Ultrasound imaging for the rheumatologist XXX. Sonographic assessment of the painful knee

The knee joint is a frequent focus of attention for rheumatologists when assessing patients presenting to a clinic and may represent underlying intra-articular inflammatory pathology or involvement of the surrounding soft tissues. This study describes the correlation between clinical and ultrasound findings in patients presenting with a variety of rheumatic disorders and knee pain. US imaging provides for a sensitive and detailed identification of different intra-and peri-articular pathology responsible for knee pain

Effectiveness of Golimumab as Second Anti-TNFα Drug in Patients with Rheumatoid Arthritis, Psoriatic Arthritis and Axial Spondyloarthritis in Italy: GO-BEYOND, a Prospective Real-World Observational Study

In this prospective observational study, data were collected from 34 rheumatology clinics in Italy in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA) and axial spondyloarthritis (axSpA) who started golimumab (GLM) as a second anti-TNFα drug. The primary objective was to evaluate the effectiveness of GLM after 6 months. Changes in quality of life using the EQ-5D-5L were also assessed. A total of 194 patients aged 53.2 ± 12 years started GLM as a second anti-TNF drug: 39 (20.1%) with RA, 91 (46.9%) with PsA and 64 (32.9%) with axSpA. After 6 months of GLM treatment, 68% of RA patients achieved low disease activity (LDA; DAS28-CRP ≤ 3.2), 31.9% of PsA patients achieved minimal disease activity and 32.5% of axSpA patients achieved LDA (ASDAS-CRP < 2.1). Good/moderate EULAR response was achieved in 61.9% and 73.8% of patients with RA and PsA, respectively, and 16% of axSpA patients achieved a 50% improvement in BASDAI. Across all indications, improvements in disease activity measures and EQ-5D-5L domains were observed over 6 months. The main reasons for GLM interruption were lack/loss of efficacy (7.2%) or adverse events (2%). This study confirms the effectiveness of GLM as a second-line anti-TNF for the treatment of RA, PsA and axSpA in a real-world setting in Italy

International consensus for ultrasound lesions in gout: Results of delphi process and web-reliability exercise

Objective. To produce consensus-based definitions of the US elementary lesions in gout and to test their reliability in a web-based exercise. Methods. The process consisted of two steps. In the first step a written Delphi questionnaire was developed from a systematic literature review and expert international consensus. This collated information resulted in four statements defining US elementary lesions: double contour (DC), tophus, aggregates and erosion. The Delphi questionnaire was sent to 35 rheumatology experts in US, asking them to rate their level of agreement or disagreement with each statement. The second step tested the reliability by a web-exercise. US images of both normal and gouty elementary lesions were collected by the participants. A facilitator then constructed an electronic database of 110 images. The database was sent to the participants, who evaluated the presence/absence of US elementary lesions. A group of 20 images was displayed twice to evaluate intra-reader reliability. Results. A total of 32 participants responded to the questionnaires. Good agreement (>80%) was obtained for US definitions on DC, tophus, aggregates and erosion in the Delphi exercise after three rounds. The reliability on images showed inter-reader κ values for DC, tophus, aggregates, erosion findings of 0.98, 0.71, 0.54 and 0.85, respectively. The mean intra-reader κ values were also acceptable: 0.93, 0.78, 0.65 and 0.78, respectively. Conclusion. This, the first consensus-based US definition of elementary lesions in gout, demonstrated good reliability overall. It constitutes an essential step in developing a core outcome measurement that permits a higher degree of homogeneity and comparability between multicentre studies

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ABSTRACT. Objective. To summarize the work performed by the Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group on the validation of US as a potential outcome measure in gout. Methods. Based on the lack of definitions, highlighted in a recent literature review on US as an outcome tool in gout, a series of iterative exercises were carried out to obtain consensus-based definitions on US elementary components in gout using a Delphi exercise and subsequently testing these definitions in static images and in patients with proven gout. Cohen's κ was used to test agreement, and values of 0-0.20 were considered poor, 0.20-0.40 fair, 0.40-0.60 moderate, 0.60-0.80 good, and 0.80-1 excellent. Results. With an agreement of > 80%, consensus-based definitions were obtained for the 4 elementary lesions highlighted in the literature review: tophi, aggregates, erosions, and double contour (DC). In static images interobserver reliability ranged from moderate to almost perfect, and similar results were found for the intrareader reliability. In patients the intraobserver agreement was good for all lesions except DC (moderate). The Outcome Measures in Rheumatology (OMERACT) US Working Group (Appendix 1) developed a gout subgroup with the purpose of validating US as an imaging tool for gout. If this objective is achieved, US may be implemented as an outcome measure in gout. Is Ultrasound a Validated Outcome Measure in Gout? In 2013, a systematic literature review was published evaluating US as an outcome tool in gout and asymptomatic hyperuricemia 10 . The report found 18 out of 67 articles published since 1975 to be eligible for review. Described in the literature were 4 main pathologies related solely to gout: tophi, double contour sign (DC), soft tissue abnormalities, and bony lesions. The review highlighted that US was able to detect tophi using magnetic resonance imaging (MRI) as a gold standard, and this measure was found sensitive to change. The DC is an articular cartilage abnormality related to the deposition of crystals on the surface of the hyaline cartilage, which seemed specific to gout, with excellent inter-reader reliability and sensitive to change (the latter only in a very small patient population). Soft tissue pathology such as intrasynovial hyperechogenicity may be indicative of gout. US was less sensitive than MRI for diagnosing erosions (bony lesions) but more sensitive than conventional radiography, as is also known from rheumatoid arthritis studies Criterion and construct validity were assessed only for tophi, and overall there was a lack of consensus on the definitions of the 4 elementary lesions and their validity according to the OMERACT filter 13 . Current Limitations of US in Gout Assessment Despite clear interest in this imaging technique for the management of gout, the literature review clearly pointed to a lack of clear US definitions for the main 4 elementary lesions identified: tophi, DC, soft tissue hyperechogenicity (punctuate crystal aggregates), and bony lesions (erosions). This lack of consensus-based definitions impairs the ability to validate US according to the OMERACT filter and hampers widespread use of US in therapeutic clinical trials, due to the difficulty to measure the same phenomenon. In order to implement US in the management of patients with established or suspected gout the "gout subgroup of the OMERACT US Working Group" initiated a validation process. The first step was to obtain consensus-based definitions for the US elementary lesion as indicated by the literature review. This was accomplished by performing a Delphi exercise 14 . Thirty-five rheumatologists performing US and with an interest in gout were invited to participate, and 32 responded positively. After 3 Delphi rounds, > 80% agreement was obtained for each definition Agreement was obtained to use the existing definitions for both synovitis and tenosynovitis 15 because these may be co-components in gout disease. Agreement could not be obtained to include synovitis (including Doppler activity) as an elementary lesion indicative of gout, because the presence of synovitis alone was not considered specific enough to define gout disease because it is a key component in other inflammatory arthropathies as well 14 . On the other hand, even if erosions may also be seen in other arthropathy conditions, since they may also be found extraarticularly in gout and may possibly have a slightly different appearance, it was decided to test, as part of the Delphi exercise, whether the existing definition worked also in gout. Perfect agreement was obtained to keep the definition close to the definition used for erosions in general. The second step was to test the reliability of the obtained definitions in a Web exercise consisting of static images of the elementary lesions. The Web exercise included 110 US images of the 4 lesions obtained from feet and knees and 20 of these images were shown twice in order to test both interand intrareader reliability. Twenty-seven of the 35 rheumatologists participating in the Delphi exercise participated in the reliability study. Cohen's κ was used to evaluate interand intrareader reliability. Κ values 0-0.20 were considered poor; 0.20-0.40 fair; 0.40-0.60 moderate; 0.60-0.80 good; and 0.80-1 excellent The third step was to test the agreement and reliability of the elementary lesions in a cohort of patients with gout. Sixteen of the rheumatologists previously involved in the first and second step participated in a workshop with 8 patients with crystal-proven gout. Both intra-and inter-reader reliability was assessed by scanning the patients twice within the same day. The areas of attention were the intercondylar region of the knee, the 1st metatarsophalangeal (MTP) joint, and the patellar tendon. Cohen's κ was used to evaluate inter-and intrareader reliability. Κ values of 0-0.20 were considered poor; 0.20-0.40 fair; 0.40-0.60 moderate; 0.60-0.80 good; and 0.80-1 excellen

How do patient-reported outcome measures affect treatment intensification and patient satisfaction in the management of psoriatic arthritis? A cross sectional study of 503 patients

Objectives The AsseSSing Impact in pSoriatic Treatment (ASSIST) study investigated prescribing in routine PsA care and whether the patient-reported outcome—PsA Impact of Disease questionnaire (PsAID-12)—impacted treatment. This study also assessed a range of patient and clinician factors and their relationship to PsAID-12 scoring and treatment modification. Methods Patients with PsA were selected across the UK and Europe between July 2021 and March 2022. Patients completed the PsAID questionnaire and the results were shared with their physician. Patient characteristics, disease activity, current treatment methods, treatment strategies, medication changes and patient satisfaction scores were recorded. Results A total of 503 patients were recruited. Some 36.2% had changes made to treatment, and 88.8% of these had treatment escalation. Overall, the mean PsAID-12 score was higher for patients with treatment escalation; increase in PSAID-12 score is associated with increased odds of treatment escalation (odds ratio 1.58; P < 0.0001). However, most clinicians reported that PsAID-12 did not impact their decision to escalate treatment, instead supporting treatment reduction decisions. Physician’s assessment of disease activity had the most statistically significant effect on likelihood of treatment escalation (odds ratio 2.68, per 1-point score increase). Escalation was more likely in patients not treated with biologic therapies. Additional factors associated with treatment escalation included: patient characteristics, physician characteristics, disease activity and disease impact. Conclusion This study highlights multiple factors impacting treatment decision-making for individuals with PsA. PsAID-12 scoring correlates with multiple measures of disease severity and odds of treatment escalation. However, most clinicians reported that the PsAID-12 did not influence treatment escalation decisions. Psoriatic Arthritis Impact of Disease (PsAID) scoring could be used to increase confidence in treatment de-escalation