Aim: The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) compete... more Aim: The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) competency assessment (COMPASS) for rheumatologists performing musculoskeletal ultrasound (MSUS) was developed and published 2 years ago. It consists of a 3 level competency system. The objective of this study was to evaluate how the EFSUMB COMPASS has been disseminated and implemented and to assess the potential obstacles encountered. Materials and methods: A questionnaire was developed and distributed by e-mail to all rheumatologists certified as EFSUMB level 3. Results: Seventeen (85%) rheumatologists considered that the EFSUMB COMPASS is useful for training MSUS. The majority of them (17; 85%) had informed their colleagues or national rheumatology societies about the EFSUMB COMPASS. The most common obstacle encountered for the implementation of the COMPASS was the lack of time for supervision of the trainees (9; 45%). A total of 83 rheumatologists had been trained and assessed for competen...
Background The sensitivity of Doppler to detect slow blood flow in inflamed joints is of utmost i... more Background The sensitivity of Doppler to detect slow blood flow in inflamed joints is of utmost importance. This may be influenced by factors such as Doppler modality, machine and settings. Power Doppler (PD) is widely regarded the most sensitive Doppler modality, however, on some machines color Doppler (CD) appears more sensitive. The effect of sensitivity (image acquisition) on the subsequent scoring (image evaluation) is important for multicenter studies because of variability in machines, modalities, and settings. Objectives 1: To determine which Doppler modality was most sensitive – CD or PD - by assessing flow in the dorsal central wrist joint in patients with RA. 2: If adjusting factory settings (FS) for CD and PD influenced the sensitivity positively and 3: If a variation in machines, Doppler modality, and Doppler settings affected the Doppler scoring. Methods Six different ultrasound machines from Esaote, General Electric, Philips, and Siemens were used. On each machine, the FS for superficial musculoskeletal scanning was used for both Doppler modalities. The settings were adjusted for increased Doppler sensitivity (1) and these settings were saved as study settings (SS). 11 RA patients with wrist involvement were scanned on the 6 machines each with 4 settings generating 264 Doppler images for scoring using grading 0-3 (2) and color fraction (CF) (3). Doppler sensitivity was measured with CF – higher CF indicated higher sensitivity. Results Using both scoring systems, PD was more sensitive on Esaote MyLab 70, Siemens S2000 and GE P6, whereas CD was more sensitive on GE E9, Philips IU22 and GE P5. This was the case both with FS and SS. There was a mean increase in Doppler sensitivity of 68% (range 0-156) when SS were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, 7 patients varied between grades 0 and 3 with the other 4 patients between grades 0 and 2. Conclusions The most sensitive Doppler modality for slow flow is machine dependable. On half of the machines, PD was more sensitive than CD – the other half vice versa. By optimizing Doppler settings, sensitivity was increased up to 156% (mean 68%). The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation in RA patients and this must be taken into account in multicenter studies. References Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology. ARD 2008;67(2):143-9. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum. 2003;48(4):955-62. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. ARD 2001;60(7):690-3. Disclosure of Interest S. Torp-Pedersen Grant/Research support from: The study was supported by a grant from General Electric, M. Szkudlarek: None Declared, K. Ellegaard: None Declared, M.-A. D’Agostino: None Declared, A. Iagnocco: None Declared, E. Naredo: None Declared, P. Balint: None Declared, R. Wakefield: None Declared, A. Torp-Pedersen: None Declared, R. Christensen: None Declared, L. Terslev: None Declared
Objectives: The aim of this paper is to investigate sensitivity to change (SRM), predictive valid... more Objectives: The aim of this paper is to investigate sensitivity to change (SRM), predictive validity and discriminative ability of a quantitative (QS) and a semi-quantitative (SQS) Doppler ultrasound scoring systems in patients with rheumatoid arthritis (RA) treated with anti-TNF-α therapy. Methods: RA patients with wrist joint affection treated with TNF-α inhibitor were followed for one year. The wrist was examined with Doppler before initiating therapy and after one year. DAS28 was determined at both visits. One person trained in the SQS system and one in the QS system evaluated the anonymised images. The SRM, predictive validity and discriminative ability for both systems were calculated using DAS28 as the measure of disease improvement. Results: Fourty-six patients with RA (80% females) were included. The mean Doppler activity at baseline was QS:24.4% (SD=17.7%) and SQS:2.0 (SD=0.6). A decrease in Doppler activity was seen for both systems after anti-TNF-α therapy. Sensitivity to change was seen, SRM=-0.52 (95%CI; -0.83 to -0.21; QS) and -0.24 (-0.53 to -0.05; SQS). Predictive value was poor (QS rs=-0.24; SQS rs=-0.05). Construct validity was; QS: rs=0.29, SQS: rs=0.23. Conclusions: Both systems were to some extent sensitive to change. Predictive validity and discriminate capacity of both systems showed only a weak association to DAS 28 in the study population. The QS was a little superior to the SQS. The results do not necessarily reflect Doppler evaluation as being ineffective, but may be caused by DAS28 not being a perfect marker of inflammation.
Objectives: Ultrasound (US) examination of the entheses is increasingly used. However, little is ... more Objectives: Ultrasound (US) examination of the entheses is increasingly used. However, little is known about US findings in the entheses in asymptomatic persons. The aim of this study was to investigate the appearance of US signs in the enthuses of the lower limb in asymptomatic subjects. Methods: We recruited 64 subjects, eight women and eight men whose ages covered four decades, from 20 to 60 years. None had tendon or joint disease in the lower limbs. Participants were examined by a rheumatologist and blood samples were collected to rule out enthesis pathology. The enthesis of the dominant leg were examined with grey-scale and Doppler US to evaluate increased thickness, changed structure, enthesophytes/calcifications, erosions, and colour Doppler signal. Results: Ultrasound examination of 320 entheses was made. At enthesis level, elementary lesions were seen at 73 (22.8%) sites, at subject-level 47 (73.4%) persons showed elementary lesions, in 27 (57%) only one enthesis was affected. Doppler activity was seen in four sites, three at the quadriceps insertion. Most common US elementary lesion was enthesophytes at the Achilles and quadriceps tendon insertion. A tendency towards more elementary lesions was seen in men, and a slight increase was seen with increasing age, however, not statistically significance. Conclusions: Our findings suggest that US can be used to diagnose/examine subjects in adulthood for pathological changes in the entheses; however, caution should be taken regarding enthesophytes of the quadriceps and Achilles tendon.
Purpose: Ultrasound examination of a group of patients with osteoarthritis (OA) of the knee for s... more Purpose: Ultrasound examination of a group of patients with osteoarthritis (OA) of the knee for signs of inflammation. Material and Methods: 71 knees in 71 patients with osteoarthritis of the knee were examined with high-resolution gray-scale ultrasound combined with color and spectral Doppler. The medial, lateral, and antero-superior compartments were examined. Hyperemia was identified as presence of color Doppler signals in the synovial membrane. Low resistance flow was defined as a resistive index <0.80 on spectral Doppler. Results: Synovial thickening was found in all knees; fluid in 61 patients; and hyperemia (color Doppler activity) in 51 patients. Of these, 44 had arterial flow on spectral Doppler – 36 with a low resistance flow. When present, fluid and color Doppler activity was found in all three compartments, but with uneven distribution. Conclusion: The finding in the majority of cases of both effusions on B-mode US and Doppler activity confirms that there is a varying degree of inflammation in knee OA as diagnosed by the ACR criteria.
ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalitie... more ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range.MethodsAdult HS (age 18–80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1–5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort.Results939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference...
ObjectiveTo summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR re... more ObjectiveTo summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR recommendations.MethodsAn overview of systematic reviews (SR) including randomised-controlled trials (RCTs) of IAT in adults with arthropathies was performed up to July 2020. Pain, function, and frequency of adverse events were the main efficacy and safety outcomes, respectively. Quality was assessed with the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool.ResultsOf 184 references identified, 16 met the inclusion criteria, and a search of their reference lists identified 16 additional SRs. After quality assessment, 29 were finally included. Of these, 18 focused on knee osteoarthritis (KOA), 6 on hip osteoarthritis (HOA), 3 on shoulder capsulitis (SC), and 3 on rheumatoid arthritis. Overall, hyaluronic acid showed a small effect on pain and function in KOA but not in HOA or shoulder capsulitis. Intra-articular glucocorticoids showed a small effect in pain and function in KOA...
Objective.The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) opera... more Objective.The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) operates research activities for the validation of US as an outcome measurement instrument according to the Filter 2.0 framework.Methods.Original publications on definitions and scoring systems for pathophysiological manifestations and elementary lesions of various rheumatic disorders were reviewed from the onset of the WG research in 2005.Results.Definitions and scoring systems according to new terminology are provided.Conclusion.We have redefined OMERACT US pathology and elementary lesions as well as scoring systems, which are now proposed for OMERACT approval for application in clinical trials.
Objectives To develop and test the reliability of a new semiquantitative scoring system for the a... more Objectives To develop and test the reliability of a new semiquantitative scoring system for the assessment of cartilage changes by ultrasound in a web-based exercise as well as a patient exercise of patients with RA. Methods A taskforce of the Outcome Measures in Rheumatology Ultrasound Working Group performed a systematic literature review on the US assessment of cartilage in RA, followed by a Delphi survey on cartilage changes and a new semiquantitative US scoring system, and finally a web-based exercise as well as a patient exercise. For the web-based exercise, taskforce members scored a dataset of anonymized static images of MCP joints in RA patients and healthy controls, which also contained duplicate images. Subsequently, 12 taskforce members used the same US to score cartilage in MCP and proximal interphalangeal joints of six patients with RA in in a patient reliability exercise. Percentage agreement and prevalence of lesions were calculated, as intrareader reliability was as...
Aim: The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) compete... more Aim: The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) competency assessment (COMPASS) for rheumatologists performing musculoskeletal ultrasound (MSUS) was developed and published 2 years ago. It consists of a 3 level competency system. The objective of this study was to evaluate how the EFSUMB COMPASS has been disseminated and implemented and to assess the potential obstacles encountered. Materials and methods: A questionnaire was developed and distributed by e-mail to all rheumatologists certified as EFSUMB level 3. Results: Seventeen (85%) rheumatologists considered that the EFSUMB COMPASS is useful for training MSUS. The majority of them (17; 85%) had informed their colleagues or national rheumatology societies about the EFSUMB COMPASS. The most common obstacle encountered for the implementation of the COMPASS was the lack of time for supervision of the trainees (9; 45%). A total of 83 rheumatologists had been trained and assessed for competen...
Background The sensitivity of Doppler to detect slow blood flow in inflamed joints is of utmost i... more Background The sensitivity of Doppler to detect slow blood flow in inflamed joints is of utmost importance. This may be influenced by factors such as Doppler modality, machine and settings. Power Doppler (PD) is widely regarded the most sensitive Doppler modality, however, on some machines color Doppler (CD) appears more sensitive. The effect of sensitivity (image acquisition) on the subsequent scoring (image evaluation) is important for multicenter studies because of variability in machines, modalities, and settings. Objectives 1: To determine which Doppler modality was most sensitive – CD or PD - by assessing flow in the dorsal central wrist joint in patients with RA. 2: If adjusting factory settings (FS) for CD and PD influenced the sensitivity positively and 3: If a variation in machines, Doppler modality, and Doppler settings affected the Doppler scoring. Methods Six different ultrasound machines from Esaote, General Electric, Philips, and Siemens were used. On each machine, the FS for superficial musculoskeletal scanning was used for both Doppler modalities. The settings were adjusted for increased Doppler sensitivity (1) and these settings were saved as study settings (SS). 11 RA patients with wrist involvement were scanned on the 6 machines each with 4 settings generating 264 Doppler images for scoring using grading 0-3 (2) and color fraction (CF) (3). Doppler sensitivity was measured with CF – higher CF indicated higher sensitivity. Results Using both scoring systems, PD was more sensitive on Esaote MyLab 70, Siemens S2000 and GE P6, whereas CD was more sensitive on GE E9, Philips IU22 and GE P5. This was the case both with FS and SS. There was a mean increase in Doppler sensitivity of 68% (range 0-156) when SS were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, 7 patients varied between grades 0 and 3 with the other 4 patients between grades 0 and 2. Conclusions The most sensitive Doppler modality for slow flow is machine dependable. On half of the machines, PD was more sensitive than CD – the other half vice versa. By optimizing Doppler settings, sensitivity was increased up to 156% (mean 68%). The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation in RA patients and this must be taken into account in multicenter studies. References Settings and artefacts relevant in colour/power Doppler ultrasound in rheumatology. ARD 2008;67(2):143-9. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum. 2003;48(4):955-62. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. ARD 2001;60(7):690-3. Disclosure of Interest S. Torp-Pedersen Grant/Research support from: The study was supported by a grant from General Electric, M. Szkudlarek: None Declared, K. Ellegaard: None Declared, M.-A. D’Agostino: None Declared, A. Iagnocco: None Declared, E. Naredo: None Declared, P. Balint: None Declared, R. Wakefield: None Declared, A. Torp-Pedersen: None Declared, R. Christensen: None Declared, L. Terslev: None Declared
Objectives: The aim of this paper is to investigate sensitivity to change (SRM), predictive valid... more Objectives: The aim of this paper is to investigate sensitivity to change (SRM), predictive validity and discriminative ability of a quantitative (QS) and a semi-quantitative (SQS) Doppler ultrasound scoring systems in patients with rheumatoid arthritis (RA) treated with anti-TNF-α therapy. Methods: RA patients with wrist joint affection treated with TNF-α inhibitor were followed for one year. The wrist was examined with Doppler before initiating therapy and after one year. DAS28 was determined at both visits. One person trained in the SQS system and one in the QS system evaluated the anonymised images. The SRM, predictive validity and discriminative ability for both systems were calculated using DAS28 as the measure of disease improvement. Results: Fourty-six patients with RA (80% females) were included. The mean Doppler activity at baseline was QS:24.4% (SD=17.7%) and SQS:2.0 (SD=0.6). A decrease in Doppler activity was seen for both systems after anti-TNF-α therapy. Sensitivity to change was seen, SRM=-0.52 (95%CI; -0.83 to -0.21; QS) and -0.24 (-0.53 to -0.05; SQS). Predictive value was poor (QS rs=-0.24; SQS rs=-0.05). Construct validity was; QS: rs=0.29, SQS: rs=0.23. Conclusions: Both systems were to some extent sensitive to change. Predictive validity and discriminate capacity of both systems showed only a weak association to DAS 28 in the study population. The QS was a little superior to the SQS. The results do not necessarily reflect Doppler evaluation as being ineffective, but may be caused by DAS28 not being a perfect marker of inflammation.
Objectives: Ultrasound (US) examination of the entheses is increasingly used. However, little is ... more Objectives: Ultrasound (US) examination of the entheses is increasingly used. However, little is known about US findings in the entheses in asymptomatic persons. The aim of this study was to investigate the appearance of US signs in the enthuses of the lower limb in asymptomatic subjects. Methods: We recruited 64 subjects, eight women and eight men whose ages covered four decades, from 20 to 60 years. None had tendon or joint disease in the lower limbs. Participants were examined by a rheumatologist and blood samples were collected to rule out enthesis pathology. The enthesis of the dominant leg were examined with grey-scale and Doppler US to evaluate increased thickness, changed structure, enthesophytes/calcifications, erosions, and colour Doppler signal. Results: Ultrasound examination of 320 entheses was made. At enthesis level, elementary lesions were seen at 73 (22.8%) sites, at subject-level 47 (73.4%) persons showed elementary lesions, in 27 (57%) only one enthesis was affected. Doppler activity was seen in four sites, three at the quadriceps insertion. Most common US elementary lesion was enthesophytes at the Achilles and quadriceps tendon insertion. A tendency towards more elementary lesions was seen in men, and a slight increase was seen with increasing age, however, not statistically significance. Conclusions: Our findings suggest that US can be used to diagnose/examine subjects in adulthood for pathological changes in the entheses; however, caution should be taken regarding enthesophytes of the quadriceps and Achilles tendon.
Purpose: Ultrasound examination of a group of patients with osteoarthritis (OA) of the knee for s... more Purpose: Ultrasound examination of a group of patients with osteoarthritis (OA) of the knee for signs of inflammation. Material and Methods: 71 knees in 71 patients with osteoarthritis of the knee were examined with high-resolution gray-scale ultrasound combined with color and spectral Doppler. The medial, lateral, and antero-superior compartments were examined. Hyperemia was identified as presence of color Doppler signals in the synovial membrane. Low resistance flow was defined as a resistive index <0.80 on spectral Doppler. Results: Synovial thickening was found in all knees; fluid in 61 patients; and hyperemia (color Doppler activity) in 51 patients. Of these, 44 had arterial flow on spectral Doppler – 36 with a low resistance flow. When present, fluid and color Doppler activity was found in all three compartments, but with uneven distribution. Conclusion: The finding in the majority of cases of both effusions on B-mode US and Doppler activity confirms that there is a varying degree of inflammation in knee OA as diagnosed by the ACR criteria.
ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalitie... more ObjectivesThis study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range.MethodsAdult HS (age 18–80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1–5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort.Results939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference...
ObjectiveTo summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR re... more ObjectiveTo summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR recommendations.MethodsAn overview of systematic reviews (SR) including randomised-controlled trials (RCTs) of IAT in adults with arthropathies was performed up to July 2020. Pain, function, and frequency of adverse events were the main efficacy and safety outcomes, respectively. Quality was assessed with the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool.ResultsOf 184 references identified, 16 met the inclusion criteria, and a search of their reference lists identified 16 additional SRs. After quality assessment, 29 were finally included. Of these, 18 focused on knee osteoarthritis (KOA), 6 on hip osteoarthritis (HOA), 3 on shoulder capsulitis (SC), and 3 on rheumatoid arthritis. Overall, hyaluronic acid showed a small effect on pain and function in KOA but not in HOA or shoulder capsulitis. Intra-articular glucocorticoids showed a small effect in pain and function in KOA...
Objective.The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) opera... more Objective.The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) operates research activities for the validation of US as an outcome measurement instrument according to the Filter 2.0 framework.Methods.Original publications on definitions and scoring systems for pathophysiological manifestations and elementary lesions of various rheumatic disorders were reviewed from the onset of the WG research in 2005.Results.Definitions and scoring systems according to new terminology are provided.Conclusion.We have redefined OMERACT US pathology and elementary lesions as well as scoring systems, which are now proposed for OMERACT approval for application in clinical trials.
Objectives To develop and test the reliability of a new semiquantitative scoring system for the a... more Objectives To develop and test the reliability of a new semiquantitative scoring system for the assessment of cartilage changes by ultrasound in a web-based exercise as well as a patient exercise of patients with RA. Methods A taskforce of the Outcome Measures in Rheumatology Ultrasound Working Group performed a systematic literature review on the US assessment of cartilage in RA, followed by a Delphi survey on cartilage changes and a new semiquantitative US scoring system, and finally a web-based exercise as well as a patient exercise. For the web-based exercise, taskforce members scored a dataset of anonymized static images of MCP joints in RA patients and healthy controls, which also contained duplicate images. Subsequently, 12 taskforce members used the same US to score cartilage in MCP and proximal interphalangeal joints of six patients with RA in in a patient reliability exercise. Percentage agreement and prevalence of lesions were calculated, as intrareader reliability was as...
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