Attitudes of United Kingdom rheumatologists to musculoskeletal ultrasound practice and training

OBJECTIVES: This study was performed to describe what clinical rheumatologists currently use musculoskeletal ultrasound (MSUS) for, how they are currently training and is the first study to survey rheumatologists to determine their preferences for MSUS training implementation. METHODS: 250 questionnaires were distributed at the British Society of Rheumatology Annual General Meeting (BSR AGM), 2005. RESULTS: 126 (50%) of questionnaires were completed by UK rheumatologists and were analysed. 117 (93%) of the respondents use MSUS imaging for patient management, with 41 (33%) indicating they perform MSUS themselves. Only two (2%) performed MSUS for >5 years. Rheumatologists use MSUS to image all peripheral joints-particularly the hands and feet-to assess joint and soft tissue inflammation and to guide joint injections. Lack of training in MSUS was the principal reason for not performing MSUS. Respondents expressed a preference for future training to be via a programme of regular sessions, with training delivered by either consultant radiologists or rheumatologists. Mentoring was the educational tool and assessment method of choice. CONCLUSIONS: The majority of respondents use MSUS in the management of their patients, with a third performing MSUS themselves. The report indicates rheumatologists' preferences on how training should be delivered in the future.     

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 2: Clinical indications for musculoskeletal ultrasound in rheumatology

Rheumatologists remain divided on whether they should introduce musculoskeletal ultrasound (MSUS) into their clinical practice. A central issue in the application of MSUS in clinical rheumatology is the need for proof of clinical relevance and improved patient care. There is now accumulating evidence that MSUS improves clinical diagnosis and intervention skills. High-resolution ultrasound is superior to clinical examination in the diagnosis and localization of joint and bursal effusion and synovitis. MSUS is the imaging modality of choice for the diagnosis of tendon pathology. MSUS is seven times more sensitive than plain radiography in the detection of rheumatoid erosions, allowing earlier diagnosis of progressive rheumatoid arthritis. Ligament, muscle, peripheral nerve and cartilage pathology can also be readily demonstrated by MSUS. There is exciting evidence that MSUS may potentially be used by rheumatologists to non-invasively diagnose and monitor not just joint and muscle disease but also nerve compression syndromes, scleroderma, vasculitis and Sj?gren's syndrome. Joint aspiration and injection accuracy can be improved by MSUS, with initial evidence confirming improved efficacy. As the number of rheumatologists performing MSUS increases and the technical capabilities of MSUS improve, there is likely to be a growing number of proven clinical indications for the application of MSUS in rheumatology practice. This paper reviews the evidence for the application of MSUS in rheumatology.     

Use of musculoskeletal ultrasound in Japan: a survey of practicing rheumatologists

We aimed to describe how often Japanese rheumatologists currently use musculoskeletal ultrasound (MSUS), and how they are currently being trained in the use of this imaging technique. Questionnaires were sent to 200 Japanese rheumatologists: 100 to participants attending the first Scientific Meeting of the Japanese Society of Imaging in Rheumatic Diseases in 2006, and 100 to other randomly selected rheumatologists certified by the Japan College of Rheumatology. A total of 139 questionnaires (74 from meeting participants, 65 from randomly selected rheumatologists) were completed and analyzed. Twenty-four of the 74 respondents (32.4%) in the meeting participants group used MSUS imaging for patient management, while only 7 of the 65 respondents (10.8%) in the certified rheumatologists group used MSUS imaging for patient management. Sixty-five of the 74 respondents (87.8%) in the meeting participants group and 54 of the 65 respondents (83.1%) in the certified rheumatologists group considered MSUS to be a useful tool. Only a minority of respondents used MSUS in the management of their patients. Lack of training in MSUS was the principal reason for not performing MSUS. Japanese rheumatologists would prefer future training in the form of intensive courses and training sessions.     

Impact of Musculoskeletal Ultrasound in an Outpatient Rheumatology Clinic

Objective

To evaluate the impact of musculoskeletal ultrasound (MSUS) as a complementary method to clinical assessment on rapid diagnosis and therapeutic decisions in a busy outpatient rheumatology clinic.

Methods

Sixty patients with different musculoskeletal symptoms were included in the study. Three expert rheumatologists performed the clinical examination and filled out a standardized clinical report sheet with the following parameters: general and/or local diagnoses, planned systemic and/or local treatment, and their decision concerning the use of MSUS evaluation complementary to clinical examination. Another rheumatologist, blinded to clinical data, performed the MSUS assessment of the anatomic areas selected by the clinicians. The impact of the new information obtained by MSUS on the initial diagnosis and therapeutic strategy was estimated by the degree of change in the initial clinical diagnosis and therapy decisions.

Results

Of 60 patients (67 anatomic areas), MSUS was considered as necessary after clinical examination in 39 patients (65%), totaling 43 anatomic areas (64.17%). An overall change of the initial clinical diagnosis was present in 60% of the anatomic areas (P = 0.0175). In all of the anatomic areas (100%), the new diagnosis was more objective and detailed. An overall change of the initial systemic therapy was present in 25% of anatomic areas (P = 0.0014) and in 36% of anatomic areas (P = 0.095) for local therapy. A guided diagnostic aspiration was decided to be performed in 15% of anatomic areas and a guided therapeutic injection in 22% of anatomic areas.

Conclusion

Enhanced information obtained by MSUS evaluation leads to changes, with a significant impact on the initial diagnosis and treatment strategy designed after clinical examination.     

Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study

OBJECTIVE: To compare joint and soft tissue aspiration using a conventional technique with an ultrasound (US) guided technique. METHODS: In the conventional group, 32 joints in 30 consecutive patients referred for joint aspiration and injection to an experienced consultant rheumatologist were aspirated. In the US guided group, 31 consecutive patients were examined by US to confirm the presence and location of fluid. Following US examination, aspiration was performed by a second rheumatologist based on the US localization of fluid or under direct US guidance. RESULTS: In the conventional group, successful aspiration was achieved in 10 (32%) joints. In the US guided group, successful aspiration was achieved in 31 (97%) joints. The mean volume of fluid obtained from successful aspirations was similar in both groups (11.7 ml in the US group and 14 ml in the conventional group). CONCLUSION: The use of US to localize joint and soft tissue fluid collection greatly improves the rate of diagnostic synovial fluid aspiration, particularly in small joints. This has important implications for accurate administration of local steroid therapy and emphasizes the importance of US as a useful tool in clinical rheumatological practice.     

Self‐directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States

Objective

Because musculoskeletal ultrasound (MSUS) is highly user dependent, we aimed to establish whether non‐mentored learning of MSUS is sufficient to achieve the same level of diagnostic accuracy and scanning reliability as has been achieved by rheumatologists recognized as international experts in MSUS.

Methods

A group of 8 rheumatologists with more experience in MSUS and 8 rheumatologists with less experience in MSUS participated in an MSUS exercise to assess patients with musculoskeletal abnormalities commonly seen in a rheumatology practice. Patients' established diagnoses were obtained from chart review (gout, osteoarthritis, rotator cuff syndrome, rheumatoid arthritis, and seronegative arthritis). Two examining groups were formed, each composed of 4 less experienced and 4 more experienced examiners. Each group scanned 1 predefined body region (hand, wrist, elbow, shoulder, knee, or ankle) in each of 8 patients, blinded to medical history and physical examination. Structural abnormalities were noted with dichotomous answers, and an open‐ended answer was used for the final diagnosis.

Results

Less experienced and more experienced examiners achieved the same diagnostic accuracy (US‐established diagnosis versus chart review diagnosis). The interrater reliability for tissue pathology was slightly higher for more experienced versus less experienced examiners (κ = 0.43 versus κ = 0.34; P = 0.001).

Conclusion

Non‐mentored training in MSUS can lead to the achievement of diagnostic accuracy in MSUS comparable to that achieved by highly experienced international experts. Reliability may increase slightly with additional experience. Further study is needed to determine the minimal training requirement to achieve proficiency in MSUS.     

The 12th International Rheumatology Symposium in Tokyo

Abstract

We aimed to describe how often Japanese rheumatologists currently use musculoskeletal ultrasound (MSUS), and how they are currently being trained in the use of this imaging technique. Questionnaires were sent to 200 Japanese rheumatologists: 100 to participants attending the first Scientific Meeting of the Japanese Society of Imaging in Rheumatic Diseases in 2006, and 100 to other randomly selected rheumatologists certified by the Japan College of Rheumatology. A total of 139 questionnaires (74 from meeting participants, 65 from randomly selected rheumatologists) were completed and analyzed. Twenty-four of the 74 respondents (32.4%) in the meeting participants group used MSUS imaging for patient management, while only 7 of the 65 respondents (10.8%) in the certified rheumatologists group used MSUS imaging for patient management. Sixty-five of the 74 respondents (87.8%) in the meeting participants group and 54 of the 65 respondents (83.1%) in the certified rheumatologists group considered MSUS to be a useful tool. Only a minority of respondents used MSUS in the management of their patients. Lack of training in MSUS was the principal reason for not performing MSUS. Japanese rheumatologists would prefer future training in the form of intensive courses and training sessions.     

Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis

OBJECTIVE: To evaluate the interobserver agreement of ultrasonographic assessment of finger and toe joints in patients with rheumatoid arthritis (RA) by 2 investigators with different medical backgrounds. METHODS: Ultrasonography and clinical examination were performed on 150 small joints of 30 patients with active RA. A General Electric LOGIQ 500 ultrasound unit with a 7-13-MHz linear array transducer was used. In each patient, 5 preselected small joints (second and third metacarpophalangeal, second proximal interphalangeal, first and second metatarsophalangeal) were examined independently on the same day by 2 ultrasound investigators (an experienced musculoskeletal radiologist and a rheumatologist with limited ultrasound training). Joint effusion, synovial thickening, bone erosions, and power Doppler signal were evaluated in accordance with an introduced 4-grade semiquantitative scoring system, on which the investigators had reached consensus prior to the study. RESULTS: Exact agreement between the 2 observers was seen in 91% of the examinations with regard to bone erosions, in 86% with regard to synovitis, in 79% with regard to joint effusions, and in 87% with regard to power Doppler signal assessments. Corresponding intraclass correlation coefficient values were 0.78, 0.81, 0.61, and 0.72, respectively, while unweighted kappa values were 0.68, 0.63, 0.48, and 0.55, respectively. Ultrasonography showed signs of inflammation in 94 joints, while clinical assessment revealed tenderness and/or swelling in 64 joints. CONCLUSION: An experienced radiologist and a rheumatologist with limited ultrasound training achieved high interobserver agreement rates for the identification of synovitis and bone erosions, using an introduced semiquantitative scoring system for ultrasonography of finger and toe joints in RA. Signs of inflammation were more frequently detected with ultrasound than with clinical examination. Ultrasonography may improve the assessment of RA patients by radiologists and rheumatologists.     

Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

Abstract

Our previous survey in 2008 revealed that only 22% of Japanese rheumatologists used musculoskeletal ultrasonography (MSUS) for patient management, because of insufficient educational opportunities. To clarify the current state of MSUS usage and to identify further challenges, we conducted a second survey between October 2010 through January 2011 by sending questionnaires to 200 randomly selected Japanese rheumatologists, consisting of 100 participants in a meeting in 2009 on imaging in rheumatic diseases and 100 board-certified rheumatologists. Among the respondents, a majority (85 and 67%, respectively) used magnetic resonance imaging (MRI). MSUS users had increased from 32 to 60% of meeting participants and from 11 to 27% of other rheumatologists. The majority of MSUS users had begun using MSUS within the previous 3 years. Whereas most respondents in the previous survey had been self-taught, in the current survey many had attended training courses or had received informal training from skilled users. Despite an increase in skills and equipment ownership, obstacles to implementing MSUS remained, most prominently a lack of time. In conclusion, training courses and informal training have contributed to the popularization of MSUS in Japan. To further increase MSUS usage, additional training opportunities and education about the advantages of MSUS will be needed.     

Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography

We evaluated the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases as seen in day-to-day rheumatology practice. Data were retrieved for demography, background condition, clinical findings, indications, regions scanned, and outcomes of MSUS, and categorised as: new-patients and follow-up. New-patient records were analysed as to whether MSUS had helped to confirm or change clinical diagnosis or was of no additional help. In follow-ups, we determined whether MSUS had helped in disease assessment, detection of co-existing problems or revision of diagnosis. Its impact on treatment decisions was noted. A total of 237 patients (146 women; mean age 55.9 +/- 17.2 years) had 264 regions scanned; hands,50.7%. In 78/237 (32.9%) there was disagreement between clinical and MSUS findings. Amongst new-patients (72), 13/39 (33.3%) referred with inflammatory arthritis had no MSUS evidence of inflammation in or around joints. In 76.3% it helped in confirming or changing diagnosis. Of the follow-ups (165), in 78.7%, 13.9% and 7.2% it helped in assessment, detection of co-existing problems and revision of diagnosis, respectively. MSUS influenced treatment in 45/165 (27.27%) cases. In 60/67 (89.55%) cases of rheumatoid arthritis (RA), it was done for disease assessment; in 31/60 (51.66%) it influenced treatment. MSUS, as a clinic-based service in rheumatology, has significant impact on the diagnosis and treatment of patients. This has potential to reduce diagnostic uncertainty and follow-up visits and ensure better outcomes.     

Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

Our previous survey in 2008 revealed that only 22% of Japanese rheumatologists used musculoskeletal ultrasonography (MSUS) for patient management, because of insufficient educational opportunities. To clarify the current state of MSUS usage and to identify further challenges, we conducted a second survey between October 2010 through January 2011 by sending questionnaires to 200 randomly selected Japanese rheumatologists, consisting of 100 participants in a meeting in 2009 on imaging in rheumatic diseases and 100 board-certified rheumatologists. Among the respondents, a majority (85 and 67%, respectively) used magnetic resonance imaging (MRI). MSUS users had increased from 32 to 60% of meeting participants and from 11 to 27% of other rheumatologists. The majority of MSUS users had begun using MSUS within the previous 3 years. Whereas most respondents in the previous survey had been self-taught, in the current survey many had attended training courses or had received informal training from skilled users. Despite an increase in skills and equipment ownership, obstacles to implementing MSUS remained, most prominently a lack of time. In conclusion, training courses and informal training have contributed to the popularization of MSUS in Japan. To further increase MSUS usage, additional training opportunities and education about the advantages of MSUS will be needed.     

Clinical approach to patients with joint disease: importance of distinguishing inflammatory from non‐inflammatory conditions

The widening gap between demand and supply of trained rheumatologists to deal with enormous numbers of patients with musculoskeletal (MSK) diseases, especially in the South‐East Asian region, was the topic of a recent oration. A possible temporary solution to the problem was offered. It was suggested that the entire time and energy of available rheumatologists may be focused only toward patients with systemic inflammatory autoimmune diseases. The argument was that these are serious life‐threatening conditions requiring urgent specialist (rheumatologist‐physician) referrals for early aggressive treatment with disease modifying antirheumatic drugs/biologicals to save permanent MSK damage and premature death. Crucial to this arrangement would be to have primary care physicians and orthopaedic surgeons who could quickly recognize serious systemic inflammatory MSK diseases (the so‐called ‘red‐flag’ conditions) from local/regional/biomechanical structural damage‐related MSK diseases (the so‐called ‘green‐flag’ conditions). Only the ‘red‐flag’ conditions may then be referred to the rheumatologist‐physician for detailed evaluation and appropriate drug therapy. This article describes a simple clinical approach for quick distinction between these two categories of MSK diseases. Rheumatologists may like to use this approach to conduct continuing medical education (CME) programs targeted towards primary care physicians and orthopaedic surgeons so that ‘red flag’ MSK disease patients reach rheumatologist‐physicians as soon as possible.     

Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography

Abstract

We evaluated the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases as seen in day-to-day rheumatology practice. Data were retrieved for demography, background condition, clinical findings, indications, regions scanned, and outcomes of MSUS, and categorised as: new-patients and follow-up. New-patient records were analysed as to whether MSUS had helped to confirm or change clinical diagnosis or was of no additional help. In follow-ups, we determined whether MSUS had helped in disease assessment, detection of co-existing problems or revision of diagnosis. Its impact on treatment decisions was noted. A total of 237 patients (146 women; mean age 55.9 ± 17.2 years) had 264 regions scanned; hands,50.7%. In 78/237 (32.9%) there was disagreement between clinical and MSUS findings. Amongst new-patients (72), 13/39 (33.3%) referred with inflammatory arthritis had no MSUS evidence of inflammation in or around joints. In 76.3% it helped in confirming or changing diagnosis. Of the follow-ups (165), in 78.7%, 13.9% and 7.2% it helped in assessment, detection of co-existing problems and revision of diagnosis, respectively. MSUS influenced treatment in 45/165 (27.27%) cases. In 60/67 (89.55%) cases of rheumatoid arthritis (RA), it was done for disease assessment; in 31/60 (51.66%) it influenced treatment. MSUS, as a clinic-based service in rheumatology, has significant impact on the diagnosis and treatment of patients. This has potential to reduce diagnostic uncertainty and follow-up visits and ensure better outcomes.     

Subclinical articular involvement in primary Sjögren's syndrome assessed by ultrasonography and its negative association with anti-centromere antibody

Objectives. To evaluate the subclinical articular involvement in patients with primary Sjögren's syndrome (pSS) using musculoskeletal ultrasound (MSUS), and to correlate the findings with laboratory results and clinical manifestations.

Methods. Forty-eight consecutive patients with pSS were enrolled. The bilateral metacarpophalangeal, proximal interphalangeal, and interphalangeal joints were examined using MSUS, and the synovial hypertrophy and power Doppler signal were recorded for each joint using semi-quantitative scores (0 = normal, 1 = mild change compared with undamaged joint, 2 = moderate change, and 3 = severe change).

Results. Mild or moderate synovial hypertrophy was found in 151 (15.7%) and 2 (0.2%) out of 960 hand joints, respectively, and power Doppler signals were present in 19 (2.0%) of the 960 joints. While anti-centromere antibody (ACA) was found in 10 patients (20.8%), none of the patients with MSUS-confirmed synovitis was positive for ACA. No other autoantibodies, laboratory tests, or clinical manifestations correlated with MSUS-confirmed synovitis.

Conclusion. MSUS is useful for detecting subclinical synovitis in pSS patients. MSUS showed that ACA-positive pSS patients had a low prevalence of synovitis.     

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology

As we begin the 21st century, musculoskeletal ultrasound (MSUS) is routinely used by an increasing number of rheumatologists throughout Europe and there is a growing interest in the application of MSUS in rheumatological practice in the UK. MSUS allows high-resolution, real-time imaging of articular and periarticular structures and has the advantages of being non-radioactive, inexpensive, portable, highly acceptable to patients and repeatable. There are a number of critical issues that need to be addressed in order to develop the role of MSUS within rheumatology. These include issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS. Rheumatologists must demonstrate the relevance of MSUS in their clinical practice through high-quality research. Emerging technologies such as power Doppler and 3D imaging will further improve imaging capabilities and the range of clinical applications of MSUS systems. This paper reviews how MSUS in rheumatology has evolved and the controversies and issues that rheumatologists must now address in developing MSUS as an indispensable, everyday clinical tool.     

Inter-observer agreement of standard joint counts in early rheumatoid arthritis: a comparison with grey scale ultrasonography--a preliminary study

OBJECTIVES: The aims of the present study were to assess the inter-observer agreement of standard joint count and to compare clinical examination with grey scale ultrasonography (US) findings in patients with early rheumatoid arthritis (RA). METHODS: The study was conducted on 44 RA patients with a disease duration of <2 yrs. Clinical evaluation was performed independently by two rheumatologists for detection of tenderness in 44 joints and swelling in 42 joints. All patients underwent US assessment by a rheumatologist experienced in this method and blinded to the clinical findings. Joint inflammation was detected by US when synovial fluid and/or synovial hypertrophy was identified using OMERACT preliminary definitions. The inter-observer reliability was calculated by overall agreement (percentage of observed exact agreement) and kappa (kappa)-statistics. The reliability of US was calculated in 12 RA patients. RESULTS: There was fair to moderate inter-observer agreement on individual joint counts for either tenderness or joint swelling apart from the glenohumeral joint. US detected a higher number of inflamed joints than did clinical examination. The mean (+/-S.D.) US joint count for joint inflammation was 19.1 (+/-4.1), while the mean (+/-S.D.) number of swollen joints was 12.6 (+/-3.6), with a significant difference of P = 0.01. CONCLUSIONS: Our results provide evidence in favour of the hypothesis that clinical examination is far from optimal for assessing joint inflammation in patients with early RA. Furthermore, this study suggests that US can considerably improve the detection of signs of joint inflammation both in terms of sensitivity and reliability.     

The role of ultrasound in the diagnosis and management of psoriatic arthritis

Psoriatic arthritis (PsA) presents many diagnostic, management and research challenges for rheumatologists who wish to obtain early diagnosis, differentiate synovitis and enthesitis, monitor disease activity accurately and objectively, prevent the development of structural damage, deliver local therapy accurately, and obtain PsA tissue for research purposes. Musculoskeletal ultrasound (MSUS) is widely used by European rheumatologists in their clinical practice to meet these challenges and has the potential to become the rheumatologist’s stethoscope in Europe and North America. This paper examines the evidence that MSUS can improve clinical evaluation of patients with PsA for synovitis and enthesitis, that MSUS is more sensitive than plain radiography in detecting structural damage in joints, that MSUS can improve the success of joint aspiration and guide biopsy of PsA tissues. Recent exciting developments in the management of PsA are detailed including the role of power Doppler in the diagnosis of enthesitis in PsA, the role of MSUS in objective monitoring of disease activity, the evaluation of MSUS in the diagnosis of sacroiliitis, and the use of MSUS to guide therapeutic injection of the sacroiliac joints.     

From confusion to consensus: Need for multi disciplinary team approach in rheumatology: An orthopaedic surgeons's perpective

Aim of joint surgeries in rheumatoid arthritis is to restore function and quality of life, prevent joint deterioration, relieve pain and correct deformity in patients afflicted with rheumatoid disorders With advent of newer therapeutic modalities, the need for joint surgeries in cases of rheumatoid disorders has drastically reduced over the past two decades. Decision-making and timing for orthopaedic intervention are complex issues because of polyarticular involvement in rheumatoid disorder. Optimal results from the surgery demands close team work between the rheumatologists and the orthopaedic surgeon. However, as studies, have indicated, there appears to be divergent views amongst rheumatologist and the orthopaedic surgeon as regards indications, timing and effectiveness of rheumatoid joint surgery. This is to the detriment of the patient's best interest. Therefore, it is imperative that a multidisciplinary team approach be adopted towards managing each patient. The need of the hour is evolution of integrated Rheumatology Team comprising of rheumatologist, orthopaedic surgeon, pain care specialist, physiotherapist and nurse, a close synergy of interests to provide holistic care to patients of inflammatory joint disorders.     

Ultrasound Joint Inflammation in Rheumatoid Arthritis in Clinical Remission: How Many and Which Joints Should Be Assessed?

Objective

To investigate the sensitivity for detecting subclinical synovitis of different reduced joint ultrasound (US) assessment models as compared with a comprehensive US assessment in rheumatoid arthritis (RA) patients in clinical remission.

Methods

Sixty‐seven RA patients (50 women, 17 men) in clinical remission as judged by their consultant rheumatologist and treated with methotrexate were prospectively recruited. Patients were evaluated for disease activity according to the Disease Activity Score in 28 joints (DAS28) and the Simplified Disease Activity Index (SDAI) by the same investigator. Each patient underwent a 44‐joint B‐mode and power Doppler (PD) assessment by a rheumatologist blinded to the clinical and laboratory data. B‐mode synovial hypertrophy (SH) and synovial PD signal were scored from 0–3 at each joint. Global indices for SH and PD signal were calculated for the 44‐joint and different joint combination models for each patient.

Results

SH was detected in 87.8% of patients with a DAS28 <2.6 and in 81.8% of patients with an SDAI <3.3. Synovial PD signal was detected in 46.3% of patients with a DAS28 <2.6 and in 36.4% of patients with an SDAI <3.3. Wrist, second through fifth metacarpophalangeal (MCP), ankle, and second through fifth metatarsophalangeal (MTP) joint and 12‐joint US assessments showed the highest correlations with the comprehensive US assessment. The wrist, MCP, ankle, and MTP joint US assessment showed the highest sensitivity for detecting SH and synovial PD signal in patients in remission according to the DAS28 and SDAI as compared to the comprehensive US assessment.

Conclusion

US assessment of the wrist, MCP, ankle, and MTP joints can be highly sensitive for detecting residual B‐mode and Doppler joint inflammation in RA patients.     

Clinical usefulness and patient satisfaction with a musculoskeletal ultrasound clinic: results of a 6-month pilot service in a Rheumatology Unit

There is no agreement among the rheumatology community in how to implement the musculoskeletal ultrasound (MSUS) technique in the Rheumatology Divisions. To test the perceived usefulness of the MSUS, under consensus indications, for referring colleagues for the clinical management of their patients with inflammatory arthritis (IA) and to score the satisfaction level of the patients with different aspects of the ultrasound (US) examination, after attend to the MSUS clinic. A written questionnaire-based survey regarding the usefulness and satisfaction with the implementation of a pilot MSUS clinic in a Rheumatology Unit. Over a 6-month period, 43 patients attended 10 MSUS clinics. Referral agreed indications were: US assisting in early/subclinical diagnosis (35 %), decision making with patient treatment (44 %), monitoring of disease activity/treatment response (39 %) and US-guided injection (11 %). Average scores of the referrers regarding usefulness of the information provided for the US for these indications were 8.0, 8.3, 8.7 and 8.6, respectively, with a high score of 9.0 regarding the valuable support of the US for the management of their patients with IA. Patient satisfaction scores in responders (44 %) were averaged 9.5 and higher for receiving an adequate explanation of the US procedure, indications, US findings and their significance, lack of discomfort and length of the appointment. The average score was slightly lower (8.5) for the waiting time frame for the appointment for the MSUS examination. The referrers expressed a perception of usefulness of our pilot US clinic, under previous consensus indications, for the clinical management of their patients with IA. In addition, this MSUS clinic seemed to show a good acceptability and a high satisfaction scores for the patients.