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      Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system

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          Abstract

          Objectives

          To test the reliability of new ultrasound (US) definitions and quantification of synovial hypertrophy (SH) and power Doppler (PD) signal, separately and in combination, in a range of joints in patients with rheumatoid arthritis (RA) using the European League Against Rheumatisms–Outcomes Measures in Rheumatology (EULAR-OMERACT) combined score for PD and SH.

          Methods

          A stepwise approach was used: (1) scoring static images of metacarpophalangeal (MCP) joints in a web-based exercise and subsequently when scanning patients; (2) scoring static images of wrist, proximal interphalangeal joints, knee and metatarsophalangeal joints in a web-based exercise and subsequently when scanning patients using different acquisitions (standardised vs usual practice). For reliability, kappa coefficients (κ) were used.

          Results

          Scoring MCP joints in static images showed substantial intraobserver variability but good to excellent interobserver reliability. In patients, intraobserver reliability was the same for the two acquisition methods. Interobserver reliability for SH (κ=0.87) and PD (κ=0.79) and the EULAR-OMERACT combined score (κ=0.86) were better when using a ‘standardised’ scan. For the other joints, the intraobserver reliability was excellent in static images for all scores (κ=0.8–0.97) and the interobserver reliability marginally lower. When using standardised scanning in patients, the intraobserver was good (κ=0.64 for SH and the EULAR-OMERACT combined score, 0.66 for PD) and the interobserver reliability was also good especially for PD (κ range=0.41–0.92).

          Conclusion

          The EULAR-OMERACT score demonstrated moderate-good reliability in MCP joints using a standardised scan and is equally applicable in non-MCP joints. This scoring system should underpin improved reliability and consequently the responsiveness of US in RA clinical trials.

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          Most cited references24

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          The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis.

          The revised criteria for the classification of rheumatoid arthritis (RA) were formulated from a computerized analysis of 262 contemporary, consecutively studied patients with RA and 262 control subjects with rheumatic diseases other than RA (non-RA). The new criteria are as follows: 1) morning stiffness in and around joints lasting at least 1 hour before maximal improvement; 2) soft tissue swelling (arthritis) of 3 or more joint areas observed by a physician; 3) swelling (arthritis) of the proximal interphalangeal, metacarpophalangeal, or wrist joints; 4) symmetric swelling (arthritis); 5) rheumatoid nodules; 6) the presence of rheumatoid factor; and 7) radiographic erosions and/or periarticular osteopenia in hand and/or wrist joints. Criteria 1 through 4 must have been present for at least 6 weeks. Rheumatoid arthritis is defined by the presence of 4 or more criteria, and no further qualifications (classic, definite, or probable) or list of exclusions are required. In addition, a "classification tree" schema is presented which performs equally as well as the traditional (4 of 7) format. The new criteria demonstrated 91-94% sensitivity and 89% specificity for RA when compared with non-RA rheumatic disease control subjects.
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            Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with grey scale and power Doppler ultrasonography.

            To compare the clinical assessment of overall inflammatory activity in patients with rheumatoid arthritis (RA) with grey scale and power Doppler (PD) ultrasonography (US). Ninety four consecutive patients with RA were included. Demographic and clinical data, C reactive protein (CRP) level, and erythrocyte sedimentation rate (ESR) were recorded for each patient. The presence of tenderness, swelling, and a subjective swelling score from 1 to 3 were independently assessed by two rheumatologists, who reached a consensus in 60 joints examined in each patient. All patients underwent a US examination by a third blinded rheumatologist, using PD. US joint effusion, synovitis, and PD signal were graded from 1 to 3 in the 60 joints. Joint count and joint index for effusion, synovitis, and PD signal were recorded. A 28 joint count for clinical and US variables was calculated. Interobserver reliability of the US examination was evaluated by a fourth blinded rheumatologist. US showed significantly more joints with effusion (mean 15.2) and synovitis (mean 14.6) than clinical examination (mean 11.5, p<0.05). A significant correlation was found between joint count and joint index for swelling, US effusion, synovitis, and PD signal. The 28 joint count for effusion, synovitis, and PD signal correlated highly with the corresponding 60 joint counts. US findings correlated better with CRP and ESR than clinical measures. Interobserver reliability was better for US findings than for clinical assessment. US is a sensitive method for assessing joint inflammatory activity in RA, complementary to clinical evaluation.
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              Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: a pilot project.

              To introduce a new standardized ultrasound score based on 7 joints of the clinically dominant hand and foot (German US7 score) implemented in daily rheumatologic practice. The ultrasound score included the following joints of the clinically dominant hand and foot: wrist, second and third metacarpophalangeal and proximal interphalangeal, and second and fifth metatarsophalangeal joints. Synovitis and synovial/tenosynovial vascularity were scored semiquantitatively (grade 0-3) by gray-scale (GS) and power Doppler (PD) ultrasound. Tenosynovitis and erosions were scored for presence. The scoring range was 0-27 for GS synovitis, 0-39 for PD synovitis, 0-7 for GS tenosynovitis, 0-21 for PD tenosynovitis, and 0-14 for erosions. Patients with arthritis were examined at baseline and after the start or change of disease-modifying antirheumatic drug (DMARD) and/or tumor necrosis factor alpha (TNFalpha) inhibitor therapy 3 and 6 months later. C-reactive protein level, erythrocyte sedimentation rate, rheumatoid factor, anti-cyclic citrullinated peptide, Disease Activity Score in 28 joints (DAS28), and radiographs of the hands and feet were performed. One hundred twenty patients (76% women) with rheumatoid arthritis (91%) and psoriatic arthritis (9%) were enrolled. In 52 cases (43%), erosions were seen in radiography at baseline. Patients received DMARDs (41%), DMARDs plus TNFalpha inhibitors (41%), or TNFalpha inhibitor monotherapy (18%). At baseline, the mean DAS28 was 5.0 and the synovitis scores were 8.1 in GS ultrasound and 3.3 in PD ultrasound. After 6 months of therapy, the DAS28 significantly decreased to 3.6 (Delta = 1.4), and the GS and PD ultrasound scores significantly decreased to 5.5 (-32%) and 2.0 (-39%), respectively. The German US7 score is a viable tool for examining patients with arthritis in daily rheumatologic practice because it significantly reflects therapeutic response.
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                Author and article information

                Journal
                RMD Open
                RMD Open
                rmdopen
                rmdopen
                RMD Open
                RMD Open (BMA House, Tavistock Square, London, WC1H 9JR )
                2056-5933
                2017
                11 July 2017
                : 3
                : 1
                : e000427
                Affiliations
                [1 ] departmentRheumatology department , Centre for Rheumatology and Spine Diseases, Rigshospitalet-Glostrup , Copenhagen, Denmark
                [2 ] departmentRheumatology and Joint and Bone Research Unit , Hospital Universitario Fundacion Jimenez Diaz , Madrid, Spain
                [3 ] departmentPublic Health Department , APHP, Hôpital Ambroise Paré, Boulogne-Billancourt; INSERM U1173, Versailles-Saint-Quentin University , Montigny le Bretonneaux, France
                [4 ] departmentLeeds Institute of Rheumatic and Musculoskeletal Medicine , University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit , Leeds, UK
                [5 ] departmentDepartment of Internal Medicine, Rheumatology and Clinical Immunology , Park-Klinik Weissensee , Berlin, Germany
                [6 ] National Institute of Rheumatology and Physiotherapy , Budapest, Hungary
                [7 ] departmentDepartment of Rheumatology , MC Groep Hospitals , Lelystad, the Netherlands
                [8 ] departmentRheumatology Unit , Università di Torino , Torino, Italy
                [9 ] departmentDepartment of Rheumatology , CHRU de Brest , Brest, France
                [10 ] departmentMedical Centre for Rheumatology , Immanuel Krankenhaus, Buch , Berlin, Germany
                [11 ] departmentDepartment of Rheumatology , Zealand's University Hospital at Kàge , Copenaghen, Denmark
                [12 ] departmentClinica Reumatologica , Università Politecnica delle Marche , Jesi, Ancona, Italy
                [13 ] departmentRheumatology Department , APHP, Ambroise Paré Hospital , Boulogne-Billancourt, France
                [14 ] departmentINSERM U1173, Laboratoire d’Excellence INFLAMEX , UFR Simone Veil, Versailles-Saint-Quentin University , Montigny le Bretonneaux, France
                Author notes
                [Correspondence to ] Professor Maria Antonietta D'Agostino, Rheumatology Department, Versailles Saint Quentin en Yvelines University, Ambroise Paré Hospital, APHP, 9 avenue Charles de Gaulle, 92100 Boulogne-Billancourt, France; maria-antonietta.dagostino@ 123456apr.aphp.fr
                Author information
                http://orcid.org/0000-0002-5347-0060
                Article
                rmdopen-2016-000427
                10.1136/rmdopen-2016-000427
                5597800
                28948984
                21d93fa6-47b6-4803-bd4a-0d29534a06c9
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 23 December 2016
                : 09 May 2017
                : 16 May 2017
                Funding
                Funded by: EULAR;
                Categories
                Imaging
                1506
                Original article
                Custom metadata
                unlocked

                ultrasound,doppler,scoring system,synovitis,omeract,eular
                ultrasound, doppler, scoring system, synovitis, omeract, eular

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