Educational recommendations for the conduct, content and format of EULAR musculoskeletal ultrasound Teaching the Teachers Courses

Solid validity evidence for two tools assessing competences in musculoskeletal ultrasound: a validity study

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is increasingly used by rheumatologists in daily clinical practice. However, MSUS is only valuable in trained hands, and assessment of trainee competences is therefore essential before independent practice. Thus, this study aimed to establish validity evidence for the EULAR and the Objective Structured Assessment of Ultrasound Skills (OSAUS) tools used for assessing MSUS competences.

METHODS

Thirty physicians with different levels of MSUS experience (novices, intermediates, and experienced) performed four MSUS examinations of different joint areas on the same rheumatoid arthritis patient. All examinations were video recorded (n = 120), anonymized, and subsequently assessed in random order by two blinded raters using first the OSAUS assessment tool followed by the EULAR tool 1 month after.

RESULTS

The inter-rater reliability between the two raters was high for both the OSAUS and EULAR tools, with a Pearson correlation coefficient (PCC) of 0.807 and 0.848, respectively. Both tools demonstrated excellent inter-case reliability, with a Cronbach's alpha of 0.970 for OSAUS and 0.964 for EULAR. Furthermore, there was a strong linear correlation between the OSAUS and the EULAR performance scores and the participants' experience levels (R2 = 0.897 and R2 = 0.868, respectively) and a significant discrimination between different MSUS experience levels (P < 0.001 for both).

CONCLUSIONS

MSUS operator competences can be assessed reliably and valid using either the OSAUS or the EULAR assessment tool, thereby allowing a uniform competency-based MSUS education in the future. Although both tools demonstrated high inter-rater reliability, the EULAR tool was superior to OSAUS.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT05256355.

The value of ultrasound-defined tenosynovitis and synovitis in the prediction of persistent arthritis

OBJECTIVES

The value of US-defined tenosynovitis in predicting the persistence of inflammatory arthritis is not well described. In particular, the predictive utility of US-defined tenosynovitis of larger tendons is yet to be reported. We assessed the value of US-defined tenosynovitis alongside US-defined synovitis and clinical and serological variables in predicting persistent arthritis in an inception cohort of DMARD-naïve patients with early arthritis.

METHODS

One hundred and fifty DMARD-naïve patients with clinically apparent synovitis of one or more joints and a symptom duration of ≤3 months underwent baseline clinical, laboratory and US (of 19 bilateral joints and 16 bilateral tendon compartments) assessments. Outcomes were classified as persistent or resolving arthritis after 18 months' follow-up. The predictive value of US-defined tenosynovitis for persistent arthritis was compared with those of US-defined synovitis, and clinical and serological variables.

RESULTS

At 18 months, 99 patients (66%) had developed persistent arthritis and 51 patients (34%) had resolving disease. Multivariate logistic regression analysis showed that US-detected digit flexor tenosynovitis [odds ratio (OR): 6.6, 95% CI: 2.0 , 22.1, P = 0.002] provided independent predictive data for persistence over and above the presence of US-detected joint synovitis and RF antibodies. In the RF/ACPA-negative subcohort, US-defined digit flexor tenosynovitis remained a significant predictive variable (OR: 4.7, 95% CI: 1.4, 15.8, P = 0.012), even after adjusting for US-defined joint synovitis.

CONCLUSION

US-defined tenosynovitis provided independent predictive data for the development of persistent arthritis. The predictive role of US-defined digit flexor tenosynovitis should be further assessed; investigators should consider including this tendon site as a candidate variable when designing imaging-based predictive algorithms for persistent inflammatory arthritis development.

Procedures for the content, conduct and format of EULAR/PReS paediatric musculoskeletal ultrasound courses

Background

Despite the worldwide increasing request of education on paediatric musculoskeletal ultrasound (PedMSUS), content, conduct and format of PedMSUS courses have never been internationally agreed.

Objectives

To produce educational procedures for the conduct, content and format of EULAR/PReS PedMSUS courses.

Methods

After a systemic literature review and expert opinion collection, a panel of items for the development of procedures on PedMSUS courses was identified. Agreement on the items was assessed through Delphi surveys among a taskforce of 24 members, which included 18 experts in PedMSUS (8 rheumatologists, 1 radiologist, 9 paediatric rheumatologists), 1 methodologist and rheumatologist expert in MSUS, 2 patient research partners, 1 health professional in rheumatology and 2 EMEUNET/EMERGE members, from 8 different European countries. Each item was assessed through a 5-point Likert scale (0, full disagreement; 5, full agreement); agreement was reached for >75% of answers rating 4–5. All items with agreement were included in the preliminary core set of educational procedures, which underwent external assessment by a broader Consensus group (Faculty and Tutors of previous EULAR PedMSUS courses and PReS Imaging Working Party members), through Delphi survey.

Results

Two Delphi surveys produced the preliminary core set of procedures for basic, intermediate, advanced and teach-the-teachers (TTT) PedMSUS courses. A Delphi survey within the Consensus group produced agreement on the proposed procedures.

Conclusions

Shared EULAR/PReS procedures for the conduct, content and format of basic, intermediate, advanced and TTT PedMSUS courses were identified on international basis.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

Musculoskeletal ultrasound imaging training, use, and knowledge among rheumatologists in China

INTRODUCTION/OBJECTIVES

Musculoskeletal ultrasound (MSUS) has been extensively studied by rheumatologists in Europe and the Americas, but less is known about MSUS use in Asia. Our hypothesis is that MSUS use is less prevalent in China as compared with its Western counterparts. This study reports the most up-to-date recommendations for MSUS use in rheumatology globally and is also the first study to characterize the current practices, training, and perceptions regarding MSUS of rheumatologists in China.

METHOD

A 43-question survey was designed and distributed via mobile application to members of the Chinese Rheumatology Association, primarily to investigate the current prevalence and utilization of MSUS in China. Statistical analyses included the use of chi-square tests and independent-samples t tests, with p values less than 0.05 considered statistically significant.

RESULTS

The results showed low rates of MSUS training (129/528, 24%) and current MSUS use (89/524, 17%) in China. However, there was a high level of interest in learning MSUS, especially among younger respondents. Lack of access to training programs and user variability in skill were seen as significant barriers to the uptake of MSUS.

CONCLUSIONS

Despite low rates of MSUS training and utilization, the vast majority of respondents believe that MSUS should become a standard clinical tool in rheumatology, and there was great interest in undergoing training. Importantly, lack of access to MSUS training programs and user variability in skill were seen as significant obstacles to the more widespread use of MSUS, which suggests a need for more standardized, high-quality MSUS training in China. Key Points • A low percentage of Chinese rheumatologists (17%) currently use MSUS. • Chinese rheumatologists expressed a high level of interest in obtaining MSUS training. • The greatest perceived obstacle to more widespread MSUS use is the lack of training programs.

Musculoskeletal ultrasound imaging - Integration with the biopsychosocial model

BACKGROUND AND METHOD

Musculoskeletal ultrasound imaging, (MSKUSI) has become a popular imaging modality in recent years and is being utilised by a variety of professions in clinical environments beyond radiology departments. A previously published study exploring physiotherapists' interests and use of MSKUSI in practice included in-depth interviews of participants, (n = 11). The data from this qualitative study were analysed thematically and five themes were identified; one was 'Application of the biopsychosocial model', the basis of this paper.

RESULT

The theme, 'Application of the biopsychosocial model' drew together three categories of analysed data: clinical reasoning, professional variance and communication opportunity. 'Clinical reasoning' reflected the participants' value on subjective assessment information and the integration of ultrasound imaging with physical examination findings. 'Professional variance' observed the scanning processes undertaken by physiotherapists tended to vary from other professionals, the physiotherapists perceived their use of dynamic imaging was greater, in particular scanning in symptom provoking positions. Another variance observed was the style of communication that physiotherapists used when scanning, this was categorised as a 'communication opportunity' as it represented an event that could be utilised to promote patient understanding of their presentation, link imaging findings to proposed management and enhance compliance with rehabilitation strategies. Participants emphasised their responsibility when communicating with patients to avoid language that could promote unhelpful behaviour, e.g. catastrophisation.

CONCLUSION

Participants placed value on integrating musculoskeletal ultrasound imaging into the biopsychosocial model, further research to explore the impact of this approach on patients' clinical outcomes and reported experiences is required.

Standardized, musculoskeletal ultrasonographic reference values for healthy Korean adults

BACKGROUND/AIMS

To define standard reference values for musculoskeletal ultrasonography (MSUS) in Korea.

METHODS

A total of 251 healthy adults were recruited for this study. Ultrasonography was performed by experienced rheumatologists who had undergone four appropriate training programs in Korea. A General Electric LOGIQ electronic ultrasound device fitted with a 12 MHz linear transducer was employed. Mean values ± standard deviations (SDs) were defined as standard reference values. Intraclass correlation coefficients was employed to evaluate the extent of inter- and intraobserver agreement when MSUS measurements were made.

RESULTS

The 251 study participants included 122 males. Mean subject age was 28.6 years. The average bone-to-capsule distance of the right-side second and third metacarpophalangeal (MCP) joints were 0.68 and 0.72 mm respectively, and those of the left-side joints 0.62 and 0.68 mm. The cartilage thicknesses of the rightside second and third MCP joints were 0.55 and 0.55 mm, and those of the leftside joints were 0.55 and 0.56 mm, respectively. The bone-to-capsule distances of the right and left wrists were 0.80 and 0.82 mm. In 12.4% of participants (31/251), the erosion score of the humeral head was 1.71. In the right-side knee joint, mean cartilage thicknesses of the medial and lateral condyles were 1.86 and 2.03 mm in longitudinal scans. High overall interobserver agreement was evident after appropriate training that included instruction on standard MSUS methodology.

CONCLUSION

We defined standard reference values for MSUS in healthy Korean adults. The reliabilities of interobserver agreements were high after appropriate training program.

Educational initiatives and training for paediatric rheumatology in Europe

The Paediatric Rheumatology European Society (PReS) has over many years, developed a portfolio of educational activities to address increasing educational needs of workforce and support young clinicians to acquire skills to develop new knowledge and deliver clinical care in the future. These educational activities aim to facilitate growth of paediatric rheumatology and ultimately improve the clinical care for children and families. This article describes the current portfolio of PReS educational activities and their relevance to the international paediatric rheumatology community.

WFUMB Position Paper. Learning Gastrointestinal Ultrasound: Theory and Practice

Gastrointestinal ultrasound (GIUS) is an ultrasound application that has been practiced for more than 30 years. Recently, GIUS has enjoyed a resurgence of interest, and there is now strong evidence of its utility and accuracy as a diagnostic tool for multiple indications. The method of learning GIUS is not standardised and may incorporate mentorship, didactic teaching and e-learning. Simulation, using either low- or high-fidelity models, can also play a key role in practicing and honing novice GIUS skills. A course for training as well as establishing and evaluating competency in GIUS is proposed in the manuscript, based on established learning theory practice. We describe the broad utility of GIUS in clinical medicine, including a review of the literature and existing meta-analyses. Further, the manuscript calls for agreement on international standards regarding education, training and indications.