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.     

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.     

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.     

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 training in rheumatology: the Belfast experience

OBJECTIVES: Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no consensus yet regarding the standards required to achieve a basic level of competence in the use of this imaging technique. A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the Regional Rheumatology Centre in Belfast, UK. METHODS: Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn the basic skills of MSUS. RESULTS: Seven of the team underwent a formal assessment of their competency in a practical examination devised by an experienced sonographer. All were judged to have attained a basic competency in MSU. CONCLUSIONS: This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless, the development of recognized training programmes and international standards of competency are important goals on the way to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.     

Musculoskeletal ultrasonography in Europe: results of a rheumatologist-based survey at a EULAR meeting

OBJECTIVE: To document the practice of musculoskeletal ultrasound (US) by a sample of European rheumatologists attending an annual general meeting of the European League Against Rheumatism (EULAR). METHODS: English-language questionnaires were distributed to 180 randomly selected participants attending imaging-related sessions at the XIV EULAR meeting in Glasgow, UK, in 1999. The questionnaire was divided into four sections: Demographics, Education and Training, Current Practice, and Equipment. RESULTS: Ninety-two rheumatologists responded, representing 74 centres from 19 European countries. Seventy-eight (85%) of the respondents either already used US in their clinical practice or would like to use it in the future. Thirty-seven (40%) respondents performed US within their own department. Few had received training at undergraduate level and most had learned informally or by attending courses. Scans were considered most useful for large joints and ligaments/tendons. Only 28 (30%) respondents valued US for guided injections. CONCLUSIONS: This study, although containing an element of selection bias, confirms a great interest in musculoskeletal US by rheumatologists across Europe and a demand which is likely to increase. The reported variation in training and practice between countries suggests a need for standardized training guidelines.     

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.     

Clinical implementation of musculoskeletal ultrasound in rheumatology in Austria

The aim of the study is to assess the clinical implementation of musculoskeletal ultrasound (MSUS) in rheumatology in Austria. A survey was conducted among Austrian rheumatologists and physicians of other specialties with a focus on rheumatology. The questionnaire was designed by the members of the Austrian Radiology–Rheumatology Initiative for Musculoskeletal UltraSound including the following items: demographics, access to MSUS and MSUS training, application of MSUS to support diagnosis, monitoring and treatment decisions, and obstacles for the routine performance of MSUS. Eighty-eight (21.9 %) out of the 402 surveyed physicians responded. No access to MSUS and/or inadequate training in the technique was more commonly reported by senior (>50 years; 64.3 and 67.7 %, respectively) than by younger physicians (16.7 %, p = 0.01 and 18.5 %, p < 0.001, respectively). The lowest availability of sonography was found among senior rheumatologists (25.0 %, p = 0.001 compared to the total group). MSUS is routinely used for diagnosis and/or monitoring purposes by 12.5 % of physicians and 20.5 % perform sonography in clinically unclear cases. A limited number of physicians apply the method to support treatment decisions and/or to evaluate treatment success. The most important obstacles for routine application of MSUS in rheumatology are limited access to ultrasound machines, lack of training/education in the technique, and time constraints in daily routine. Low access to high-end ultrasound devices, lack of training, and time constraints may explain the low appreciation of MSUS among Austrian physicians evaluating patients with rheumatic diseases.     

Comparison of musculoskeletal ultrasound practices of a rheumatologist and a radiologist

OBJECTIVE: There is considerable debate regarding the role of the rheumatologist ultrasonographer and how this development will impact on musculoskeletal ultrasound (MSUS) performed by radiologists. We compared the MSUS practices of a rheumatologist and a radiologist working within the same National Health Service Trust. METHODS: A retrospective review of MSUS reports of consecutive scans performed by a consultant rheumatologist with a special interest in MSUS and a consultant musculoskeletal radiologist. Reports were analysed for referring specialties, indications for MSUS, joint regions scanned, MSUS findings, frequency with which patients were referred for injection and how often injection was performed. RESULTS: A total of 170 patients were referred to the rheumatologist for MSUS of 282 joint regions (91% referred by rheumatologists). Of those, 84 (49%) patients had MSUS examination of more than one joint region, with up to five regions scanned per sitting. One hundred patients were referred to the radiologist for MSUS of 111 joint regions (49% referred by orthopaedic surgeons). The most frequently requested primary indication for MSUS performed by the rheumatologist was detection of synovitis [74 (44%) patients] while MSUS performed by the radiologist was most frequently for assessment for major structural changes [44 (44%) patients]. The rheumatologist performed MSUS-guided injection in 59 of 170 (35%) patients scanned and the radiologist in 13 of 100 (13%). CONCLUSION: MSUS performed by the rheumatologist was predominantly requested by rheumatologists to aid diagnosis of synovial and tendon inflammation and to guide injections, while MSUS performed by the radiologist was predominantly requested by orthopaedic surgeons to aid diagnosis of structural pathology. Curriculums in MSUS designed for rheumatologists may need to place appropriate emphasis on the identification of synovial and tendon inflammation, and injection guidance.     

Rheumatologists’ perception of systemic lupus erythematosus quality indicators: significant interest and perceived barriers

Differences in quality of care may contribute to health disparities in systemic lupus erythematosus (SLE). Studies show low physician adherence rates to the SLE quality indicators but do not assess physician perception of SLE quality indicators or quality improvement. Using a cross-sectional survey of rheumatologists in the southeastern USA, we assessed the perception and involvement of rheumatologists in quality improvement and the SLE quality indicators. Using electronic mail, an online survey of 32 questions was delivered to 568 rheumatologists. With a response rate of 19% (n = 106), the majority of participants were male, Caucasian, with over 20 years of experience, and seeing adult patients in an academic setting. Participants had a positive perception toward quality improvement (81%) with a majority responding that the SLE quality indicators would significantly impact quality of care (54%). While 66% of respondents were familiar with the SLE quality indicators, only 18% of respondents reported using them in everyday practice. The most commonly reported barrier to involvement in quality improvement and the SLE quality indicators was time. Rheumatologists had a positive perception of the SLE quality indicators and agreed that use of the quality indicators could improve quality of care in SLE; however, they identified time as a barrier to implementation. Future studies should investigate methods to increase use of the SLE quality indicators.     

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.     

Calidad percibida de formación en ecografía musculoesquelética en los servicios de reumatología españoles

Background and objectiveUltrasound has been included in the training of residents in rheumatology in recent years, as a result of its increased use in daily clinical practice. Our objective is to evaluate the perceived quality of ultrasound training of residents in rheumatology services in Spain.Material and methodsOnline survey aimed at rheumatologists who began their training in rheumatology between 2009 and 2019.ResultsOne hundred thirty-nine rheumatologists participated in the survey, of which 97.1% had at least one ultrasound machine in their training centre. Up to 51.1% performed a rotation in ultrasound and 56% had an ultrasound consultation. Access to SER courses was high (87.8%) while access to EULAR courses was limited (17.3%) and up to 69.1% of residents did not complete the competency accreditation. Training in evaluation of inflammatory joint activity, entheses and microcrystalline diseases received the highest scores. Evaluation of ultrasound training during the residency was good in 36% of cases, fair in 28.1%, poor in 18% and excellent in 12.9%. Of those surveyed, 88% consider their clinical practice as a rheumatologist to have improved.ConclusionsMost residents have performed ultrasound rotations. Participation in SER ultrasound courses is high and moderate in EULAR courses, while only a minority completed the competency accreditation. The overall degree of satisfaction with training in ultrasound during residency is good and, in the opinion of residents, contributes to the improvement of their skills as rheumatologists.     

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.     

Musculoskeletal ultrasonography in routine rheumatology practice: data from Central and Eastern European countries

The main aim was to gain structured insight into the use of musculoskeletal ultrasonography (MSUS) in routine rheumatology practices in Central and Eastern European (CEE) countries. In a cross-sectional, observational, international, multicenter survey, a questionnaire was sent to investigational sites in CEE countries. Data on all subsequent routine MSUS examinations, site characteristics, MSUS equipment, and investigators were collected over 6 months or up to 100 examinations per center. A total of 95 physicians at 44 sites in 9 countries provided information on a total of 2810 MSUS examinations. The most frequent diagnoses were rheumatoid arthritis (RA) and spondyloarthritis (34.8 and 14.9 % of cases, respectively). Mean number of joints examined was 6.8. MSUS was most frequently performed for diagnostic purposes (58 %), particularly in patients with undifferentiated arthritis, suspected soft tissue disorders, or osteoarthritis (73.0–85.3 %). In RA patients, 56.3 % of examinations were conducted to monitor disease activity. Nearly all investigations (99 %) had clinical implications, while the results of 78.6 % of examinations (51.6–99.0 %) were deemed useful for patient education. This first standardized multicountry survey performed in CEEs provided a structured documentation of the routine MSUS use in participating countries. The majority of MSUS examinations were performed for diagnostic purposes, whereas one-third was conducted to monitor disease activity in RA. A majority of examinations had an impact on clinical decision making and were also found to be useful for patient education.     

Does practice mirror the evidence base in the treatment of rheumatoid arthritis?

A large base of evidence exists regarding treatments for rheumatoid arthritis (RA) and how they may be used to preserve long-term function and improve patient outcomes. However, little is known about whether real-life rheumatology practice reflects the evidence base. This survey aimed to capture differing perceptions among rheumatologists in the identification and treatment of patients and to understand how their management of and treatment decisions for patients with RA may be influenced by the current published literature. Rheumatologists from five European countries and Canada participated in a survey between April and May 2006 to establish how rheumatologists identify and treat particular patient types in everyday practice. In total, 458 rheumatologists responded to the online and telephone survey. Rapidly progressing disease was overwhelmingly recognized (97%) as a distinct subtype among patients with RA, and the majority (88%) of respondents make treatment decisions based on this distinction. Most rheumatologists use measures including C-reactive protein, erythrocyte sedimentation rate, tender/swollen joint counts, and X-ray progression to diagnose and monitor this particular group of patients; a minority (30%) used magnetic resonance imaging to identify and monitor patients with rapidly progressing disease. Although treatment goals for these patients were similar among rheumatologists, the treatment approach varied considerably across countries. Overall, rheumatologists agree on the management goals for patients with rapidly progressing RA; however, their treatment patterns have some dissimilarities.     

Survey of attitudes of non-pediatric rheumatologists among councilors of the Japan College of Rheumatology regarding transitional care

Objectives: The transition from pediatric to adult healthcare systems has recently received worldwide attention. Surveys of the attitudes of Japanese non-pediatric rheumatologists regarding transitional care were conducted.

Methods: Non-pediatric rheumatologists among councilors of the Japan College of Rheumatology were enrolled in the surveys. Experiences of adult patients with childhood-onset rheumatic diseases, ideal medical care for these patients, and factors that made the transition to adult care difficult were examined via e-mail.

Results: Overall, 201 non-pediatric rheumatologists (21.2%) responded to the surveys. Ninety-one percent had previous experience with patients with childhood-onset rheumatic disorders. Transition to non-pediatric institutes was supported by about 90% of respondents. However, only 32% of non-pediatric rheumatologists had no hesitation about caring for adults with childhood-onset rheumatology disorders. Two main factors prevented smooth transitions to non-pediatric care: inadequacy of non-pediatric care (57%) and lack of independence from parents/family (53%). The majority of non-pediatric rheumatologists hesitated about medical care for patients with autoinflammatory syndromes, whereas they became familiar with articular juvenile idiopathic arthritis without hesitation (86.6%); 93% of respondents requested more opportunities to learn about pediatric rheumatology disorders.

Conclusions: Sharing additional knowledge about pediatric rheumatology within the non-pediatric rheumatology field is required.     

National survey of knowledge,attitude and practice of fibromyalgia among rheumatologists in China

Aim

Fibromyalgia (FM) is a chronic disorder characterized by widespread musculoskeletal pain and fatigue. It is a less frequently diagnosed disease in China, thus Chinese rheumatologists may have lower awareness of FM compared with colleagues in Western countries. The aim of this study is to investigate the perceptions of FM in Chinese rheumatologists and analyze their therapeutic approach in clinical practice.

Method

An anonymous questionnaire survey was conducted among a nationwide sample of Chinese rheumatologists at the 15th National Rheumatology Conference in 2010. The 20‐question survey included questions regarding background, work experience, perceptions of diagnosis and behaviors of treatment related to FM. Continuing medical education (CME) information was also collected in the survey.

Results

Seven hundred and seven rheumatologists responded to the questionnaire, a response rate of 60%. Less than one‐fifth of the respondents were experienced in dealing with FM. Although most of the respondents regarded FM as a distinct pathological entity, nearly 30% of Chinese rheumatologists believed that FM was only a psychological disorder. The respondents recognized some of the FM‐related symptoms, but had limited knowledge on the diagnostic criteria. Eighty percent of the respondents declared they had difficulties in treating FM patients. However, nearly all (90.8%) respondents believed that the prognosis of FM patients was usually benign. Our data also showed that most Chinese rheumatologists were eager for CME on FM.

Conclusion

The awareness and perception of FM are still low among Chinese rheumatologists. CME on FM is needed for improving the quality of health care in China.     

Knowledge about and behaviors affecting the spread of AIDS: a street survey of intravenous drug users and their associates in New York City

An informal survey of knowledge about and behaviors relevant to the spread of AIDS was conducted on the street in New York City during October 1986. The sample (n = 204) includes IV drug users (60%) and others (40%). The informal nature of the interview suggests that respondents gave "salient" answers rather than the complete answers that would be expected in a formal interview situation. A smaller proportion of respondents reported salient knowledge about drug-related transmission of AIDS than had been found in other populations, using formal interview methods. A close association was found between any accurate knowledge about spread of AIDS and likelihood of practicing one or more risk reduction behaviors. New users (persons who had been using drugs for only 1 or 2 years) were significantly less likely than others to have salient knowledge about AIDS transmission and also less likely to practice risk reduction measures.     

Original research: UK-wide study of the opinions of gastroenterology trainees: COVID-19, Shape of Training and the future workforce

IntroductionThe COVID-19 pandemic has disrupted training. Gastroenterology higher specialty training is soon to be reduced from 5 years to 4. The British Society of Gastroenterology Trainees Section biennial survey aims to delineate the impact of COVID-19 on training and the opinions on changes to training.MethodsAn electronic survey allowing for anonymised responses at the point of completion was distributed to all gastroenterology trainees from September to November 2020.ResultsDuring the first wave of the COVID-19 pandemic, 71.0% of the respondents stated that more than 50% of their clinical time was mostly within general internal medicine. Trainees reported a significant impact on all aspects of their gastroenterology training due to lost training opportunities and increasing service commitments. During the first wave, 88.5% of the respondents reported no access to endoscopy training lists. Since this time, 66.2% of the respondents stated that their endoscopy training lists had restarted. This has resulted in fewer respondents achieving endoscopy accreditation. The COVID-19 pandemic has caused 42.2% of the respondents to consider extending their training to obtain the skills required to complete training. Furthermore, 10.0% of the respondents reported concerns of a delay to completion of training. The majority of respondents (84.2%) reported that they would not feel ready to be a consultant after 4 years of training.ConclusionsReductions in all aspects of gastroenterology training were reported. This is mirrored in anticipated concerns about completion of training in a shorter training programme as proposed in the new curriculum. Work is now required to ensure training is restored following the pandemic.