Validation of the Southend giant cell arteritis probability score in a Scottish single-centre fast-track pathway.

OBJECTIVE: The aim was to provide external validation of the Southend GCA probability score (GCAPS) in patients attending a GCA fast-track pathway (GCA FTP) in NHS Lanarkshire. METHODS: Consecutive GCA FTP patients between November 2018 and December 2020 underwent GCAPS assessment as part of routine care. GCA diagnoses were supported by US of the cranial and axillary arteries (USS), with or without temporal artery biopsy (TAB), and confirmed at 6 months. Percentages of patients with GCA according to GCAPS risk group, performance of total GCAPS in distinguishing GCA/non-GCA final diagnoses, and test characteristics using different GCAPS binary cut-offs were assessed. Associations between individual GCAPS components and GCA and the value of USS and TAB in the diagnostic process were also explored. RESULTS: Forty-four of 129 patients were diagnosed with GCA, including 0 of 41 GCAPS low-risk patients (GCAPS <9), 3 of 40 medium-risk patients (GCAPS 9-12) and 41 of 48 high-risk patients (GCAPS >12). Overall performance of GCAPS in distinguishing GCA/non-GCA was excellent [area under the receiver operating characteristic curve, 0.976 (95% CI 0.954, 0.999)]. GCAPS cut-off ≥10 had 100.0% sensitivity and 67.1% specificity for GCA. GCAPS cut-off ≥13 had the highest accuracy (91.5%), with 93.2% sensitivity and 90.6% specificity. Several individual GCAPS components were associated with GCA. Sensitivity of USS increased by ascending GCAPS risk group (nil, 33.3% and 90.2%, respectively). TAB was diagnostically useful in cases where USS was inconclusive. CONCLUSION: This is the first published study to describe application of GCAPS outside the specialist centre where it was developed. Performance of GCAPS as a risk stratification tool was excellent. GCAPS might have additional value for screening GCA FTP referrals and guiding empirical glucocorticoid treatment.

Scottish rheumatology sonography course: five-year experience of delivering a mentorship-model rheumatology ultrasound training programme accredited by the consortium for the accreditation of sonographic education.

BACKGROUND AND AIMS: Ultrasound training for rheumatology practice in the UK is variable. Currently, there is no agreed minimum standard for training in ultrasound applied to rheumatology patient management. We present our experiences of implementing a competency driven ultrasound training, focused on hands and feet. METHODS AND RESULTS: The Rheumatology Sonography Course (RSC) was developed by the Scottish Rheumatology Ultrasound Group in collaboration with Glasgow Caledonian University. The RSC is delivered via a blended learning approach and includes training workshops, mentorship and clinical competency assessments. Mentors are supported and developed within their role. 31 trainees have enrolled on the course between 2014 and 2019. To date, 22 (71%) have completed. Change of job role was the main factor leading to non-completion. Thirteen mentors have supported the training and assessment of RSC trainees. All trainees reported positively that ultrasound training via the RSC model fulfilled their learning needs. CONCLUSION: The RSC is a feasible ultrasound training model for rheumatology practitioners. Whilst it provides a robust training framework, mentorship fees and university overheads increase the cost. The RSC provides motivation to mentors to train external trainees and supports the development of new ultrasound-based rheumatology services.

Recommendations for rheumatology ultrasound training and practice in the UK.

OBJECTIVE: The aim of this paper is to present a UK-based consensus of principles and recommendations to guide rheumatology US training and practice. METHOD: A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK. A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG) members made seven proposals that were presented to the whole group for further discussion. This resulted in minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consensus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination of the results and future development work. RESULTS: Using a validated process, experts in rheumatology US have worked through an iterative process and have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning, as well as a commitment to support mentors and trainers through the BSRUSSIG. CONCLUSION: These are the first specific education and practice recommendations for rheumatology US in the UK and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support and validate rheumatology US practice and inform the development of future rheumatology training curricula and education programmes.

Implementation and role of modern musculoskeletal imaging in rheumatological practice in member countries of EULAR.

Objectives: To document the current training, implementation and role of modern musculoskeletal imaging techniques: ultrasound, magnetic resonance imaging, computed tomography and positron emission tomography, among rheumatologists in the member countries of the EULAR. Methods: English-language questionnaires for each imaging modality developed by a EULAR task force were sent out to national and international scientific societies as well as imaging experts in the given modalities involved in research and/or training. The surveys were distributed via an online survey tool (SurveyMonkey). Simple descriptive and summary statistics were calculated from the responses. Results: More than 90% of ultrasound (US) experts reported the availability of a US unit in their department. Suspicion of rheumatoid arthritis and spondyloarthritides were the main clinical indications for performing US for diagnostic purposes. Suspicion of sacroiliitis and degenerative spine disease were the most common indications to perform magnetic resonance imaging (MRI) or computed tomography (CT) for diagnostic purposes, while positron emission tomography was mainly performed to diagnose large vessel vasculitis and to investigate fever of unknown origin. The reported percentage of rheumatologists performing US was highly variable, ranging from more than 80% in 6% of countries to less than 10% in 15% of countries. The majority of experts (77%) reported that their national rheumatology societies organise musculoskeletal US courses, while courses in MRI or CT organised by the national rheumatology societies were less commonly reported (29% and 8%, respectively). Conclusions: Rheumatologists in Europe utilise modern imaging techniques; however, access to the techniques and training offered is varied.

Ultrasound image of malignant bone tumors in children. An analysis of nine patients diagnosed in 2011-2016.

INTRODUCTION: The diagnostic process of bone tumors, including malignant ones, is based on conventional radiological methods, such as radiography and computed tomography, and with precise assessment of local advancement in magnetic resonance imaging. Ultrasonography is not included in the diagnostic algorithms as a tool suitable to detect this type of pathology. More and more frequent usage of musculoskeletal ultrasound in children as the first imaging method or, in some cases, as the only diagnostic method, makes it necessary to be familiar with sonographic presentation of bone tumors to suggest this diagnosis early enough and, after its verification, start treatment without a significant delay. Aim: The aim of this study was to determine changes in the sonographic image that might indicate a bone malignancy and suggest the need to extend the diagnostic process in this direction. MATERIAL AND METHOD: This article discusses 10 bone tumors in 9 children who had an ultrasound scan performed at the beginning of the diagnostic process before the histopathological diagnosis was established and treatment initiated. The assessment involved ultrasonographic features indicating the presence of a tumor. Results: In the group of 9 patients, 8 malignant bone tumors were diagnosed in ultrasonography and later verified histopathologically: 4 osteosarcomas and 4 Ewing's sarcomas. In one case, two bone tumors were detected in ultrasonography without specification of their nature (malignant/benign, primary/secondary). MATERIAL AND METHOD: In the analyzed cases, ultrasonography enabled the correct diagnosis of a focal bone lesion, and in most cases (8/9) it presented an image that suggested its malignant nature and the necessity of further diagnosis and treatment.

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients.

The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen's kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

Inter & intra-observer reliability of grading ultrasound videoclips with hand pathology in rheumatoid arthritis by using non- sophisticated internet tools (LUMINA study).

AIM: To evaluate the inter- and intraobserver agreement of a group of European rheumatologist ultrasonographers in grading musculoskeletal ultrasound videoclips posted on the Internet by using a non-sophisticated electronic environment. METHODS: Forty short movie clips (less than 30 secs) were made available over the Internet to all participants. Normal and pathological RA hand joints and tendons were included in the movie clips. In the first phase 30 investigators from European countries were invited to evaluate the clips and to interpret/grade them. No instruction session was held prior to the initiation of the study. For synovitis the requested scoring system included 0 to3 grades and for tenosynovitis a binary variable 0/1; separate evaluations were performed for gray scale (GS) and Power Doppler (PD) examinations. In the second phase the responders were asked to grade the same clips in a different order without having access to their first grading scale. Light's k and Cohen's k were used to analyse inter- and intraobserver reliability. RESULTS: Twenty two European rheumatologists agreed to finalise both study phases. Mean Cohen's κ for intraobserver reliability was 0.614/0.689 for tenosynovitis GS/PD and 0.523/0.621 for synovitis GS/PD. Light's k for interobserver reliability was 0.503 for tenosynovitis evaluation and 0.455 for global (synovitis and tenosynovitis) evaluation. Mean global overall agreement was 84.95% (90.2% for global synovitis). CONCLUSIONS: An over-the-net US evaluation and grading has shown moderate to good reliability. The results could be improved if a training session is added at the beginning of the study.

[Magnetic resonance imaging of the hand in rheumatoid arthritis]. / Rezonans magnetyczny--badanie reki w reumatoidalnym zapaleniu stawów.

The aim of the study was to show the magnetic resonance (MR) images of changes in hands of patients with rheumatoid arthritis (RA). The SE sequence T1-weighted (TR600, TE15) and fat-suppressed (A-250, TR1155, TE22) were obtained with 3 mm coronal scans and matrix 256 x 512, both before and after contrast medium administration. Knee coil was used. The images in both sequences of the following changes were obtained: bone erosions, synovitis, periarticular oedema, joint effusion, tendonitis and bone marrow oedema. The administration of intravenous contrast was found very useful. Changes of the joint synovium in osteoarthritis were characterised to differentiate them from changes due to RA. The authors suggest that MR imaging--because of its exceptional diagnostic value--may become a basic imaging method in evaluation of patients with RA.

[Ultrasonography of the hand in rheumatoid arthritis]. / Ultrasonografia reki u chorych na reumatoidalne zapalenie stawów.

Authors present the ability of ultrasonography and Color and power Doppler sonography in evaluation of the hand structures in patients with rheumatoid arthritis. Imaging of bony contours allows to identify bone erosions. Thickness, oedema and presence of increased blood flow (hyperaemia) in the synovium in joints and tendon sheaths are characteristic features of an active inflammation. Changes of the tendon structure indicate its damage. US allows to image the carpal tunnel structures, to visualise changes of the median nerve in the carpal tunnel syndrome and gives possibilities to find the cause of its compression.