of the urea cycle. As this is the primary means of ammonia metabolism, serious elevation in serum ammonia levels may occur in patients on this anticonvulsant medication. In this patient with active NP-SLE, the combined autoimmune and metabolic brain insult contributed to a fatal outcome.

A B cell explanation for autoimmune disease: the forbidden clone returns

More than 60 years ago, Burnet first proposed the 'forbidden clone' hypothesis postulating that autoimmune disease arises as a result of persistence of self-reactive clones of lymphocytes that should have been deleted via immune tolerance. These autoreactive clones could effect immune-mediated end-organ damage via peripheral self-antigen recognition. Recent evidence that stretches across the boundaries of many medical specialties supports this proposal, implicating a B cell precursor as the culprit. The success of B cell depleting therapy in rheumatoid arthritis, anti-neutrophil cytoplasmic antibodies (ANCA) associated vasculitis, polymyositis, lupus and autoimmune diseases as diverse as multiple sclerosis and idiopathic thrombocytopenic purpura supports this proposal. Clonality of B cells and plasma cells has been described in a number of autoimmune disorders and the presence of autoantibodies, which may arise years before the onset of clinical disease, supports the notion of autoreactivity within the B cell lineage. T cell activation within the end-organ would be predicted by cognate B-T cell interactions and resultant tissue inflammation and destruction could produce diverse clinical manifestations dictated by the original specificity of the autoimmune B cell.

Evaluating intratester reliability of manual masking of plantar pressure measurements associated with chronic gout

BACKGROUND

Plantar pressure measurements are commonly used to evaluate foot function in chronic musculoskeletal conditions. However, manually identifying anatomical landmarks is a source of measurement error and can produce unreliable data. The aim of this study was to evaluate intratester reliability associated with manual masking of plantar pressure measurements in patients with gout.

METHODS

Twenty-five patients with chronic gout (mean disease duration, 22 years) were recruited from rheumatology outpatient clinics. Patients were excluded if they were experiencing an acute gout flare at the time of assessment, had lower-limb amputation, or had diabetes mellitus. Manual masking of peak plantar pressures and pressure-time integrals under ten regions of the foot were undertaken on two occasions on the same day using an in-shoe pressure measurement system. Test-retest reliability was assessed by using intraclass correlation coefficients, SEM, 95% limits of agreement, and minimal detectable change.

RESULTS

Mean peak pressure intraclass correlation coefficients ranged from 0.92 to 0.97, with SEM of 8% to 14%. The 95% limits of agreement ranged from-150.3 to 133.5 kPa, and the minimal detectable change ranged from 30.8 to 80.6 kPa. For pressure-time integrals, intraclass correlation coefficients were 0.86 to 0.94, and SEM were 5% to 29%, with the greater errors observed under the toes. The 95% limits of agreement ranged from -48.5 to 48.8 kPa/sec, and the minimal detectable change ranged from 6.8 to 21.0 kPa/sec.

CONCLUSIONS

These findings provide clinicians with information confirming the errors associated with manual masking of plantar pressure measurements in patients with gout.

Quantifying synovitis in rheumatoid arthritis using computer-assisted manual segmentation with 3 Tesla MRI scanning

PURPOSE

To investigate the reliability, validity and feasibility of a computer-assisted manual segmentation method for determining the synovial membrane volume as a surrogate measure for synovitis in patients with rheumatoid arthritis (RA).

MATERIALS AND METHODS

The 3 Tesla (T) MRI scans were acquired in 22 early RA and 16 established RA patients. Synovial membrane volumes in postcontrast T1w axial images at three wrist joint regions were determined by two nonradiologist observers using a computer-assisted manual segmentation method.

RESULTS

Intraobserver reliability, measured by intraclass correlation coefficients (ICCs), was excellent in the early (ICC = 0.99) and established (ICC = 0.99) RA cohorts. Interobserver reliability (mean ICC [95% Confidence Interval]) was moderate to excellent in the early and established RA groups (ICCs = 0.87 [0.68,0.94] and 0.88 [0.66, 0.96], respectively). There was a strong correlation between the synovial membrane volumes derived by segmentation and the RA MRI scoring system (RAMRIS) scores for synovitis at all joints in the early (Spearman rho = 0.86-0.96) and established (Spearman rho = 0.85-0.93) RA cohorts. The entire segmentation technique took 19 to 21 min per patient.

CONCLUSION

Measurement of MRI synovitis using a computer-assisted manual segmentation method demonstrated excellent intraobserver and very good interobserver reliability, content validity (represented by its strong correlation with RAMRIS synovitis), and moderate feasibility.

Basing musculoskeletal curriculum changes on the opinions of practicing physicians

AIM

To establish which musculoskeletal conditions are deemed to be the most important in clinical practice. To use this information to inform the development of a new musculoskeletal curriculum, with emphasis on common and relevant conditions.

METHODS

A survey listing 29 musculoskeletal conditions was sent to 150 doctors in Auckland, New Zealand. Doctors from 5 specialties, including general practice, were asked to score each condition on a rating scale from 0 to 7, to determine which conditions were perceived to be the most important as encountered in day-to-day clinical practice.

RESULTS

The overall response rate to the survey was 36% and this was predominantly due to the low response rate from general practitioners. Fifteen conditions were given average ratings of 4.5/7 or greater and the top 5 of these were as follows: prolapsed intervertebral disc, hip fracture, mechanical back pain, gout at the great toe and osteoarthritis of the hip.

CONCLUSION

This study has used a consensus approach to identify specific musculoskeletal conditions deemed to be the most important in clinical practice. The information obtained can be used for designing a contemporary and relevant musculoskeletal medical curriculum.

Zoledronic acid does not reduce MRI erosive progression in PsA but may suppress bone oedema: the Zoledronic Acid in Psoriatic Arthritis (ZAPA) Study

BACKGROUND

The effect of zoledronic acid (ZA) on articular bone in patients with psoriatic arthritis (PsA) was investigated using MRI.

METHODS

Patients with erosive PsA were randomised to receive 3-monthly infusions of ZA or placebo for 1 year. An additional 'tests alone' group received no infusions. Clinical assessments and MRI scans were performed at baseline and 1 year.

RESULTS

Paired 1.5T MRI scans were available in 22 patients including 6 who received ZA and 16 who did not (non-ZA = 6 placebo + 10 'tests alone' patients). The Disease Activity Score (28 swollen and tender joints, C reactive protein fell over 12 months to a greater degree in patients on ZA than in non-ZA patients (-1.6 vs -0.3, p=0.023). The MRI bone oedema score decreased in the ZA group (15.5 to 8.5) but increased in the non-ZA group (14.0 to 18.0) (p= 0.0056) with regression of bone oedema at 13.5% of sites in ZA patients vs 1.3% in non-ZA patients (p = 0.0073) and progression in 1.3% of sites in ZA patients vs 6.9% in non-ZA patients (p = 0.072). There was no difference between groups in change in MRI erosion score.

CONCLUSIONS

In this pilot study ZA reduced the progression of MRI bone oedema, indicating probable suppression of osteitis concordant with reduction in clinical measures of disease activity.

Intentional and unintentional treatment nonadherence in patients with systemic lupus erythematosus

OBJECTIVE

Patients may be defined as nonadherent if they do not take their medications as prescribed by their physicians. Determinants of nonadherence may vary between and within patient groups. This study investigated the extent to which patients with systemic lupus erythematosus (SLE) show intentional and unintentional nonadherence, and the associations of nonadherence with psychological and medical parameters.

METHODS

The study included 106 patients who were receiving at least one immunosuppressive agent to control their SLE. Level of self-reported adherence and a measure of both intentional and unintentional nonadherence were obtained. Questionnaires were completed to assess associations between adherence and problems with cognitive functioning, beliefs about medicines, illness perceptions, emotional health, and disease characteristics.

RESULTS

The mean self-reported adherence rate for the total patient group was 86.7%. At least occasional intentional nonadherence was reported by 46.2% of patients and 58.5% of patients were at least occasionally unintentionally nonadherent. Problems with cognitive functioning, concerns about adverse effects of medication, and younger age were the strongest predictors of (non)adherence. Patients who were emotionally affected by their SLE were more likely to report low adherence, but this was not a significant predictor after accounting for other variables. Disease characteristics showed no relationship to measures of adherence.

CONCLUSION

Although SLE patients reported high levels of adherence on average, they commonly reported intentional and unintentional nonadherence. Adherence was associated with both cognitions and emotions. Nonadherence may be reduced by targeting emotional and cognitive functioning and by fine tuning doctor-patient communication to address patients' individual concerns about their medications.

Assessment of cartilage loss at the wrist in rheumatoid arthritis using a new MRI scoring system

OBJECTIVES

To develop and test an MRI cartilage scoring system for use at the wrist in rheumatoid arthritis (RA).

METHODS

MRI scans were obtained using a 3T MRI scanner with dedicated wrist coil in 22 early and 16 established RA patients plus 22 controls. Axial and coronal T1-weighted (precontrast and postcontrast) and T2-weighted turbo spin echo sequences were obtained. Eight wrist joints were scored for cartilage narrowing: distal radioulnar, radiolunate, radioscaphoid, triquetrum-hamate, capitate-lunate, scaphotrapezoid, second metacarpal base-trapezoid and third metacarpal base-capitate, using a system based on the Sharp van der Heijde x-ray joint space narrowing (JSN) score by three radiologists. Fifteen sites at the wrist were also scored for synovitis, bone oedema and erosion using the RA MRI score.

RESULTS

Interobserver (three-reader) and intraobserver reliability (readers 1 and 2) for the cartilage score were excellent: intraclass correlations (ICC (95% CI)) 0.91, (0.86 to 0.94), 0.98 (0.96 to 1.00) and 0.94 (0.87 to 1.00), respectively. Cartilage scores (median, range) were higher in the established RA group (11.9, 2.3-27.3) than the early RA group (2.15, 0-6) (p≤0.001) but early RA scores did not differ from healthy controls (2.3, 1-8.7). Cartilage scores correlated with synovitis (R=0.52), bone oedema (R=0.63) and erosion scores (R=0.66), p<0.001 for all, and with x-ray JSN scores (R=0.68 to 0.78).

CONCLUSION

This MRI cartilage score demonstrated excellent reliability when tested in a three-reader system. However, cartilage loss in early RA could not be distinguished from that seen in healthy controls.

Outcome domains for studies of acute and chronic gout

Discussion and voting at OMERACT 9 confirmed 5 essential domains for outcomes of acute gout: pain, joint swelling, joint tenderness, patient global assessment and activity limitations. For studies in chronic gout 7 essential domains are: serum urate, acute gout attacks, tophus burden, health-related quality of life, activity limitations, pain, and patient global assessment. Implications of patient perspectives, discretionary domains for specific studies, measurement instruments and a possible responder index are under study.

A modified Delphi exercise to determine the extent of consensus with OMERACT outcome domains for studies of acute and chronic gout

OBJECTIVES

To reach consensus with recommendations made by an OMERACT Special Interest Group (SIG).

METHODS

Rheumatologists and industry representatives interested in gout rated and clarified, in three iterations, the importance of domains proposed by the OMERACT SIG for use in acute and chronic gout intervention studies. Consensus was defined as a value of less than 1 of the UCLA/RAND disagreement index.

RESULTS

There were 33 respondents (61% response rate); all agreed the initial items were necessary, except "total body urate pool". Additional domains were suggested and clarification sought for defining "joint inflammation" and "musculoskeletal function". Items that demonstrated no clear decision were re-rated in the final iteration. There were six highly rated items (rating 1-2) with four slightly lower rating items (rating 3) for acute gout; and 11 highly rated items with eight slightly lower ratings for chronic gout.

CONCLUSIONS

Consensus is that the following domains be considered mandatory for acute gout studies: pain, joint swelling, joint tenderness, patient global, physician global, functional disability; and for chronic gout studies: serum urate, gout flares, tophus regression, health-related quality of life, functional disability, pain, patient global, physician global, work disability and joint inflammation. Several additional domains were considered discretionary.

A multireader reliability study comparing conventional high-field magnetic resonance imaging with extremity low-field MRI in rheumatoid arthritis

The use of extremity low-field magnetic resonance imaging (E-MRI) is increasing, but relatively few data exist on its reproducibility and accuracy in comparison with high-field MRI, especially for multiple readers. The aim of this multireader exercise of rheumatoid arthritis wrist and metacarpophalangeal joints was to assess the intermachine (high vs low-field) agreement and to assess the interreader agreement on high and low-field images. Study findings suggested that E-MRI performs similarly to conventional high-field MRI regarding assessment of bone erosions. However, for synovitis and bone edema, considerable intermachine and interreader variability was found. Further studies are needed before recommendations on multireader E-MRI assessment of these pathologies can be given.

A multicenter reliability study of extremity-magnetic resonance imaging in the longitudinal evaluation of rheumatoid arthritis

There are limited data on the reliability of extremity magnetic resonance imaging (E-MRI) in the longitudinal evaluation of rheumatoid arthritis (RA). Our aim was to assess the interreader reliability of the OMERACT RA MRI score in the assessment of change in disease activity and bone erosion scores using 0.2 T E-MRI hand and wrist images from 2 timepoints, evaluated by 3 readers at different international centers. The intraclass correlation coefficients and smallest detectable difference results for the change scores were generally good for erosions and synovitis, but were not acceptable for bone edema. Overall, E-MRI demonstrated ability to detect change comparable to that reported for high-field MRI for erosion and synovitis.

Developing a magnetic resonance imaging scoring system for peripheral psoriatic arthritis

We describe the first steps in developing an OMERACT magnetic resonance imaging (MRI) scoring system for peripheral psoriatic arthritis (PsA). A preexisting MRI dataset (finger joints) from 10 patients with PsA was scored by 4 readers for bone erosion, bone edema, synovitis, tendinopathy, and extracapsular features of inflammation (including enthesitis) according to specified criteria. Scoring reliability between readers was moderate to high for bone edema and erosion, but lower for soft tissue inflammation. Measures to improve reliability for future exercises will include reviewing definitions of pathological features and prior reader calibration.

The OMERACT Magnetic Resonance Imaging Inflammatory Arthritis Group - advances and priorities

This article updates the work and research priorities of the OMERACT working group on magnetic resonance imaging (MRI) in inflammatory arthritis, as presented to the OMERACT 8 meeting in Malta in May 2006. This work focused on testing the reliability of dedicated extremity MRI in rheumatoid arthritis and on the initial steps in the development of an MRI score for peripheral psoriatic arthritis.

Validation of a radiographic damage index in chronic gout

OBJECTIVE

To identify a valid method to measure radiographic damage in patients with chronic gout.

METHODS

The scoring method that best represented radiographic damage in individual joints was analyzed by comparing a gold standard rheumatologist consensus global score with recognized scoring methods, including the Sharp/van der Heijde erosion and narrowing scores, Ratingen destruction score, and Steinbrocker score. Ninety-five proximal interphalangeal joints from 12 patients with gout were included in this analysis. Scoring of hand and feet radiographs from an additional 35 patients with gout was used to analyze the sites to be included in a scoring system and the additional features to be recorded.

RESULTS

For individual joints, the combination of the Sharp/van der Heijde erosion and narrowing scores correlated best with the consensus global score. In addition, the limits of agreement were narrowest for the combined Sharp/van der Heijde erosion and narrowing score. All joint areas in the Sharp/van der Heijde rheumatoid arthritis score and the distal interphalangeal joints were affected by chronic gout and contributed to the total score. Additional features (extraarticular erosions, joint space widening, and ankylosis) occurred infrequently, and scoring of these features did not increase the reliability of the total score. The reliability of the total score was high: intraclass correlation coefficient for intraobserver reproducibility was 0.993-0.998 and for interobserver reproducibility was 0.963-0.966. The modified Sharp/van der Heijde score was able to discriminate between early and advanced disease.

CONCLUSION

A modified Sharp/van der Heijde system accurately and reliably represents radiographic joint damage in chronic gout.

Using a quality control approach to define an 'adequately cellular' liquid-based cervical cytology specimen

OBJECTIVE

To define a minimum acceptable total squamous cellularity for (ThinPrep) liquid-based cervical cytology (LBC) specimens using quality control techniques.

METHODS

Two hundred LBC preparations were made containing varying numbers (<200) of severely dyskaryotic squamous cells and with varying total cellularities.

RESULTS

Ninety-eight per cent of the LBC preparations that were missed by one or more of three cytoscreeners had fewer than 16 abnormal objects (single dyskaryotic cells or clumps of cells) and 87 dyskaryotic cells. The minimum ratio of dyskaryotic to total squamous cells that, in a preparation of 5000 squamous cells has a probability of at least 0.98 that 87 or more dyskaryotic cells will be present is 1:47. Twenty-three preparations diagnosed as abnormal had ratios of dyskaryotic to total squamous cells of between 1:2.5 and 1:4596. There is thus no feasible minimum acceptable squamous cellularity that will give an acceptable probability of detection of all specimen vials containing abnormal cells in the observed proportions.

CONCLUSIONS

It is suggested that the minimum acceptable cellularity for LBC specimens is set pragmatically by the screening programme to give a feasible percentage of repeat tests.

Magnetic resonance imaging in psoriatic arthritis: a review of the literature

Psoriatic arthritis is a diverse condition that may be characterized by peripheral inflammatory arthritis, axial involvement, dactylitis and enthesitis. Magnetic resonance imaging (MRI) allows visualization of soft tissue, articular and entheseal lesions, and provides a unique picture of the disease process that cannot be gained using other imaging modalities. This review focuses on the literature on MRI in psoriatic arthritis published from 1996 to July 2005. The MRI features discussed include synovitis, tendonitis, dactylitis, bone oedema, bone erosions, soft tissue oedema, spondylitis/sacroiliitis and subclinical arthropathy. Comparisons have been drawn with the more extensive literature describing the MRI features of rheumatoid arthritis and ankylosing spondylitis.

Pitfalls in scoring MR images of rheumatoid arthritis wrist and metacarpophalangeal joints

This paper outlines the most important pitfalls which are likely to be encountered in the assessment of magnetic resonance images of the wrist and metacarpophalangeal joints in patients with rheumatoid arthritis. Imaging artefacts and how these can be recognised using various sequences and views are discussed. Normal structures such as interosseous ligaments and nutrient foramina may appear prominent on certain images and need to be identified correctly. Pathological change in the rheumatoid hand involves many tissues and when substantial damage has occurred, it may be difficult to identify individual structures correctly. Bone erosion, bone oedema, synovitis, and tenosynovitis frequently occur together and in close proximity to each other, potentially leading to false positive scoring of any of these. Examples are given to illustrate the various dilemmas the user of this atlas may face when scoring the rheumatoid hand and suggestions are made to assist correct interpretation of what can be very complex images.

The EULAR-OMERACT rheumatoid arthritis MRI reference image atlas: the metacarpophalangeal joints

This paper presents the metacarpophalangeal (MCP) joint magnetic resonance images of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. The illustrations include synovitis in the MCP joints (OMERACT RA magnetic resonance imaging scoring system (RAMRIS), grades 0-3), bone oedema in the metacarpal head and the phalangeal base (grades 0-3), and bone erosion in the metacarpal head and the phalangeal base (grades 0-3, and examples of higher grades). The presented reference images can be used to guide scoring of MCP joints according to the OMERACT RA MRI scoring system.

An introduction to the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas

This article gives a short overview of the development and characteristics of the OMERACT rheumatoid arthritis MRI scoring system (RAMRIS), followed by an introduction to the use of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. With this atlas, MRIs of wrist and metacarpophalangeal joints of patients with rheumatoid arthritis can be scored for synovitis, bone oedema, and bone erosion, guided by standard reference images.

The development of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas

Based on a previously developed rheumatoid arthritis MRI scoring system (OMERACT 2002 RAMRIS), the development team agreed which joints, MRI features, MRI sequences, and image planes would best illustrate the scoring system in an atlas. After collecting representative examples for all grades for each abnormality (synovitis, bone oedema, and bone erosion), the team met for a three day period to review the images and choose by consensus the most illustrative set for each feature, site, and grade. A predefined subset of images (for example, for erosion--all coronal slices through the bone) was extracted. These images were then re-read by the group at a different time point to confirm the scores originally assigned. Finally, all selected images were photographed and formatted by one centre and distributed to all readers for final approval.

The EULAR-OMERACT rheumatoid arthritis MRI reference image atlas: the wrist joint

This paper presents the wrist joint MR images of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. Reference images for scoring synovitis, bone oedema, and bone erosions according to the OMERACT RA MRI scoring (RAMRIS) system are provided. All grades (0-3) of synovitis are illustrated in each of the three wrist joint areas defined in the scoring system--that is, the distal radioulnar joint, the radiocarpal joint, and the intercarpal-carpometacarpal joints. For reasons of feasibility, examples of bone abnormalities are limited to five selected bones: the radius, scaphoid, lunate, capitate, and a metacarpal base. In these bones, grades 0-3 of bone oedema are illustrated, and for bone erosion, grades 0-3 and examples of higher grades are presented. The presented reference images can be used to guide scoring of wrist joints according to the OMERACT RA MRI scoring system.

Level of agreement and biopsy correlation using two- and three-tier systems to grade cervical dyskaryosis

At present, a three-tier system is used to grade cervical dyskaryosis in the UK, although the two-tier Bethesda system is used in the United States, and the British Society for Clinical Cytology has recommended that a two-tier system be implemented here. In this study, we have retrospectively re-graded 117 conventional cervical smears using both systems to determine the intra- and interobserver variation and compare the cytology grading in both systems with the final histology. The intra and interobserver agreement was moderate using both grading systems, but the agreement between cytology grade and final histology was poor in both the two- and three-tier systems, and slightly worse using two-tier grading. However, when each of the three histological categories is considered separately the two-tier system appears to work better. Therefore, changing the way in which cervical dyskaryosis is graded in the UK may result in poorer agreement between the cervical smear result and the final histological diagnosis if introduced without proper training, monitoring and assessment.

Detection of erosions in the rheumatoid hand; a comparative study of multidetector computerized tomography versus magnetic resonance scanning

OBJECTIVE

To compare the detection and scoring of erosions in patients with rheumatoid arthritis (RA) using magnetic resonance (MR) and multidetector helical computerized tomographic (CT) scanning.

METHODS

Comparative CT and MR scans of the dominant wrist were obtained from 9 patients with RA and clinical examination was performed to assess disease activity. MR and CT scans were scored for erosions and MR scans for bone edema by 2 radiologists using a validated system. Radiographs of the hands and feet were also scored for erosions using the modified Sharp score.

RESULTS

In 117 of 135 (87%) sites there was concordance for erosions between MR and CT scans. At the remaining 18/135 sites (13%), erosions were identified by CT but not MR in 12/135 (9%) and by MR but not CT in 6/135 (4%). Partial volume artefacts on MR images and shifts in slice position were the most common reasons for erosion mismatch between MR and CT. The mean CT bone erosion score was significantly higher than the MR erosion score when individual bony sites were examined (p = 0.024), with the greatest difference being at the metacarpal bases. The total bone erosion score also tended to be higher on CT than MR [median scores of 20 (range 0-66) and 12 (0-51), respectively; p = 0.060]. MR and CT erosion scores correlated strongly with the total Sharp score (r = 0.93, p = 0.0002 and r = 0.94, p = 0.0002, respectively) and with the Disease Activity Score (MR: r = 0.77, p = 0.02; CT: r = 0.71, p = 0.03).

CONCLUSION

Most erosions were detected using both modalities, but erosion scores were higher on CT than MR scans, especially at the metacarpal bases. It is possible that small erosions in some regions are more easily detected by CT because of its ability to clearly delineate cortical bony margins.