Challenges to expanding the clinical application of musculoskeletal ultrasonography (MSUS) among rheumatologists: from a second survey in Japan

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.

Digital Medicine in Rheumatology: Challenges and Opportunities

The exponential growth in technology has had a significant effect on the practice of medicine and will likely transform the practice of medicine. In this article, the authors review select technologies that are already influencing the practice of rheumatology. Social media Websites such as Twitter are now important sources of information and discussion for health care professionals interested in rheumatology. Virtual reality is an innovative technology with great potential for acute and chronic pain management. The authors also review several low-cost technology alternatives to commonly used tools used in rheumatology.

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.

Consensus-based identification of factors related to false-positives in ultrasound scanning of synovitis and tenosynovitis

INTRODUCTION

We aimed to identify causes of false-positives in ultrasound scanning of synovial/tenosynovial/bursal inflammation and provide corresponding imaging examples.

METHODS

We first performed systematic literature review to identify previously reported causes of false-positives. We next determined causes of false-positives and corresponding example images for educational material through Delphi exercises and discussion by 15 experts who were an instructor and/or a lecturer in the 2013 advanced course for musculoskeletal ultrasound organized by Japan College of Rheumatology Committee for the Standardization of Musculoskeletal Ultrasonography.

RESULTS

Systematic literature review identified 11 articles relevant to sonographic false-positives of synovial/tenosynovial inflammation. Based on these studies, 21 candidate causes of false-positives were identified in the consensus meeting. Of these items, 11 achieved a predefined consensus (≥ 80%) in Delphi exercise and were classified as follows: (I) Gray-scale assessment [(A) non-specific synovial findings and (B) normal anatomical structures which can mimic synovial lesions due to either their low echogenicity or anisotropy]; (II) Doppler assessment [(A) Intra-articular normal vessels and (B) reverberation)]. Twenty-four corresponding examples with 49 still and 23 video images also achieved consensus.

CONCLUSIONS

Our study provides a set of representative images that can help sonographers to understand false-positives in ultrasound scanning of synovitis and tenosynovitis.

Predicting joint destruction in rheumatoid arthritis with power Doppler, anti-citrullinated peptide antibody, and joint swelling

OBJECTIVE

To determine combined evaluation of musculoskeletal ultrasonography (MSUS) and power Doppler (PD) signals, anti-citrullinated peptide antibody (ACPA), and other clinical findings improve the prediction of joint destruction in rheumatoid arthritis (RA).

METHODS

We performed a retrospective study of 331 RA patients (female n = 280 and male n = 51, mean age: 57.9 ± 13.2 years) who underwent MSUS from 2002 to 2012. Correlations with progression of joint destructions in 1,308 2nd and 3rd metacarpophalangeal (MCP) joints and various factors including PD signals of the same joints, clinical findings, age, disease duration at the study entry, gender, observation period, radiographic bone scores according to modified Sharp-van der Heijde methods, ACPA, and rheumatoid factor (RF) were analyzed in patient- and joint-based fashions, using univariate and multivariate logistic regression analyses and generalized linear mixed model.

RESULTS

Patients' characteristics were as follows: mean disease duration: 5.7 ± 7.5 years, observation period: 4.6 ± 2.6 years, RF positivity: 79.9%, and ACPA positivity: 77.5%. PD-positive 2nd and 3rd joints showed higher rate of joint destruction, especially in ACPA-positive patients. Moreover, PD-positive joints in ACPA-positive patients showed joint destruction even in joints without swelling. Multivariate analysis determined PD, swollen joint (SJ), observation period, basal radiographic bone scores, and ACPA as independent risks for joint destruction.

CONCLUSION

PD, SJ, basal radiographic bone scores, and ACPA are independent predictors for the joint destruction of 2nd and 3rd MCPs in RA; thus, considering these factors would be useful in daily practice.