Interobserver reliability of Masei index validation by a multicenter collaborative group of rheumatologists.

MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Recommendations for the prescription of physical exercise for patients with spondyloarthritis. / Recomendaciones para la prescripción de ejercicio físico en pacientes con espondiloartritis.

OBJECTIVE: To develop expert-based recommendations on physical activity and exercise for patients with spondyloarthritis (SpA). METHODS: Two discussion groups, one of physical therapists, rehabilitation physicians, and professionals of physical activity and sports, and another of rheumatologists interested in SpA, were held to discuss the results of a survey of rheumatologists on exercise and two focus groups with patients on barriers to exercise. Preliminary recommendations were drafted. These were submitted to the opinion of the experts in both groups according to a two round Delphi methodology. RESULTS: Twenty one recommendations covering general aspects of exercise, adaptation to patient, how to deliver messages, pain management, and type of exercise and monitoring were issued. The level of agreement varied slightly between expert groups but it was high overall. Items with poor agreement were removed from the consensus. CONCLUSIONS: We present recommendations on when and how to prescribe and monitor exercise in patients with SpA based on the opinion of experts in exercise and in SpA. We must now test whether these recommendations are useful for clinical practice and have an effect on patients with SpA seen by rheumatologists.

Recommendations by the Spanish Society of Rheumatology on the Use of Biological Therapies in Axial Spondyloarthritis. / Recomendaciones de la Sociedad Española de Reumatología sobre el uso de terapias biológicas en espondiloartritis axial.

OBJECTIVE: Recent data published on biological therapy in axial spondyloarthritis (axSpA) since the last publication of the recommendations of the Spanish Society of Rheumatology (SER) has led to the generation of a review of these recommendations based on the best possible evidence. These recommendations should be a reference for rheumatologists and those involved in the treatment of patients with axSpA. METHODS: Recommendations were drawn up following a nominal group methodology and based on systematic reviews. The level of evidence and grade of recommendation were classified according to the model proposed by the Centre for Evidence Based Medicine at Oxford. The level of agreement was established through the Delphi technique. RESULTS: In this review, we did an update of the evaluation of disease activity and treatment objectives. We included the new drugs with approved therapeutic indication for axSpA. We reviewed both the predictive factors of the therapeutic response and progression of radiographic damage. Finally, we drafted some recommendations for the treatment of patients refractory to anti-tumor necrosis factor, as well as for the possible optimization of biological therapy. The document also includes a table of recommendations and a treatment algorithm. CONCLUSIONS: We present an update of the SER recommendations for the use of biological therapy in patients with axSpA.

Diagnostic validity of Doppler ultrasound in giant cell arteritis.

OBJECTIVES: To assess the validity of Doppler ultrasound in the diagnosis of giant cell arteritis (GCA), using the American College of Rheumatology (ACR) criteria and biopsy and using as gold standard the patient's definitive clinical diagnosis. METHODS: An observational, descriptive and analytical study of 451 consecutive patients with suspected GCA was conducted, and the clinical history and ultrasound findings of the patients were reviewed. The validity of ACR criteria, temporal arteritis biopsy (TAB) and Doppler ultrasound in the diagnosis of GCA was calculated using the final diagnosis of the doctor in charge as the gold standard. RESULTS: The validity and security of the diagnostic tests used were as follows: ACR criteria had 65.37% sensitivity and 62.89% specificity; positive predictive value [PPV] 70%; negative predictive value [NPV] 57.82%, likelihood ratio [LR] + 1.7619 and LR - 0.5506. Doppler ultrasonography had 91.60% sensitivity and 95.83% specificity; PPV 96.62%; NPV 89.76%, LR + 21.81 and LR - 0.0876; TA biopsy 42.86% sensitivity and 100% specificity; PPV 100%; NPV 35.71% and LR - 0.5714. CONCLUSIONS: The halo sign, especially if bilateral, is a strong predictor of GCA with a level of accuracy sufficient to recommend its introduction into clinical practice and, in our opinion, should be considered in future classification criteria sets.

Discriminant validity study of Achilles enthesis ultrasound. / Estudio sobre la validez discriminante de la ecografía de entesis aquílea.

OBJECTIVE: We want to know if the ultrasound examination of the Achilles tendon in spondyloarthritis is different compared to other rheumatic diseases. MATERIAL AND METHODS: We studied 97 patients divided into five groups: rheumatoid arthritis, spondyloarthritis, gout, chondrocalcinosis and osteoarthritis, exploring six elementary lesions in 194 Achilles entheses examined. RESULTS: In our study the total index ultrasonographic Achilles is higher in spondyloarthritis with significant differences. The worst elementary spondyloarthritis lesions for discriminations against other pathologies were calcification. CONCLUSIONS: This study aims to demonstrate the discriminant validity of Achilles enthesitis observed by ultrasound in spondyloarthritis compared with other rheumatic diseases that may also have ultrasound abnormalities such enthesis level.

Usefulness of ultrasonography in the assessment of peripheral enthesis in spondyloarthritis.

Enthesitis is one of the characteristic etiopathogenic manifestations of spondyloarthritis. However, in clinical practice, its presence often goes unnoticed because of the lack of precision and sensitivity of physical examination to detect it. Viable, valid and reliable imaging tests are needed for early diagnosis, as well as a good sensitivity to change to monitor therapeutic response. In this paper we review the most relevant aspects of current knowledge of the enthesis and discusses the validity of ultrasound for assessing enthesitis in spondyloarthritis and its sensitivity to change to monitor therapeutic response.

[Present and future of echography in spondyloarthritis]. / Presente y futuro de la ecografía en las espondiloartritis.

Today ultrasound in spondyloarthritis is being developed in three main areas. Joint ultrasound is similar to that described in rheumatoid arthritis and other synovitis, with extensive literature on the matter. Enthesis ultrasound has a growing number of publications that describe the main elementary lesions. Several ultrasound enthesis scores have been developed that provide an overall view of the patient status and this information is useful both in the field of diagnosis and in assessing disease activity. The sacroiliac joints have also received attention and the published sensitivity and specificity could be useful in clinical practice. The future is unknown, but ultrasound has many possibilities that include improving the reliability, the incorporation of enthesis ultrasound assessment to the diagnostic classification criteria as well as the likelyhood developing simplified scores.

[Ultrasound scores in spondyloarthritis]. / Índices ecográficos en espondiloartritis.

Ultrasound is proving its validity in the assessment of patients with spondyloarthritis. This paper reviews the various indices validated for the quantification of the activity or for the diagnosis of involvement of peripheral joints, enthesis and sacroiliac joints of these patients. The studies are still preliminary but point to future uses of ultrasound in spondyloarthritis.

[Validity and usefulness of echography in the carpal tunnel syndrome]. / Validez y utilidad de la ecografía en el síndrome del túnel carpiano.

OBJECTIVE: To evaluate the accuracy and utility of ultrasonography for the diagnosis of carpal tunnel syndrome (CTS). MATERIAL AND METHOD: Prospective and blind study of 75 wrists in 42 consecutive patients with suspected CTS. Electrodiagnostic testing (EDT) was used as gold standard. We measure different ultrasonographic parameters and based on a fitted receiver operating characteristic curve, we estimated post-test probabilities for the proximal, middle and distal cross-sectional area of median nerve. We analyzed interobserver and interreader reliability by 3 different explorers and 2 different readers, cost and the patient discomfort. RESULTS: Mean ultrasound measurements were significantly higher in the EDT positive group. There was a high concordance between sonography and nerve conduction. A cut-off of 9.5 mm(2) resulted in the correct classification of 83% of cases (sensitivity 88% and specificity 67%). Conversely, a cut-off of >14 mm(2) or <7 mm(2) had excellent power to rule in CTS, with a post-test probability of 100% of specificity and sensitivity respectively. The interobserver acquisition ICC was 0.915-0.980, and the inter-reader ICC was 0.912-0.987. Ultrasound cost savings in this study were €J3217.59 (€42.9 per symptomatic wrist) and the discomfort perceived by the patient was significantly lesser 6.3 vs 56 in EDT (P <.0005). CONCLUSIONS: Ultrasound median nerve crosssectional area is reliable and may be used to accurately rule in or rule out CTS. Sonography as a first-line test is cost-effective and is more satisfactory to the patients.