The role of PET/CT in connective tissue disorders: systemic sclerosis, Sjögren's syndrome and systemic lupus erythematosus.

Advanced imaging techniques are needed to help clinicians in the diagnosis, in the choice of the right time for therapeutic interventions or for modifications and monitoring of treatment response in patients with autoimmune connective tissue diseases. Nuclear medicine imaging, especially PET/CT and PET/MRI, may play an important role in detecting disease activity, assessing early treatment response as well as in clarifying the complex mechanisms underlying systemic sclerosis, Sjögren's syndrome or systemic lupus erythematosus. In addition, [18F]FDG PET/CT may help in excluding or detecting coexisting malignancies. Other more specific radiopharmaceuticals are being developed and investigated, targeting specific cells and molecules involved in connective tissue diseases. Further larger studies with standardized imaging protocol and image interpretation are strongly required before including PET/CT in the diagnostic work-up of subsets of patients with autoimmune connective tissue diseases.

Ultrasonography of Inflammatory and Structural Lesions in Hand Osteoarthritis: An Outcome Measures in Rheumatology Agreement and Reliability Study.

OBJECTIVE: To standardize and assess the reliability of ultrasonographic assessment of inflammatory and structural lesions in patients with hand osteoarthritis (OA). METHODS: The Outcome Measures in Rheumatology Ultrasound Working Group selected synovial hypertrophy (SH), joint effusion (JE), and power Doppler (PD) signals as the main inflammatory lesions in hand OA, and suggested osteophytes in the scapho-trapezio-trapezoid (STT) and cartilage defects in the proximal interphalangeal (PIP) joints as novel additions to previous structural scoring systems. A complementary imaging atlas provided detailed examples of the scores. A reliability exercise of static images was performed for the inflammatory features, followed by a patient-based exercise with 6 sonographers testing inflammatory and structural features in 12 hand OA patients. We used Cohen's kappa for intrareader and Light's kappa for interreader reliability for all features except PD, in which prevalence-adjusted bias-adjusted kappa (PABAK) was applied. Percentage agreement was also assessed. RESULTS: The web-based reliability exercise demonstrated substantial intra- and interreader reliability for all inflammatory features (κ > 0.64). In the patient-based exercise, intra- and interreader reliability, respectively, varied: SH κ = 0.73 and 0.45; JE κ = 0.70 and 0.55; PD PABAK = 0.90 and 0.88; PIP joint cartilage κ = 0.56 and 0.45; and STT osteophytes κ = 0.62 and 0.36. Percentage close agreement was high for all features (>85%). CONCLUSION: With ultrasound, substantial to excellent intrareader reliability was found for inflammatory features of hand OA. Interreader reliability was moderate, but overall high close agreement between readers suggests that better reliability is achievable after further training. Assessment of osteophytes in the STT joint and cartilage in the PIP joints achieved less reliability and the latter is not endorsed.

Current state of musculoskeletal ultrasound training and implementation in Europe: results of a survey of experts and scientific societies.

OBJECTIVE: To document the current state of musculoskeletal US (MSUS) training and extent of implementation among rheumatologists in the member countries of EULAR. METHODS: An English-language questionnaire, divided into five sections (demographics, clinical use of MSUS, overall MSUS training for rheumatologists, MSUS education in the rheumatology training curriculum and education in MSUS offered by the national rheumatology society) was sent by e-mail to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology; and (iii) 19 senior rheumatologists involved in MSUS training from 14 European countries. RESULTS: Thirty-one (70.5%) out of 44 countries responded to the questionnaire (59.1% of national rheumatology societies, 34.5% of the national US societies and 100% of expert ultrasonographers). Rheumatology was listed among medical specialties that mainly perform MSUS in 20 (64.5%) countries; however, in most [19 (63.3%)] countries<10% of rheumatologists routinely perform MSUS in clinical practice. Training varies widely from country to country, with low rates of competency assessment. MSUS education is part of the rheumatology training curriculum in over half the surveyed countries, being compulsory in 7 (22.6%) countries and optional in 11 (35.5%). CONCLUSIONS: This study confirms the high uptake of MSUS across Europe. The reported variation in training and practice between countries suggests a need for standardization in areas including training guidelines.

Self-directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States.

OBJECTIVE: Because musculoskeletal ultrasound (MSUS) is highly user dependent, we aimed to establish whether non-mentored learning of MSUS is sufficient to achieve the same level of diagnostic accuracy and scanning reliability as has been achieved by rheumatologists recognized as international experts in MSUS. METHODS: A group of 8 rheumatologists with more experience in MSUS and 8 rheumatologists with less experience in MSUS participated in an MSUS exercise to assess patients with musculoskeletal abnormalities commonly seen in a rheumatology practice. Patients' established diagnoses were obtained from chart review (gout, osteoarthritis, rotator cuff syndrome, rheumatoid arthritis, and seronegative arthritis). Two examining groups were formed, each composed of 4 less experienced and 4 more experienced examiners. Each group scanned 1 predefined body region (hand, wrist, elbow, shoulder, knee, or ankle) in each of 8 patients, blinded to medical history and physical examination. Structural abnormalities were noted with dichotomous answers, and an open-ended answer was used for the final diagnosis. RESULTS: Less experienced and more experienced examiners achieved the same diagnostic accuracy (US-established diagnosis versus chart review diagnosis). The interrater reliability for tissue pathology was slightly higher for more experienced versus less experienced examiners (kappa = 0.43 versus kappa = 0.34; P = 0.001). CONCLUSION: Non-mentored training in MSUS can lead to the achievement of diagnostic accuracy in MSUS comparable to that achieved by highly experienced international experts. Reliability may increase slightly with additional experience. Further study is needed to determine the minimal training requirement to achieve proficiency in MSUS.