Over the last years, musculoskeletal ultrasound (MSUS) has been increasingly integrated by rheumatologists into clinical practice. Nowadays, it is considered an important imaging modality for the diagnosis, monitoring, and prognosis of various rheumatic diseases, along with its role in the guidance of interventional procedures. Formal training is needed to ensure a skilled and safe MSUS practice. Data regarding the use of MSUS by Portuguese rheumatologists is, however, lacking. Herein, we present a study on the current state of practice and training of MSUS in Portugal.publishersversionpublishe

Falcão, Sandra

Figueiredo, Guilherme

Neto, Agna

Saraiva, Fernando

English

Repositório da Universidade Nova de Lisboa

ÓRgÃO OFICIAL DA SOCIEDADE PORTUgUESA DE REUMATOLOgIA152LETTERS TO THE EDITOR1. Serviço de Reumatologia, Hospital Central do Funchal, Funchal,Madeira2. Serviço de Reumatologia, Hospital de Egas Moniz, CentroHospitalar de Lisboa Ocidental, Lisboa3. Centro de Estudos de Doenças Crónicas (CEDOC), NOVA MedicalSchool/Faculdade de Ciências Médicas, Universidade Nova deLisboa, Lisboa4. Serviço de Reumatologia, Hospital do Divino Espírito Santo,Ponta Delgada, Açores5. Serviço de Reumatologia e Doenças Ósseas Metabólicas,Hospital de Santa Maria, Centro Hospitalar Universitário de LisboaNorte, Centro Académico de Medicina de Lisboa, LisboaMusculoskeletal ultrasound among rheumatologists in Portugal: state of practice and trainingNeto A1,2,3, Figueiredo G4, Saraiva F5, Falcão S3,2Table I summarizes the main results obtained in thissurvey and in the previous one performed in 2015.Concerning the present survey, a total of 81 out of225 (36%) questionnaires were returned: 19 partiallyfilled and 62 fully completed. Most respondents (89%)worked in, at least, a public hospital. In 81% of cases,practitioners reported that the rheumatology depart-ment provides its own facilities for the practice of MSUSand, of these, only 18% are shared with other special-ties. Furthermore, 91% of practitioners reported thatrheumatology departments have their own MSUSequipment, which is shared among colleagues in 87%of cases. The available equipment is mostly from Ge -neral Electric (72%) and has multi-frequency lineartransducers (4-18 MHz), of which 6% operate only inlow frequency (4-8 MHz). They all comprise Dopplermode.Most practitioners consider important or very im-portant to have a practice support tool to enhance con-tinuous training and standardized activity registry. Infact, 43% of practitioners rated the development of anational registry platform for MSUS practice as impor-tant or very important, and 50% intend to use it in thefuture. Among respondents, 59% often or always use MSUSas a diagnostic tool, 66% as a technical support to the -rapeutic intervention and only 35% often or always useit for monitoring purposes. The most common indica-tions for diagnostic examinations were periarticular dis-orders, followed by undifferentiated arthritis andrheumatoid arthritis (RA). On the other hand, os-teoarthritis, vasculitis and polymyalgia rheumatica werethe diseases for which MSUS was less often performedaiming at diagnostic purpose. Overall, MSUS practi-tioners requested this imaging method more often thannon-practitioners.Regarding RA, 72% of 64 respondents consider thatMSUS is superior to clinical examination in the eva -luation of patients, and is particularly useful in patientsat risk or with suspected RA, or in the setting of thera-ACTA REUMATOL PORT. 2020;45:152-154Over the last years, musculoskeletal ultrasound (MSUS)has been increasingly integrated by rheumatologistsinto clinical practice. Nowadays, it is considered an im-portant imaging modality for the diagnosis, monitoring,and prognosis of various rheumatic diseases, along withits role in the guidance of interventional procedures1-5.Parallel to the widespread use of MSUS, there is a grow-ing need for education and formal training to ensure askilled and safe practice by rheumatologists. This is re-flected in the wide variety of available scientific papersaddressing the standardized use of MSUS6-8, and in thedistinct training programs that have been developed inmany European countries9. The ultrasound school ofthe Portuguese Society of Rheumatology (ESPER/SPR)was created in 2009 and, since then, has organized se -veral national multilevel courses in MSUS.Although MSUS is becoming a consolidated imagingtool in rheumatology care, there is a lack of data aboutits practice by Portuguese rheumatologists. Therefore,we performed a study to assess the current state ofpracti ce and training of MSUS in Portugal, as well as toidentify potential obstacles for its implementation. APortuguese-language questionnaire consisting of 54items was designed, for practitioners and non-practi-tioners of MSUS, and sent by e-mail to all members ofthe SPR. Data were collected through the portal Ad-Hoc Research AskIt®. A Field Research Manager wasresponsible for quality control, project monitoring andvalidation. The results were then compared with thosefound in another survey conducted in 201510.ÓRgÃO OFICIAL DA SOCIEDADE PORTUgUESA DE REUMATOLOgIA153neto a et alpeutic failure or dissociation of clinical and la boratoryfindings. Concerning spondylarthritis (SpA), 54% of63 respondents consider that MSUS has an added val-ue in the detection of enthesitis over clinical examina-tion. In SpA, the most useful indications for request-ing an MSUS examination are suspicious or risk of dis-ease, or therapeutic failure.Overall, 92% of 70 respondents classify the practi -ce of MSUS as important or very important in the clini -cal activity of a rheumatologist. Among 62 respon-dents, 81% assign the same degree of importance to afuture Competence Certification in MSUS. Additio -nally, 90% consider important or very important tocontinue performing MSUS more frequently. Inte -restingly, non-practitioners addressed it more thanpractitioners. According to the respondents’ experien -ce, the waiting time for an MSUS examination is 5.1 ±4.7 weeks. The main obstacles to more frequent use ofMSUS are the limited access to the equipment, follo -wed by the insufficient number of machines and lackTABLE I. ChArACTErIzATIon of rEspondEnTs, ThEIr MsUs TrAInIng And prACTICE, In ThE qUEsTIonnAIrEs of 2015 And 20192015 2019Number of questionnaires sent 202 225Number of questionnaires returned 63 81Number of questions 28 54Respondents’ characterizationFemale (%) 54 63Age, years (mean ± SD) 41.5±11.5 40.0±11.1Attending physician (%) 75 74Duration of clinical practice, years (mean ± SD) 12.2±10.1 13.0±9.3MSUS training (%) 70 71MSUS practitioners after residency (%) 48 74ᵃStart of MSUS training during residency (%) 62 93ᵇTraining modalities (%)Direct learning (e.g., during internships) 63 55Courses/Workshops 63 31Both - 14Locations of MSUS training In Portugal, in a rheumatology department 43 67In Portugal, in a radiology department 8 5In Portugal, in another place (e.g., ESPER/SPR courses) - 36In a foreign country, in a rheumatology department 37 33In a foreign country, in a radiology department 3 0In a foreign country, in another place (e.g., EULAR courses) - 45Practice of MSUS in public hospital (%) 44 88ᵇPractice of MSUS in private clinics/hospital (%) 24 45ᵇDuration of MSUS practice, years (mean ± SD) 4.4±5.1 7.1±5.6ᶜTime spent performing MSUS, hours per week (mean ± SD) 5.6±4.2 6.3±4.4ᶜNumber of MSUS performed (mean ± SD) 441.0±458.8/ year 53.3±56.8/ weekᶜProduction of MSUS reports (%) 51 86ᶜActivity registry (%) 57 89ᶜESPER: Ultrasound School of Portuguese Society of Rheumatology; EULAR: European League Against Rheumatism; MSUS: musculoskeletal ultrasound; SD: standard deviation; SPR: Portuguese Society of Rheumatology. ᵃAmong the 57 respondents who received MSUS training.ᵇAmong the 42 MSUS practitioners.ᵇData available on 36 respondents (out of 42 practitioners). ÓRgÃO OFICIAL DA SOCIEDADE PORTUgUESA DE REUMATOLOgIA154Musculoskeletal ultrasound aMong rheuMatologists in Portugal: state of Practice and trainingof time for the examination.Comparing the results obtained in the current sur-vey with those of 2015, there is a notable increase inthe number of rheumatologists performing MSUS(48% vs 74%), either in public hospitals (44% vs 88%)or private practice (24% vs 45%); and there is a risingpercentage of practitioners who received training inPortuguese rheumatology departments (43% vs 67%)or who started learning it during the residency (62%vs 93%). Moreover, compared to 2015, more practi-tioners are registering their activity (57% vs 89%) orproducing reports (51% vs 86%), which are hallmarksof a high standard of practice, emphasizing the im-provement of MSUS quality indicators. The exponen-tial development in this field is probably driven by thewide variety of educational offers by SPR and the in-clusion of MSUS in the rheumatology training cur-riculum. Nonetheless, further financial support andavailability of MSUS equipment, as well as the pro-motion of continuous high-quality MSUS educationshould be encouraged.Despite a good overall response rate, we recognizesome limitations on this study, such as the possibilityof sampling bias that may have led to an overestimateof the results, the missing data due to item nonres -ponse, and the comparison of two different question-naires, though they both contained similar items.Overall, this survey showed that there is a growinguse of MSUS by Portuguese rheumatologists, similar-ly to what has been reported in other countries. Struc-tured training and competency in MSUS are crucial toprovide high quality examinations and support clini-cal care. CorrEspondEnCE ToAgna NetoServiço de Reumatologia, Hospital de Egas Moniz Centro Hospitalar de Lisboa Ocidental, Lisboa E-mail: agnaneto@gmail.comrEfErEnCEs 1. Hassan S. Overview of musculoskeletal ultrasound for the cli-nical rheumatologist. Clin Exp Rheumatol. 2018;36 Suppl114:3-9.2. Colebatch AN, Edwards CJ, Østergaard M, van der Heijde D,Balint PV, D'Agostino MA et al. EULAR recommendations forthe use of imaging of the joints in the clinical management ofrheumatoid arthritis. Ann Rheum Dis. 2013;72:804-814.3. Mandl P, Navarro-Compán V, Terslev L, Aegerter P, van der Heij-de D, D'Agostino MA et al. EULAR recommendations for theuse of imaging in the diagnosis and management of spondy-loarthritis in clinical practice. Ann Rheum Dis. 2015;74:1327--1339.4.D'Agostino MA, Ayral X, Baron G, Ravaud P, Breban M, Douga-dos M. Impact of ultrasound imaging on local corticosteroid in-jections of symptomatic ankle, hind-, and mid-foot in chronicinflammatory diseases. Arthritis Rheum. 2005;53:284-292.5. Koski JM, Hammer HB. Ultrasound-guided procedures: tech-niques and usefulness in controlling inflammation and disea-se progression. Rheumatology (Oxford). 2012;51 Suppl7:vii31-5.6. Möller I, Janta I, Backhaus M, Ohrndorf S, Bong DA, Martino-li C et al. The 2017 EULAR standardised procedures for ultra-sound imaging in rheumatology. Ann Rheum Dis.2017;76:1974-1979.7. Bruyn GA, Iagnocco A, Naredo E, Balint PV, Gutierrez M, Ham-mer HB et al. OMERACT Definitions for Ultrasonographic Pat-hologies and Elementary Lesions of Rheumatic Disorders 15Years On. J Rheumatol. 2019;46:1388-1393.8. Terslev L, Iagnocco A, Bruyn GAW, Naredo E, Vojinovic J, Col-lado P et al. The OMERACT Ultrasound Group: A Report fromthe OMERACT 2016 Meeting and Perspectives. J Rheumatol.2017;44:1740-1743.9. Naredo E, D'Agostino MA, Conaghan PG, Backhaus M, BalintP, Bruyn GA et al. Current state of musculoskeletal ultrasoundtraining and implementation in Europe: results of a survey ofexperts and scientific societies. Rheumatology (Oxford).2010;49:2438-2443.10. Figueiredo G, Falcão S, Pereira JP. Questões em torno da eco-grafia musculoesquelética (EME) por reumatologistas em Por-tugal. Acta Reumatol Port. 2015:40:35-123 (sup).

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