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Bernal JA, Andrés M, López-Salguero S, Jovaní V, Vela-Casasempere P, Pascual E. Agreement Among Multiple Observers on Crystal Identification by Synovial Fluid Microscopy. Arthritis Care Res (Hoboken) 2023; 75:682-688. [PMID: 36426584 DOI: 10.1002/acr.24874] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 02/06/2022] [Accepted: 02/24/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Despite the fact that polarized microscopy remains the gold standard for diagnosing crystal arthritis, some uncertainties hamper full implementation in clinical practice. We undertook this study to analyze the agreement among multiple observers in crystal identification using compensated polarized microscopy, as well as to assess potential outcome modifiers. METHODS This was a cross-sectional, observational study with consecutive synovial fluid sampling. Samples were immediately analyzed when possible or kept refrigerated at 4°C. Five observers analyzed them separately, blinded to clinical data, using a compensated polarized optical microscope (400×), through 3 stages (ordinary, simple polarized, and compensated polarized light) to detect and identify crystals. They recorded the presence and type of crystal (no crystals, monosodium urate [MSU], and calcium pyrophosphate dihydrate [CPP]). Interrater agreement was measured by Cohen's kappa. Subanalyses were performed on visualization delay and cumulative expertise. Discrepancies between each stage of the microscopy and the final decision were also examined. RESULTS A total of 250 observations from 50 samples completed full assessment. Overall, κ = 0.74 (95% confidence interval [95% CI] 0.64-0.84), indicating good agreement. Agreement for crystal detection was κ = 0.71 (95% CI 0.59-0.82), for MSU was κ = 0.88 (95% CI 0.75-1.0), and for CPP was κ = 0.69 (95% CI 0.56-0.82). Most of the crystal identifications were already made by ordinary light. No differences between observations made before or after 24 hours (P = 0.859) or in expertise on crystal analysis (P = 0.989) were found. Observations performed under ordinary light matched the final diagnosis in 96.8% of cases (242 of 250). CONCLUSION Compensated polarized microscopy remained consistent in detecting and identifying crystals in synovial fluid, even when examined among multiple observers, confirming its high utility for clinical practice.
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Affiliation(s)
| | - Mariano Andrés
- Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, and Universidad Miguel Hernández, Alicante, Spain
| | | | - Vega Jovaní
- Hospital General Universitario de Alicante and Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
| | - Paloma Vela-Casasempere
- Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, and Universidad Miguel Hernández, Alicante, Spain
| | - Eliseo Pascual
- Instituto de Investigación Sanitaria y Biomédica de Alicante, Alicante, Spain
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Coiffier G, Berthoud O, Albert JD, Robin F, Goussault C, Gougeon-Jolivet A, Bendavid C, Guggenbuhl P. Elaboration of a new synovial predictive score of septic origin for acute arthritis on the native joint (RESAS). Rheumatology (Oxford) 2021; 60:2238-2245. [PMID: 33197255 DOI: 10.1093/rheumatology/keaa567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/21/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To establish a new predictive score for the diagnosis of septic arthritis (SA) according to different synovial fluid (SF) variables. METHODS First, we analysed the different clinical, biological and SF variables associated with the diagnosis of SA (according to the Newman's criteria) in a monocentric cohort of acute arthritis (<30 days) (n = 233) (SYNOLACTATE cohort). A new score predictive of SA (RESAS) was created using the independent discriminant variables after multivariate analysis. A value was attributed to each variable of the score according to the weighting based on their likelihood ratio for the diagnosis of SA. RESAS performance was then tested on the first cohort (internal validation) and then checked on a second independent cohort (n = 70) (external validation). RESULTS After multivariate analysis, four independent variables of the SF were included for RESAS: (i) purulent SF or white blood cells count ≥70 000/mm3; (ii) absence/presence of crystals; (iii) lactate; and (iv) glucose synovial level. RESAS ranged between -4 and +13 points. The performance of RESAS to predicted SA was excellent with area under the curve (AUC)=0.928 (0.877-0.980) in internal validation and AUC=0.986 (0.962-1.00) in external validation. For a RESAS threshold ≥+4, SA was diagnosed with Se=56.0% (0.371-0.733), Sp=98.1% (0.952-0.993), LR+=29.1 (10.4-81.6) in the first cohort and with Se=91.7% (0.646-0.985), Sp=98.3% (0.909-0.997), LR+=53.2 (7.56-373) in the second cohort. CONCLUSION RESAS is a new composite score of four SF variables with excellent performance to predicted SA in acute arthritis population.
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Affiliation(s)
| | | | | | - François Robin
- Rheumatology Department, CHU Rennes.,U1241, CIMIAD Unit, INSERM
| | | | | | - Claude Bendavid
- U1241, CIMIAD Unit, INSERM.,Biochemistry Department, CHU Rennes, University of Rennes 1, Rennes, France
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Albert JD, Le Corvec M, Berthoud O, David C, Guennoc X, Hoppe E, Jousse-Joulin S, Le Goff B, Tariel H, Sire O, Jolivet-Gougeon A, Coiffier G, Loréal O. Ruling out septic arthritis risk in a few minutes using mid-infrared spectroscopy in synovial fluids. Rheumatology (Oxford) 2021; 60:1158-1165. [PMID: 32885254 DOI: 10.1093/rheumatology/keaa373] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/19/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The aim of this study was to show the usefulness of a mid-infrared fibre evanescent wave spectroscopy point of care device in the identification of septic arthritis patients in a multicentre cohort, and to apply this technology to clinical practice among physicians. METHODS SF samples from 402 patients enrolled in a multicentre cohort were frozen for analysis by mid-infrared fibre evanescent wave spectroscopy. The calibration cohort was divided into two groups of patients (septic arthritis and non-septic arthritis) and relevant spectral variables were used for logistic regression model. Model performances were tested on an independent set of 86 freshly obtained SF samples from patients enrolled in a single-centre acute arthritis cohort and spectroscopic analyses performed at the patient's bedside. RESULTS The model set-up, using frozen-thawed SFs, provided good performances, with area under the curve 0.95, sensitivity 0.90, specificity 0.90, positive predictive value 0.41 and negative predictive value 0.99. Performances obtained in the validation cohort were area under the curve 0.90, sensitivity 0.92, specificity 0.81, positive predictive value 0.46 and negative predictive value 0.98. The septic arthritis probability has been translated into a risk score from 0 to 4 according to septic risk. For a risk score of 0, the probability of identifying a septic patient is very low (negative predictive value of 1), whereas a risk score of 4 indicates very high risk of septic arthritis (positive predictive value of 1). CONCLUSION Mid-infrared fibre evanescent wave spectroscopy could distinguish septic from non-septic synovial arthritis fluids with good performances, and showed particular usefulness in ruling out septic arthritis. Our data supports the possibility of technology transfer. TRIAL REGISTRATION ClinicalTrials.gov, http://clinicaltrials.gov, NCT02860871.
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Affiliation(s)
- Jean-David Albert
- Rheumatology Department, Centre Hospitalier Universitaire de Rennes, Rennes, France.,INSERM, Université de Rennes, INRAe, UMR 1241, Institut NUMECAN CHU Rennes, Rennes, France
| | | | - Olivia Berthoud
- Rheumatology Department, Centre Hospitalier Universitaire de Rennes, Rennes, France
| | - Claire David
- Rheumatology Department, Centre Hospitalier de Bretagne Atlantique, Vannes, France
| | - Xavier Guennoc
- Rheumatology Department, Centre Hospitalier St-Brieuc, St-brieuc, France
| | - Emmanuel Hoppe
- Rheumatology Department, Centre Hospitalier Universitaire Angers, Angers, France
| | - Sandrine Jousse-Joulin
- Rheumatology Department, Centre Hospitalier Universitaire and Inserm, LBAI, UMR1227, Brest, France
| | - Benoît Le Goff
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, France
| | | | | | - Anne Jolivet-Gougeon
- INSERM, Université de Rennes, INRAe, UMR 1241, Institut NUMECAN CHU Rennes, Rennes, France
| | - Guillaume Coiffier
- Rheumatology Department, Centre Hospitalier Universitaire de Rennes, Rennes, France.,INSERM, Université de Rennes, INRAe, UMR 1241, Institut NUMECAN CHU Rennes, Rennes, France
| | - Olivier Loréal
- INSERM, Université de Rennes, INRAe, UMR 1241, Institut NUMECAN CHU Rennes, Rennes, France
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Robin F, Berthoud O, Albert JD, Cadiou S, Gougeon-Jolivet A, Bendavid C, Guggenbuhl P, Coiffier G. External validation of Gout-calculator performance on a cohort of acute arthritis (SYNOLACTATE) sparing distal joints such as hallux and midfoot. A cross-sectional study of 170 patients. Clin Rheumatol 2020; 40:1983-1988. [PMID: 33113024 DOI: 10.1007/s10067-020-05382-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/04/2020] [Accepted: 08/28/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the performance of the Gout-calculator in a cohort of consecutive acute arthritis affecting large and intermediate joints (without an attack on hallux or midfoot joints). METHODS A retrospective study. Gout-calculator data were collected in medical records of patients included in the prospective consecutive cohort of acute arthritis called SYNOLACTATE. The diagnosis of gout was defined by the presence of sodium urate crystals in synovial fluid. The diagnostic performance of the Gout-calculator was studied by performing an ROC curve with the calculation of its AUC (95% CI) as well as the calculation of Sensitivity (Se), Specificity (Sp), and positive likelihood ratio (LR+). RESULTS 170 patients with acute arthritis were included. Variables associated with the diagnosis of gout were as follows: serum uric acid > 350 μmol/L (OR 5.52 (2.52-12.1), p < 0.001), joint redness (OR 5.08 (1.85-14.0), p = 0.001), previous patient-reported arthritis attack (OR 4.04 (1.92-8.49), p < 0.001), male (OR 3.00 (1.17-7.69), p = 0.02), hypertension or cardiovascular disease (OR 2.33 (1.07-5.06), p = 0.03). The median (IQR) of Gout-calculator was significantly higher in gouty arthritis (7.0 [5.5-8.1]) than in associated-CPP acute arthritis (4.0 [2.0-5.8]), septic arthritis (3.0 [2.0-5.1]), or others arthritis (3.5 [2.0-5.5]). The AUC was 0.833 (0.768-0.897) with for the threshold ≥ 8, a Se at 27.5% (0.161-0.428), Sp 97.7% (0.934-0.992), and LR+ 11.9 (3.5-40). CONCLUSION Despite diagnostic performances close to those published, the use of the Gout-calculator is not sufficient for the diagnosis of gout or to exclude the differential diagnosis of septic arthritis in the SYNOLACTATE cohort. KEY POINTS • For a Gout-calculator threshold of ≤ 4, Sensitivity is 92.5%, Specificity 50.8% and LR- 0.15 to the gout diagnosis. • For a Gout-calculator threshold of > = 8, Sensitivity is 27.5%, Specificity 97.7% and LR+ 11.9 to the gout diagnosis. • In a population of acute arthritis affecting large joints, Gout-calculator is not sufficient to discriminate between gouty arthritis and septic arthritis.
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Affiliation(s)
- F Robin
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes, Cedex 2, France.,UMR INSERM U 1241, University of Rennes, Rennes, France
| | - O Berthoud
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes, Cedex 2, France
| | - J D Albert
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes, Cedex 2, France.,UMR INSERM U 1241, University of Rennes, Rennes, France
| | - S Cadiou
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes, Cedex 2, France
| | - A Gougeon-Jolivet
- UMR INSERM U 1241, University of Rennes, Rennes, France.,Bacteriology Laboratory, Rennes University Hospital - Pontchaillou, 2 Rue Henri Le Guilloux, 35000, Rennes, France
| | - C Bendavid
- UMR INSERM U 1241, University of Rennes, Rennes, France.,Department of Biochemistry, Rennes University Hospital - Pontchaillou, 2 Rue Henri Le Guilloux, 35000, Rennes, France
| | - P Guggenbuhl
- Department of Rheumatology, Rennes University Hospital, Hôpital Sud, 16 boulevard de Bulgarie, BP 90347, 35203, Rennes, Cedex 2, France.,UMR INSERM U 1241, University of Rennes, Rennes, France
| | - Guillaume Coiffier
- Rheumatology Department, Groupe Territorial Hospitalier Rance-Emeraude Dinan Hospital, 74 boulevard Chateaubriand, 22100, Dinan, France.
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Ferreyra M, Coiffier G, Albert JD, David C, Perdriger A, Guggenbuhl P. Combining cytology and microcrystal detection in nonpurulent joint fluid benefits the diagnosis of septic arthritis. Joint Bone Spine 2017; 84:65-70. [DOI: 10.1016/j.jbspin.2016.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2016] [Indexed: 12/23/2022]
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Abstract
Joint fluid analysis must be performed as part of the diagnostic workup for acute arthritis, most notably to rule out septic arthritis and to allow the identification of crystal-induced arthritis (gout or calcium pyrophosphate deposition disease), which is one of the most common causes. However, the detection of monosodium urate or calcium pyrophosphate microcrystals is not the only goal of the polarized light microscopy examination of joint fluid. Other, less common microcrystals may be found. Among them are phospholipid microspherules, which are easily recognized microscopically based on their Maltese cross-like appearance. Phospholipid microspherules are a cause of acute arthritis that is often missed by rheumatologists and may therefore be more common than generally believed.
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Wu Y, Chen K, Terkeltaub R. Systematic review and quality analysis of emerging diagnostic measures for calcium pyrophosphate crystal deposition disease. RMD Open 2016; 2:e000339. [PMID: 27933211 PMCID: PMC5133413 DOI: 10.1136/rmdopen-2016-000339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/16/2016] [Accepted: 10/10/2016] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES Calcium pyrophosphate crystal deposition disease (CPPD) is common, yet prevalence and overall clinical impact remain unclear. Sensitivity and specificity of CPPD reference standards (conventional crystal analysis (CCA) and radiography (CR)) were meta-analysed by EULAR (published 2011). Since then, new diagnostic modalities are emerging. Hence, we updated 2009-2016 literature findings by systematic review and evidence grading, and assessed unmet needs. METHODS We performed systematic search of full papers (PubMed, Scopus/EMBASE, Cochrane 2009-2016 databases). Search terms included CPPD, chondrocalcinosis, pseudogout, ultrasound, MRI, dual energy CT (DECT). Paper selection, data abstraction, EULAR evidence level, and Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 bias and applicability grading were performed independently by 3 authors. RESULTS We included 26 of 111 eligible papers, which showed emergence in CPPD diagnosis of ultrasound (U/S), and to lesser degree, DECT and Raman spectroscopy. U/S detected CPPD crystals in peripheral joints with sensitivity >80%, superior to CR. However, most study designs, though analytical, yielded low EULAR evidence level. DECT was marginally explored for CPPD, compared with 35 published DECT studies in gout. QUADAS-2 grading indicated strong applicability of U/S, DECT and Raman spectroscopy, but high study bias risk (in ∼30% of papers) due to non-controlled designs, and non-randomised subject selection. CONCLUSIONS Though CCA and CR remain reference standards for CPPD diagnosis, U/S, DECT and Raman spectroscopy are emerging U/S sensitivity appears to be superior to CR. We identified major unmet needs, including for randomised, blinded, controlled studies of CPPD diagnostic performance and rigorous analyses of 4 T MRI and other emerging modalities.
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Affiliation(s)
- Y Wu
- Department of Rheumatology , VAMC/UCSD , San Diego, California , USA
| | - K Chen
- Department of Radiology , VAMC/UCSD , San Diego, California , USA
| | - R Terkeltaub
- Department of Rheumatology , VAMC/UCSD , San Diego, California , USA
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Albert JD, Monbet V, Jolivet-Gougeon A, Fatih N, Le Corvec M, Seck M, Charpentier F, Coiffier G, Boussard-Pledel C, Bureau B, Guggenbuhl P, Loréal O. A novel method for a fast diagnosis of septic arthritis using mid infrared and deported spectroscopy. Joint Bone Spine 2015; 83:318-23. [PMID: 26677999 DOI: 10.1016/j.jbspin.2015.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 05/28/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the ability of mid infrared deported spectroscopy to discriminate synovial fluids samples of septic arthritis patients from other causes of joint effusion. METHODS Synovial fluids obtained from patients with clinically suspected arthritis were collected, analysed and classified according to standard diagnostic procedures as septic or non-septic. A spectroscopic analysis on synovial fluid samples was then performed using a coiled optical fiber made with chalcogenide glass. After a factorial analysis of the normalized spectra and the computation of a Fisher test used to select the most relevant components, a logistic regression model was fitted, allowing to attribute a score between 0 - non-septic -, and 1 - septic. RESULTS In a first phase, we analysed the synovial fluids from 122 different synovial fluids including 6 septic arthritis among arthritis of various origins. Septic synovial fluids were identified with a sensitivity of 95.8% and a specificity of 93.9% and an AUROC of 0.977. The analysis of an independent set of samples (n=42, including two septic arthritis) gave similar values. CONCLUSIONS Our data strongly supports the interest of mid infrared deported spectroscopy, which could be used potentially at point of care, for a rapid and easy diagnosis of septic arthritis. Now, the precision of the diagnosis must be evaluated through a multicentric study on a larger panel of patients.
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Affiliation(s)
- Jean-David Albert
- Department of Rheumatology, CHU of Rennes, 2, rue Henri-le-Guilloux, 35000 Rennes, France; INSERM UMR 991, 35033 Rennes, France.
| | - Valérie Monbet
- University of Rennes 1, 35043 Rennes, France; UMR-CNRS 6625, IRMAR Mathematics Research Institute of Rennes, 35033 Rennes, France; INRIA/ASPI, 35033 Rennes, France
| | - Anne Jolivet-Gougeon
- Pole of Biology, EA 1254 Microbiologie, CHU of Rennes, University of Rennes 1, 35033 Rennes, France
| | - Nadia Fatih
- Diafir™, avenue Chardonnet, Parc Lorans, 26J, 35700 Rennes, France
| | - Maëna Le Corvec
- Diafir™, avenue Chardonnet, Parc Lorans, 26J, 35700 Rennes, France; Laboratoire d'Ingénierie des Matériaux de Bretagne (LIMATB), University of Bretagne-Sud, CER Yves-Coppens, BP 573, 56017 Vannes cedex, France
| | - Malik Seck
- University of Rennes 1, 35043 Rennes, France
| | | | - Guillaume Coiffier
- Department of Rheumatology, CHU of Rennes, 2, rue Henri-le-Guilloux, 35000 Rennes, France; INSERM UMR 991, 35033 Rennes, France
| | | | - Bruno Bureau
- ISCR UMR-CNRS 6226, Verres et Céramiques, Université de Rennes 1, 35042 Rennes, France
| | - Pascal Guggenbuhl
- Department of Rheumatology, CHU of Rennes, 2, rue Henri-le-Guilloux, 35000 Rennes, France; INSERM UMR 991, 35033 Rennes, France; University of Rennes 1, 35043 Rennes, France
| | - Olivier Loréal
- INSERM UMR 991, 35033 Rennes, France; University of Rennes 1, 35043 Rennes, France
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Why are rheumatologists still reluctant to perform joint-fluid analysis? Joint Bone Spine 2015; 82:139-40. [PMID: 25677411 DOI: 10.1016/j.jbspin.2015.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2011] [Indexed: 01/07/2023]
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