Current state of musculoskeletal ultrasound training and implementation in Europe: results of a survey of experts and scientific societies

Objective. To document the current state of musculoskeletal US (MSUS) training and extent of implementation among rheumatologists in the member countries of EULAR. Methods. An English-language questionnaire, divided into five sections (demographics, clinical use of MSUS, overall MSUS training for rheumatologists, MSUS education in the rheumatology training curriculum and education in MSUS offered by the national rheumatology society) was sent by e-mail to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology; and (iii) 19 senior rheumatologists involved in MSUS training from 14 European countries. Results. Thirty-one (70.5%) out of 44 countries responded to the questionnaire (59.1% of national rheumatology societies, 34.5% of the national US societies and 100% of expert ultrasonographers). Rheumatology was listed among medical specialities that mainly perform MSUS in 20 (64.5%) countries; however, in most [19 (63.3%)] countries <10% of rheumatologists routinely perform MSUS in clinical practice. Training varies widely from country to country, with low rates of competency assessment. MSUS education is part of the rheumatology training curriculum in over half the surveyed countries, being compulsory in 7 (22.6%) countries and optional in 11 (35.5%). Conclusions. This study confirms the high uptake of MSUS across Europe. The reported variation in training and practice between countries suggests a need for standardization in areas including training guideline

OMERACT Definitions for Ultrasonographic Pathology and Elementary Lesions Of Rheumatic Disorders Fifteen Years On

Objective. The Outcome Measures in Rheumatology (OMERACT) ultrasound (US) working group (WG) operates research activities for the validation of US as an outcome measurement instrument according to the Filter 2.0 framework Methods. From the onset of the WG research in 2005 through now, original publications on definitions and scoring systems for pathophysiological manifestations and elementary lesions of various rheumatic disorders were reviewed Results. Definitions and scoring systems according to new terminology are provided Conclusions. We have redefined OMERACT definitions of US pathology and elementary lesions as well as scoring systems which are now proposed for OMERACT approval for application in clinical trial

Ultrasonography of Inflammatory and Structural Lesions in Hand Osteoarthritis: An OMERACT Agreement and Reliability Study

Objective: To standardize and assess the reliability of ultrasonographic assessment of inflammatory and structural lesions in patients with hand osteoarthritis (OA). Methods: The Outcome Measures in Rheumatology (OMERACT) Ultrasound Working Group selected synovial hypertrophy (SH), joint effusion (JE), and power Doppler (PD) signals as the main inflammatory lesions in hand OA, and suggested osteophytes in the scapho-trapezio-trapezoid (STT) and cartilage defects in the proximal interphalangeal (PIP) joints as novel additions to previous structural scoring systems. A complementary imaging atlas provided detailed examples of the scores. A reliability exercise of static images was performed for the inflammatory features, followed by a patient-based exercise with six sonographers testing inflammatory and structural features in twelve hand OA patients. We used Cohen's kappa (\u3ba) for intra-reader and Light's \u3ba for inter-reader reliability for all features except PD, in which Prevalence-Adjusted Bias-Adjusted Kappa (PABAK) was applied. Percentage agreement was also assessed. Results: The web-based reliability exercise demonstrated substantial intra- and inter-reader reliability for all inflammatory features (\u3ba&gt;0.64). In the patient-based exercise, intra- and inter-reader reliability varied: SH \u3ba=0.73 and 0.45; JE \u3ba=0.70 and 0.55; PD PABAK=0.90 and 0.88; PIP cartilage \u3ba=0.56 and 0.45; STT osteophytes \u3ba=0.62 and 0.36. Percentage close agreement was high for all features (&gt;85%). Conclusion: With ultrasound, substantial to excellent intra-reader reliability was found for inflammatory features of hand OA. Inter-reader reliability was moderate, but overall high close agreement between readers suggest that better reliability is achievable after further training. Assessment of osteophytes in the STT joint and cartilage in the PIP joints achieved less good reliability and the latter is not endorsed. Keywords: Hand osteoarthritis; outcome measures; ultrasonography

Practice of ultrasound-guided arthrocentesis and joint injection, including training and implementation, in Europe: results of a survey of experts and scientific societies

Objectives. To document the practice and training opportunities of US-guided arthrocentesis and joint injection (UGAJ) among rheumatologists in the member countries of the European League Against Rheumatism (EULAR). Methods. An English-language questionnaire, containing questions on demographics, clinical and practical aspects of UGAJ, training options in UGAJ for rheumatologists, UGAJ education in the rheumatology training curriculum and other structured education programmes in UGAJ was sent to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB); and (iii) 22 senior rheumatologists involved in EULAR musculoskeletal US training from 14 European countries, who were also asked to circulate the questionnaire among relevant colleagues. Results. Thirty-three (75%) of 44 countries responded to the questionnaire (61.3% of national rheumatology societies, 25% of the national US societies and 100% of expert ultrasonographers). In the majority of countries (85%) 80%) rate of rheumatologists performing conventional joint injection in most of the surveyed countries. The reported variations in practice and the lack of available structured training programmes for trainees in most countries indicates the need for standardization in areas including training guideline

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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&apos;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 &gt; 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 &quot;gout subgroup of the OMERACT US Working Group&quot; 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, &gt; 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&apos;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&apos;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 Friendship Network Characteristics Influence Subjective Well-Being

This article explores how friendship network characteristics influence subjective well-being (SWB). Using data from the 2003 General Social Survey of Canada, three components of the friendship network are differentiated: number of friends, frequency of contact, and heterogeneity of friends. We argue that these characteristics shape SWB through the benefits they bring. Benefits considered are more social trust, less stress, better health, and more social support. Results confirm that higher frequency of contacts and higher number of friends, as well as lower heterogeneity of the friendship network are related to more social trust, less stress, and a better health. Frequency of contact and number of friends, as well as more heterogeneity of the friendship network increase the chance of receiving help from friends. With the exception of receiving help from friends, these benefits are in turn related to higher levels of SWB. Only the frequency of meeting friends face-to-face has a remaining positive direct influence on SWB

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Value of ultrasonography as a marker of early response to abatacept in patients with rheumatoid arthritis and an inadequate response to methotrexate: results from the APPRAISE study

Objectives: To study the responsiveness of a combined power Doppler and greyscale ultrasound (PDUS) score for assessing synovitis in biologic-naïve patients with rheumatoid arthritis (RA) starting abatacept plus methotrexate (MTX). Methods: In this open-label, multicentre, single-arm study, patients with RA (MTX inadequate responders) received intravenous abatacept (∼10 mg/kg) plus MTX for 24 weeks. A composite PDUS synovitis score, developed by the Outcome Measures in Rheumatology–European League Against Rheumatism (OMERACT–EULAR)-Ultrasound Task Force, was used to evaluate individual joints. The maximal score of each joint was added into a Global OMERACT–EULAR Synovitis Score (GLOESS) for bilateral metacarpophalangeal joints (MCPs) 2–5 (primary objective). The value of GLOESS containing other joint sets was explored, along with clinical efficacy. Results: Eighty-nine patients completed the 24-week treatment period. The earliest PDUS sign of improvement in synovitis was at week 1 (mean change in GLOESS (MCPs 2–5): −0.7 (95% CIs −1.2 to −0.1)), with continuous improvement to week 24. Early improvement was observed in the component scores (power Doppler signal at week 1, synovial hyperplasia at week 2, joint effusion at week 4). Comparable changes were observed for 22 paired joints and minimal joint subsets. Mean Disease Activity Score 28 (C reactive protein) was significantly reduced from weeks 1 to 24, reaching clinical meaningful improvement (change ≥1.2) at week 8. Conclusions: In this first international prospective study, the composite PDUS score is responsive to abatacept. GLOESS demonstrated the rapid onset of action of abatacept, regardless of the number of joints examined. Ultrasound is an objective tool to monitor patients with RA under treatment. Trial registration number: NCT00767325