Assessment of joint inflammation at the wrist of patients with rheumatoid arthritis: thermography findings closely mirror those from ultrasonography.

OBJECTIVES: To determine if thermography (in comparison with ultrasonography) may be helpful in detecting joint inflammation at the RA wrist categorised according to its clinical manifestations. METHODS: Four wrist groups were derived from the right wrist of RA subjects as follows: (1) swollen; tender (S1T1); (2) swollen; non-tender (S1T0); (3) non-swollen; tender (S0T1); (4) non-swollen; non-tender (S0T0). Thermographic parameters included the maximum (Tmax), average (Tavg) and minimum (Tmin) temperatures. Ultrasound parameters included the Total PD (TPD) and Total GS (TGS) scores. One-way ANOVA and Kruskal-Wallis test (for normally and non-normally distributed imaging parameters, respectively) and subsequent post-hoc tests were carried out for the comparative analysis of the wrist groups. RESULTS: A total of 70 wrist joints of 70 RA subjects were included in this cross-sectional study. For all imaging parameters (Tmax, Tavg, Tmin, TPD and TGS), statistically significant differences (all p<0.05) were detected (a) between the 4 wrist groups using either the one-way ANOVA or Kruskal-Wallis test and (b) for subsequent pairwise comparison of wrist group 1 (S1T1) vs. group 4 (S0T0) and group 2 (S1T0) vs. group 4 (S0T0). No significant differences (all p>0.05) were found for pairwise comparison of wrist group 3 (S0T1) vs. group 4 (S0T0) for all imaging parameters. CONCLUSIONS: Thermography at the wrist appears promising in RA with its findings closely mirroring those from ultrasonography. Swollen joints (regardless of tenderness status) have higher joint surface temperatures and greater ultrasound-detected joint inflammation, findings which were not observed for tender only (non-swollen) joints.

Appropriateness of lumbar spine radiography and factors influencing imaging ordering patterns: paving the path toward value-driven health care.

The demand for diagnostic imaging continues to rise. Against the backdrop of rising health care costs and finite resources, this has prompted a paradigm shift toward value-driven patient care. Inappropriate imaging is a barrier toward achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral Emergency Department (ED) and assess whether physicians' specialization and years of experience influence appropriateness. A total of 1030 lumbar spine radiographs performed in the ED of an academic medical center over a consecutive 3-month period were reviewed retrospectively. Referral indications were reviewed for adherence to 2021 American College of Radiology appropriateness guidelines for lower back pain, and referral patterns were evaluated among physician groups based on specialists' training and years in practice. 63.8% of lumbar spine radiographs were appropriate, with trauma being the most common indication. 36.2% of orders were inappropriate, with lower back pain of <6 weeks duration being the most common indication. Significant differences in inappropriate orders were found (P < .001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in training (27.8%), and non-specialists with ≥3 (60.0%) and <3 (36.9%) years in practice, respectively. Approximately one-third of lumbar spine radiographs performed in the ED were inappropriately ordered by American College of Radiology guidelines; specialists training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce health care costs.

Montreal cognitive assessment as a screening instrument for cognitive impairment in systemic lupus erythematosus patients without overt neuropsychiatric manifestations.

OBJECTIVES: The Montreal Cognitive Assessment (MoCA) is an increasingly used screening tool for cognitive impairment. The aim of this study was to examine how MoCA performed in identifying cognitive impairment (CI) domains in SLE patients compared with formal standardized neuropsychological testing (NPT). Factors related to SLE disease, immunologic and psychological state associated with CI were also explored. METHODS: This cross-sectional study recruited 50 SLE patients without overt neuropsychiatric manifestations from April 2017 to May 2018. The patients were evaluated with MoCA, formal NPT and the Depression, Anxiety, and Stress Scales (DASS) 42-item self-report questionnaire. Values of sensitivity and specificity were computed for different cut-offs of MoCA within each cognitive domain of NPT and descriptive analysis was used to identify the factors affecting cognitive function. RESULTS: The median score for MoCA was 27.5 (range 22-30). Using a MoCA cutoff of <26, 18 (36%) were identified to have CI using NPT compared to 8 (16%) using MoCA. The most frequently affected cognitive domain was executive functioning with 15 affected patients. Sensitivities and specificities of the MoCA range from 50% to 100% and 5.7% to 16.7%, respectively, across cognitive domains. A lower MoCA cutoff of <25 improve sensitivity of identifying impairment in executive functioning from 60% to 80%. In univariate analysis, DASS scores, disease activity, presence of antiphospholipid antibodies, presence of concurrent autoimmune disease, current, and cumulative corticosteroid therapy did not predict cognitive performance. CONCLUSION: MoCA may be a useful screening tool to identify the most frequently affected cognitive domain which is executive functioning using a lower cutoff of <25 in SLE patients without overt neuropsychiatric manifestations.