Three-dimensional volumetric ultrasonography. Does it improve reliabililty of musculoskeletal ultrasound?

OBJECTIVE: To compare the interobserver reliability of three-dimensional (3D) volumetric ultrasonography (US) and 2D real-time US in detecting inflammatory and destructive changes in rheumatoid arthritis (RA) wrist and hand. METHODS: Two RA patients were selected by a rheumatologist who performed independently a grey-scale and power Doppler (PD) volumetric acquisition at three anatomic sites in their more symptomatic wrist/hand using two identical scanners equipped with 3D volumetric probe. Twelve rheumatologists expert in MSUS were randomly assigned to a US scanner and a patient. In the first part of the study, each group of experts blindly, independently, and consecutively performed a 2D real-time grey-scale and PD US investigation of inflammatory changes and/or bone erosions at the three anatomic sites. In the second part of the study, each group of investigators blindly evaluated the same pathologic changes in the 6 volumes from the patient not scanned by them. RESULTS: The kappa values were higher for 3D volumetric US than for 2D US in the detection of synovitis/tenosyno-vitis (0.41 vs. 0.37) and PD signal (0.82 vs 0.45) and in the PD signal grading (0.81 vs. 0.55). CONCLUSION: 3D volumetric US may improve the interobserver reliability in RA multicentre studies.

Learning and reliability of colour Doppler ultrasound in giant cell arteritis.

OBJECTIVE: To evaluate a standardized training program and a reliability exercise in colour Doppler ultrasound (CDUS) for giant cell arteritis (GCA). METHODS: Two workshops were conducted in 2007 and 2008 to train rheumatologists in CDUS for GCA ultrasound diagnosis. Twenty-nine and forty-three participants without previous experience in GCA ultrasound were admitted in 2007 and 2008, respectively. First, some theoretical knowledge about GCA ultrasound signs was provided; second, a reader evaluation session of temporal artery video recording examinations of 27 and 30 patients were projected in the 2007 meeting and the 2008 workshop, respectively (50% were cases and 50% were controls). Twenty-four cases were common to both reader sessions. A mean of six videos were shown of each patient. Each video had to be assessed as normal or pathologic. Finally, hands-on scanning training was performed. To assess the efficacy of the workshop: 1) a structured satisfaction questionnaire was graded (1-5 Likert scale), and 2) the reliability, specificity, and percentage of correctly classified cases by each participant were calculated. RESULTS: The kappa coefficient of inter-reader agreement for the 29 and 43 participants was excellent (Kappa: 0.846) in 2007 and (Kappa: 0.848) in 2008. The intra-reader kappa result was also excellent (Kappa: 0.950). The satisfaction, sensitivity, specificity, and percentage of correctly classified patients and controls were very high. CONCLUSION: The proposed learning method seemed to be effective and well accepted by the target audience. The inter-reader reliability of GCA ultrasound was excellent. These encouraging results support the need for planned standardized training programs.

Ultrasound validity in the measurement of knee cartilage thickness.

OBJECTIVE: To assess the multiexaminer reproducibility and the accuracy comparing with cadaver anatomic specimens of ultrasound (US) measurement of femoral articular cartilage (FAC) thickness. METHODS: In 8 flexed cadaver knees, FAC thickness was blindly, independently and consecutively measured twice by 10 rheumatologists at the lateral condyle (LC), medial condyle (MC) and intercondylar notch (IN) with US. After the US measurements, the knees were dissected. Articular cartilage integrity was evaluated macroscopically in the femoral condyles. FAC thickness was blindly measured in the specimens using a stereoscopic magnifying loupe and a digitised image software. Interexaminer and intraexaminer reliability of US FAC thickness measurement and agreement between US and anatomic measurements were assessed by estimating the intraclass correlation coefficient (ICC). RESULTS: Interexaminer ICCs were higher than 0.90 for MC (p<0.001) and IN (p<0.001) and higher than 0.75 for LC (p<0.01). Mean intraexaminer ICCs were 0.832 for MC (p<0.001), 0.696 for LC (p<0.001) and, 0.701 for IN (p<0.001). Agreement between US and anatomic FAC thickness measurements was good for MC (ICC 0.719; p = 0.020) and poor for LC (p = 0.285) and IN (p = 0.332). Bland-Altman analysis showed that the difference between US and anatomic values was considerably high in the one knee with severely damaged FAC. After eliminating this knee from the analysis, ICCs were 0.883 (p<0.001) for MC, 0.795 (p = 0.016) for LC and 0.732 for IN (p = 0.071). CONCLUSION: US demonstrated a good reproducibility in FAC thickness measurement by multiple examiners. In addition, US FAC thickness measurement was accurate in normal to moderately damaged cartilage.

Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses.

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.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course.

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.

Association study between corticotrophin-releasing hormone genomic region (8q13) and rheumatoid arthritis in the Spanish population.

OBJECTIVE: To investigate whether the corticotrophin-releasing hormone (CRH) genomic region confers genetic susceptibility to rheumatoid arthritis (RA) in the Spanish population. METHODS: DNA was obtained from 121 simplex RA families and 101 healthy controls, all from Spanish origin. Two microsatellites, CRHRA1 and CRHRA2, located 25 and 20 kb downstream respectively from the CRH gene were examined using a new multiplex design. Linkage disequilibrium (LD) between the markers was assessed and association studies were carried out using the transmission disequilibrium test (TDT) implemented in TRANSMIT. RESULTS: Both markers are in Hardy-Weinberg equilibrium and there is significant LD between them in the Spanish population. Neither the polymorphic alleles of CRHRA1 and CRHRA2 markers nor their resulting haplotypes were significantly associated to RA. The associated haplotype in the UK population (CRHRA1*10; CRHRA2*14) was undertransmitted in RA patients (12 obs vs 17.43 exp), although the difference is not statistically significant (P > 0.05). CONCLUSIONS: This is the first follow-up study of the association between the CRH genomic region and RA and suggests that the CRH gene may not be involved in the pathogenesis of RA in the Spanish population. Further studies in other populations will help untangle the real contribution of this genomic region to the susceptibility to RA.