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D'Agostino MA, Boers M, Wakefield RJ, Emery P, Conaghan PG. Is it time to revisit the role of ultrasound in rheumatoid arthritis management? Ann Rheum Dis 2016; 76:7-8. [PMID: 27941072 DOI: 10.1136/annrheumdis-2016-210453] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/16/2016] [Accepted: 10/21/2016] [Indexed: 11/04/2022]
Abstract
For over a decade, a large number of studies have highlighted the benefits of ultrasound (US) in the diagnosis and management of rheumatic diseases, especially rheumatoid arthritis (RA). However, its benefits in routine practice have been less studied and trials examining US as part of various clinical strategies are just emerging, with recent randomised trials examining the added value of US in tight-control paradigms. The conclusions of these trials have raised questions on the role of US in RA management. This Viewpoint analyses the recent studies, and discusses potential limitations in study designs as well as the methodological challenges of assessing the added value of an imaging technique.
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Affiliation(s)
- M A D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France.,Leeds institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - M Boers
- Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, Netherlands
| | - R J Wakefield
- Leeds institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - P Emery
- Leeds institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - P G Conaghan
- Leeds institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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Iagnocco A, Terslev L, Backhaus M, Balint P, Bruyn GAW, Damjanov N, Filippucci E, Hammer HB, Jousse-Joulin S, Kane D, Koski JM, Mandl P, Möller I, Peetrons P, Schmidt W, Szkudlarek M, Vojinovic J, Wakefield RJ, Hofer M, D'Agostino MA, Naredo E. Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses. RMD Open 2015; 1:e000139. [PMID: 26535148 PMCID: PMC4623365 DOI: 10.1136/rmdopen-2015-000139] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 08/06/2015] [Accepted: 08/22/2015] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses. METHODS A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds. CONCLUSIONS This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.
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Affiliation(s)
- A Iagnocco
- Ultrasound Unit, Rheumatology Department , Sapienza Università di Roma , Rome , Italy
| | - L Terslev
- Centre of Rheumatology and Spine Diseases, Rigshospitalet-Glostrup , Copenhagen , Denmark
| | - M Backhaus
- Department of Internal Medicine, Rheumatology and Clinical Immunology , Park-Klinik Weissensee Berlin, Academic Hospital of the Charité , Berlin , Germany
| | - P Balint
- 3rd Rheumatology Department , National Institute of Rheumatology and Physiotherapy , Budapest , Hungary
| | - G A W Bruyn
- Department of Rheumatology , MC Groep Hospitals , Lelystad , The Netherlands
| | - N Damjanov
- Institute of Rheumatology, Belgrade University School of Medicine , Belgrade , Serbia
| | - E Filippucci
- Clinica Reumatologica , Università Politecnica delle Marche , Jesi (Ancona) , Italy
| | - H B Hammer
- Department of Rheumatology , Diakonhjemmet Hospital , Oslo , Norway
| | - S Jousse-Joulin
- Department of Rheumatology , Cavale Blanche Hospital , Brest , France
| | - D Kane
- Trinity College Dublin , Dublin , Ireland
| | - J M Koski
- Mikkeli Central Hospital , Mikkeli , Finland
| | - P Mandl
- Division of Rheumatology, 3rd Department of Internal Medicine , Medical University of Vienna , Vienna , Austria
| | - I Möller
- Instituto Poal de Reumatologia , Barcelona , Spain
| | - P Peetrons
- Radiology Department , Free University of Brussels, Hopitaux Iris Sud , Brussels , Belgium
| | - W Schmidt
- Immanuel Krankenhaus Medical Center for Rheumatology Berlin , Buch , Germany
| | - M Szkudlarek
- Department of Rheumatology , University of Copenhagen Hospital at Køge , Køge , Denmark
| | - J Vojinovic
- Department of Pediatric Rheumatology, Faculty of Medicine , University of Nis , Nis , Serbia
| | - R J Wakefield
- Department of Rheumatology , Leeds Institute of Rheumatic and Musculoskeletal Medicine, Chapel Allerton Hospital , Leeds , UK
| | - M Hofer
- Diagnostic Radiologist, Department for Medical Education , H Heine University , Duesseldorf , Germany
| | - M A D'Agostino
- APHP, Hôpital Ambroise Paré, Rheumatology Department, Boulogne-Billancourt, France
| | - E Naredo
- Department of Rheumatology , Hospital GU Gregorio Marañón. Complutense University , Madrid , Spain
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Burska AN, Hensor EMA, Nam JL, Kozera L, Emery P, Wakefield RJ, Morgan AW. A6.11 Evaluation of soluble biomarkers of synovial inflammation using weighted joint counts assessed clinically and on ultrasound imaging. Ann Rheum Dis 2015. [DOI: 10.1136/annrheumdis-2015-207259.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hammer HB, Iagnocco A, Mathiessen A, Filippucci E, Gandjbakhch F, Kortekaas MC, Möller I, Naredo E, Wakefield RJ, Aegerter P, D'Agostino MA. Global ultrasound assessment of structural lesions in osteoarthritis: a reliability study by the OMERACT ultrasonography group on scoring cartilage and osteophytes in finger joints. Ann Rheum Dis 2014; 75:402-7. [PMID: 25520476 DOI: 10.1136/annrheumdis-2014-206289] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 12/01/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Ultrasonography is sensitive for the evaluation of cartilage pathology and degree of osteophytes in patients with hand osteoarthritis (OA). High consistency of assessments is essential, and the OMERACT (Outcome Measures in Rheumatology) ultrasonography group took the initiative to explore the reliability of a global ultrasonography score in patients with hand OA using semiquantitative ultrasonography score of cartilage and osteophytes in finger joints. METHODS Ten patients with hand OA were examined by 10 experienced sonographers over the course of two days. Semiquantitative scoring (0-3) was performed on osteophytes (carpo-metacarpal 1, metacarpo-phalangeal (MCP) 1-5, proximal interphalangeal 1-5 and distal interphalangeal 2-5 joints bilaterally with an ultrasonography atlas as reference) and cartilage pathology (MCP 2-5 bilaterally). A web-based exercise on static cartilage images was performed a month later. Reliability was assessed by use of weighted κ analyses. RESULTS Osteophyte scores were evenly distributed, and the intraobserver and interobserver reliabilities were substantial to excellent (κ range 0.68-0.89 and mean κ 0.65 (day 1) and 0.67 (day 2), respectively). Cartilage scores were unevenly distributed, and the intraobserver and interobserver reliability was fair to moderate (κ range 0.46-0.66 and mean κ 0.39 (day 1) and 0.33 (day 2), respectively). The web-based exercise showed acceptable agreement for cartilage being normal (κ 0.47) or with complete loss (κ 0.68), but poor for the intermediate scores (κ 0.22-0.30). CONCLUSIONS Use of the present semiquantitative ultrasonography scoring system for cartilage pathology in hand OA is not recommended (while normal or total loss of cartilage may be assessed). However, the OMERACT ultrasonography group will endorse the use of semiquantitative scoring of osteophytes with the ultrasonography atlas as reference.
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Affiliation(s)
- H B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - A Iagnocco
- Rheumatology Unit, Sapienza Università di Roma, Rome, Italy
| | - A Mathiessen
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - E Filippucci
- Clinica Reumatologica, Università Politecnica delle Marche, Jesi (Ancona), Italy
| | - F Gandjbakhch
- Department of Rheumatology, AP-HP, Pitie-Salpetriere Hospital, Paris, France UPMC Université Paris 06, Paris, France
| | - M C Kortekaas
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands Department of Rheumatology, Flevoziekenhuis, The Netherlands
| | - I Möller
- Instituto Poal de Reumatologia, Barcelona, Spain
| | - E Naredo
- Department of Rheumatology, Hospital GU Gregorio Marañón, Madrid, Spain
| | - R J Wakefield
- Leeds Institute of Rheumatic and Rehabilitation Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - P Aegerter
- Université Versailles-Saint Quentin En Yvelines, Paris, France Department of Public Health, AP-HP, Ambroise Paré Hospital, Boulogne-Billancourt, France
| | - M-A D'Agostino
- Université Versailles-Saint Quentin En Yvelines, Inserm U987, Boulogne-Billancourt, France Department of Rheumatology, AP-HP, Ambroise Paré Hospital, Boulogne-Billancourt, France
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Terslev L, Naredo E, Iagnocco A, Balint PV, Wakefield RJ, Aegerter P, Aydin SZ, Bachta A, Hammer HB, Bruyn GAW, Filippucci E, Gandjbakhch F, Mandl P, Pineda C, Schmidt WA, D'Agostino MA. Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise. Arthritis Care Res (Hoboken) 2014; 66:741-8. [PMID: 24151222 DOI: 10.1002/acr.22191] [Citation(s) in RCA: 141] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 09/24/2013] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To standardize ultrasound (US) in enthesitis. METHODS An initial Delphi exercise was undertaken to define US-detected enthesitis and its core components. These definitions were subsequently tested on static images taken from spondyloarthritis patients in order to evaluate their reliability. RESULTS Excellent agreement (>80%) was obtained for including hypoechogenicity, increased thickness of the tendon insertion, calcifications, enthesophytes, erosions, and Doppler activity as core elementary lesions of US-detected enthesitis. US definitions were subsequently obtained for each elementary component. On static images, the intraobserver reliability showed a high degree of variability for the detection of elementary lesions, with kappa coefficients ranging from 0.13-1. The interobserver kappa values were variable, with the lowest kappa coefficient for enthesophytes (0.24) and the highest coefficient for Doppler activity at the enthesis (0.63). CONCLUSION This is the first consensus-based US definition of enthesitis and its elementary components and the first step performed to ensure a higher degree of homogeneity and comparability of results between studies and in daily clinical work.
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Affiliation(s)
- L Terslev
- Copenhagen University Hospital at Glostrup, Copenhagen, Denmark
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Rakieh C, Nam JL, Hunt L, Hensor EMA, Das S, Bissell LA, Villeneuve E, McGonagle D, Hodgson R, Grainger A, Wakefield RJ, Conaghan PG, Emery P. Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal symptoms: a prospective observational cohort study. Ann Rheum Dis 2014; 74:1659-66. [PMID: 24728331 DOI: 10.1136/annrheumdis-2014-205227] [Citation(s) in RCA: 150] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2014] [Accepted: 03/22/2014] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To monitor progression to inflammatory arthritis (IA) in individuals with non-specific musculoskeletal (MSK) symptoms and positive anticyclic citrullinated peptide (anti-CCP) antibodies. To develop a pragmatic model to predict development of IA in this patient group. METHODS In this prospective observational cohort, patients with new non-specific MSK symptoms and positive anti-CCP were recruited from regional primary care and secondary care referrals. Clinical, imaging and serological parameters were assessed at baseline. Cox regression analysis was performed to identify predictors of progression to IA and develop a risk score to stratify patients at presentation. FINDINGS 100 consecutive patients (73 women, mean age 51 years) were followed up for median 19.8 months (range 0.1-69.0); 50 developed IA after a median 7.9 months (range 0.1-52.4), 34 within 12 months. The majority (43/50) fulfilled the 2010 American College of Rheumatology/European League Against Rheumatism criteria for rheumatoid arthritis. A model for progression to IA was devised using four variables: tenderness of hand or foot joints, early morning stiffness ≥30 min, high-positive autoantibodies, and positive ultrasonographic power Doppler signal. None of the five individuals at low risk (score 0) progressed to IA, compared with 31% of 29 at moderate risk (1-2) and 62% of 66 at high risk (≥3). Adding shared epitope increased the number at low risk (score 0-1; 0/11 progressed). CONCLUSIONS In patients presenting with non-specific MSK symptoms and anti-CCP, the risk of progression to IA could be quantified using data available in clinical practice. The proposed risk score may be used to stratify patients for early therapeutic intervention. TRIAL REGISTRATION NUMBER NCT02012764 at ClinicalTrials.gov.
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Affiliation(s)
- C Rakieh
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - J L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - L Hunt
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E M A Hensor
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - S Das
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - L-A Bissell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - E Villeneuve
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK Rheumatology Department, Centre Hospitalier de l'Université de Montréal Hôpital, Montréal, Quebec, Canada
| | - D McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - R Hodgson
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - A Grainger
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - R J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - P G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - P Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Nam JL, Villeneuve E, Hensor EMA, Wakefield RJ, Conaghan PG, Green MJ, Gough A, Quinn M, Reece R, Cox SR, Buch MH, van der Heijde DM, Emery P. A randomised controlled trial of etanercept and methotrexate to induce remission in early inflammatory arthritis: the EMPIRE trial. Ann Rheum Dis 2014; 73:1027-36. [PMID: 24618266 DOI: 10.1136/annrheumdis-2013-204882] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the efficacy of etanercept (ETN) and methotrexate (MTX) versus MTX monotherapy for remission induction in patients with early inflammatory arthritis. METHODS In a 78-week multicentre randomised placebo-controlled superiority trial, 110 DMARD-naïve patients with early clinical synovitis (≥1 tender and swollen joint, and within 3 months of diagnosis) and either rheumatoid factor, anticitrullinated protein antibodies or shared epitope positive were randomised 1:1 to receive MTX+ETN or MTX+placebo (PBO) for 52 weeks. Injections (ETN or PBO) were stopped in all patients at week 52. In those with no tender or swollen joints (NTSJ) for >26 weeks, injections were stopped early. If patients had NTSJ >12 weeks after stopping the injections, MTX was weaned. The primary endpoint was NTSJ at week 52. RESULTS No statistically significant difference was seen for the primary endpoint (NTSJ at week 52 (32.5% vs 28.1% [adjusted OR 1.32 (0.56 to 3.09), p=0.522]) in the MTX+ETN and MTX+PBO groups, respectively). The secondary endpoints did not differ between groups at week 52 or 78. Exploratory analyses showed a higher proportions of patients with DAS28-CRP<2.6 in the MTX+ETN group at week 2 (38.5% vs 9.2%, adjusted OR 8.87 (2.53 to 31.17), p=0.001) and week 12 (65.1% vs 43.8%, adjusted OR 2.49 (1.12 to 5.54), p=0.026). CONCLUSIONS In this group of patients with early inflammatory arthritis, almost a third had no tender, swollen joints after 1 year. MTX+ETN was not superior to MTX monotherapy in achieving this outcome. Clinical responses, however, including DAS28-CRP<2.6, were achieved earlier with MTX+ETN combination therapy. TRIAL REGISTRATION NUMBER The EMPIRE trial is registered on the following trial registries: Eudract-2005-005467-29; ISRCTN 55428162 (http://www.controlled-trials.com/ISRCTN55428162/EMPIRE). The full trial protocol can be obtained from the corresponding author.
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Affiliation(s)
- J L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, , Leeds, UK
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Rakieh C, Nam JL, Hunt L, Villeneuve E, Bissell LA, Das S, Conaghan PG, McGonagle D, Wakefield RJ, Emery P. OP0180 Risk of Developing Clinical Synovitis in ACPA Positive Patients with Non-Specific Musculoskeletal Symptoms. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2013-eular.385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Nam JL, Villeneuve E, Hensor EMA, Conaghan PG, Keen HI, Buch MH, Gough AK, Green MJ, Helliwell PS, Keenan AM, Morgan AW, Quinn M, Reece R, van der Heijde DM, Wakefield RJ, Emery P. Remission induction comparing infliximab and high-dose intravenous steroid, followed by treat-to-target: a double-blind, randomised, controlled trial in new-onset, treatment-naive, rheumatoid arthritis (the IDEA study). Ann Rheum Dis 2013; 73:75-85. [PMID: 23912798 DOI: 10.1136/annrheumdis-2013-203440] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES In disease modifying antirheumatic drug (DMARD)-naive early rheumatoid arthritis (RA), to compare the efficacy of methotrexate (MTX) and infliximab (IFX) with MTX and intravenous corticosteroid for remission induction. METHODS In a 78-week multicentre randomised controlled trial, double-blinded to week 26, 112 treatment-naive RA patients (1987 American College of Rheumatology classification criteria) with disease activity score 44 (DAS44)>2.4 were randomised to MTX + IFX or MTX + single dose intravenous methylprednisolone 250 mg. A treat-to-target approach was used with treatment escalation if DAS44>2.4. In the IFX group, IFX was discontinued for sustained remission (DAS44<1.6 for 6 months). The primary outcome was change in modified total Sharp-van der Heijde score (mTSS) at week 50. RESULTS The mean changes in mTSS score at week 50 in the IFX and intravenous steroid groups were 1.20 units and 2.81 units, respectively (adjusted difference (95% CI) -1.45 (-3.35 to 0.45); p=0.132). Radiographic non-progression (mTSS<2.0) occurred in 81% vs 71% (OR 1.77 (0.56 to 5.61); p=0.328). DAS44 remission was achieved at week 50 in 49% and 36% (OR 2.13 (0.91 to 5.00); p=0.082), and at week 78 in 48% and 50% (OR 1.12 (0.47 to 2.68); p=0.792). Exploratory analyses suggested higher DAS28 remission at week 6 and less ultrasound synovitis at week 50 in the IFX group. Of the IFX group, 25% (14/55) achieved sustained remission and stopped IFX. No substantive differences in adverse events were seen. CONCLUSIONS In DMARD-naive early RA patients, initial therapy with MTX+high-dose intravenous steroid resulted in good disease control with little structural damage. MTX+IFX was not statistically superior to MTX+intravenous steroid when combined with a treat-to-target approach.
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Affiliation(s)
- J L Nam
- Institute Rheumatic and Musculoskeletal Medicine, Leeds Institute of Molecular Medicine, University of Leeds, and NIHR Leeds Musculoskeletal Biomedical Research Unit, LTHT, , Leeds, UK
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Rakieh C, Saleem B, Takase K, Nam JL, Keen H, Wakefield RJ, Emery P. THU0136 Long Term Outcomes of Stopping Tumour Necrosis Factor Inhibitors (TNFI) in Patients with Established Rheumatoid Arthritis (RA) Who are in Sustained Remission: Is it Worth the Risk? Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Aydin SZ, Gallego CC, Nam J, Freeston J, Horton S, Wakefield RJ, Emery P. OP0135 The New ACR/EULAR Criteria for Rheumatoid Arthritis is Able to Identify Patients with Same Disease Activity but Less Damage by Ultrasound. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Horton SC, Wakefield RJ, Tan AL, Freeston JE, Buch MH, Emery P. SAT0011 What is Undifferentiated Arthritis (UA) in 2013, and can Progression to Rheumatoid Arthritis (RA) be Predicted? Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Ohrndorf S, D’Agostino MA, Schicke B, Wakefield RJ, Vogler L, Messerschmidt J, Reiche BE, Burmester GR, Naredo E, Iagnocco A, Backhaus M. SAT0488 Sensitivity to Change of a Combined Gray-Scale and Power Doppler Ultrasound Score for Synovitis in Comparison to a Sum Score of 5 Joints of the Wrist and Hand – One-Year Evaluation of an RA Cohort. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.2212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Mandl P, Balint PV, Brault Y, Backhaus M, D'Agostino MA, Grassi W, van der Heijde D, de Miguel E, Wakefield RJ, Logeart I, Dougados M. Clinical and Ultrasound-Based Composite Disease Activity Indices in Rheumatoid Arthritis: Results From a Multicenter, Randomized Study. Arthritis Care Res (Hoboken) 2013; 65:879-87. [DOI: 10.1002/acr.21913] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 11/06/2012] [Indexed: 01/01/2023]
Affiliation(s)
- P. Mandl
- Medical University of Vienna, Vienna, Austria, and National Institute of Rheumatology and Physiotherapy; Budapest; Hungary
| | - P. V. Balint
- National Institute of Rheumatology and Physiotherapy; Budapest; Hungary
| | | | - M. Backhaus
- University Hospital Charité; Berlin; Germany
| | - M. A. D'Agostino
- Versailles-Saint Quentin en Yvelines University; AP-HP, Ambroise-Paré Hospital; Boulogne-Billancourt; France
| | - W. Grassi
- Università Politecnica delle Marche; Jesi; Ancona; Italy
| | | | | | | | | | - M. Dougados
- Paris-Descartes University; UPRES-EA 4058; AP-HP; Cochin Hospital; Paris; France
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Cornell P, Trehane A, Thompson P, Rahmeh F, Greenwood M, Baqai TJ, Cambridge S, Shaikh M, Rooney M, Donnelly S, Tahir H, Ryan S, Kamath S, Hassell A, McCuish WJ, Bearne L, Mackenzie-Green B, Price E, Williamson L, Collins D, Tang E, Hayes J, McLoughlin YM, Chamberlain V, Campbell S, Shah P, McKenna F, Cornell P, Westlake S, Thompson P, Richards S, Homer D, Gould E, Empson B, Kemp P, Richards AG, Walker J, Taylor S, Bari SF, Alachkar M, Rajak R, Lawson T, O'Sullivan M, Samant S, Butt S, Gadsby K, Flurey CA, Morris M, Hughes R, Pollock J, Richards P, Hewlett S, Edwards KR, Rowe I, Sanders T, Dunn K, Konstantinou K, Hay E, Jones LE, Adams J, White P, Donovan-Hall M, Hislop K, Barbosa Boucas S, Nichols VP, Williamson EM, Toye F, Lamb SE, Rodham K, Gavin J, Watts L, Coulson N, Diver C, Avis M, Gupta A, Ryan SJ, Stangroom S, Pearce JM, Byrne J, Manning VL, Hurley M, Scott DL, Choy E, Bearne L, Taylor J, Morris M, Dures E, Hewlett S, Wilson A, Adams J, Larkin L, Kennedy N, Gallagher S, Fraser AD, Shrestha P, Batley M, Koduri G, Scott DL, Flurey CA, Morris M, Hughes R, Pollock J, Richards P, Hewlett S, Kumar K, Raza K, Nightingale P, Horne R, Chapman S, Greenfield S, Gill P, Ferguson AM, Ibrahim F, Scott DL, Lempp H, Tierney M, Fraser A, Kennedy N, Barbosa Boucas S, Hislop K, Dziedzic K, Arden N, Burridge J, Hammond A, Stokes M, Lewis M, Gooberman-Hill R, Coales K, Adams J, Nutland H, Dean A, Laxminarayan R, Gates L, Bowen C, Arden N, Hermsen L, Terwee CB, Leone SS, vd Zwaard B, Smalbrugge M, Dekker J, vd Horst H, Wilkie R, Ferguson AM, Nicky Thomas V, Lempp H, Cope A, Scott DL, Simpson C, Weinman J, Agarwal S, Kirkham B, Patel A, Ibrahim F, Barn R, Brandon M, Rafferty D, Sturrock R, Turner D, Woodburn J, Rafferty D, Paul L, Marshall R, Gill J, McInnes I, Roderick Porter D, Woodburn J, Hennessy K, Woodburn J, Steultjens M, Siddle HJ, Hodgson RJ, Hensor EM, Grainger AJ, Redmond A, Wakefield RJ, Helliwell PS, Hammond A, Rayner J, Law RJ, Breslin A, Kraus A, Maddison P, Thom JM, Newcombe LW, Woodburn J, Porter D, Saunders S, McCarey D, Gupta M, Turner D, McGavin L, Freeburn R, Crilly A, Lockhart JC, Ferrell WR, Goodyear C, Ledingham J, Waterman T, Berkin L, Nicolaou M, Watson P, Lillicrap M, Birrell F, Mooney J, Merkel PA, Poland F, Spalding N, Grayson P, Leduc R, Shereff D, Richesson R, Watts RA, Roussou E, Thapper M, Bateman J, Allen M, Kidd J, Parsons N, Davies D, Watt KA, Scally MD, Bosworth A, Wilkinson K, Collins S, Jacklin CB, Ball SK, Grosart R, Marks J, Litwic AE, Sriranganathan MK, Mukherjee S, Khurshid MA, Matthews SM, Hall A, Sheeran T, Baskar S, Muether M, Mackenzie-Green B, Hetherington A, Wickrematilake G, Williamson L, Daniels LE, Gwynne CE, Khan A, Lawson T, Clunie G, Stephenson S, Gaffney K, Belsey J, Harvey NC, Clarke-Harris R, Murray R, Costello P, Garrett E, Holbrook J, Teh AL, Wong J, Dogra S, Barton S, Davies L, Inskip H, Hanson M, Gluckman P, Cooper C, Godfrey K, Lillycrop K, Anderton T, Clarke S, Rao Chaganti S, Viner N, Seymour R, Edwards MH, Parsons C, Ward K, Thompson J, Prentice A, Dennison E, Cooper C, Clark E, Cumming M, Morrison L, Gould VC, Tobias J, Holroyd CR, Winder N, Osmond C, Fall C, Barker D, Ring S, Lawlor D, Tobias J, Davey Smith G, Cooper C, Harvey NC, Toms TE, Afreedi S, Salt K, Roskell S, Passey K, Price T, Venkatachalam S, Sheeran T, Davies R, Southwood TR, Kearsley-Fleet L, Hyrich KL, Kingsbury D, Quartier P, Patel G, Arora V, Kupper H, Mozaffarian N, Kearsley-Fleet L, Baildam E, Beresford MW, Davies R, Foster HE, Mowbray K, Southwood TR, Thomson W, Hyrich KL, Saunders E, Baildam E, Chieng A, Davidson J, Foster H, Gardner-Medwin J, Wedderburn L, Thomson W, Hyrich K, McErlane F, Beresford M, Baildam E, Chieng SE, Davidson J, Foster HE, Gardner-Medwin J, Lunt M, Wedderburn L, Thomson W, Hyrich K, Rooney M, Finnegan S, Gibson DS, Borg FA, Bale PJ, Armon K, Cavelle A, Foster HE, McDonagh J, Bale PJ, Armon K, Wu Q, Pesenacker AM, Stansfield A, King D, Barge D, Abinun M, Foster HE, Wedderburn L, Stanley K, Morrissey D, Parsons S, Kuttikat A, Shenker N, Garrood T, Medley S, Ferguson AM, Keeling D, Duffort P, Irving K, Goulston L, Culliford D, Coakley P, Taylor P, Hart D, Spector T, Hakim A, Arden N, Mian A, Garrood T, Magan T, Chaudhary M, Lazic S, Sofat N, Thomas MJ, Moore A, Roddy E, Peat G, Rees F, Lanyon P, Jordan N, Chaib A, Sangle S, Tungekar F, Sabharwal T, Abbs I, Khamashta M, D'Cruz D, Dzifa Dey I, Isenberg DA, Chin CW, Cheung C, Ng M, Gao F, Qiong Huang F, Thao Le T, Yong Fong K, San Tan R, Yin Wong T, Julian T, Parker B, Al-Husain A, Yvonne Alexander M, Bruce I, Jordan N, Abbs I, D'cruz D, McDonald G, Miguel L, Hall C, Isenberg DA, Magee A, Butters T, Jury E, Yee CS, Toescu V, Hickman R, Leung MH, Situnayake D, Bowman S, Gordon C, Yee CS, Toescu V, Hickman R, Leung MH, Situnayake D, Bowman S, Gordon C, Lazarus MN, Isenberg DA, Ehrenstein M, Carter LM, Isenberg DA, Ehrenstein MR, Chanchlani N, Gayed M, Yee CS, Gordon C, Ball E, Rooney M, Bell A, Reynolds JA, Ray DW, O'Neill T, Alexander Y, Bruce I, Sutton EJ, Watson KD, Isenberg D, Rahman A, Gordon C, Yee CS, Lanyon P, Jayne D, Akil M, D'Cruz D, Khamashta M, Lutalo P, Erb N, Prabu A, Edwards CJ, Youssef H, McHugh N, Vital E, Amft N, Griffiths B, Teh LS, Zoma A, Bruce I, Durrani M, Jordan N, Sangle S, D'Cruz D, Pericleous C, Ruiz-Limon P, Romay-Penabad Z, Carrera-Marin A, Garza-Garcia A, Murfitt L, Driscoll PC, Giles IP, Ioannou Y, Rahman A, Pierangeli SS, Ripoll VM, Lambrianides A, Heywood WE, Ioannou J, Giles IP, Rahman A, Stevens C, Dures E, Morris M, Knowles S, Hewlett S, Marshall R, Reddy V, Croca S, Gerona D, De La Torre Ortega I, Isenberg DA, Leandro M, Cambridge G, Reddy V, Cambridge G, Isenberg DA, Glennie M, Cragg M, Leandro M, Croca SC, Isenberg DA, Giles I, Ioannou Y, Rahman A, Croca SC, Isenberg DA, Giles I, Ioannou Y, Rahman A, Artim Esen B, Pericleous C, MacKie I, Ioannou Y, Rahman A, Isenberg DA, Giles I, Skeoch S, Haque S, Pemberton P, Bruce I. BHPR: Audit and Clinical Evaluation * 103. Dental Health in Children and Young Adults with Inflammatory Arthritis: Access to Dental Care. Rheumatology (Oxford) 2013. [DOI: 10.1093/rheumatology/ket196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Fleischmann R, van Vollenhoven RF, Smolen J, Emery P, Florentinus S, Rathmann S, Kupper H, Kavanaugh A, Taylor P, Genovese M, Keystone EC, Drescher E, Berclaz PY, Lee C, Fidelus-Gort R, Schlichting D, Beattie S, Luchi M, Macias W, Kavanaugh A, Emery P, van Vollenhoven RF, Dikranian AH, Alten R, Klearman M, Musselman D, Agarwal S, Green J, Gabay C, Weinblatt ME, Schiff MH, Fleischmann R, Valente R, van der Heijde D, Citera G, Zhao C, Maldonado MA, Rakieh C, Nam JL, Hunt L, Villeneuve E, Bissell LA, Das S, Conaghan P, McGonagle D, Wakefield RJ, Emery P, Wright HL, Thomas HB, Moots R, Edwards SW, Hamann P, Heward J, McHugh N, Lindsay MA, Haroon M, Giles JT, Winchester R, FitzGerald O, Karaderi T, Cohen CJ, Keidel S, Appleton LH, Macfarlane GJ, Siebert S, Evans D, Paul Wordsworth B, Plant D, Bowes J, Orozco G, Morgan AW, Wilson AG, Isaacs J, Barton A, Williams FM, Livshits G, Spector T, MacGregor A, Williams FM, Scollen S, Cao D, Memari Y, Hyde CL, Zhang B, Sidders B, Ziemek D, Shi Y, Harris J, Harrow I, Dougherty B, Malarstig A, McEwen R, Stephens JL, Patel K, Shin SY, Surdulescu G, He W, Jin X, McMahon SB, Soranzo N, John S, Wang J, Spector TD, Baker J, Litherland GJ, Rowan AD, Kite KA, Bayley R, Yang P, Smith JP, Williams J, Harper L, Kitas GD, Buckley C, Young SP, Fitzpatrick MA, Young SP, McGettrick HM, Filer A, Raza K, Nash G, Buckley C, Muthana M, Davies H, Khetan S, Adeleke G, Hawtree S, Tazzyman S, Morrow F, Ciani B, Wilson G, Quirke AM, Lugli E, Wegner N, Charles P, Hamilton B, Chowdhury M, Ytterberg J, Potempa J, Fisher B, Thiele G, Mikuls T, Venables P, Adebajo AO, Kavanaugh A, Mease P, Gomez-Reino JJ, Wollenhaupt J, Hu C, Stevens R, Sieper J, van der Heijde D, Dougados M, Van den Bosch F, Goupille P, Rathmann SS, Pangan AL, van der Heijde D, Sieper J, Maksymowych WP, Brown MA, Rathmann S, Pangan AL, Sieper J, van der Heijde D, Elewaut D, Pangan AL, Anderson J, Haroon M, Ramasamy P, O'Rourke M, Murphy C, Fitzgerald O, Jani M, Moore S, Mirjafari H, Macphie E, Chinoy H, Rao C, McLoughlin Y, Preeti S. Oral Abstracts 7: RA Clinical * O37. Long-Term Outcomes of Early RA Patients Initiated with Adalimumab Plus Methotrexate Compared with Methotrexate Alone Following a Targeted Treatment Approach. Rheumatology (Oxford) 2013. [DOI: 10.1093/rheumatology/ket198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Terslev L, D'Agostino MA, Brossard M, Aegerter P, Balint P, Backhaus M, Bruyn GA, Chary-Valckenare I, Filippucci E, Freeston J, Gandjbakhch F, Iagnocco A, Jousse-Joulin S, Mandl P, Möller I, Naredo E, Szkudlarek M, Wakefield RJ, Zayat A, Schmidt WA. Which knee and probe position determines the final diagnosis of knee inflammation by ultrasound? Results from a European multicenter study. Ultraschall Med 2012; 33:E173-E178. [PMID: 22194046 DOI: 10.1055/s-0031-1281973] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
PURPOSE To investigate which knee and probe position best identifies knee inflammation and to determine a cut-off level for abnormal synovial effusion. MATERIALS AND METHODS 18 experienced sonographers (all rheumatologists) performed ultrasound examinations of the knee joint in patients with knee symptoms and in healthy controls. Each sonographer performed longitudinal suprapatellar ultrasound scans using 9 different configurations at each knee: Midline, parapatallar lateral and parapatellar medial from midline in neutral position (0°) with and without quadriceps muscle contraction and in 30° flexion of the knee. The presence of synovial effusion (SE), the effusion measured in millimeters and the presence of synovial hypertrophy (SH) was noted. RESULTS A total of 298 knees of 149 subjects (129 patients and 20 controls) were examined. The detection of SH is more sensitive and specific than the detection of SE, independently of the knee and probe position, for the final diagnosis of abnormality. The detection of both synovial hypertrophy and effusion in the knee in neutral position (0°) with quadriceps contraction and with the probe in the midline position, are the best independent predictors for knee abnormalities. Knee effusion > 3.2 mm measured with the probe in the lateral aspect of the knee is the best diagnostic characteristics for predicting pathological SE. CONCLUSION The best combination for detecting SH and SE is obtained by placing the probe in the midline position with the knee in 0° with quadriceps contraction. A cut-off value for pathological effusion may be obtained in the lateral aspect of the knee.
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Affiliation(s)
- L Terslev
- Department of Rheumatology, University of Copenhagen, Hospitals at Glostrup, Copenhagen, Denmark
| | - M A D'Agostino
- Paris Ouest-Versailles-Saint Quentin en Yvelines University; EA 2506, Rheumatology Department Ambroise-Paré Hospital, APHP, Boulogne-Billancourt, France
| | - M Brossard
- Paris Ouest-Versailles-Saint Quentin en Yvelines University; EA 2506, Rheumatology Department Ambroise-Paré Hospital, APHP, Boulogne-Billancourt, France
| | - P Aegerter
- Paris Ouest-Versailles-Saint Quentin en Yvelines University; EA 2506, Public Health Department Ambroise-Paré-Hospital, APHP, Boulogne-Billancourt, France
| | - P Balint
- National Institute of Rheumatology and Physiotherapy, 3rd Department of Pediatric and General Rheumatology Budapese, Hungary
| | - M Backhaus
- Department of Rheumatology and Clinical Immunology, Charité, Berlin, Gremany
| | - G A Bruyn
- MC Groep hospitals, Lelystad, Netherlands
| | - I Chary-Valckenare
- Department of Rheumatology, University of Nancy, Le Brabois Hospital, Nancy, France
| | - E Filippucci
- Cattedra di Reumatologia, Università Politecnica delle Marche, Ancona, Italy
| | - J Freeston
- LIMM Section of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, England
| | - F Gandjbakhch
- Department of Rheumatology, la Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - A Iagnocco
- Rheumatology Unit, Clinica e Terapia Medica Department, Sapienza Università di Roma, Rome, Italy
| | - S Jousse-Joulin
- Rheumatology Department, La Cavale Blanche Brest Teaching Hospital, Brest, France
| | - P Mandl
- National Institute of Rheumatology and Physiotherapy, 3rd Department of Pediatric and General Rheumatology Budapese, Hungary
| | - I Möller
- Instituto Poal de Reumatologia, Barcelona, Spain
| | - E Naredo
- Rheumatology Department, Hospital Severo Ochoa, Madrid, Spain
| | - M Szkudlarek
- Department of Rheumatology, University of Copenhagen Hospital at Koege, Koege, Denmark
| | - R J Wakefield
- LIMM Section of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, England
| | - A Zayat
- LIMM Section of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, England
| | - W A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
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Freeston JE, Coates LC, Helliwell PS, Hensor EMA, Wakefield RJ, Emery P, Conaghan PG. Is there subclinical enthesitis in early psoriatic arthritis? A clinical comparison with power doppler ultrasound. Arthritis Care Res (Hoboken) 2012; 64:1617-21. [PMID: 22623271 DOI: 10.1002/acr.21733] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
OBJECTIVE Enthesitis is a recognized feature of spondylarthritides (SpA), including psoriatic arthritis (PsA). Previously, ultrasound imaging has highlighted the presence of subclinical enthesitis in established SpA, but there are little data on ultrasound findings in early PsA. The aim of our study was to compare ultrasound and clinical examination (CE) for the detection of entheseal abnormalities in an early PsA cohort. METHODS Forty-two patients with new-onset PsA and 10 control subjects underwent CE of entheses for tenderness and swelling, as well as gray-scale (GS) and power Doppler (PD) ultrasound of a standard set of entheses. Bilateral elbow lateral epicondyles, Achilles tendons, and plantar fascia were assessed by both CE and ultrasound, the latter scored using a semiquantitative (SQ) scale. Inferior patellar tendons were assessed by ultrasound alone. A GS SQ score of >1 and/or a PD score of >0 was used to describe significant ultrasound entheseal abnormality. RESULTS A total of 24 (57.1%) of 42 patients in the PsA group and 0 (0%) of 10 controls had clinical evidence of at least 1 tender enthesis. In the PsA group, for sites assessed by both CE and ultrasound, 4% (7 of 177) of nontender entheses had a GS score >1 and/or a PD score >0 compared to 24% (9 of 37) of tender entheses. CE overestimated activity in 28 (13%) of 214 of entheses. All the nontender ultrasound-abnormal entheses were in the lower extremity. CONCLUSION The prevalence of subclinical enthesitis in this early PsA cohort was low. CE may overestimate active enthesitis. The few subclinically inflamed entheses were in the lower extremity, where mechanical stress is likely to be more significant.
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Affiliation(s)
- J E Freeston
- University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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Bruyn GAW, Moller I, Garrido J, Bong D, d'Agostino MA, Iagnocco A, Karim Z, Terslev L, Swen N, Balint P, Baudoin P, van Reesema DS, Pineda C, Wakefield RJ, Naredo E. Reliability testing of tendon disease using two different scanning methods in patients with rheumatoid arthritis. Rheumatology (Oxford) 2012; 51:1655-61. [DOI: 10.1093/rheumatology/kes103] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Mandl P, Brossard M, Aegerter P, Backhaus M, Bruyn GA, Chary-Valckenaere I, Iagnocco A, Filippucci E, Freeston J, Gandjbakhch F, Jousse-Joulin S, Möller I, Naredo E, Schmidt WA, Szkudlarek M, Terslev L, Wakefield RJ, Zayat A, D'Agostino MA, Balint PV. Ultrasound evaluation of fluid in knee recesses at varying degrees of flexion. Arthritis Care Res (Hoboken) 2012; 64:773-9. [PMID: 22232128 DOI: 10.1002/acr.21598] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Various methods are utilized in daily practice to obtain optimal information on effusion in the knee. Our aim is to investigate which scanning position provides the best information about synovial fluid in the knee by using ultrasound and to evaluate the magnitude of difference for measuring synovial fluid in 3 major recesses (suprapatellar, medial parapatellar, and lateral parapatellar) of the knee according to various degrees of flexion. METHODS Sonographers in 14 European centers documented bilateral knee joint ultrasound examinations on a total of 148 knee joints. The largest sagittal diameter of fluid was measured in scans corresponding to the 3 major recesses at different (0°, 15°, 30°, 45°, 60°, and 90°) degrees of flexion of the knee. The difference of measurement of effusion according to transducer position, knee position, and the interaction between them was investigated by analysis of variance followed by Tukey's test. RESULTS No correlation was noted between patient characteristics and ultrasound detection of effusion. The sagittal diameter of synovial fluid in all 3 recesses was greatest at 30° flexion. Analysis of variance and Tukey's test revealed that the suprapatellar scan and 30° flexion is the best combination for detecting effusion as confirmed by receiver operator characteristic curve analysis. CONCLUSION The suprapatellar scan of the knee in 30° flexion was the most sensitive position to detect fluid in knee joints. Sagittal diameter of fluid in all 3 recesses increased with the knee in the 30° flexed position as compared to the extended position.
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Affiliation(s)
- P Mandl
- Division of Rheumatology, Medical University of Vienna, 18-20 Währinger Gürtel, Vienna, Austria.
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Backhouse MR, Vinall KA, Redmond A, Helliwell P, Keenan AM, Dale RM, Thomas A, Aronson D, Turner-Cobb J, Sengupta R, France B, Hill I, Flurey CA, Morris M, Pollock J, Hughes R, Richards P, Hewlett S, Ryan S, Lille K, Adams J, Haq I, McArthur M, Goodacre L, Birt L, Wilson O, Kirwan J, Dures E, Quest E, Hewlett S, Rajak R, Thomas T, Lawson T, Petford S, Hale E, Kitas GD, Ryan S, Gooberman-Hill R, Jinks C, Dziedzic K, Boucas SB, Hislop K, Rhodes C, Adams J, Ali F, Jinks C, Ong BN, Backhouse MR, White D, Hensor E, Keenan AM, Helliwell P, Redmond A, Ferguson AM, Douiri A, Scott DL, Lempp H, Halls S, Law RJ, Jones J, Markland D, Maddison P, Thom J, Law RJ, Thom JM, Maddison P, Breslin A, Kraus A, Gordhan C, Dennis S, Connor J, Chowdhary B, Lottay N, Juneja P, Bacon PA, Isaacs D, Jack J, Keller M, Tibble J, Haq I, Hammond A, Gill R, Tyson S, Tennant A, Nordenskiold U, Pease EE, Pease CT, Trehane A, Rahmeh F, Cornell P, Westlake SL, Rose K, Alber CF, Watson L, Stratton R, Lazarus M, McNeilly NE, Waterfield J, Hurley M, Greenwood J, Clayton AM, Lynch M, Clewes A, Dawson J, Abernethy V, Griffiths AE, Chamberlain VA, McLoughlin Y, Campbell S, Hayes J, Moffat C, McKenna F, Shah P, Rajak R, Williams A, Rhys-Dillon C, Goodfellow R, Martin JC, Rajak R, Bari F, Hughes G, Thomas E, Baker S, Collins D, Price E, Williamson L, Dunkley L, Youll MJ, Rodziewicz M, Reynolds JA, Berry J, Pavey C, Hyrich K, Gorodkin R, Wilkinson K, Bruce I, Barton A, Silman A, Ho P, Cornell T, Westlake SL, Richards S, Holmes A, Parker S, Smith H, Briggs N, Arthanari S, Nisar M, Thwaites C, Ryan S, Kamath S, Price S, Robinson SM, Walker D, Coop H, Al-Allaf W, Baker S, Williamson L, Price E, Collins D, Charleton RC, Griffiths B, Edwards EA, Partlett R, Martin K, Tarzi M, Panthakalam S, Freeman T, Ainley L, Turner M, Hughes L, Russell B, Jenkins S, Done J, Young A, Jones T, Gaywood IC, Pande I, Pradere MJ, Bhaduri M, Smith A, Cook H, Abraham S, Ngcozana T, Denton CP, Parker L, Black CM, Ong V, Thompson N, White C, Duddy M, Jobanputra P, Bacon P, Smith J, Richardson A, Giancola G, Soh V, Spencer S, Greenhalgh A, Hanson M, De Lord D, Lloyd M, Wong H, Wren D, Grover B, Hall J, Neville C, Alton P, Kelly S, Bombardieri M, Humby F, Ng N, Di Cicco M, Hands R, Epis O, Filer A, Buckley C, McInnes I, Taylor P, Pitzalis C, Freeston J, Conaghan P, Grainger A, O'Connor PJ, Evans R, Emery P, Hodgson R, Emery P, Fleischmann R, Han C, van der Heijde D, Conaghan P, Xu W, Hsia E, Kavanaugh A, Gladman D, Chattopadhyay C, Beutler A, Han C, Zayat AS, Conaghan P, Freeston J, Hensor E, Ellegard K, Terslev L, Emery P, Wakefield RJ, Ciurtin C, Leandro M, Dey D, Nandagudi A, Giles I, Shipley M, Morris V, Ioannou J, Ehrenstein M, Sen D, Chan M, Quinlan TM, Brophy R, Mewar D, Patel D, Wilby MJ, Pellegrini V, Eyes B, Crooks D, Anderson M, Ball E, McKeeman H, Burns J, Yau WH, Moore O, Foo J, Benson C, Patterson C, Wright G, Taggart A, Drew S, Tanner L, Sanyal K, Bourke BE, Lloyd M, Alston C, Baqai C, Chard M, Sandhu V, Neville C, Jordan K, Munns C, Zouita L, Shattles W, Davies U, Makadsi R, Griffith S, Kiely PD, Ciurtin C, Dimofte I, Dabu M, Dabu B, Dobarro D, Schreiber BE, Warrell C, Handler C, Coghlan G, Denton C, Ishorari J, Bunn C, Beynon H, Denton CP, Stratton R, George Malal JJ, Boton-Maggs B, Leung A, Farewell D, Choy E, Gullick NJ, Young A, Choy EH, Scott DL, Wincup C, Fisher B, Charles P, Taylor P, Gullick NJ, Pollard LC, Kirkham BW, Scott DL, Ma MH, Ramanujan S, Cavet G, Haney D, Kingsley GH, Scott D, Cope A, Singh A, Wilson J, Isaacs A, Wing C, McLaughlin M, Penn H, Genovese MC, Sebba A, Rubbert-Roth A, Scali J, Zilberstein M, Thompson L, Van Vollenhoven R, De Benedetti F, Brunner H, Allen R, Brown D, Chaitow J, Pardeo M, Espada G, Flato B, Horneff G, Devlin C, Kenwright A, Schneider R, Woo P, Martini A, Lovell D, Ruperto N, John H, Hale ED, Treharne GJ, Kitas GD, Carroll D, Mercer L, Low A, Galloway J, Watson K, Lunt M, Symmons D, Hyrich K, Low A, Mercer L, Galloway J, Davies R, Watson K, Lunt M, Dixon W, Hyrich K, Symmons D, Balarajah S, Sandhu A, Ariyo M, Rankin E, Sandoo A, van Zanten JJV, Toms TE, Carroll D, Kitas GD, Sandoo A, Smith JP, Kitas GD, Malik S, Toberty E, Thalayasingam N, Hamilton J, Kelly C, Puntis D, Malik S, Hamilton J, Saravanan V, Rynne M, Heycock C, Kelly C, Rajak R, Goodfellow R, Rhys-Dillon C, Winter R, Wardle P, Martin JC, Toms T, Sandoo A, Smith J, Cadman S, Nightingale P, Kitas G, Alhusain AZ, Verstappen SM, Mirjafari H, Lunt M, Charlton-Menys V, Bunn D, Symmons D, Durrington P, Bruce I, Cooney JK, Thom JM, Moore JP, Lemmey A, Jones JG, Maddison PJ, Ahmad YA, Ahmed TJ, Leone F, Kiely PD, Browne HK, Rhys-Dillon C, Wig S, Chevance A, Moore T, Manning J, Vail A, Herrick AL, Derrett-Smith E, Hoyles R, Moinzadeh P, Chighizola C, Khan K, Ong V, Abraham D, Denton CP, Schreiber BE, Dobarro D, Warrell CE, Handler C, Denton CP, Coghlan G, Sykes R, Muir L, Ennis H, Herrick AL, Shiwen X, Thompson K, Khan K, Liu S, Denton CP, Leask A, Abraham DJ, Strickland G, Pauling J, Betteridge Z, Dunphy J, Owen P, McHugh N, Abignano G, Cuomo G, Buch MH, Rosenberg WM, Valentini G, Emery P, Del Galdo F, Jenkins J, Pauling JD, McHugh N, Khan K, Shiwen X, Abraham D, Denton CP, Ong V, Moinzadeh P, Howell K, Ong V, Nihtyanova S, Denton CP, Moinzadeh P, Fonseca C, Khan K, Abraham D, Ong V, Denton CP, Malaviya AP, Hadjinicolaou AV, Nisar MK, Ruddlesden M, Furlong A, Baker S, Hall FC, Hadjinicolaou AV, Malaviya AP, Nisar MK, Ruddlesden M, Raut-Roy D, Furlong A, Baker S, Hall FC, Peluso R, Dario Di Minno MN, Iervolino S, Costa L, Atteno M, Lofrano M, Soscia E, Castiglione F, Foglia F, Scarpa R, Wallis D, Thomas A, Hill I, France B, Sengupta R, Dougados M, Keystone E, Heckaman M, Mease P, Landewe R, Nguyen D, Heckaman M, Mease P, Winfield RA, Dyke C, Clemence M, Mackay K, Haywood KL, Packham J, Jordan KP, Davies H, Brophy S, Irvine E, Cooksey R, Dennis MS, Siebert S, Kingsley GH, Ibrahim F, Scott DL, Kavanaugh A, McInnes I, Chattopadhyay C, Krueger G, Gladman D, Beutler A, Gathany T, Mudivarthy S, Mack M, Tandon N, Han C, Mease P, McInnes I, Sieper J, Braun J, Emery P, van der Heijde D, Isaacs J, Dahmen G, Wollenhaupt J, Schulze-Koops H, Gsteiger S, Bertolino A, Hueber W, Tak PP, Cohen CJ, Karaderi T, Pointon JJ, Wordsworth BP, Cooksey R, Davies H, Dennis MS, Siebert S, Brophy S, Keidel S, Pointon JJ, Farrar C, Karaderi T, Appleton LH, Wordsworth BP, Adshead R, Tahir H, Greenwood M, Donnelly SP, Wajed J, Kirkham B. BHPR research: qualitative * 1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis. Rheumatology (Oxford) 2012. [DOI: 10.1093/rheumatology/kes110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Mandl P, Balint PV, Brault Y, Backhaus M, D'Agostino MA, Grassi W, van der Heijde D, de Miguel E, Wakefield RJ, Logeart I, Dougados M. Metrologic properties of ultrasound versus clinical evaluation of synovitis in rheumatoid arthritis: Results of a multicenter, randomized study. ACTA ACUST UNITED AC 2012; 64:1272-82. [DOI: 10.1002/art.33491] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Mandl P, Naredo E, Conaghan PG, D'Agostino MA, Wakefield RJ, Bachta A, Backhaus M, Hammer HB, Bruyn GAW, Damjanov N, Filippucci E, Grassi W, Iagnocco A, Jousse-Joulin S, Kane D, Koski JM, Moller I, De Miguel E, Schmidt WA, Swen WAA, Szkudlarek M, Terslev L, Ziswiler HR, Ostergaard M, Balint PV. Practice of ultrasound-guided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies. Rheumatology (Oxford) 2011; 51:184-90. [DOI: 10.1093/rheumatology/ker331] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Keen HI, Redmond A, Wakefield RJ, Freeston J, Grainger AJ, Hensor EMA, Emery P, Conaghan PG. An ultrasonographic study of metatarsophalangeal joint pain: synovitis, structural pathology and their relationship to symptoms and function. Ann Rheum Dis 2011; 70:2140-3. [DOI: 10.1136/annrheumdis-2011-200349] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Din OS, Dodwell D, Wakefield RJ, Bradburn M, Emery P, Wilson G, Tan AL, O'Connor P, Highland A, Horgan K, Coleman RE. Abstract P5-11-18: Investigating Early Features of Aromatase Inhibitor-Induced Arthralgia. Cancer Res 2010. [DOI: 10.1158/0008-5472.sabcs10-p5-11-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Aromatase inhibitors (AI) are well known to be associated with troublesome musculoskeletal side effects but the underlying mechanisms are poorly understood and methods of objective assessment poorly defined. We have performed a prospective detailed evaluation of grip strength (primary endpoint), symptoms, imaging and biomarkers in patients receiving either an AI, tamoxifen or no endocrine therapy. Methods: 77 patients with early breast cancer from two specialist Breast Units were recruited prior to starting one of 4 treatment arms: upfront AI (A), switch from tamoxifen to AI (B), tamoxifen (C) and no treatment (D). Arthralgia was defined as worsening of joint pain score at 3 months and a positive Tinel's or Phalen's test was taken as evidence of carpal tunnel syndrome. Grip strength was measured (average of three readings from each hand) using a Jamar Dynamometer at baseline, 1, 2, 3, 6 and 12 months. In addition, biochemical (endocrine and collagen markers), rheumatological (inflammatory and cytokine markers) and radiological assessments of the hands (diagnostic ultrasound, bone density using DXA and plain radiograph) were performed at protocol-specified intervals. A subset of patients also underwent hand MRI at baseline, 3 and 12 months. Detailed rheumatological examination and questionnaire (DAS-28, SF-36, HAQ-DI and BPI-SF) assessment were performed at each visit. Grip strength was analysed using analysis of covariance with age, prior chemotherapy and baseline grip as covariates. The Kruskal-Wallis test was used for questionnaire data. The 3 month data on grip strength, questionnaire, clinical assessment and hand ultrasound are presented here. Results: 47 patients received an AI (34 upfront, 13 switch), 22 tamoxifen and 8 no endocrine treatment (controls). Median age (yearrs) for each group was: 62.1 (A), 51.0 (B), 65.2 (C) and 61.2 (D). The incidence of arthralgia at 3 months was 38% (A), 17% (B), 38% (C) and 14% (D). Mean baseline grip strength was similar in each arm: 22.5kg (A), 23.1kg (B), 20.2kg (C) and 23.2kg (D) (p=0.342 ANOVA). At 3 months, the mean percentage change in grip strength was +0.2% (A), +2.2% (B), +4.5% (C),+1.2% (D) (p=ns ANCOVA). In those on AI, the development of arthralgia was not shown to be associated with change in grip strength (p=0.82). Morning stiffness was also no different at 3 months. Clinical signs of carpal tunnel syndrome were evident in 10/45 (22%) of patients receiving AI therapy compared to 4/28 (14%) on tamoxifen/control. There were 4 cases of trigger thumb or finger, all in patients receiving AI treatment. Changes in HAQ-DI and pain (VAS) at 3 months were no different between groups (p=0.27, p=0.1 respectively). Ultrasound assessment of the flexor tendons at 3 month identified an increase in median score for tendon sheath fluid in those in the AI groups (3 (AI) v 1 (No AI) p=0.07, Mann-Whitney U test). There was no significant change in average median nerve cross-sectional area at 3 month.
Conclusion: This study suggests that patient reported arthalgia does not correlate with early changes in and mean grip strength. However, there may be early signs of carpal tunnel syndrome, trigger finger and fluid in the flexor tendon sheaths detectable by ultrasound.
Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P5-11-18.
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Affiliation(s)
- OS Din
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - D Dodwell
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - RJ Wakefield
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - M Bradburn
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - P Emery
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - G Wilson
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - AL Tan
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - P O'Connor
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - A Highland
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - K Horgan
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
| | - RE. Coleman
- University of Sheffield, South Yorkshire, United Kingdom; St James ‘ Institute of Oncology, Leeds, West Yorkshire, United Kingdom; Leeds Institute of Molecular Medicine, Leeds, West Yorkshire, United Kingdom; Sheffield School of Health and Related Research, West Yorkshire, United Kingdom; Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, United Kingdom; Sheffield Teaching Hospitals NHS Foundation Trust, South Yorkshire, United Kingdom
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Freeston JE, Garnero P, Wakefield RJ, Hensor EMA, Conaghan PG, Emery P. Urinary type II collagen C-terminal peptide is associated with synovitis and predicts structural bone loss in very early inflammatory arthritis. Ann Rheum Dis 2010; 70:331-3. [DOI: 10.1136/ard.2010.129304] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Wig S, Bischoff P, Holt M, Collins S, Goodfellow R, Martin J, Rhys-Dillon C, Lyle S, Rowan Phillips J, Mease PJ, Perdok R, Kary S, Kupper H, Humphreys E, Amos N, Nash J, Jones S, McHugh K, Giles J, Kollnberger S, Kuroi K, Maenaka K, Bowness P, El Miedany Y, El Gaafary M, Youssef S, Palmer D, Marshall CL, Harrison PV, Bukhari M, Greenwood MC, Omar F, Hakim AJ, Donnelly SP, Rooney MM, Lanham JG, Tahir H, Mease PJ, Kavanaugh A, Perdok R, Kupper H, Lavie F, Barlow JH, McFarland L, Tindall L, Ravindran J, Perkins P, Ciurtin C, Doufexi D, Bartko J, Roussou E, Phillips JR, Collins S, Lyle S, Goodfellow R, Martin J, Rhys-Dillon C, Thompson B, Rapley T, Broderick W, May C, Kay L, Sandhu J, Packham JC, Healey EL, Jordan K, Garratt AM, Haywood KL, Utriainen L, Cerovic V, McInnes I, Milling S, Ritchlin CT, Mease PJ, Perdok R, Kupper H, Lavie F, Freeston JE, Coates LC, Helliwell PS, Hensor EM, Wakefield RJ, Emery P, Conaghan PG, Skerrett J, van der Weide I, Barlow J, Keat A, van der Heijde D, Braun J, Sieper J, Wishneski C, Vlahos B, Szumski A, Foehl J, Freundlich B, Koenig A, Gatia A, Bartko J, Doufexi D, Roussou E, Kavanaugh A, Gladman D, Chattopadhyay C, Mease P, McInnes IB, Beutler A, Zrubek J, Buchanan J, Parasuraman S, Mack M, Krueger GG, Wazir TU, Cairns AP, Bell A, Giles JL, Shaw J, McHugh K, Ridley A, Bowness P, Kollnberger S, Pritchard GS, Bukhari M, Wilcox L, Freeston JE, Coates LC, Helliwell PS, Hensor EM, Wakefield RJ, Emery P, Conaghan PG, Packham J, Jordan KP, Lebmeier M, Garratt AM, Healey EL, Haywood KL, Ciurtin C, Roussou E, Clarke L, Kay L, Gingold MJ, Bansback N, Guh DP, Cavill C, Porteous R, Kyle SD, Waldron N, Korendowych E, McHugh N, Braun J, van der Heijde AD, Deodhar L, Diekman J, Sieper SI, Kim A, Beutler M, Mack S, Xu J, Zrubek B, Hsu R, Inman O. Spondyloarthropathies (Including Psoriatic Arthritis) [40-69]: 40. Eagle's Syndrome: An Unusual Association with Sero-Negative Arthropathy. Rheumatology (Oxford) 2010. [DOI: 10.1093/rheumatology/keq716] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
BACKGROUND Ultrasonography has been increasingly utilised to aid the understanding and management of rheumatic conditions. In recent years there has been a focus on the validity and utility of ultrasonography in demonstrating joint pathology, although this has largely focused on inflammatory arthritis. AIMS To undertake a systematic review of the published literature evaluating ultrasonography as an assessment tool in osteoarthritis. METHODS Medline and Pubmed were searched to identify original manuscripts, published before June 2008, utilising ultrasonography to assess the joints of cohorts of subjects with osteoarthritis. Data were extracted from manuscripts meeting the inclusion criteria, with a particular focus on the pathology imaged, the definitions used, scoring systems and their metric properties. RESULTS Forty-seven studies were identified that utilised ultrasonography to assess structural pathology in osteoarthritis. Doppler function was only assessed in 10 studies and contrast agents in one. There was heterogeneity with regard to the pathology examined, the definition of pathology, quantification and the reporting of these factors. There was also a lack of construct and criterion validity and data demonstrating reliability and sensitivity to change. CONCLUSIONS Whereas there is increasing evidence of the validity of ultrasonography in detecting structural pathology in inflammatory arthritis, more work is required to develop standardised definitions of pathology and to demonstrate the validity of ultrasonography in osteoarthritis.
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Affiliation(s)
- H I Keen
- School of Medicine and Pharmacology, Royal Perth Hospital, Perth, WA, Western Australia.
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Freeston JE, Wakefield RJ, Conaghan PG, Hensor EMA, 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 Dis 2009; 69:417-9. [DOI: 10.1136/ard.2008.106658] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives:The aim of this study was to assess the value of power Doppler ultrasound (PDUS) in combination with routine management in a cohort of patients with very early inflammatory arthritis (IA).Methods:50 patients with ⩽12 weeks of inflammatory symptoms with or without signs had clinical, laboratory and imaging assessments. Diagnosis was recorded at 12 months. Assuming a 15% pre-test probability of IA, post-test probabilities for various assessments were calculated and used to develop a diagnostic algorithm.Results:All patients positive for rheumatoid factor (RF) and/or cyclic citrullinated peptide (CCP) developed persistent IA, so the added value of PDUS was assessed in the seronegative (RF and CCP negative) group. The probability of IA in a seronegative patient was 6%. The addition of clinical and radiographic features raised the probability of IA to 30% and, with certain ultrasound features, this rose to 94%.Conclusions:In seronegative patients with early IA, combining PDUS with routine assessment can have a major impact on the certainty of diagnosis.
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Brown AK, Conaghan PG, Karim Z, Quinn MA, Ikeda K, Peterfy CG, Hensor E, Wakefield RJ, O'Connor PJ, Emery P. An explanation for the apparent dissociation between clinical remission and continued structural deterioration in rheumatoid arthritis. ACTA ACUST UNITED AC 2008; 58:2958-67. [PMID: 18821687 DOI: 10.1002/art.23945] [Citation(s) in RCA: 566] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- A K Brown
- Leeds Institute of Molecular Medicine, University of Leeds, and Chapel Allerton Hospital, Leeds, UK
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Bruyn GAW, Naredo E, Möller I, Moragues C, Garrido J, de Bock GH, d’Agostino MA, Filippucci E, Iagnocco A, Backhaus M, Swen WAA, Balint P, Pineda C, Milutinovic S, Kane D, Kaeley G, Narvaez FJ, Wakefield RJ, Narvaez JA, de Augustin J, Schmidt WA. Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis. Ann Rheum Dis 2008; 68:357-61. [DOI: 10.1136/ard.2008.089243] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objective:To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.Methods:A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.Results:Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver κ was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, −0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver κ for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.Conclusions:US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.
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Wakefield RJ, Freeston JE, O'Connor P, Reay N, Budgen A, Hensor EMA, Helliwell PS, Emery P, Woodburn J. The optimal assessment of the rheumatoid arthritis hindfoot: a comparative study of clinical examination, ultrasound and high field MRI. Ann Rheum Dis 2008; 67:1678-82. [PMID: 18258710 DOI: 10.1136/ard.2007.079947] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The aim of this pilot study was to compare clinical examination (CE) and ultrasound (US) with high field MRI (as the reference standard) for the detection of rearfoot and midtarsal joint synovitis and secondly tenosynovitis of the ankle tendons in patients with established rheumatoid arthritis (RA). METHODS Patients with RA (as determined by the modified American College of Rheumatology (ACR) criteria) with symptoms of midfoot and rearfoot disease were recruited. Demographic data were collected. All underwent CE, US and high field MRI (with intravenous gadolinium contrast) of their right foot. Percentage exact agreement (PEA), sensitivity and specificity were calculated for CE and US when compared to MRI. Inter-reader reliability for CE and US was also assessed. RESULTS Compared to the gold standard of MRI, for CE (joint synovitis) the ranges for sensitivity, specificity and PEA were 55-83%, 23-46% and 46-60%, and for US were 64-89%, 60-80% and 64-78%, respectively. Compared to the gold standard of MRI, for CE (tenosynovitis) the ranges for sensitivity, specificity and PEA were 0-100%, 20-91% and 55-91%, and for US were 0-67%, 86-100% and 59-86%, respectively. CONCLUSION CE was sensitive but US more specific in identifying hindfoot pathology in RA when compared to the reference standard of MRI. There was poor interobserver variability between ultrasonographers suggesting a need for standardisation of acquisition and interpretation of US images of the hindfoot.
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Affiliation(s)
- R J Wakefield
- Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.
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Keen HI, Wakefield RJ, Grainger AJ, Hensor EMA, Emery P, Conaghan PG. Can ultrasonography improve on radiographic assessment in osteoarthritis of the hands? A comparison between radiographic and ultrasonographic detected pathology. Ann Rheum Dis 2007; 67:1116-20. [PMID: 18037626 DOI: 10.1136/ard.2007.079483] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Ultrasonography (US) is used in rheumatology to assess small joints in inflammatory arthritis. Recently there has been some investigation into the utility of US in osteoarthritis (OA), however there has been little comparison of US to other imaging modalities in OA. This study aimed to compare the detection of osteophytosis and joint space narrowing (JSN) by US and conventional radiography (CR) in OA of the hand. METHODS SUBJECTS with OA of the hand underwent US and CR examination of the small joints of both hands to identify osteophytosis and joint space narrowing. RESULTS 1106 joints of 37 patients were imaged with US and CR. US detected osteophytosis in 448 joints, compared to CR that detected osteophytosis in 228 joints (approximately 30% fewer joints). Where osteophytosis was detected by US but not CR, this was usually proximal to the joint line. Joint space narrowing was detected in 450 joints by US, but only 261 joints by CR. The distribution of US and CR detected osteoarthritis changes in this cohort was consistent with population studies of radiographic hand OA, although metacarpophalangeal (MCP) involvement was higher than might be expected CONCLUSIONS US detected more osteophytosis and joint space narrowing than CR in OA of the hand. Involvement of MCP joints was more common than would be expected from population radiographic studies. The increased detection of OA structural pathology by US may make this a useful tool for hand OA research.
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Affiliation(s)
- H I Keen
- Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK.
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Naredo E, Bijlsma JWJ, Conaghan PG, Acebes C, Balint P, Berner-Hammer H, Bruyn GAW, Collado P, D'Agostino MA, de Agustin JJ, de Miguel E, Filippucci E, Grassi W, Iagnocco A, Kane D, Koski JM, Manger B, Mayordomo L, Möller I, Moragues C, Rejón E, Szkudlarek M, Terslev L, Uson J, Wakefield RJ, Schmidt WA. Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses. Ann Rheum Dis 2007; 67:1017-22. [PMID: 17921183 PMCID: PMC2564786 DOI: 10.1136/ard.2007.082560] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses. METHODS We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels. RESULTS The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses. CONCLUSION We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.
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Affiliation(s)
- E Naredo
- Rheumatology Department, Hospital Severo Ochoa, Madrid, Spain.
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Keen HI, Lavie F, Wakefield RJ, D'Agostino MA, Hammer HB, Hensor E, Pendleton A, Kane D, Guerini H, Schueller-Weidekamm C, Kortekaas MC, Birrel F, Kloppenburg M, Stamm T, Watt I, Smolen JS, Maheu E, Dougados M, Conaghan PG. The development of a preliminary ultrasonographic scoring system for features of hand osteoarthritis. Ann Rheum Dis 2007; 67:651-5. [PMID: 17704062 DOI: 10.1136/ard.2007.077081] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Painful osteoarthritis (OA) of the hand is common and a validated ultrasound (US) scoring system would be valuable for epidemiological and therapeutic outcome studies. US is increasingly used to assess peripheral joints, though most of the US focus in rheumatic diseases has been on rheumatoid arthritis. We aimed to develop a preliminary US hand OA scoring system, initially focusing on relevant pathological features with potentially high reliability. METHODS A group of experts in the fields of OA, US and novel tool development agreed on domains and suggested scaling of the items to be used in US hand OA scoring systems. A multi-observer reliability exercise was then performed to evaluate the draft items. RESULTS Synovitis (grey scale and Power Doppler) and osteophytes (representing activity and damage domains) were included and evaluated as the initial components of the scoring system. All three features were evaluated for their presence/absence and if present were scored using a 1-3 scale. The reliability exercise demonstrated intra-reader kappa values of 0.444-1.0, 0.211-1.0 and 0.087-1.0 for grey scale synovitis, power Doppler and osteophytes respectively. Inter-reader reliability kappa values were 0.398, 0.327 and 0.530 grey-scale synovitis, power Doppler and osteophytes respectively. Without extensive standardisation, both intra- and inter-reader reliability were moderately good. CONCLUSIONS The draft scoring system demonstrated substantive to almost perfect percentage exact agreement on the presence/absence of the selected OA features and moderate to substantive percentage exact agreement on semi-quantitative grading. This preliminary process provides a good basis from which to further develop an US outcome tool for hand OA that has the potential to be utilised in multicentre clinical trials.
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Affiliation(s)
- H I Keen
- Academic Unit of Musculoskeletal Disease, Chapel Allerton Hospital, University of Leeds, Leeds, UK.
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Brown AK, Roberts TE, O'connor PJ, Wakefield RJ, Karim Z, Emery P. The development of an evidence-based educational framework to facilitate the training of competent rheumatologist ultrasonographers. Rheumatology (Oxford) 2007; 46:391-7. [PMID: 17264091 DOI: 10.1093/rheumatology/kel415] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Musculoskeletal ultrasonography (MSKUS) has been described by some rheumatologists as the 'stethoscope of the joint'. Such enthusiasm is supported by evidence confirming validity and clinical utility in evaluation of musculoskeletal diseases. But if rheumatologist-performed MSKUS is to emulate the impact of cardiologist-performed echocardiography, a number of educational challenges need be addressed. Evaluation of current training reveals the absence of a unified educational structure, ad hoc teaching and assessment and published data are insufficient to make practice and training recommendations specific to rheumatology. METHODS Informed by developments in adult-learning theory, we have utilized a competency-based approach to develop an educational programme for rheumatologist ultrasonographers. Fundamental to this process has been accurate functional analysis of the role of the rheumatologist ultrasonographer and precise translation of these data into educational outcomes. This involved a thorough, transparent, iterative, curriculum-defining approach, employing quantitative and qualitative research techniques including interview, questionnaire, Delphi and standard setting methodologies. All relevant stakeholders were engaged, including international US experts and clinical rheumatologists. RESULTS Outcomes include clarification of the role of a rheumatologist ultrasonographer; definition of appropriate knowledge and skills; establishment of competency standards; a balanced, clearly defined, clinically relevant educational outcome blueprint. Teaching and assessment approaches have been piloted as part of an accessible modular curriculum strategy. Thorough validation and evaluation confirms effectiveness, efficiency and suitability. CONCLUSIONS A comprehensive evidence-based, expert consensus-defined educational framework is proposed that provides a template for teaching and learning and standards for competency assessment. This should facilitate common principles of training, uniform professional practice and a justifiable governance structure.
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Affiliation(s)
- A K Brown
- Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, UK.
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Brown AK, Roberts TE, Wakefield RJ, Karim Z, Hensor E, O'connor PJ, Emery P. The challenges of integrating ultrasonography into routine rheumatology practice: addressing the needs of clinical rheumatologists. Rheumatology (Oxford) 2007; 46:821-9. [PMID: 17237482 DOI: 10.1093/rheumatology/kel412] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES The practice of musculoskeletal ultrasonography (MSKUS) by UK rheumatologists remains limited, despite their reported enthusiasm. This study aimed to investigate factors that may encourage or limit future dissemination of rheumatologist-performed MSKUS and provide insights into perceived clinical importance and learning motivation relating to published recommendations by MSKUS experts. METHODS A written questionnaire study was conducted, involving 48 rheumatologists. Questions included the potential role of self-performed MSKUS, skills that they would be willing to learn and factors that may encourage or limit learning and practice. Competency recommendations proposed by imaging experts (142 skills in 7 anatomical areas) were reviewed, and quantitative and qualitative data collected regarding 'value to their practice' and 'learning motivation'. RESULTS Eighty-nine percent wished to learn MSKUS. Factors influencing learning and practice included time to achieve competency; relative-added clinical value of MSKUS examination; limited training infrastructure; access to existing imaging service; equipment funding. Skills offering greatest clinical utility were inflammatory arthritis assessment and guided procedures; least useful were evaluation of ligament/muscle lesions and soft tissue masses. There was a close correlation between clinical utility, learning motivation and competency standard. CONCLUSIONS A trade-off between added clinical value and time to achieve competency is the major factor influencing practice and training in MSKUS. Most rheumatologists report limited time to devote to training and therefore need to prioritize areas of importance for dedicated learning. Educational programmes need to be highly focused and relevant to clinical and job-plan requirements in order to encourage future dissemination of MSKUS practice by rheumatologists.
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Affiliation(s)
- A K Brown
- Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds, UK.
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Wakefield RJ, O'Connor PJ, Conaghan PG, McGonagle D, Hensor EMA, Gibbon WW, Brown C, Emery P. Finger tendon disease in untreated early rheumatoid arthritis: A comparison of ultrasound and magnetic resonance imaging. ACTA ACUST UNITED AC 2007; 57:1158-64. [PMID: 17907233 DOI: 10.1002/art.23016] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To investigate the frequency and distribution of finger tenosynovitis in patients with early, untreated rheumatoid arthritis (RA) using gray-scale ultrasound (US) and magnetic resonance imaging (MRI). METHODS Fifty patients underwent US and MRI of metacarpophalangeal (MCP) joints 2-5. Twenty healthy controls underwent US only. Flexor and extensor involvement was documented for each joint. Intrareader reliability (IRR) was calculated by rereading static images. RESULTS Flexor tenosynovitis was found in 57 (28.5%) of 200 joints in 24 (48%) of 50 patients on US compared with 128 (64%) of 200 joints in 41 (82%) of 50 patients on MRI. Periextensor tenosynovitis was found in 14 (7%) joints in 9 (18%) patients on US compared with 80 (40%) joints in 36 (72%) patients on MRI. No controls had imaging tenosynovitis. Using MRI as the gold standard, the sensitivity, specificity, and negative and positive predictive values for US were 0.44, 0.99, 0.49, and 0.98, respectively, for flexor tenosynovitis and 0.15, 0.98, 0.63, and 0.86 for extensor tenosynovitis, respectively. The IRR was 0.85 and 0.8 for US and MRI, respectively. The most frequently involved joints on US and MRI were the second and third MCP joints. CONCLUSION This is the first study to compare US and MRI for the detection of tenosynovitis in the fingers of patients with early untreated RA. Tenosynovitis was found to be common using both modalities, with MRI being more sensitive. A negative US scan does not exclude inflammation and an MRI should be considered. Further work is recommended to standardize definitions and image acquisition for both US and MRI images.
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Brown AK, O'Connor PJ, Roberts TE, Wakefield RJ, Karim Z, Emery P. Ultrasonography for rheumatologists: the development of specific competency based educational outcomes. Ann Rheum Dis 2006; 65:629-36. [PMID: 16192291 PMCID: PMC1798129 DOI: 10.1136/ard.2005.039974] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2005] [Indexed: 11/03/2022]
Abstract
BACKGROUND A competency based approach to the education of rheumatologists in musculoskeletal ultrasonography (MSK US) ensures standards are documented, transparent, accountable, and defensible, with clear benefit to all stakeholders. Specific competency outcomes will facilitate informed development of a common curriculum and structured programme of training and assessment. OBJECTIVE To determine explicit competency based learning outcomes for rheumatologists undertaking MSK US. METHODS International experts in MSK US, satisfying specific selection criteria, were asked to define the minimum standards required by a rheumatologist to be judged competent in MSK US. They reviewed 115 MSK US skills, comprising bone and soft tissue pathology, in seven joints regions of the upper and lower limbs, and rated their relative importance according to specific criteria. These data are presented as specific educational outcomes within designated competency categories. RESULTS 57 expert MSK US practitioners were identified and 35 took part in this study. Ten generic core competency outcomes were recognised including physics, anatomy, technique, and interpretation. Regarding specific regional competencies, 53% (61/115) were considered "must know" core learning outcomes, largely comprising inflammatory joint/tendon/bone pathology and guided procedures; 45% (52/115) were required at an intermediate/advanced level (18/115 "should know", 34/115 "could know"), and 2% (2/115) were deemed inappropriate/unnecessary for rheumatologist ultrasonographers. CONCLUSIONS This is the first study to developing a competency model for the education of rheumatologists in MSK US based on the evidence of international experts. A specific set of learning outcomes has been defined, which will facilitate future informed education and practice development and provide a blueprint for a structured rheumatology MSK US curriculum and assessment process.
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Affiliation(s)
- A K Brown
- Academic Unit of Musculoskeletal Disease, University of Leeds, Chapel Allerton Hospital, Leeds LS7 4SA, UK.
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Brown AK, Quinn MA, Karim Z, Conaghan PG, Peterfy CG, Hensor E, Wakefield RJ, O'Connor PJ, Emery P. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug–induced clinical remission: Evidence from an imaging study may explain structural progression. ACTA ACUST UNITED AC 2006; 54:3761-73. [PMID: 17133543 DOI: 10.1002/art.22190] [Citation(s) in RCA: 459] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE More timely and effective therapy for rheumatoid arthritis (RA) has contributed to increasing rates of clinical remission. However, progression of structural damage may still occur in patients who have satisfied remission criteria, which suggests that there is ongoing disease activity. This questions the validity of current methods of assessing remission in RA. The purpose of this study was to test the hypothesis that modern joint imaging improves the accuracy of remission measurement in RA. METHODS We studied 107 RA patients receiving disease-modifying antirheumatic drug therapy who were judged by their consultant rheumatologist to be in remission and 17 normal control subjects. Patients underwent clinical, laboratory, functional, and quality of life assessments. The Disease Activity Score 28-joint assessment and the American College of Rheumatology remission criteria, together with strict clinical definitions of remission, were applied. Imaging of the hands and wrists using standardized acquisition and scoring techniques with conventional 1.5T magnetic resonance imaging (MRI) and ultrasonography (US) were performed. RESULTS Irrespective of which clinical criteria were applied to determine remission, the majority of patients continued to have evidence of active inflammation, as shown by findings on the imaging assessments. Even in asymptomatic patients with clinically normal joints, MRI showed that 96% had synovitis and 46% had bone marrow edema, and US showed that 73% had gray-scale synovial hypertrophy and 43% had increased power Doppler signal. Only mild synovial thickening was seen in 3 of the control subjects (18%), but no bone marrow edema. CONCLUSION Most RA patients who satisfied the remission criteria with normal findings on clinical and laboratory studies had imaging-detected synovitis. This subclinical inflammation may explain the observed discrepancy between disease activity and outcome in RA. Imaging assessment may be necessary for the accurate evaluation of disease status and, in particular, for the definition of true remission.
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Affiliation(s)
- A K Brown
- Chapel Allerton Hospital, University of Leeds, Leeds, UK
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Haugeberg G, Green MJ, Quinn MA, Marzo-Ortega H, Proudman S, Karim Z, Wakefield RJ, Conaghan PG, Stewart S, Emery P. Hand bone loss in early undifferentiated arthritis: evaluating bone mineral density loss before the development of rheumatoid arthritis. Ann Rheum Dis 2005; 65:736-40. [PMID: 16284095 PMCID: PMC1798164 DOI: 10.1136/ard.2005.043869] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES (1) To examine the change in regional bone mineral density (BMD), including the hands, and assess its role as a predictor of outcome in patients presenting with an early undifferentiated inflammatory arthritis; (2) to examine for associations with the changes in hand BMD. METHODS 74 patients with undifferentiated hand arthritis of less than 12 months' duration were examined at baseline and then at three, six, and 12 months follow up, including BMD measurement of the femoral neck, spine (L2-4), and the whole hands using dual energy absorptiometry (DXA). RESULTS During the study, 13 patients were diagnosed as having rheumatoid arthritis, 19 as having inflammatory non-rheumatoid joint disorders, and 42 as having non-inflammatory joint disorders. At the femoral neck and lumbar spine no significant bone loss was seen in any of the three subgroups. At the 12 months follow up the mean (95% confidence interval) hand BMD loss in the patients with rheumatoid arthritis was -4.27% (-1.41 to -7.13); in the inflammatory non-rheumatoid group, -0.49% (-1.33 to +0.35); and in the non-inflammatory joint disorder group, -0.87% (-1.51 to -0.23). In a multivariate linear regression model (including age, rheumatoid factor, mean C reactive protein, mean HAQ score, and cumulative glucocorticoid dose), only mean C reactive protein (p<0.001) and rheumatoid factor (p = 0.04) were independently associated with change in hand BMD during follow up. CONCLUSIONS Hand DXA provides a very sensitive tool for measuring bone loss in early rheumatoid arthritis and may be useful in identifying patients at high risk of developing progressive disease. Further studies are needed to evaluate the role of hand bone loss as a prognostic factor and outcome measure in rheumatoid arthritis.
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Affiliation(s)
- G Haugeberg
- Academic Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK
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Naredo E, Möller I, Moragues C, de Agustín JJ, Scheel AK, Grassi W, de Miguel E, Backhaus M, Balint P, Bruyn GAW, D'Agostino MA, Filippucci E, Iagnocco A, Kane D, Koski JM, Mayordomo L, Schmidt WA, Swen WAA, Szkudlarek M, Terslev L, Torp-Pedersen S, Uson J, Wakefield RJ, Werner C. Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course. Ann Rheum Dis 2005; 65:14-9. [PMID: 15941835 PMCID: PMC1797981 DOI: 10.1136/ard.2005.037382] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography. METHODS The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results. RESULTS Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae. CONCLUSIONS Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.
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Affiliation(s)
- E Naredo
- Rheumatology, Hospital Severo Ochoa, Madrid, Spain.
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Brown AK, Wakefield RJ, Karim Z, Roberts TE, O'Connor PJ, Emery P. Evidence of effective and efficient teaching and learning strategies in the education of rheumatologist ultrasonographers: evaluation from the 3rd BSR musculoskeletal ultrasonography course. Rheumatology (Oxford) 2005; 44:1068-9. [PMID: 15927995 DOI: 10.1093/rheumatology/keh692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Scheel AK, Schmidt WA, Hermann KGA, Bruyn GA, D'Agostino MA, Grassi W, Iagnocco A, Koski JM, Machold KP, Naredo E, Sattler H, Swen N, Szkudlarek M, Wakefield RJ, Ziswiler HR, Pasewaldt D, Werner C, Backhaus M. Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course. Ann Rheum Dis 2005; 64:1043-9. [PMID: 15640263 PMCID: PMC1755572 DOI: 10.1136/ard.2004.030387] [Citation(s) in RCA: 155] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard". METHODS The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed. RESULTS Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%). CONCLUSION Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.
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Affiliation(s)
- A K Scheel
- Department of Medicine, Nephrology and Rheumatology, Robert-Koch-Strasse 40, D-37075 Göttingen, Germany.
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Brown AK, Wakefield RJ, Conaghan PG, Karim Z, O'Connor PJ, Emery P. New approaches to imaging early inflammatory arthritis. Clin Exp Rheumatol 2004; 22:S18-25. [PMID: 15552510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Imaging techniques such as musculoskeletal ultrasonography (MUS) and magnetic resonance imaging (MRI) are playing an increasingly important role in the assessment of patients with inflammatory arthritis. Such modalities are now used routinely in the evaluation of joint, tendon and soft tissue inflammation and bone damage in many early arthritis clinics. They have the ability to directly visualise, characterise and quantify the earliest inflammatory changes and have proved not only to be useful additional complimentary clinical tools to improve the speed and accuracy of diagnosis, direct appropriate treatment, monitor response to therapy, measure disease progression and outcome but also continue to contribute to our understanding of disease pathogenesis. These imaging methods may therefore offer a significant advantage as they endorse the principles of early diagnosis and optimal targeted therapy essential to providing the most favourable long term outcome for patients with inflammatory arthritis. This article reviews the current evidence supporting the role of MUS and MRI in the assessment of patients with inflammatory arthritis.
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Affiliation(s)
- A K Brown
- Academic Unit of Musculoskeletal Disease, Department of Rheumatology, University of Leeds, Leeds General Infirmary, UK
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Wakefield RJ, Brown AK, O'Connor PJ, Karim Z, Grainger A, Emery P. Musculoskeletal ultrasonography: what is it and should training be compulsory for rheumatologists? Rheumatology (Oxford) 2004; 43:821-2. [PMID: 15173601 DOI: 10.1093/rheumatology/keh227] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Wakefield RJ, McGonagle D, Tan AL, Evangelisto A, Emery P. Ultrasound detection of knee patellar enthesitis. Ann Rheum Dis 2004; 63:753; author reply 753-4. [PMID: 15140792 PMCID: PMC1755034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Wakefield RJ, Green MJ, Marzo-Ortega H, Conaghan PG, Gibbon WW, McGonagle D, Proudman S, Emery P. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis 2004; 63:382-5. [PMID: 15020331 PMCID: PMC1754934 DOI: 10.1136/ard.2003.007062] [Citation(s) in RCA: 263] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the prevalence of subclinical synovitis using ultrasound (US) imaging of both painful and asymptomatic joints, in patients with early (<12 months), untreated oligoarthritis (</=5 joints). METHODS Eighty patients underwent a detailed clinical assessment by two physicians. All painful joints were identified, which were immediately scanned by a sonographer. In the last 40 patients, an additional standard group of joints was scanned to establish the prevalence of synovitis in asymptomatic joints. RESULTS In 80 patients, 644 painful joints (with and without clinical synovitis) were identified and each underwent a US assessment. Of these joints, 185 had clinical synovitis, of which, US detected synovitis in only 79% (147/185). In the other 38 joints US demonstrated tenosynovitis instead of synovitis in 12 joints and possible, but not definite, synovitis in 11 joints. Fifteen joints were, however, normal on US. In 459 joints that were not clinically synovitic, US detected synovitis in 33% (150/459). In 64% (51/80) of patients, US detected synovitis in more joints than clinical examination and in 36% (29/80) of patients, US detected a polyarthritis (>6 joints). Of the 826 asymptomatic (non-painful) joints scanned, 13% (107/826) had US detected synovitis. CONCLUSION Sonography detected more synovitis than clinical examination in patients with oligoarthritis. In almost two thirds of patients there was evidence of subclinical disease while one third could be reclassified as polyarticular. These findings suggest that a definition of oligoarthritis based purely on clinical findings may be inappropriate, which may have important implications for disease management.
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Affiliation(s)
- R J Wakefield
- Academic Department of Musculoskeletal Medicine, 1st Floor, Old Nurse's Home, General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
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Karim Z, Wakefield RJ, Quinn M, Conaghan PG, Brown AK, Veale DJ, O'Connor P, Reece R, Emery P. Validation and reproducibility of ultrasonography in the detection of synovitis in the knee: A comparison with arthroscopy and clinical examination. ACTA ACUST UNITED AC 2004; 50:387-94. [PMID: 14872480 DOI: 10.1002/art.20054] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Accurate detection of synovitis is important in both the diagnosis and outcome assessment of arthritis. This study was undertaken to assess the validity and reproducibility of ultrasonography (US) as a means of detecting synovitis in the knee, by comparing US findings with findings of arthroscopy and clinical examination. METHODS Sixty consecutive patients with knee pain due to various arthritides had a clinical examination and US of their knee performed immediately prior to arthroscopy. All 3 assessments were performed by different clinicians who were blinded to the results obtained with the other modalities. US and clinical examination were compared with arthroscopically detected synovitis as the gold standard. Data from a subset of patients were used for calculating the inter- and intrareader reproducibility of US results, using a standard dichotomous (absence/presence of synovitis) as well as a graded (absence/grade of synovitis) scoring system. RESULTS With the use of arthroscopy as the gold standard, US had a higher sensitivity (98% versus 85%), specificity (88% versus 25%), accuracy (97% versus 77%), positive predictive value (98% versus 88%), and negative predictive value (88% versus 20%) compared with clinical examination. The Cohen kappa values for inter- and intrareader reproducibility of US for distinguishing between presence and absence of synovitis were 0.71 and 0.85, respectively (P < 0.05 for both). The weighted kappa values for distinguishing grade of synovitis were 0.65 for inter- and 0.74 for intrareader reproducibility. The kappa value for intrareader reproducibility of arthroscopy results was 0.88. CONCLUSION Ultrasonography is a valid and reproducible technique for detecting synovitis in the knee, and is more accurate than clinical examination. It may be valuable as a tool in studies investigating pain, diagnosis, and treatment response in knee arthritis.
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Affiliation(s)
- Z Karim
- University of Leeds and Leeds General Infirmary, Leeds, UK
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