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Diagnostic utility of musculoskeletal ultrasound in patients with suspected arthritis--a probabilistic approach.

Rezaei H, Torp-Pedersen S, af Klint E, Backheden M, Kisten Y, Györi N, van Vollenhoven RF - Arthritis Res. Ther. (2014)

Bottom Line: Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist.With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001).MSUS findings agreed with the final diagnosis in 95% of patients.

View Article: PubMed Central - PubMed

ABSTRACT

Introduction: This study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach.

Methods: One hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale.

Results: The rheumatologists' certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P <0.001). With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001). MSUS findings agreed with the final diagnosis in 95% of patients.

Conclusion: Musculoskeletal ultrasound, when added to routine rheumatologic investigation, greatly increases the diagnostic certainty in patients referred for the evaluation of inflammatory arthritis. The changes from pre-test to post-test probability quantify the diagnostic utility of musculoskeletal ultrasound in probabilistic terms.

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Related in: MedlinePlus

Proportion of patients on anti-rheumatic therapy, including DMARDs, corticosteroids and biologics in pre-test (A) and post-test (B) evaluation of likelihood for inflammatory arthritis. RA, rheumatoid arthritis.
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Fig5: Proportion of patients on anti-rheumatic therapy, including DMARDs, corticosteroids and biologics in pre-test (A) and post-test (B) evaluation of likelihood for inflammatory arthritis. RA, rheumatoid arthritis.

Mentions: With regard to the final rheumatologic diagnosis and accuracy of MSUS to establish the diagnosis inflammatory arthritis or not, based on positive and negative findings, Figure 4A demonstrates the impact of MSUS on both confirming and denying the presence of arthritis. In the vast majority (>95%) of patients, there was agreement between the MSUS findings and final diagnosis. A similar result was obtained when the accuracy of MSUS was investigated in terms of the number of patients on anti-rheumatic treatment at the end of the follow-up time, as shown in Figure 4B. The proportion of patients for whom diagnostic certainty was more than 80% and who were being treated with anti-rheumatic therapy (DMARDs, biologics and corticosteroids) was 23/103 (22.0%) before MSUS and 48/103 (46.6%) after MSUS (McNemar test P-value <0.001). As shown in Figure 5B, when the post-test likelihood for inflammatory arthritis was below 40% there was no prescription of anti-rheumatic treatment, which demonstrated the practical consequence of using MSUS. However when the pre-test diagnostic certainty was below 40%, the patients were very unlikely to be prescribed anti-rheumatic therapy (2 of 28 patients, as shown in Figure 5A). The data for anti-rheumatic treatment were also checked in the patients’ journals one year after inclusion of the last patient. The decision to treat patients with anti-rheumatic therapy, including DMARDs, biologics and corticosteroids, was made after knowing the ultrasound results.Figure 4


Diagnostic utility of musculoskeletal ultrasound in patients with suspected arthritis--a probabilistic approach.

Rezaei H, Torp-Pedersen S, af Klint E, Backheden M, Kisten Y, Györi N, van Vollenhoven RF - Arthritis Res. Ther. (2014)

Proportion of patients on anti-rheumatic therapy, including DMARDs, corticosteroids and biologics in pre-test (A) and post-test (B) evaluation of likelihood for inflammatory arthritis. RA, rheumatoid arthritis.
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4209056&req=5

Fig5: Proportion of patients on anti-rheumatic therapy, including DMARDs, corticosteroids and biologics in pre-test (A) and post-test (B) evaluation of likelihood for inflammatory arthritis. RA, rheumatoid arthritis.
Mentions: With regard to the final rheumatologic diagnosis and accuracy of MSUS to establish the diagnosis inflammatory arthritis or not, based on positive and negative findings, Figure 4A demonstrates the impact of MSUS on both confirming and denying the presence of arthritis. In the vast majority (>95%) of patients, there was agreement between the MSUS findings and final diagnosis. A similar result was obtained when the accuracy of MSUS was investigated in terms of the number of patients on anti-rheumatic treatment at the end of the follow-up time, as shown in Figure 4B. The proportion of patients for whom diagnostic certainty was more than 80% and who were being treated with anti-rheumatic therapy (DMARDs, biologics and corticosteroids) was 23/103 (22.0%) before MSUS and 48/103 (46.6%) after MSUS (McNemar test P-value <0.001). As shown in Figure 5B, when the post-test likelihood for inflammatory arthritis was below 40% there was no prescription of anti-rheumatic treatment, which demonstrated the practical consequence of using MSUS. However when the pre-test diagnostic certainty was below 40%, the patients were very unlikely to be prescribed anti-rheumatic therapy (2 of 28 patients, as shown in Figure 5A). The data for anti-rheumatic treatment were also checked in the patients’ journals one year after inclusion of the last patient. The decision to treat patients with anti-rheumatic therapy, including DMARDs, biologics and corticosteroids, was made after knowing the ultrasound results.Figure 4

Bottom Line: Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist.With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001).MSUS findings agreed with the final diagnosis in 95% of patients.

View Article: PubMed Central - PubMed

ABSTRACT

Introduction: This study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach.

Methods: One hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale.

Results: The rheumatologists' certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P <0.001). With regard to a diagnosis of RA, the proportions were 31.1% pre-test and 61.2% post-test (P <0.001). MSUS findings agreed with the final diagnosis in 95% of patients.

Conclusion: Musculoskeletal ultrasound, when added to routine rheumatologic investigation, greatly increases the diagnostic certainty in patients referred for the evaluation of inflammatory arthritis. The changes from pre-test to post-test probability quantify the diagnostic utility of musculoskeletal ultrasound in probabilistic terms.

Show MeSH
Related in: MedlinePlus