Background The aim of the survey was to evaluate the impact of clinic-based musculoskeletal ultrasonography (MSUS) on diagnosis and management of cases seen in the Nuffield Orthopaedic Hospital emergency rheumatology clinic.
Objectives Primary: To assess the clinical utility of US in the emergency clinic:
assess disease severity
Secondary: Does US alter clinical management decisions?
Methods MSUS was performed on a selected population of cases, which included new patients with diagnostic uncertainty and challenging follow-up patients requiring assessment of disease activity/severity. The service was provided by a consultant rheumatologist trained and experienced in MSUS; the scans were performed during the emergency clinic appointment. Clinician evaluating patient requested MSUS for confirmation of diagnosis or in cases of diagnostic uncertainty. All scans were performed on a GE Logiq E9 using a linear transducer, recording grey-scale and power Doppler findings. Data from all patients who had undergone scans during October 2011- November 2012 was reviewed for demographics, suspected or existing diagnosis of inflammatory arthritis, clinical presentation, clinical findings and management outcome as a direct result of MSUS.
Results There were 62 patients studied (25 men, 38 women); their mean age was 57.17 years (range 30-88). A set joint scan was performed in all patients consisting of 10 MCP and PIP joints, radiocarpal joint and ulnar styloid.
The new patient group consisted of 34 patients; all had been referred for inflammatory arthritis. Of these, at ultrasound 17 (50%) had osteophytes, 16 (47%) had grey-scale synovitis, with 15 (44%) power Doppler. In one, (3%) no abnormality was detected. This resulted in change in final diagnosis in 22 (65%) new patients and a confirmed diagnosis of active inflammatory arthritis in 12 (35%) patients. Overall, management of new patients directly influenced by ultrasound scan resulted in the discharge of 50% of patients. Of the 17/34 new patients who had a confirmed diagnosis of inflammatory arthritis, 14 (82%) started combination disease modifying anti rheumatic agents at first visit.
There were 28 patients in the follow-up group who were referred for diagnostic uncertainty. Rheumatoid arthritis, psoriatic arthritis, connective tissue disease accounted for the majority, with 17 (61%), 5 (18%), 4 (14%) and 3 (11%) patients, respectively. The impact of MSUS on the follow-up group influenced change in treatment in 13/28 (47%) of patients. Specifically, all RA patients underwent scanning for disease assessment. In 15/17 (88%) patients, treatment escalation was directly influenced by MSUS findings; co-existing pathology was detected in 3/17 (18%) which included findings of gout and osteoarthritis. Ultrasound remission was identified in 5/17 (30%) with 2/17 (12%) were started on neuromodulators for pain management.
Conclusions This data shows the positive impact of MSUS in the rheumatology clinic, specifically highlighting multiple benefits in daily practice of reduced visits, discharge at first encounter, immediate management decisions. Our survey shows the importance of integrating MSUS service in a one-stop clinic.
Agrawal S, Bhagat S, Dasgupta B. Improvement in diagnosis and management of musculoskeletal conditions with one-stop clinic-based ultrasonography. Mod Rheumatol. 2009;19(1):53-6.
Disclosure of Interest None declared