Use of musculoskeletal ultrasound in Japan: a survey of practicing rheumatologists

Ultrasound-Guided Needle Aspiration of Subperiosteal Abscess in a Child with Acute Osteomyelitis of the Fibula: A Case Report

CASE

An 8-year-old boy with left lateral ankle pain was diagnosed with acute osteomyelitis after methicillin-susceptible Staphylococcus aureus was identified in a subperiosteal abscess in the distal fibula that had been aspirated using an ultrasound-guided needle. Symptoms improved after 2 weeks of intravenous and 4 weeks of oral antimicrobial therapy; no additional treatment was required. No growth retardation or sequelae were observed at the 6-year follow-up.

CONCLUSIONS

In acute osteomyelitis, the identification of subperiosteal abscess is key for early diagnosis. Ultrasound evaluation of the distal fibula should also be considered in the diagnosis of lateral ankle pain in children.

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.

Perceptions of Doppler ultrasound for rheumatoid arthritis disease activity assessment and education

AIM

The aim of this qualitative study was to report the findings of the Defining rheumatoid arthritis progression using Doppler Ultrasound in Clinical practice (DEDUCE) Medical Practice Activity, which was developed to facilitate the utilization of Doppler ultrasound (DUS) by Australian rheumatologists in the treatment of patients with rheumatoid arthritis (RA).

METHOD

Twenty-one rheumatologists recruited a total of 80 patients with RA in Disease Activity Score of 28 joints (DAS28) remission for DUS assessment and completed a pre- and post-activity questionnaire assessing their experience with DUS, as well as a 6-month follow-up questionnaire. Rheumatologists discussed DUS results with patients using visual aids. Patients completed a pre- and post-DUS assessment questionnaire. Data were summarized using descriptive statistics.

RESULTS

Following completion of the activity, 95% of rheumatologists (20/21) believed DUS was a useful assessment tool for patients with RA. The majority found the DUS results useful and more than half thought the DUS assessment fit well into their consultation. A majority of rheumatologists indicated they would use DUS imaging in patients with low disease activity and remission, and for disease activity assessment to inform in therapeutic decision-making. All patients who responded found the visual aids useful and most felt that discussing DUS results improved understanding of their disease and would help with medication adherence.

CONCLUSION

Incorporation of DUS imaging into routine clinical practice is feasible, encourages rheumatologists to utilize and expand their clinical application of DUS imaging in patients with RA, and may improve patient understanding of their disease and adherence to medication.

Musculoskeletal ultrasonography delineates ankle symptoms in rheumatoid arthritis

OBJECTIVES

To clarify the use of musculoskeletal ultrasonography (US) of ankle joints in rheumatoid arthritis (RA).

METHODS

Consecutive RA patients with or without ankle symptoms participated in the study. The US, clinical examination (CE), and patients' visual analog scale for pain (pVAS) for ankles were assessed. Prevalence of tibiotalar joint synovitis and tenosynovitis were assessed by grayscale (GS) and power Doppler (PD) US using a semi-quantitative grading (0-3). The positive US and CE findings were defined as GS score ≥2 and/or PD score ≥1, and joint swelling and/or tenderness, respectively. Multivariate analysis with the generalized linear mixed model was performed by assigning ankle pVAS as a dependent variable.

RESULTS

Among a total of 120 ankles from 60 RA patients, positive ankle US findings were found in 21 (35.0%) patients. The concordance rate of CE and US was moderate (kappa 0.57). Of the 88 CE negative ankles, US detected positive findings in 9 (10.2%) joints. Multivariate analysis revealed that ankle US, clinical disease activity index, and foot Health Assessment Questionnaire, but not CE, was independently associated with ankle pVAS.

CONCLUSION

US examination is useful to illustrate RA ankle involvement, especially for patients who complain ankle pain but lack CE findings.

Current state of the use of musculoskeletal ultrasound (MSUS) and view on the future development of MSUS training and services in Hong Kong: Results of a survey among the members of the Hong Kong Society of Rheumatology

Objective

To document the current state of the use of musculoskeletal US (MSUS) and view on the future development of MSUS training and services among the members of the Hong Kong Society of Rheumatology.

Methods

A three-page anonymous questionnaire, divided into three sections (demographics, current state of the MSUS service, and view on future development of MSUS training and services), was sent (either in electronic format or in hardcopy) to 79 members (70 full members and 9 ordinary members) of the Hong Kong Society of Rheumatology. The aim is to inquire about the use of MSUS by rheumatologists, their views on the future development of MSUS training and service in Hong Kong.

Results

28 (35%) out of 79 members responded to the questionnaire (including 25 fellows and 3 trainees working in public hospitals and private sector). 25 responders (89.3%; 25/28) were using MSUS in their daily practice for making diagnoses, guiding interventions or follow-up disease. Although 90% (25/28) of the responders’ institutes provided the MSUS service by the Radiology Department, 70% of them got long waiting time, and the Radiology Department did not provide the MSUS service to every joint region. Despite the widespread use of MSUS among rheumatologists, more than 90% of the responders could only do less than 10 scans per week. Lack of time and manpower, lack of expertise, high cost of equipment, and lack of support for training were important obstacles in developing the MSUS service. 18 (64%) responders in our survey tended to agree that MSUS training should be incorporated in the rheumatology training.

Conclusions

In conclusion, this is the first survey demonstrating the current state of the use of MSUS in Hong Kong and a huge growth in demand for the service development and formal training in MSUS. A number of challenges in terms of lack of time and manpower, lack of expertise, high cost of equipment, and lack of support for training is evident.

Ultrasound learning curve in gout: a disease-oriented training program

OBJECTIVE

To describe the learning curve of rheumatologists with limited experience using ultrasound (US) attending an intensive disease-oriented training program focusing on the skills required to obtain and interpret US signs of monosodium urate (MSU) crystal deposits in joint and periarticular tissues.

METHODS

Three investigators participated in a 7-day training program involving 12 men with gout. The agreement between the expert and beginners was calculated in 4 sessions involving 8 patients with gout. The US assessment was performed at the second and third metacarpophalangeal joints, knee, tibiotalar and first metatarsophalangeal joints, second and third finger flexors, quadriceps and patellar posterior tibialis, peroneus longus and brevis, and Achilles tendons. The presence or absence of synovial fluid/synovial hypertrophy, double contour sign, intra- or periarticular and intratendinous tophi, bursitis, bone erosions, and tendon tears was recorded.

RESULTS

A total of 416 anatomic sites were studied. Kappa values and overall agreement percentages of qualitative assessments of US gout findings at the end of the exercise both showed moderate to excellent agreement, while in the first session they showed poor/fair agreement. At the end of the training session, sensitivity, specificity, and capability of the beginners were also improved.

CONCLUSION

After 1 week of the disease-oriented training program, rheumatologists with limited experience in US were satisfactorily able to detect and interpret the main US signs indicative of MSU crystal deposits at different tissues in patients with gout.

Clinical implementation of musculoskeletal ultrasound in rheumatology in Austria

The aim of the study is to assess the clinical implementation of musculoskeletal ultrasound (MSUS) in rheumatology in Austria. A survey was conducted among Austrian rheumatologists and physicians of other specialties with a focus on rheumatology. The questionnaire was designed by the members of the Austrian Radiology-Rheumatology Initiative for Musculoskeletal UltraSound including the following items: demographics, access to MSUS and MSUS training, application of MSUS to support diagnosis, monitoring and treatment decisions, and obstacles for the routine performance of MSUS. Eighty-eight (21.9 %) out of the 402 surveyed physicians responded. No access to MSUS and/or inadequate training in the technique was more commonly reported by senior (>50 years; 64.3 and 67.7 %, respectively) than by younger physicians (16.7 %, p = 0.01 and 18.5 %, p < 0.001, respectively). The lowest availability of sonography was found among senior rheumatologists (25.0 %, p = 0.001 compared to the total group). MSUS is routinely used for diagnosis and/or monitoring purposes by 12.5 % of physicians and 20.5 % perform sonography in clinically unclear cases. A limited number of physicians apply the method to support treatment decisions and/or to evaluate treatment success. The most important obstacles for routine application of MSUS in rheumatology are limited access to ultrasound machines, lack of training/education in the technique, and time constraints in daily routine. Low access to high-end ultrasound devices, lack of training, and time constraints may explain the low appreciation of MSUS among Austrian physicians evaluating patients with rheumatic diseases.