Validation and incorporation of digital entheses into a preliminary GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis.

OBJECTIVES: The main objective was to generate a GLobal OMERACT Ultrasound DActylitis Score (GLOUDAS) in psoriatic arthritis and to test its reliability. To this end, we assessed the validity, feasibility and applicability of ultrasound assessment of finger entheses to incorporate them into the scoring system. METHODS: The study consisted of a stepwise process. First, in cadaveric specimens, we identified enthesis sites of the fingers by ultrasound and gross anatomy, and then verified presence of entheseal tissue in histological samples. We then selected the entheses to be incorporated into a dactylitis scoring system through a Delphi consensus process among international experts. Next, we established and defined the ultrasound components of dactylitis and their scoring systems using Delphi methodology. Finally, we tested the interobserver and intraobserver reliability of the consensus- based scoring systemin patients with psoriatic dactylitis. RESULTS: 32 entheses were identified in cadaveric fingers. The presence of entheseal tissues was confirmed in all cadaveric samples. Of these, following the consensus process, 12 entheses were selected for inclusion in GLOUDAS. Ultrasound components of GLOUDAS agreed on through the Delphi process were synovitis, tenosynovitis, enthesitis, subcutaneous tissue inflammation and periextensor tendon inflammation. The scoring system for each component was also agreed on. Interobserver reliability was fair to good (κ 0.39-0.71) and intraobserver reliability good to excellent (κ 0.80-0.88) for dactylitis components. Interobserver and intraobserver agreement for the total B-mode and Doppler mode scores (sum of the scores of the individual abnormalities) were excellent (interobserver intraclass correlation coefficient (ICC) 0.98 for B-mode and 0.99 for Doppler mode; intraobserver ICC 0.98 for both modes). CONCLUSIONS: We have produced a consensus-driven ultrasound dactylitis scoring system that has shown acceptable interobserver reliability and excellent intraobserver reliability. Through anatomical knowledge, small entheses of the fingers were identified and histologically validated.

Subclinical synovitis impact on the progression of lupus joint disease: A 10-year longitudinal multicenter study.

OBJECTIVE: To determine the effect of subclinical synovitis on the progression of joint disease in a cohort of patients with systemic lupus erythematosus over a mean follow-up of 10 years. METHODS: A longitudinal follow-up of 96 patients diagnosed with lupus was performed. All patients were considered clinically free of joint disease or with minimal joint impairment at baseline and were studied through ultrasound study of their dominant hand to assess the prevalence of subclinical synovitis. Now, over 10 years after we contacted them and reviewed their evolution to determine the impact of had or had not been diagnosed with subclinical synovitis in their current joint condition. RESULTS: Thirty-one of the 91 reached patients developed clinical progression in their joint manifestations (at least one ordinal degree of worsening). Of these, 23 (74,9%) had demonstrated subclinical synovitis at baseline. In the group of patients who did not progress clinically, 46 (76,6%) did not have this finding at the start of follow-up (p < .01, OR 9,44 95%CI 3,46-25,74). The patients in whom clinical progression was demonstrated had worse combined ultrasound scores than the rest of the patients: 6,41 SD 1,45 vs. 1,15 SD 0,97 (p < .01). CONCLUSIONS: The finding of subclinical synovitis in patients with systemic lupus erythematosus is associated with the development of joint disease progression both clinically and ultrasonographically.

Usefulness of ultrasound in clinical decision-making in rheumatology clinical practice: A single-center longitudinal study.

OBJECTIVE: The purpose of the present study is to identify the extent to which it affects clinical decisions in a single-centre observational retrospective study. METHOD: The results of 801 requests and 1174 consecutive individual ultrasound examinations performed over 10 months were analysed. RESULTS: The most frequent indication was diagnostic assistance (39%) followed by assessment of inflammatory activity (34%). By topography, the hand was the most frequently studied region (51%), followed by the foot (18.1%). Of all requests, 67% had an impact on decision-making. The impact on clinical decision-making was associated with a shorter waiting time for the evaluation of the results, being the greatest in those ultrasound scans performed on demand on the same day of the request. In 73% of bilateral ultrasound studies, findings in one of the joints exemplified the overall result reported. CONCLUSIONS: Rheumatological musculoskeletal ultrasound has proven to be a useful decision-making technique, the greater the impact of which is seen the shorter the waiting time before it is performed.

Ultrasound Changes in the Enthesis and Peri-enthesis Area of the Patellar and Achilles Tendons in Response to Physical Exercise: Comparison Between Healthy Subjects and Patients with Spondyloarthritis in Clinical Remission.

RATIONALE AND OBJECTIVES: The goal of achieving clinical remission in patients with spondyloarthritis does not necessarily include the resolution of entheseal inflammation from a histological perspective. However, enthesis not clinically inflamed, under mechanical stress, may behave differently from healthy subjects considering the physiopathology of SpA. Our goal was to determine whether ultrasound changes in entheses differ between SpA patients in clinical remission and healthy subjects. METHODS: SpA patients in clinical remission and matched healthy controls were recruited. At baseline, the following variables were measured on the dominant side by ultrasound: thickness of the distal patellar enthesis (hDP), the deep infrapatellar bursa (hDIB), the Achilles enthesis (hA), the preachilleal bursa (hPAB), effusion in the preachileal bursa (hePAB), and the presence of power Doppler signal in both enthesis. All measurements except hDP and hA were collected again after exercise (post-stress ultrasound). RESULTS: 30 patients and 30 controls were enrolled. In all subjects, hDIB, hPAB, and the preachileal bursa occupancy index increased significantly after the exercise. The increase was significantly greater in patients for all variables. At baseline, in patients, hyperemia was detected in one patellar tendon (3.3%) and in two Achilles tendons (6.7%). After exercise, the number of tendons with hyperemia increased to 11/30 (36.7%) and 12/30 (40%), respectively. Among controls, there was no detectable basal hyperemia, but after exercise, it was detected in 1/30 patellar tendons (3.3%) and 2/30 Achilles tendons (6.7%). CONCLUSION: Exercise triggers a greater effusive and hyperemic synovial response in patients in remission than in healthy controls. These findings suggest that the definition of remission should also include an assessment of the synovial response to mechanical stress.

Impact of ultrasound on the perception of health quality in adult patients with rheumatoid arthritis / Impacto de la ecografía en la percepción de la calidad en salud de pacientes adultos con artritis reumatoide

ABSTRACT Introduction: Ultrasound has shown its usefulness in multiple aspects in the management of inflammatory joint disease and in particular of rheumatoid arthritis (RA). The evidence using patient outcomes and its aspects related to quality of health care is scarce. The aim of this study is to determine the level of satisfaction in the perception of the quality of health care in a group of patients with RA who underwent ultrasound during the consultation, and whether it is higher than those who did not have the ultrasound. Methods: An observational, cross-sectional descriptive study was performed. Patients older than 18 years with a diagnosis of RA using the ACR/EULAR classification criteria were included. One group underwent skeletal muscle ultrasound to study RA during the out-patient medical consultation, as decided by the attending physician. After the completion of the medical action according to prior verbal acceptance by the patient, the Servqhos questionnaire and an ultrasound questionnaire were completed. A satisfied patient was defined as one who had 70% or more in the responses in the Servqhos questionnaire greater than or equal to 4, and a score of 5 in this questionnaire was defined as maximum satisfaction. There were no significant differences between the number of satisfied patients in the two groups. Univariate analysis was performed according to the distribution in the ultrasound or non-performing groups. Subsequently, a bivariate analysis of the different questions was carried out according to the distribution in the satisfaction and very high satisfaction groups. It was established if there was any degree of association using the Chi squared test for categorical variables, and the parametric tests (Mann Whitney U) or non-parametric tests (Kruskal-Wallis test) for the numerical variables were performed according to the distribution. Results: A total of 126 patients were obtained, of whom 62 corresponded to the group of patients who underwent ultrasound during the consultation and 62 to the control group in whom no ultrasound was performed. The majority were women (91%). Ultrasound was mostly performed to study joint disease (93%), with a third of the time to assess more than one aspect. In those on whom the ultrasound was performed, the number of satisfied patients was 56 (90%) and for the control group it was 48 (77%). The difference in the proportion of satisfied patients (13%) was statistically significant (P = .05). A difference was found between the groups in the number of patients with the highest level of satisfaction in the questions regarding presentation of staff and technology (P < .05). The vast majority of patients considered that ultrasound was useful during the consultation (93%), and that it generates greater confidence in the treatments and the doctor (93%). Conclusions: Performing skeletal muscle ultrasound during consultation in patients with RA improves satisfaction rates of health care, perception of the doctor, and treatments.

RESUMEN Introducción: La ecografía ha mostrado su utilidad en múltiples aspectos del manejo de la enfermedad articular inflamatoria, particularmente en la artritis reumatoide (AR). Su utilidad usando desenlaces derivados de pacientes y relacionados con aspectos de la calidad de la atención en salud es escasa. El objetivo del estudio es determinar si el grado de satisfacción de la calidad de la atención en un grupo de pacientes con AR, en quienes se realizó ecografía durante la consulta, es superior al de un grupo en los que esta no se llevó a cabo. Métodos: Se realizó un estudio observacional, descriptivo transversal. Se incluyeron pacientes mayores de 18 años con diagnóstico de AR por criterios clasificatorios ACR/EULAR que posteriormente a la finalización del acto médico respondieron las preguntas del cuestionario Servqhos. Quienes se sometieron a ecografía musculoesquelética para estudio de AR durante la consulta ambulatoria, según decisión del médico tratante, respondieron adicionalmente el cuestionario de ecografía. Se define paciente satisfecho como aquel que tiene un 70% o más en las respuestas del cuestionario Servqhos con un puntaje mayor o igual a 4, y se define como la máxima satisfacción al puntaje de 5 en una pregunta de dicho cuestionario. Se determinó si había diferencias significativas entre las proporciones de pacientes satisfechos en los dos grupos con y sin ecografía. Se realizó un análisis univariado según la distribución en los grupos, y posteriormente se hizo un análisis bivariado de las diferentes preguntas según la distribución en los grupos de satisfacción y muy alta satisfacción. Se estableció si había algún grado de asociación con las pruebas de chi-cuadrado para las variables categóricas, en tanto que para las variables numéricas se llevaron a cabo pruebas paramétricas (U de Mann Whitnney) y no paramétricas (test de Kruskal-Wallis), según la distribución. Resultados: Se obtuvo un total de 126 pacientes, de los cuales 62 corresponden al grupo de aquellos en quienes se realizó ecografía durante la consulta, mientras que otros 62 hacen parte del grupo control, en quienes no se realizó ecografía. La mayoría eran mujeres (91%). En quienes se hizo la ecografía, el número de pacientes satisfechos fue de 56 (90%), en tanto que para el grupo control fue de 48 (77%). La diferencia en la proporción de pacientes satisfechos entre los grupos fue del 13%, siendo estadísticamente significativa (p = 0,05). Se encontró diferencia entre los grupos en las preguntas referentes a presentación del personal y la tecnología de los equipos (p < 0,05). La gran mayoría de los pacientes consideró que la ecografía fue útil durante la consulta (93%) y que genera mayor seguridad en los tratamientos y en el criterio médico (93%). Conclusiones: La realización de ecografía musculoesquelética durante la consulta en pacientes con AR mejora los índices de satisfacción de atención en salud, así como la percepción del criterio médico y de los tratamientos.

Incidencia y factores de riesgo para adquirir diarrea aguda en una comunidad rural de la selva peruana / Incidence and risk factors for acute diarrhoea in a peruvian jungle rural community

Objetivo: Determinar la incidencia y factores de riesgo para adquirir diarrea aguda en una comunidad rural localizada en la selva del departamento de San Martín, Perú. Material y métodos: Una cohorte de 119 personas fue seleccionada al azar entre la población de 446 habitantes y seguida diariamente por un mes entre enero y febrero de 1999, buscando casos de diarrea aguda, definida como tres ó más cámaras de deposiciones al día por no más de 3 días. Un estudio caso control pareado fue diseñado para determinar los factores de riesgo para adquirir diarrea. Resultados: Fueron observados 18 casos de diarrea aguda; la incidencia fue de 15.1 casos por 100 personas-mes (IC 95 por ciento: 9.45-23.12). La edad media de los casos fue de 10.7 años (rango: 1-34 años) y 66 por ciento de los casos fueron niños menores de 10 años de edad. Los factores de riesgo para adquirir diarrea fueron: consumo de alimentos crudos, RR: 2.2 (IC 95 por ciento: 1.12-4.33), consumo de alimentos no lavados, RR: 4.47 (IC 95 por ciento: 1.56-12.82), falta de lavado de manos antes de alimentarse, RR: 9.61 (95 por ciento IC: 1.44-64.16), consumo de agua no hervida, RR: 4.52 (IC 95 por ciento: 1.23-16.65) y alimentación fuera de casa, RR: 2.2 (IC 95 por ciento: 1.51-3.20). La diferencia en el número promedio (DE) de personas que vivían por casa entre casos y controles fue de 4.38 (1.03) vs. 3.22 (0.54), p=0.0003, respectivamente. No hubo diferencia en el tiempo de residencia en la comunidad entre casos y controles, media de 5.61 ((5.04) años vs. 8.83 ((9.79), p=0.5747. Conclusiones: Diarrea aguda es un problema de salud pública en la selva de San Martín. Hacinamiento, carencia de saneamiento y pobres prácticas higiénicas son los responsables para adquirir diarrea aguda en esta comunidad de bajo nivel socioeconómico. Campañas educativas y mejora en las condiciones sanitarias son claramente necesarias para superar este problema.