Recommendations for rheumatology ultrasound training and practice in the UK.

OBJECTIVE: The aim of this paper is to present a UK-based consensus of principles and recommendations to guide rheumatology US training and practice. METHOD: A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK. A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG) members made seven proposals that were presented to the whole group for further discussion. This resulted in minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consensus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination of the results and future development work. RESULTS: Using a validated process, experts in rheumatology US have worked through an iterative process and have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning, as well as a commitment to support mentors and trainers through the BSRUSSIG. CONCLUSION: These are the first specific education and practice recommendations for rheumatology US in the UK and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support and validate rheumatology US practice and inform the development of future rheumatology training curricula and education programmes.

Ultrasound findings in finger flexor tendons in systemic sclerosis: A cross-sectional pilot study.

Objective: Finger flexion contractures are an important cause of disability in patients with systemic sclerosis; however, their pathophysiology is poorly understood. Our aim was to assess the feasibility of scanning finger flexor tendons in patients with systemic sclerosis and explore the ultrasound findings in these tendons, including measurement of finger flexor tendon complex. Methods: Grey-scale and power Doppler ultrasound assessment of the finger flexor tendon complex including tendon structure and surrounding soft tissue. Measurements of the finger flexor tendon complex (A1 pulley, tendon and palmar plate) were made. Feasibility was assessed by the number of fingers which could be measured. Results: We studied the second to fifth flexor tendons (n = 160) of both hands in 20 patients with systemic sclerosis, including early and established disease. We were able to assess the finger flexor tendon complex and make measurements of the flexor tendon and palmar plate in all (n = 40) and A1 pulley in almost all (n = 39) of the studied fingers. Common pathologies identified included peritendinous (n = 12) and soft tissue (n = 8) calcification. Tendon thickening was seen in six patients, but synovitis/tenosynovitis was rare. The A1 pulley was thickened in patients with systemic sclerosis (0.46 mm), in particular, those with diffuse cutaneous systemic sclerosis (0.50 mm). Conclusion: We were able to successfully assess, including making measurements of, the finger flexor tendon complex in patients with systemic sclerosis. Our study showed calcifications in the peritendinous areas and soft tissue and thickening of the A1 pulley. These findings may play a role in the pathophysiology of systemic sclerosis-hand contractures by causing mechanical impingement of the finger flexion mechanism. This pilot study will guide future research to look for potential (treatable) causes of finger flexion contractures in patients with systemic sclerosis.

Tight control of disease activity fails to improve body composition or physical function in rheumatoid arthritis patients.

OBJECTIVE: RA typically features rheumatoid cachexia [loss of muscle mass (MM) and excessive total fat mass (TFM), especially trunk FM], which contributes to physical disability. Since rheumatoid cachexia is driven by inflammation, it would be anticipated that the success of tight control of disease activity, such as treat-to-target (T2T), in attenuating inflammation would benefit body composition and physical function. This aim of this cross-sectional study was to assess the impact of T2T on body composition and objectively assessed function in RA patients. METHODS: A total of 82 RA patients exclusively treated by T2T, were compared with 85 matched sedentary healthy controls (HCs). Body composition was estimated by DXA, with appendicular lean mass the surrogate measure of total MM. Physical function was assessed by knee extensor strength, handgrip strength, 30 s sit-to-stands, 8' up and go, and 50' walk (tests which reflect the ability to perform activities of daily living). RESULTS: Although generally well treated (mean DAS28 = 2.8, with 49% in remission), RA patients had ∼10% proportionally less appendicular lean mass and were considerably fatter (by ∼27%), particularly in the trunk (∼32%), than HCs. All measures of function were 24-34% poorer in the RA patients relative to HC. CONCLUSIONS: Despite marked improvements in disease control (most patients achieving or approaching remission), the relative loss of MM and increased adiposity in RA patients compared with matched HCs was similar to that observed pre-T2T. Additionally, performance of objective function tests was unchanged from that reported by our group for pre-T2T RA patients. Thus T2T, even in responsive RA patients, did not attenuate rheumatoid cachexia or improve objectively assessed function.

Can Creatine Supplementation Improve Body Composition and Objective Physical Function in Rheumatoid Arthritis Patients? A Randomized Controlled Trial.

OBJECTIVE: Rheumatoid cachexia (muscle wasting) in rheumatoid arthritis (RA) patients contributes to substantial reductions in strength and impaired physical function. The objective of this randomized controlled trial was to investigate the effectiveness of oral creatine (Cr) supplementation in increasing lean mass and improving strength and physical function in RA patients. METHODS: In a double-blind design, 40 RA patients were randomized to either 12 weeks' supplementation of Cr or placebo. Body composition (dual x-ray absorptiometry and bioelectrical impedance spectroscopy [BIS]), strength, and objectively assessed physical function were measured at baseline, day 6, week 12, and week 24. Data analysis was performed by analysis of covariance. RESULTS: Cr supplementation increased appendicular lean mass (ALM; a surrogate measure of muscle mass) by mean ± SE 0.52 ± 0.13 kg (P = 0.004 versus placebo), and total LM by 0.60 ± 0.37 kg (P = 0.158). The change in LM concurred with the gain in intracellular water (0.64 ± 0.22 liters; P = 0.035) measured by BIS. Despite increasing ALM, Cr supplementation, relative to placebo, failed to improve isometric knee extensor strength (P = 0.408), handgrip strength (P = 0.833), or objectively assessed physical function (P = 0.335-0.764). CONCLUSION: In patients with RA, Cr supplementation increased muscle mass, but not strength or objective physical function. No treatment-related adverse effects were reported, suggesting that Cr supplementation may offer a safe and acceptable adjunct treatment for attenuating muscle loss; this treatment may be beneficial for patients experiencing severe rheumatoid cachexia.

Magnetic resonance imaging and musculoskeletal ultrasonography detect and characterize covert inflammatory arthropathy in systemic sclerosis patients with arthralgia.

OBJECTIVES: Arthropathy, particularly synovial inflammation in SSc, is not well characterized. We explored the role of MRI and musculoskeletal ultrasonography (MSUS) in detecting and characterizing synovial inflammation in SSc patients with arthralgia while comparing the two imaging modalities. METHODS: Seventeen SSc patients with arthralgia and no overt inflammatory arthritis had a baseline MSUS of their hands. Six months later, 13 unselected patients had a second MSUS and 8 of these 13 patients also had MRI with gadolinium of their most symptomatic hand. RESULTS: Of the eight patients undergoing MRI scan, all (100%) patients had synovitis and 88% of patients had tenosynovitis. MRI also showed erosions in 75% of patients. On MSUS, on baseline and second scans, tenosynovitis was seen in 46% and 47% of the patients and synovitis in 6% and 23%, respectively. No erosions were identified. Applying the RAMRIS system (a semi-quantitative MRI scoring system used in RA), the mean values for synovitis, oedema and erosions fell within the range seen in RA. CONCLUSIONS: This study demonstrates the presence of a persistent inflammatory, erosive, peripheral arthropathy, similar to that seen in RA, in SSc patients with arthralgia without overt inflammatory joint disease. While both MRI and MSUS are useful in characterizing synovial inflammation in SSc, MRI is clearly more sensitive than MSUS in this setting. Further studies to establish the clinical and radiological musculoskeletal outcomes over time in this group of patients are required in order to identify the appropriate management of arthralgia in SSc.

Abatacept: the first T lymphocyte co-stimulation modulator, for the treatment of rheumatoid arthritis.

Rheumatoid arthritis (RA) is a multisystem autoimmune disease, of unknown aetiology with high morbidity and significantly increased mortality. Over recent years, the introduction of targeted therapies with biologic agents have made major inroads to the outcomes in RA. The first such agents developed were TNF-alpha inhibitors. However, despite their high efficacy, up to 30% patients fail to respond adequately, or develop adverse reaction to TNF-alpha inhibitors. This suggests that other pathological mechanisms are involved, in addition to those mediated by TNF-alpha. Abnormal T-cell function has long been thought to play a key role in the pathogenesis of RA, stimulating both the production of pro-inflammatory cytokines and recruitment of other inflammatory cells, resulting in joint destruction and systemic disease. Abatacept, the first of a group of T-cell co-stimulation modulators, targeting T-cell activation, has recently been licensed for use in RA and shows promise as a useful drug to treat this major disabling disease.