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Routine musculoskeletal ultrasound findings impact diagnostic decisions maximally in autoantibody-seronegative early arthritis patients

Lookup NU author(s): Kundan Iqbal, Dr Dennis Lendrem, Ben Hargreaves, Professor John Isaacs, Dr Ben Thompson, Dr Arthur Pratt

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This is the authors' accepted manuscript of an article that has been published in its final definitive form by Oxford University Press, 2019.

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Abstract

Objective: The diagnostic value added by musculoskeletal ultrasound (MSUS) over standard clinical and laboratory parameters has proved difficult to quantify. The additive contribution to diagnostic classification of a pragmatic, 15 min MSUS protocol was appraised in a large, unselected cohort of early arthritis clinic attendees.Methods: Detailed baseline characteristics were recorded. Semi-quantitative MSUS scoring of the most symptomatic wrist, second/third MCPs and PIPs and second/fifth MTPs was recorded, along with the sonographer's scan impression (definitely inflammatory, possibly inflammatory or non-inflammatory). MSUS findings were available to rheumatologist diagnosticians during subsequent consultations. Persistent inflammatory arthritis (PIA) was classified only where patients were started on ≥1 DMARD. Multivariate and receiver operating characteristic (ROC) curve analyses were used to identify independent discriminators of PIA, and the added value of MSUS parameters.Results: Eight hundred and thirty-one patients were enrolled, of whom 31.3% acquired a PIA diagnosis. Swollen joint count, CRP, age and ACPA status were non-redundant clinical/laboratory predictors of a PIA diagnosis by consulting rheumatologists, with good discriminatory utility (area under the ROC curve, AUROC, 0.88). While the additive contribution of summed parameters from the seven-joint MSUS protocol to this model was statistically significant (P = 0.004), it was numerically small (ΔAUROC 0.02). However, the additive contribution to diagnostic outcome of sonographer's scan impression over clinical parameters alone became substantial in the sub-cohort of ACPA-negative patients, increasing the AUROC by 9% from 0.81 to 0.90 (P < 0.0001).Conclusion: The clinical utility of a 15-min MSUS screen for diagnosing PIA requiring DMARDs is most evident among ACPA-negative patients attending an early arthritis clinic.


Publication metadata

Author(s): Iqbal K, Lendrem DW, Hargreaves B, Isaacs JD, Thompson B, Pratt AG

Publication type: Article

Publication status: Published

Journal: Rheumatology

Year: 2019

Volume: 58

Issue: 7

Pages: 1268–1273

Print publication date: 01/07/2019

Online publication date: 08/02/2019

Acceptance date: 21/12/2018

Date deposited: 03/03/2019

ISSN (print): 1462-0324

ISSN (electronic): 1462-0332

Publisher: Oxford University Press

URL: https://doi.org/10.1093/rheumatology/kez008

DOI: 10.1093/rheumatology/kez008


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