Scottish rheumatology sonography course: five-year experience of delivering a mentorship-model rheumatology ultrasound training programme accredited by the consortium for the accreditation of sonographic education.

BACKGROUND AND AIMS: Ultrasound training for rheumatology practice in the UK is variable. Currently, there is no agreed minimum standard for training in ultrasound applied to rheumatology patient management. We present our experiences of implementing a competency driven ultrasound training, focused on hands and feet. METHODS AND RESULTS: The Rheumatology Sonography Course (RSC) was developed by the Scottish Rheumatology Ultrasound Group in collaboration with Glasgow Caledonian University. The RSC is delivered via a blended learning approach and includes training workshops, mentorship and clinical competency assessments. Mentors are supported and developed within their role. 31 trainees have enrolled on the course between 2014 and 2019. To date, 22 (71%) have completed. Change of job role was the main factor leading to non-completion. Thirteen mentors have supported the training and assessment of RSC trainees. All trainees reported positively that ultrasound training via the RSC model fulfilled their learning needs. CONCLUSION: The RSC is a feasible ultrasound training model for rheumatology practitioners. Whilst it provides a robust training framework, mentorship fees and university overheads increase the cost. The RSC provides motivation to mentors to train external trainees and supports the development of new ultrasound-based rheumatology services.

A randomized, double-blind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis.

OBJECTIVE: Most corticosteroid injections into the joint are guided by the clinical examination (CE), but up to 70% are inaccurately placed, which may contribute to an inadequate response. The aim of this study was to investigate whether ultrasound (US) guidance improves the accuracy and clinical outcome of joint injections as compared with CE guidance in patients with inflammatory arthritis. METHODS: A total of 184 patients with inflammatory arthritis and an inflamed joint (shoulder, elbow, wrist, knee, or ankle) were randomized to receive either US-guided or CE-guided corticosteroid injections. Visual analog scales (VAS) for assessment of function, pain, and stiffness of the target joint, a modified Health Assessment Questionnaire, and the EuroQol 5-domain questionnaire were obtained at baseline and at 2 weeks and 6 weeks postinjection. The erythrocyte sedimentation rate and C-reactive protein level were measured at baseline and 2 weeks. Contrast injected with the steroid was used to assess the accuracy of the joint injection. RESULTS: One-third of CE-guided injections were inaccurate. US-guided injections performed by a trainee rheumatologist were more accurate than the CE-guided injections performed by more senior rheumatologists (83% versus 66%; P = 0.010). There was no significant difference in clinical outcome between the group receiving US-guided injections and the group receiving CE-guided injections. Accurate injections led to greater improvement in joint function, as determined by VAS scores, at 6 weeks, as compared with inaccurate injections (30.6 mm versus 21.2 mm; P = 0.030). Clinicians who used US guidance reliably assessed the accuracy of joint injection (P < 0.001), whereas those who used CE guidance did not (P = 0.29). CONCLUSION: US guidance significantly improves the accuracy of joint injection, allowing a trainee to rapidly achieve higher accuracy than more experienced rheumatologists. US guidance did not improve the short-term outcome of joint injection.

Predicting persistent inflammatory arthritis amongst early arthritis clinic patients in the UK: is musculoskeletal ultrasound required?

INTRODUCTION: Analyses of large clinical datasets from early arthritis cohorts permit the development of algorithms that may be used for outcome prediction in individual patients. The value added by routine use of musculoskeletal ultrasound (MSUS) in an early arthritis setting, as a component of such predictive algorithms, remains to be determined. METHODS: The authors undertook a retrospective analysis of a large, true-to-life, observational inception cohort of early arthritis patients in Newcastle upon Tyne, UK, which included patients with inflammatory arthralgia but no clinically swollen joints. A pragmatic, 10-minute MSUS assessment protocol was developed, and applied to each of these patients at baseline. Logistic regression was used to develop two "risk metrics" that predicted the development of a persistent inflammatory arthritis (PIA), with or without the inclusion of MSUS parameters. RESULTS: A total of 379 enrolled patients were assigned definitive diagnoses after ≥12 months follow-up (median 28 months), of whom 162 (42%) developed a persistent inflammatory arthritis. A risk metric derived from 12 baseline clinical and serological parameters alone had an excellent discriminatory utility with respect to an outcome of PIA (area under receiver operator characteristic (ROC) curve 0.91; 95% CI 0.88 to 0.94). The discriminatory utility of a similar metric, which incorporated MSUS parameters, was not significantly superior (area under ROC curve 0.91; 95% CI 0.89 to 0.94). Neither did this approach identify an added value of MSUS over the use of routine clinical parameters in an algorithm for discriminating PIA patients whose outcome diagnosis was rheumatoid arthritis (RA). CONCLUSIONS: MSUS use as a routine component of assessment in an early arthritis clinic did not add substantial discriminatory value to a risk metric for predicting PIA.

Attitudes of United Kingdom rheumatologists to musculoskeletal ultrasound practice and training.

OBJECTIVES: This study was performed to describe what clinical rheumatologists currently use musculoskeletal ultrasound (MSUS) for, how they are currently training and is the first study to survey rheumatologists to determine their preferences for MSUS training implementation. METHODS: 250 questionnaires were distributed at the British Society of Rheumatology Annual General Meeting (BSR AGM), 2005. RESULTS: 126 (50%) of questionnaires were completed by UK rheumatologists and were analysed. 117 (93%) of the respondents use MSUS imaging for patient management, with 41 (33%) indicating they perform MSUS themselves. Only two (2%) performed MSUS for >5 years. Rheumatologists use MSUS to image all peripheral joints-particularly the hands and feet-to assess joint and soft tissue inflammation and to guide joint injections. Lack of training in MSUS was the principal reason for not performing MSUS. Respondents expressed a preference for future training to be via a programme of regular sessions, with training delivered by either consultant radiologists or rheumatologists. Mentoring was the educational tool and assessment method of choice. CONCLUSIONS: The majority of respondents use MSUS in the management of their patients, with a third performing MSUS themselves. The report indicates rheumatologists' preferences on how training should be delivered in the future.

Causes of death in patients with rheumatoid arthritis: comparison with siblings and matched osteoarthritis controls.

OBJECTIVE: Survival of patients with rheumatoid arthritis (RA) is reduced when compared to the general population. We assessed differences in causes and age of death between patients with RA and their siblings. Comparisons were also made with a control group of subjects with lower limb osteoarthritis (OA). METHODS: A population of 257 patients with RA studied in 1991 was compared to 371 of their same-sex siblings and 485 patients with hip and knee OA who were also attending the department at this time. Death certificates were obtained and compared. RESULTS: Among patients with RA, 54% (139/257) were deceased, compared to 28% (105/371) of the siblings and 32% (154/485) of OA patients (RA vs siblings or OA, p < 0.05). There were more deaths due to ischemic heart disease (IHD) in both the RA and OA groups compared to those expected; ratio observed/expected, 1.66 (95% CI 1.01, 2.79) and 1.96 (95% CI 1.21, 3.25), respectively, but not for siblings: observed/expected = 1.05 (95% CI 0.53, 2.08). There was a significant deficit in cancer related deaths in RA patients, observed/expected = 0.62 (95% CI 0.36, 1.03). CONCLUSION: Significantly more patients with RA had died than in either of the comparator populations. RA and OA patients died more frequently of IHD than the siblings. The RA population had a 40% reduced rate of cancer related deaths than expected and compared to their siblings.