Ultrasound assessment of hands and feet for synovitis at time of first clinical visit markedly reduces time to diagnosis in routine care

OBJECTIVES

The role of musculoskeletal ultrasound (MSUS) in routine care for diagnosing arthritis is not fully elucidated, but US is more sensitive than clinical joint examination for detecting synovitis. Therefore, the use of US may facilitate diagnosis of arthritis. The aim of the study was to assess if MSUS examination of hands and feet in relation to the first clinical visit had an impact on the time to reach a final diagnosis and the number of clinical follow-up visits needed after first consultation.

METHODS

Two cohorts referred to the outpatient arthritis clinic with suspected arthritis were compared with each other, 1. MSUS (October 2017 to June 2018) of hands and feet performed prior to the first clinical visit and 2. MSUS (November 2016 to June 2017) was performed Ad hoc, for following aspects: time to clinical diagnosis, number of clinical visits needed, and number of ultrasound examinations.

RESULTS

In total, 163 and 109 patients were included in the MSUS and comparative cohorts, respectively. Adding MSUS to the first clinical visit reduced the time to diagnosis from mean 31(SD ± 32.2) days to 12(±17.3) days(p< 0.01). The number of clinical visits needed was reduced from mean 2.8(±1.1)-2.1(±1.3),(p< 0.01) corresponding to a reduction of 114 visits in the MSUS cohort. A final diagnosis with inflammatory arthritis was found in 76(47%) of patients in the MSUS cohort vs 29(27%) in the comparative cohort(p< 0.01).

CONCLUSION

In patients referred for suspected arthritis, routine MSUS in relation to the first clinical visit significantly reduces time to diagnosis and number of clinical visits needed to reach a final diagnosis.

Morphological characteristics of sacroiliac joint MRI lesions in axial spondyloarthritis and control subjects

OBJECTIVES

To investigate sacroiliac joint(SIJ) MRI inflammation, structural and degenerative lesion characteristics in patients with axial spondyloarthritis(axSpA) and various control groups.

METHODS

Patients with axSpA(n = 41) and lumbar disc herniation(n = 25), women with(n = 46) and without(n = 14) post-partum(childbirth within 4-16 months) buttock/pelvic pain, cleaning assistants(n = 26), long-distance runners(n = 23) and healthy men(n = 29) had MRI of the SIJs prospectively performed. MRI lesions were assessed on 9 slices covering the cartilaginous compartment by two experienced readers according to the definitions of the Spondyloarthritis Research Consortium of Canada(SPARCC) SIJ inflammation and structural scores, and were evaluated according to depth and extent. Other morphological characteristics were also analysed.

RESULTS

Total depth scores for bone marrow oedema(BME) and fat lesion(FAT) and total extent score for erosion were statistically significantly highest in axSpA, while scores for sclerosis were numerically highest in women with post-partum pain. Maximum BME depth > 10mm was frequently and exclusively found in axSpA and post-partum women(39% vs 14-17%) while FAT depth > 5mm was predominantly found in axSpA(76% vs 0-10%). Erosions were primarily seen in axSpA, especially when extensive(≥4 or confluent; 17% vs 0%). Capsulitis was absent in non-axSpA groups. BME and FAT in the ligamentous compartment were primarily found in axSpA(17/22% vs 0/2% in non-axSpA groups). In non-axSpA, osteophytes(axSpA vs non-axSpA: 0% vs 3-17%) and vacuum phenomenon(7% vs 30-66%) were more frequent, and the joint space was wider(mean(SD) 1.5(0.9)mm vs 2.2(0.5)mm).

CONCLUSIONS

FAT depth > 5mm, but not BME depth > 10mm, could almost differentiate axSpA patients from all other groups. When excluding post-partum women, BME >5mm and erosion were highly specific for axSpA.

The utility of magnetic resonance imaging lesion combinations in the sacroiliac joints for diagnosing patients with axial spondyloarthritis. A prospective study of 204 participants including post-partum women, patients with disc herniation, cleaning staff, runners and healthy persons

OBJECTIVES

To investigate the diagnostic utility of different combinations of SI joint MRI lesions for differentiating patients with axial SpA (axSpA) from other conditions with and without buttock/pelvic pain.

METHODS

A prospective cross-sectional study included patients with axSpA (n = 41), patients with lumbar disc herniation (n = 25), women with (n = 46) and without (n = 14) post-partum (birth within 4-16 months) buttock/pelvic pain and cleaning assistants (n = 26), long-distance runners (n = 23) and healthy men (n = 29) without pain. Two independent readers assessed SI joint MRI lesions according to the Spondyloarthritis Research Consortium of Canada MRI definitions and pre-defined MRI lesion combinations with bone marrow oedema (BME) and fat lesions (FAT), respectively. Statistical analyses included the proportion of participants with scores above certain thresholds, sensitivity, specificity, positive and negative predictive values and likelihood ratios.

RESULTS

BME adjacent to the joint space (BME@joint space) was most frequent in axSpA (63.4%), followed by women with post-partum pain (43.5%), but was present in nearly all groups. BME adjacent to fat lesions (BME@FAT) and BME adjacent to erosions (BME@erosion) were only present in axSpA patients and in women with post-partum pain, but scores ≥3 and ≥4, respectively, were only seen in axSpA patients. FAT@erosion was exclusively recorded in axSpA patients. FAT@joint space and FAT@sclerosis were present in most groups, but with higher scores in the axSpA group.

CONCLUSION

BME@joint space and FAT@joint space were frequent in axSpA but also in other conditions, reducing the diagnostic utility. FAT@erosion, and BME@FAT, BME@erosion and FAT@sclerosis above certain thresholds, were exclusively seen in axSpA patients and may thus have diagnostic utility in the differentiation of axSpA from other conditions.

Patient-Initiated Follow-Up (PIFU) as reorganized support for increased patient involvement - focus group discussions among patients' with inflammatory arthritis

Background

Inflammatory Arthritis is characterized by lifelong medical treatment and an unpredictable trajectory because of the fluctuating nature of the diseases. Proactive disease management is recommended, which includes close monitoring of disease activity that traditionally has been ensured by outpatient visits to rheumatologists at various fixed intervals. Internationally, there is a growing interest in how healthcare systems can be more flexible, individual-oriented and increasingly involve patients with lifelong diseases in their own treatment and care. We aimed to explore how patients with Inflammatory Arthritis with low disease activity or remission (DAS-CRP < 2.9) experience patient involvement in a reorganized follow-up care based on flexibility and patient-initiated contact.

Methods

We conducted a qualitative study based on four mixed group discussions focused on patients with inflammatory arthritis (rheumatoid arthritis [n = 21], axial spondyloarthritis [n = 3] and psoriatic arthritis [n = 1]) participating in a reorganized follow-up care. Changes in follow-up included access to a nurse and patient-initiated follow-up (PIFU). The analysis was based on content analysis. The reporting adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ).

Results

In total, 25 patients (20 females (80%), mean age 61.8 [range 28–79]) participated. We identified three categories. 1) Patient-Initiated Follow-Up do not affect patients’ perceived support in disease control; this refers to patients’ experience of more time available through better resource utilization, as well as trust that access to professional support would be available whenever needed. The category 2) Information is valued by patients to delineate responsibilities in a new patient role reflects patients’ uncertainty in the transition to PIFU, combined with confusion about the distribution of responsibilities. 3) Patients need both extended perspectives of their arthritis and focused dialogue is about expanding patients’ understanding of their arthritis by interaction over time with both a rheumatologist and a rheumatology nurse in a focused dialogue to involve the patient.

Conclusions

Patients participating in PIFU welcome the flexibility and involvement. However, patients need relevant information to act adequately within a new patient role. Interaction with both rheumatologists and nurses, combined with sufficient time for dialogue, broaden patients’ perspective, make opportunities for action visible, and contribute to patients’ ability to participate in follow-up care.

Protocol for evaluating and implementing a pragmatic value-based healthcare management model for patients with inflammatory arthritis: a Danish population-based regional cohort and qualitative implementation study

INTRODUCTION

The provision of healthcare for patients with inflammatory arthritis occurs in the context of somewhat conflicting targets, values and drivers. Therefore, there is a need for introducing 'value-based healthcare' defined as the value of patient relevant health outcomes in relation to costs. This term is a central part of tomorrow's healthcare sector, especially for rheumatic diseases, yet the transition is a huge challenge, as it will impact the development, delivery and assessment of healthcare.

AIMS

The aim of this study is to compare medical and patient evaluated impact of the traditional settlement and financing production (DAGS) controlled healthcare setting with a value-based and patient-centred adjunctive to standard care.

METHODS AND ANALYSIS

Patients with inflammatory arthritis receiving treatment in routine care at the outpatient clinics in the Capital Region of Denmark will prospectively and consecutively be enrolled in a Non-Intervention-Study framework providing a pragmatic value-based management model. A Danish reference cohort, used for comparison will be collected as part of routine clinical care. The enrolment period will be from 1 June 2018 until 31December 2023. Baseline and follow-up visits will be according to routine clinical care. Registry data will be obtained directly from patients and include personal, clinical and outcomes information. The study results will be reported in accordance with the STROBE statement.

ETHICS AND DISSEMINATION

The study has been notified to the Danish Data Protection Agency and granted authorisation for the period June 2018 to January 2025 (pending). Informed consent will be obtained from all patients before enrolment in the study. The study is approved by the ethics committee, Capital Region of Denmark (H-18013158). Results of the study will be disseminated through publication in international peer-reviewed journals.

Postural sway in normal subjects aged 20-70 years

So far, no population-based reference material of postural sway has been presented in the literature. This study evaluated postural control by measuring posturographic parameters, with the aim of establishing useful standards with regard to gender, age, body weight, cigarette smoking, alcohol consumption and articular hypermobility. This was performed in an age-stratified random sample of 195 subjects from the Copenhagen City Heart Study, of whom, 133 agreed to participate. Measurement of postural sway was performed the Balance Master Pro(R). Outcome parameters were average angular velocity, target sway area, per cent maximum stability and per cent ankle strategy. Using SAS Proc Mixed, backward stepwise elimination was performed and 95% prediction intervals were obtained. Sway increased with increasing difficulty of the test (P<0.001) and with increasing age (P<0.001). No differences were found between the sexes. Ankle-strategy did not change with age, but decreased with increasing body weight, and increased in subjects reporting a consumption of modest amounts of alcohol (P<0.001), or with the finding of increased hypermobility (P = 0.006). The present material may be used as a reference in further studies of postural control.

The twitch interpolation technique for the estimation of true quadriceps muscle strength

The aim of this study was to examine the reliability of the twitch interpolation technique when used to estimate the true isometric knee extensor muscle strength. This included an examination of whether submaximal activation causes any bias in the estimation of the true muscle strength and an examination of the precision of the method. Twenty healthy subjects completed three contraction series, in which the subjects were told to perform as if their voluntary strength was 60%, 80% or 100% of that determined by a maximal voluntary contraction (MVC). Electrical muscle stimulations were given at each of five different contraction levels in each series. At torque levels above 25% of MVC the relationship between torque and twitch size could be approximated to be linear. The true muscle strength (TMS) could therefore be estimated using linear regression of the twitch-torque relationship to the torque point of no twitch in each of the three series, termed TMS60, TMS80 and TMS100. The TMS80 was slightly lower (P < 0.01), median 94% (IQ range 87-101%) of the TMS100. The TMS60 was median 99% (IQ range 83-125%) (NS) of TMS100, but a few severe outliers were observed. In conclusion, we found the reliability of the method acceptable for many research purposes, if series with estimated central activation of below 40-50% were excluded. The only moderate precision and the slightly lower estimations in subjects applying submaximal does, however, limit its usefulness.

Muscle strength, working capacity and effort in patients with fibromyalgia

The objective of the study was to evaluate the physical capacity and effort in patients with fibromyalgia. Muscle strength and the coefficient of variation of the strength measurements of 181 female fibromyalgia patients and 126 healthy females were compared. These measurements and ergometer exercise capacity, work status and psychometric scoring (SCL-90-R) were correlated. The fibromyalgia patients exhibited significant reduction in voluntary muscle strength of the knee and elbow, flexors and extensors in the order of 20-30%. However, the coefficient of variation was higher among patients, thus indicating lower effort. The physical performance during an ergometer test corresponded to a maximal oxygen consumption of 21 ml/kg-1 x min-1. The maximal increase in heart rate was only 63% (44-90%) of the predicted increase. Degree of effort or physical capacity did not correlate to psychometric scores. Work status was related to psychometric scoring, but not to physical capacity or effort. In conclusion, we found a low degree of effort but near normal physical capacity in the fibromyalgia patients.