Imaging

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

Ultrasound is just as accurate as magnetic resonance imaging in identifying osteophytes in patients with hand osteoarthritis.

Ultrasound found even more moderate-to-large osteophytes than MRI, and trumped both conventional radiographs and clinical examination in identifying the bony spurs, Dr. Alexander Mathiessen and his colleagues wrote in the April 20 online edition of Annals of the Rheumatic Diseases.

"This is most likely due to the multiplanar imaging capability of ultrasound and the fact that posterior-anterior radiographs are only able to detect osteophytes tangentially to the beam, and therefore, mainly on the lateral and medial side of the joints," wrote Dr. Mathiessen of Diakonhjemmet Hospital, Oslo, and his colleagues.

They prospectively examined 127 patients (mean age, 69 years), of whom 116 were women. All the patients had hand osteoarthritis, with a mean disease duration of 18 years.

The investigators compared the sensitivity and specificity of osteophyte detection by ultrasound, MRI, radiographs, and clinical exam.

Ultrasonography was performed and interpreted by an experienced clinician and a trainee. Still ultrasound images representative of the different joint groups were collected into a unique reference atlas, which was also validated during the study. Clinical exams were performed by a single experienced rheumatologist. Almost 4,000 joints were imaged and clinically examined.

Ultrasound identified osteophytes in 53% of 3,771 joints examined.

In all, 851 patients had both MRI and ultrasound on 851 joints; ultrasound detected osteophytes in 75% and MRI in 87%.

A total of 117 patients had ultrasound, radiography, and clinical exam. Ultrasound detected osteophytes in 53% of the joints and radiography in 30% of them. Clinical exams revealed joint enlargement in 37%.

Ultrasound detected a median of 16 osteophytes/bony enlargements per patient – significantly more than the number detected by radiography (8) or clinical exam (11) (Ann. Rheum Dis. 2012 April 20 [doi: 10.1136/annrheumdis-2011-201195]).

Using MRI as the reference, the investigators found that ultrasound displayed a sensitivity of 83% and a specificity of 75%. The method actually identified more severe pathology than did MRI, finding 401 instances compared with 288.

"Ultrasound detected osteophytes in all joints in which MRI had scored 2-3 [on the Oslo Hand Osteoarthritis MRI scale], except for two joints in which the osteophytes were found by MRI in the lateral part of the joints," the authors noted. "Among 129 joints in which osteophytes were detected by MRI but not ultrasounds, 127 of the joints were scored as grade 1 on MRI. ... Conversely, [radiography] detected osteophytes in 41 joints without identified ultrasound pathology, and 37 of these joints had scored 1 by [radiography]."

The atlas of representative ultrasound images displayed "excellent intra- and inter-reader reliability for both readers and scoring sessions," with a greater than 88% rate of close reader agreement and a 100% rate of exact agreement."

Ultrasounds were performed only on the hands’ dorsal surfaces, which might have underestimated the total number of osteophytes identified. But because MRI demonstrated that most osteophytes occurred on the dorsal surface, "the current finding of high concordance between MRI and ultrasound suggests that it may be sufficient to perform ultrasound only on the dorsal sides of the finger joints," the authors said.

The study was sponsored by Abbott. The authors had no financial disclosures.

POINT: All rheumatologists should offer it to their patients.

Like other point-of-care tests used all the time in medicine – spirometry, blood pressure measurement, the finger-stick glucose test – point-of-care ultrasound is invaluable in the diagnosis and management of rheumatologic conditions.

Ultrasound has a number of merits: It is portable and inexpensive; can be used on multiple joints; allows imaging of both bones and soft tissue, and assessment of vascularity; permits contralateral-side comparison; facilitates accurate injections; and serves as an informational and educational tool for patients. Contemporary machines have resolution down to 0.1 mm, much greater than the 1-2 mm for magnetic resonance imaging.

Photo: Susan London/IMNG Medical Media

A recent poll of Canadian rheumatologists about musculoskeletal ultrasound yielded some eye-opening findings. For example, 83% reported having to wait more than 2 weeks to obtain this exam if they referred patients to a radiology service, and just 56% reported that their radiology service offered assessment for inflammatory arthritis (Clin. Rheumatol. 2011;30:1277-83).

We know that information provided by ultrasound changes behavior in rheumatology: It leads to a change in diagnosis in 53% of patients and a change in management in 56% (Arthritis Rheum. 2001;44:2932-3). Ultrasound also improves diagnostic confidence in clinical findings (Skeletal Radiol. 2009;38:1049-54). Diagnostic certainty is key, as musculoskeletal symptoms are some of the most imprecise, and although we now have powerful medications for rheumatologic diseases, they don’t come cheap. Yet we are basing treatment decisions on clinical assessment alone. In an era of budget constraints, we owe it to patients and payers to make an accurate diagnosis and assessment: This is really all about providing an adequate standard of diagnosis and care.

In addition to aiding diagnosis, ultrasound helps in other ways, such as determining the risk of erosions (Arthritis Res. Ther. 2003;5:210-3) and predicting response to treatment (Arthritis Care Res. 2011;63:1477-81). It is more sensitive than clinical measures for assessing disease remission (Arthritis Rheum. 2008;58:2958-67). As patients have to live decades with their joints, and their quality of life is on the line, it is our responsibility to confirm clinically apparent remission with ultrasound.

An ultrasound exam can be done in the office in as few as 5 minutes; often, evaluation of just a single joint will suffice. The time spent more than makes up for the time that would be needed to coordinate a referral to radiology and to follow up on that referral. And there are plenty of examples on how to successfully integrate ultrasound into your office workflow.

In summary, ultrasound should be used as an extension of our clinical examination. It allows for immediate imaging correlation, and it assists with decision making in an environment where radiology services have limitations. It is also phenomenally powerful when it comes to patient contact and education. True point-of-care ultrasound is fast, high quality, and cost efficient. If you show this information to patients, their families, taxpayers, and politicians, they will agree: There is no question that point-of-care ultrasound is the way to go.

Dr. Maggie Larché is a rheumatologist at St. Joseph’s Hospital and McMaster University Hospital, both in Hamilton, Ont. She is also vice president and treasurer of the Canadian Rheumatology Ultrasound Society. Dr. JohannesRoth is head of pediatric rheumatology at Children’s Hospital of Eastern Ontario, Ottawa, and is president of the Canadian Rheumatology Ultrasound Society. Dr. Larché disclosed no relevant conflicts of interest. Dr. Roth disclosed no relevant conflicts of interest.

COUNTERPOINT: Its use at present is best left to experts.

Ultrasound is an amazing tool, and we are not disputing its merits. Thus, the question is not so much whether it should be used in the rheumatologist’s office, but whether you should use it in your office.

Europe is often cited as a hotbed of ultrasound use in rheumatology to be emulated. But in fact, in only 10% of European countries do the majority of rheumatologists use ultrasound, and in no country do the majority of rheumatologists perform ultrasound-guided arthrocentesis (Rheumatol. 2012;51:184-90).

We don’t know if it is feasible to use ultrasound findings as outcome measures in routine clinical care. A recent systematic review noted the difficulty of determining the minimum number of joints to be included in a global ultrasound score and recommended further validation (J. Rheumatol. 2011;38:2055-62). The time needed to perform the exam ranged from 15 to 60 minutes.

Indeed, time and resource constraints are rightly cited as major barriers to wider use of ultrasound in the rheumatology office. Exam time is not the only consideration: The time to acquire ultrasound skills and then to maintain and improve them is also considerable. There is unquestionably a learning curve; it takes about 4-6 months to become good at this. Then you have to continually upgrade your skills.

Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).

Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).

Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.

In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.

Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.

POINT: All rheumatologists should offer it to their patients.

Like other point-of-care tests used all the time in medicine – spirometry, blood pressure measurement, the finger-stick glucose test – point-of-care ultrasound is invaluable in the diagnosis and management of rheumatologic conditions.

Ultrasound has a number of merits: It is portable and inexpensive; can be used on multiple joints; allows imaging of both bones and soft tissue, and assessment of vascularity; permits contralateral-side comparison; facilitates accurate injections; and serves as an informational and educational tool for patients. Contemporary machines have resolution down to 0.1 mm, much greater than the 1-2 mm for magnetic resonance imaging.

Photo: Susan London/IMNG Medical Media

A recent poll of Canadian rheumatologists about musculoskeletal ultrasound yielded some eye-opening findings. For example, 83% reported having to wait more than 2 weeks to obtain this exam if they referred patients to a radiology service, and just 56% reported that their radiology service offered assessment for inflammatory arthritis (Clin. Rheumatol. 2011;30:1277-83).

We know that information provided by ultrasound changes behavior in rheumatology: It leads to a change in diagnosis in 53% of patients and a change in management in 56% (Arthritis Rheum. 2001;44:2932-3). Ultrasound also improves diagnostic confidence in clinical findings (Skeletal Radiol. 2009;38:1049-54). Diagnostic certainty is key, as musculoskeletal symptoms are some of the most imprecise, and although we now have powerful medications for rheumatologic diseases, they don’t come cheap. Yet we are basing treatment decisions on clinical assessment alone. In an era of budget constraints, we owe it to patients and payers to make an accurate diagnosis and assessment: This is really all about providing an adequate standard of diagnosis and care.

In addition to aiding diagnosis, ultrasound helps in other ways, such as determining the risk of erosions (Arthritis Res. Ther. 2003;5:210-3) and predicting response to treatment (Arthritis Care Res. 2011;63:1477-81). It is more sensitive than clinical measures for assessing disease remission (Arthritis Rheum. 2008;58:2958-67). As patients have to live decades with their joints, and their quality of life is on the line, it is our responsibility to confirm clinically apparent remission with ultrasound.

An ultrasound exam can be done in the office in as few as 5 minutes; often, evaluation of just a single joint will suffice. The time spent more than makes up for the time that would be needed to coordinate a referral to radiology and to follow up on that referral. And there are plenty of examples on how to successfully integrate ultrasound into your office workflow.

In summary, ultrasound should be used as an extension of our clinical examination. It allows for immediate imaging correlation, and it assists with decision making in an environment where radiology services have limitations. It is also phenomenally powerful when it comes to patient contact and education. True point-of-care ultrasound is fast, high quality, and cost efficient. If you show this information to patients, their families, taxpayers, and politicians, they will agree: There is no question that point-of-care ultrasound is the way to go.

Dr. Maggie Larché is a rheumatologist at St. Joseph’s Hospital and McMaster University Hospital, both in Hamilton, Ont. She is also vice president and treasurer of the Canadian Rheumatology Ultrasound Society. Dr. JohannesRoth is head of pediatric rheumatology at Children’s Hospital of Eastern Ontario, Ottawa, and is president of the Canadian Rheumatology Ultrasound Society. Dr. Larché disclosed no relevant conflicts of interest. Dr. Roth disclosed no relevant conflicts of interest.

COUNTERPOINT: Its use at present is best left to experts.

Ultrasound is an amazing tool, and we are not disputing its merits. Thus, the question is not so much whether it should be used in the rheumatologist’s office, but whether you should use it in your office.

Europe is often cited as a hotbed of ultrasound use in rheumatology to be emulated. But in fact, in only 10% of European countries do the majority of rheumatologists use ultrasound, and in no country do the majority of rheumatologists perform ultrasound-guided arthrocentesis (Rheumatol. 2012;51:184-90).

We don’t know if it is feasible to use ultrasound findings as outcome measures in routine clinical care. A recent systematic review noted the difficulty of determining the minimum number of joints to be included in a global ultrasound score and recommended further validation (J. Rheumatol. 2011;38:2055-62). The time needed to perform the exam ranged from 15 to 60 minutes.

Indeed, time and resource constraints are rightly cited as major barriers to wider use of ultrasound in the rheumatology office. Exam time is not the only consideration: The time to acquire ultrasound skills and then to maintain and improve them is also considerable. There is unquestionably a learning curve; it takes about 4-6 months to become good at this. Then you have to continually upgrade your skills.

Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).

Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).

Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.

In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.

Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.

POINT: All rheumatologists should offer it to their patients.

Like other point-of-care tests used all the time in medicine – spirometry, blood pressure measurement, the finger-stick glucose test – point-of-care ultrasound is invaluable in the diagnosis and management of rheumatologic conditions.

Ultrasound has a number of merits: It is portable and inexpensive; can be used on multiple joints; allows imaging of both bones and soft tissue, and assessment of vascularity; permits contralateral-side comparison; facilitates accurate injections; and serves as an informational and educational tool for patients. Contemporary machines have resolution down to 0.1 mm, much greater than the 1-2 mm for magnetic resonance imaging.

Photo: Susan London/IMNG Medical Media

A recent poll of Canadian rheumatologists about musculoskeletal ultrasound yielded some eye-opening findings. For example, 83% reported having to wait more than 2 weeks to obtain this exam if they referred patients to a radiology service, and just 56% reported that their radiology service offered assessment for inflammatory arthritis (Clin. Rheumatol. 2011;30:1277-83).

We know that information provided by ultrasound changes behavior in rheumatology: It leads to a change in diagnosis in 53% of patients and a change in management in 56% (Arthritis Rheum. 2001;44:2932-3). Ultrasound also improves diagnostic confidence in clinical findings (Skeletal Radiol. 2009;38:1049-54). Diagnostic certainty is key, as musculoskeletal symptoms are some of the most imprecise, and although we now have powerful medications for rheumatologic diseases, they don’t come cheap. Yet we are basing treatment decisions on clinical assessment alone. In an era of budget constraints, we owe it to patients and payers to make an accurate diagnosis and assessment: This is really all about providing an adequate standard of diagnosis and care.

In addition to aiding diagnosis, ultrasound helps in other ways, such as determining the risk of erosions (Arthritis Res. Ther. 2003;5:210-3) and predicting response to treatment (Arthritis Care Res. 2011;63:1477-81). It is more sensitive than clinical measures for assessing disease remission (Arthritis Rheum. 2008;58:2958-67). As patients have to live decades with their joints, and their quality of life is on the line, it is our responsibility to confirm clinically apparent remission with ultrasound.

An ultrasound exam can be done in the office in as few as 5 minutes; often, evaluation of just a single joint will suffice. The time spent more than makes up for the time that would be needed to coordinate a referral to radiology and to follow up on that referral. And there are plenty of examples on how to successfully integrate ultrasound into your office workflow.

In summary, ultrasound should be used as an extension of our clinical examination. It allows for immediate imaging correlation, and it assists with decision making in an environment where radiology services have limitations. It is also phenomenally powerful when it comes to patient contact and education. True point-of-care ultrasound is fast, high quality, and cost efficient. If you show this information to patients, their families, taxpayers, and politicians, they will agree: There is no question that point-of-care ultrasound is the way to go.

Dr. Maggie Larché is a rheumatologist at St. Joseph’s Hospital and McMaster University Hospital, both in Hamilton, Ont. She is also vice president and treasurer of the Canadian Rheumatology Ultrasound Society. Dr. JohannesRoth is head of pediatric rheumatology at Children’s Hospital of Eastern Ontario, Ottawa, and is president of the Canadian Rheumatology Ultrasound Society. Dr. Larché disclosed no relevant conflicts of interest. Dr. Roth disclosed no relevant conflicts of interest.

COUNTERPOINT: Its use at present is best left to experts.

Ultrasound is an amazing tool, and we are not disputing its merits. Thus, the question is not so much whether it should be used in the rheumatologist’s office, but whether you should use it in your office.

Europe is often cited as a hotbed of ultrasound use in rheumatology to be emulated. But in fact, in only 10% of European countries do the majority of rheumatologists use ultrasound, and in no country do the majority of rheumatologists perform ultrasound-guided arthrocentesis (Rheumatol. 2012;51:184-90).

We don’t know if it is feasible to use ultrasound findings as outcome measures in routine clinical care. A recent systematic review noted the difficulty of determining the minimum number of joints to be included in a global ultrasound score and recommended further validation (J. Rheumatol. 2011;38:2055-62). The time needed to perform the exam ranged from 15 to 60 minutes.

Indeed, time and resource constraints are rightly cited as major barriers to wider use of ultrasound in the rheumatology office. Exam time is not the only consideration: The time to acquire ultrasound skills and then to maintain and improve them is also considerable. There is unquestionably a learning curve; it takes about 4-6 months to become good at this. Then you have to continually upgrade your skills.

Our patients already wait for care. If we begin doing ultrasound in the office, they will wait even longer to see us. This is important, as, for example, just a few months of early rheumatoid arthritis is destructive to the joints. Additionally, even with rheumatologists working at their current pace, there is already a projected shortfall of nearly two-thirds in the number needed in Canada by 2026 (J. Rheumatol. 2010;37:1749-55).

Ultrasound-guided needle placement in joint spaces sounds wonderful, but we need more long-term proof that it improves outcomes. For instance, when it comes to sacroiliac joint injections, clinical outcome is the same whether the needle is placed in the joint space or in the adjacent tissue (Rheumatology 2010;49:1479-82).

Ultrasound is incredibly subjective and user dependent. You need a lot of training to become good at it: There is only fair to moderate agreement in assessing synovitis for beginners just getting up to speed (Int. J. Rheumatol. 2010;164518). So unless you are an elite expert, you are not going to be that proficient, and there is potential for doing more harm than good.

In summary, point-of-care ultrasound in rheumatology needs more investigation. At present, we recommend against widespread adoption in rheumatologists’ offices. Rheumatologists’ time is too precious to waste on ultrasound exams. Even cardiologists and obstetrician-gynecologists have techs who do the exams; if we try to do them ourselves, our patient wait lists will skyrocket. The cost to you and society makes the choice clear: We should not be doing ultrasound routinely in our office.

Dr. Christopher Penney is a rheumatologist at Foothills Hospital in Calgary, Alta. Dr. David Collins is a rheumatologist at Vancouver (B.C.) General Hospital. Dr. Penney disclosed no relevant conflicts of interest. Dr. Collins disclosed no relevant conflicts of interest. The comments were based on presentations given at the annual meeting of the Canadian Rheumatology Association in Victoria, B.C.

NEW YORK – Smoking worsened the course of axial spondyloarthritis, leading to earlier onset of inflammatory back pain, more severe disease, more frequent inflammation and structural lesions of the sacroiliac joints and spine, and an increased risk of developing severe radiographic sacroiliitis, according to Dr. Christopher T. Ritchlin, who discussed the findings from two studies.

Unlike most other risk factors, smoking is modifiable, noted Dr. Ritchlin, professor of medicine and director of the translational immunology research center at the University of Rochester (N.Y.) Medical Center.

The studies involved patients who were in their 30s and early 40s. "These findings help us to focus on the risk factors we should be worried about in [spondyloarthritis (SpA)]," Dr. Ritchlin said at a rheumatology meeting sponsored by New York University.

At the 2011 American College of Rheumatology annual meeting, Dr. Pedro Machado of Leiden (the Netherlands) University Medical Center presented results from the DESIR (Devenir des Spondyloarthropathies Indifferenciées Récentes) cohort, a multicenter study in France (Ann. Rheum. Dis. 2011 Oct. 11 [doi:10.1136/annrheumdis-2011-200180]). This retrospective analysis looked at the records of 654 patients who met at least one set of international criteria for SpA. The patients were young (mean age, 33.6 years) and had back pain of relatively short duration (mean, 1.5 years). About one-third of the patients were classified as smokers, which was determined by physician interview. Information as to whether the patients were current smokers or how much they smoked was not provided. Multivariate analyses were adjusted for age, sex, duration of inflammatory back pain, race, and HLA-B27 status (Rheumatology News, June 2011, p. 38).

Smoking was found to be associated with a significantly earlier onset of back pain (P = .04) and higher disease activity, as measured on both the Ankylosing Spondylitis Disease Activity Index (P = .03) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (P = .003). Those who smoked also had worse functional status, as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI) (P = .02). Quality of life was impaired for smokers, as measured by the Ankylosing Spondylitis Quality of Life Score (ASQol, P less than .001) and Short Form 36 physical and mental component scores (both P less than .001).

For the first time, smoking was determined to be associated with the presence of MRI inflammation and structural damage, according to Dr. Machado. MRI findings showed that those who smoked had more inflammation of the sacroiliac joints (odds ratio, 1.57; P = .02) and spine (OR, 2.33; P less than .001). Smoking was also associated with more extensive structural lesions of the sacroiliac joints (OR, 1.54; P = .03) and spine (OR, 2.02; P = .01) and a higher modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS, P = .03), a measure of new bone formation.

"Taking into account that smoking is a potentially modifiable lifestyle factor, axial SpA patients who smoke should be strongly advised to quit this habit, as there seem to be disease-specific benefits that go beyond those described for the general population," Dr. Machado said.

Findings from the second study discussed by Dr. Ritchlin showed that smoking was also found to be a risk factor for severe radiographic sacroiliitis in patients with bilateral axial SpA in a cohort study of 151 patients meeting ASAS (Assessment of Spondyloarthritis International Society) criteria for axial SpA (Arthritis Rheum. 2011;63[suppl. 10]:512). Patients were divided into those who had mild disease (sacroilitis less than grade 4, n = 109) and those with more severe disease (sacroiliitis grade 4, n = 42). Most patients were in their late 30s or early 40s, and had the disease for 13 years or more. The study was presented at the 2011 American College of Rheumatology meeting by Grace Yoon of the University of California at San Francisco, where she is in the rheumatology division of the department of medicine.

In a multivariate logistic regression analysis, after adjustment for age and sex, smoking increased the risk of severe radiographic sacroiliitis (OR, 1.13, P = .006). The disease duration also increased the risk of severe radiographic sacroiliitis (OR, 1.07; P = .05) as did nonwhite ethnicity (OR, 3.3; P = .02), total hip arthroplasty (OR, 27.9; P = .0004), and a family history of ankylosing spondylitis (OR, 4.65; P = .01).

"What was really intriguing to me was the finding on MRI that there was an increase in inflammation seen in smokers," said Dr. Ritchlin. "The big question is, How does inflammation lead to osteoproliferation or new bone formation?" He suggested that both genetic factors and mechanobiologic factors such as axial myofascial tonicity influence the process.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Janssen, Pfizer, and UCB. Dr. Machado and Ms. Yoon reported that they had no relevant financial disclosures.

NEW YORK – Smoking worsened the course of axial spondyloarthritis, leading to earlier onset of inflammatory back pain, more severe disease, more frequent inflammation and structural lesions of the sacroiliac joints and spine, and an increased risk of developing severe radiographic sacroiliitis, according to Dr. Christopher T. Ritchlin, who discussed the findings from two studies.

Unlike most other risk factors, smoking is modifiable, noted Dr. Ritchlin, professor of medicine and director of the translational immunology research center at the University of Rochester (N.Y.) Medical Center.

The studies involved patients who were in their 30s and early 40s. "These findings help us to focus on the risk factors we should be worried about in [spondyloarthritis (SpA)]," Dr. Ritchlin said at a rheumatology meeting sponsored by New York University.

At the 2011 American College of Rheumatology annual meeting, Dr. Pedro Machado of Leiden (the Netherlands) University Medical Center presented results from the DESIR (Devenir des Spondyloarthropathies Indifferenciées Récentes) cohort, a multicenter study in France (Ann. Rheum. Dis. 2011 Oct. 11 [doi:10.1136/annrheumdis-2011-200180]). This retrospective analysis looked at the records of 654 patients who met at least one set of international criteria for SpA. The patients were young (mean age, 33.6 years) and had back pain of relatively short duration (mean, 1.5 years). About one-third of the patients were classified as smokers, which was determined by physician interview. Information as to whether the patients were current smokers or how much they smoked was not provided. Multivariate analyses were adjusted for age, sex, duration of inflammatory back pain, race, and HLA-B27 status (Rheumatology News, June 2011, p. 38).

Smoking was found to be associated with a significantly earlier onset of back pain (P = .04) and higher disease activity, as measured on both the Ankylosing Spondylitis Disease Activity Index (P = .03) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (P = .003). Those who smoked also had worse functional status, as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI) (P = .02). Quality of life was impaired for smokers, as measured by the Ankylosing Spondylitis Quality of Life Score (ASQol, P less than .001) and Short Form 36 physical and mental component scores (both P less than .001).

For the first time, smoking was determined to be associated with the presence of MRI inflammation and structural damage, according to Dr. Machado. MRI findings showed that those who smoked had more inflammation of the sacroiliac joints (odds ratio, 1.57; P = .02) and spine (OR, 2.33; P less than .001). Smoking was also associated with more extensive structural lesions of the sacroiliac joints (OR, 1.54; P = .03) and spine (OR, 2.02; P = .01) and a higher modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS, P = .03), a measure of new bone formation.

"Taking into account that smoking is a potentially modifiable lifestyle factor, axial SpA patients who smoke should be strongly advised to quit this habit, as there seem to be disease-specific benefits that go beyond those described for the general population," Dr. Machado said.

Findings from the second study discussed by Dr. Ritchlin showed that smoking was also found to be a risk factor for severe radiographic sacroiliitis in patients with bilateral axial SpA in a cohort study of 151 patients meeting ASAS (Assessment of Spondyloarthritis International Society) criteria for axial SpA (Arthritis Rheum. 2011;63[suppl. 10]:512). Patients were divided into those who had mild disease (sacroilitis less than grade 4, n = 109) and those with more severe disease (sacroiliitis grade 4, n = 42). Most patients were in their late 30s or early 40s, and had the disease for 13 years or more. The study was presented at the 2011 American College of Rheumatology meeting by Grace Yoon of the University of California at San Francisco, where she is in the rheumatology division of the department of medicine.

In a multivariate logistic regression analysis, after adjustment for age and sex, smoking increased the risk of severe radiographic sacroiliitis (OR, 1.13, P = .006). The disease duration also increased the risk of severe radiographic sacroiliitis (OR, 1.07; P = .05) as did nonwhite ethnicity (OR, 3.3; P = .02), total hip arthroplasty (OR, 27.9; P = .0004), and a family history of ankylosing spondylitis (OR, 4.65; P = .01).

"What was really intriguing to me was the finding on MRI that there was an increase in inflammation seen in smokers," said Dr. Ritchlin. "The big question is, How does inflammation lead to osteoproliferation or new bone formation?" He suggested that both genetic factors and mechanobiologic factors such as axial myofascial tonicity influence the process.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Janssen, Pfizer, and UCB. Dr. Machado and Ms. Yoon reported that they had no relevant financial disclosures.

NEW YORK – Smoking worsened the course of axial spondyloarthritis, leading to earlier onset of inflammatory back pain, more severe disease, more frequent inflammation and structural lesions of the sacroiliac joints and spine, and an increased risk of developing severe radiographic sacroiliitis, according to Dr. Christopher T. Ritchlin, who discussed the findings from two studies.

Unlike most other risk factors, smoking is modifiable, noted Dr. Ritchlin, professor of medicine and director of the translational immunology research center at the University of Rochester (N.Y.) Medical Center.

The studies involved patients who were in their 30s and early 40s. "These findings help us to focus on the risk factors we should be worried about in [spondyloarthritis (SpA)]," Dr. Ritchlin said at a rheumatology meeting sponsored by New York University.

At the 2011 American College of Rheumatology annual meeting, Dr. Pedro Machado of Leiden (the Netherlands) University Medical Center presented results from the DESIR (Devenir des Spondyloarthropathies Indifferenciées Récentes) cohort, a multicenter study in France (Ann. Rheum. Dis. 2011 Oct. 11 [doi:10.1136/annrheumdis-2011-200180]). This retrospective analysis looked at the records of 654 patients who met at least one set of international criteria for SpA. The patients were young (mean age, 33.6 years) and had back pain of relatively short duration (mean, 1.5 years). About one-third of the patients were classified as smokers, which was determined by physician interview. Information as to whether the patients were current smokers or how much they smoked was not provided. Multivariate analyses were adjusted for age, sex, duration of inflammatory back pain, race, and HLA-B27 status (Rheumatology News, June 2011, p. 38).

Smoking was found to be associated with a significantly earlier onset of back pain (P = .04) and higher disease activity, as measured on both the Ankylosing Spondylitis Disease Activity Index (P = .03) and the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) (P = .003). Those who smoked also had worse functional status, as assessed by the Bath Ankylosing Spondylitis Functional Index (BASFI) (P = .02). Quality of life was impaired for smokers, as measured by the Ankylosing Spondylitis Quality of Life Score (ASQol, P less than .001) and Short Form 36 physical and mental component scores (both P less than .001).

For the first time, smoking was determined to be associated with the presence of MRI inflammation and structural damage, according to Dr. Machado. MRI findings showed that those who smoked had more inflammation of the sacroiliac joints (odds ratio, 1.57; P = .02) and spine (OR, 2.33; P less than .001). Smoking was also associated with more extensive structural lesions of the sacroiliac joints (OR, 1.54; P = .03) and spine (OR, 2.02; P = .01) and a higher modified Stoke Ankylosing Spondylitis Spinal Score (mSASSS, P = .03), a measure of new bone formation.

"Taking into account that smoking is a potentially modifiable lifestyle factor, axial SpA patients who smoke should be strongly advised to quit this habit, as there seem to be disease-specific benefits that go beyond those described for the general population," Dr. Machado said.

Findings from the second study discussed by Dr. Ritchlin showed that smoking was also found to be a risk factor for severe radiographic sacroiliitis in patients with bilateral axial SpA in a cohort study of 151 patients meeting ASAS (Assessment of Spondyloarthritis International Society) criteria for axial SpA (Arthritis Rheum. 2011;63[suppl. 10]:512). Patients were divided into those who had mild disease (sacroilitis less than grade 4, n = 109) and those with more severe disease (sacroiliitis grade 4, n = 42). Most patients were in their late 30s or early 40s, and had the disease for 13 years or more. The study was presented at the 2011 American College of Rheumatology meeting by Grace Yoon of the University of California at San Francisco, where she is in the rheumatology division of the department of medicine.

In a multivariate logistic regression analysis, after adjustment for age and sex, smoking increased the risk of severe radiographic sacroiliitis (OR, 1.13, P = .006). The disease duration also increased the risk of severe radiographic sacroiliitis (OR, 1.07; P = .05) as did nonwhite ethnicity (OR, 3.3; P = .02), total hip arthroplasty (OR, 27.9; P = .0004), and a family history of ankylosing spondylitis (OR, 4.65; P = .01).

"What was really intriguing to me was the finding on MRI that there was an increase in inflammation seen in smokers," said Dr. Ritchlin. "The big question is, How does inflammation lead to osteoproliferation or new bone formation?" He suggested that both genetic factors and mechanobiologic factors such as axial myofascial tonicity influence the process.

Dr. Ritchlin reported financial relationships with Abbott, Amgen, Janssen, Pfizer, and UCB. Dr. Machado and Ms. Yoon reported that they had no relevant financial disclosures.

Ultrasound, a technology that was once mainly in the purview of radiologists, is becoming an integral part of the surgeon’s toolbox.

Across specialties, an increasing number of surgeons are incorporating ultrasound into their practices, whether in the office or in the operating room, especially as procedures become less invasive.

The once-cumbersome machines have gotten smaller over the past three decades, the technology has improved dramatically, and – compared with some other types of imaging – ultrasound is more cost-effective and affordable, experts say.

"It’s a technology that I think is going to expand in use," said Dr. Jay K. Harness, an early adopter of ultrasound in breast surgery and coauthor of the textbook "Ultrasound in Surgical Practice." "I started using it in the 1990s, and it’s like we’ve gone from analog TV to digital."

Dr. Heidi Frankel, chair of American College of Surgeons’ (ACS) National Ultrasound Faculty, compared the developments in use of ultrasound in surgery to laparoscopy.

"Ultimately, the patients and the market pushed the need for it," said Dr. Frankel, professor of surgery at University of Maryland Shock Trauma Center, Baltimore. "Surgeons who didn’t do it had to learn to do it, and it became part of surgical training. I suspect the same thing is going to happen with ultrasound."

And while training and certification requirements vary widely, the surgeons currently using ultrasound predict that guidelines may ultimately become somewhat standardized within and across specialties.

Breast Surgery

Dr. Harness, who is also a member of the ACS National Ultrasound Faculty and the past-president of the American Society of Breast Surgeons (ASBS), was among the first to incorporate ultrasound into his practice. Today, he said, "for the contemporary breast surgeon, [ultrasound] is a fundamental tool ... Ultrasound is our stethoscope."

In breast surgery, ultrasound is an adjunctive tool for the physical exam, said Dr. Harness. It is used for diagnostic biopsy, and it can speed up the diagnostic process. Ultrasound also is used in the operating room, notably for procedures such as lumpectomies. And finally, ultrasound can help guide the placement of partial breast brachyradiation therapy devices.

Breast surgeons can obtain ultrasound certification through ASBS, although becoming certified is not a requirement. "A major goal of the Society’s breast ultrasound certification program is to improve the quality of care for patients with breast disease by encouraging education and training to advance expertise and clinical competency for surgeons who use ultrasound and ultrasound-guided procedures in their practices," according to the ASBS website.

Dr. Harness said that ultrasound combined with other imaging techniques such as MRI provides the most complete imaging possible, given that there’s no single technology that captures everything.

Abdominal Surgery

In the 1980s, not many surgeons used ultrasound in their day-to-day practice and there were few publications on the topic, said Dr. Junji Machi. At that time, x-rays were commonly used to check areas such as the bile duct for stones. "But, it was cumbersome and took 15-30 minutes. So we used ultrasound instead. It was quicker, and the results were accurate," said Dr. Machi, professor of surgery at University of Hawaii, and director of the Abdominal Ultrasound Module at the ACS.

Dr. Machi has published a number of studies on cases and findings, and he uses ultrasound, especially during liver, biliary, and pancreatic surgery.

"For liver surgery, intraoperative ultrasound is a must," he said. "Without it, we consider the procedure suboptimal, because we may miss lesions and cannot perform the best operations."

Among the indications for ultrasound use in abdominal surgery were laparoscopic procedures, which were introduced in the 1990s, he said. "You can see, but not touch, the tissue," said Dr. Machi. "So we needed something to evaluate under the surface. ... With ultrasound, we can see without much dissection."

Surgeons could be discouraged from using ultrasound because the learning curve is steep (usually several months’ experience is needed) and because the equipment is relatively expensive. Yet, "once you learn it, it’s much more cost effective," he said, adding that this imaging technique does not expose the patient and operative team to radiation.

There’s no specialty limitation in the use of ultrasound, and abdominal surgeons can perform it once they master ultrasound. The ACS ultrasound course is an excellent way to learn, said Dr. Machi. Surgeons receive a certificate upon completion of a course.

Indeed, "the training issues are really paramount," said Dr. Ellen Hagopian, who did her liver training in France, and studied with radiologists and surgeons. Ultrasound is used much more frequently in Europe than in the United States, she said. "I sit on the education and training committee of Americas Hepato-Pancreato-Biliary Association [AHPBA], and I think ultrasound training throughout the fellowship programs needs to be more consistent."

Dr. Hagopian, who sits on ACS’s National Ultrasound Faculty board, coordinated and taught the first advanced ultrasound course in hepato-pancreato-biliary surgery at the AHPBA Annual Meeting in March. The course will be given again this year at the ACS Clinical Congress in San Francisco. Surgeons receive a certification of completion.

"Feedback and interest at AHPBA was excellent," said Dr. Hagopian. "There were many more surgeons who wanted to take the course than we could accommodate." She anticipates that similar interest will be shown during the ACS Clinical Congress.

Head and Neck Surgery

"Basically, the best way to evaluate the thyroid gland is ultrasound," said Dr. Robert Sofferman, an otolaryngologist who does thyroid and parathyroid surgery as part of his practice. "It’s cheaper and incredibly accurate."

Dr. Sofferman, professor emeritus of surgery at the University of Vermont in Burlington, said that some 15 years ago, ultrasound machines were too big and didn’t have good resolution. But over time, the equipment has become smaller, better, portable, and less expensive, he said. He predicts that the machines will eventually shrink to the size of an iPad.

"We operate in the neck on a daily basis," said Dr. Sofferman. "Ultrasound is very helpful for us. I couldn’t do my work without it."

Having the imaging available in the office is also convenient for the patients. "We arrange everything before the patient comes in. We do the physical exam. We do the ultrasound exam. We do ultrasound-guided biopsy, so the patient is done in one visit."

He said ultrasound can be used to evaluate the size and characteristics of a tumor before deciding whether to operate or to monitor the tumor’s response to treatment. "It’s a technology that has some advantages. It’s an extension of our physical examination."

It also comes with a few drawbacks. Aside from the price, which can be upwards of $30,000, ultrasound can slow down the day, and it does have a moderate learning curve, according to Dr. Sofferman.

Neither the ACS nor American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) require certification for the use of ultrasound. However, the ACS offers training in thyroid/parathyroid ultrasound to all surgeons who do neck surgery, either during the annual Clinical Congress or in other courses. Participants who complete training receive certification from the ACS.

Vascular Surgery

Ultrasound is a major component of vascular surgery training and practice, and many vascular surgeons have obtained the Registered Vascular Technologist (RVT) credential from the American Registry for Diagnostic Medical Sonography (ARDMS.)

While the RVT credential has been available since the 1980s, the ARDMS introduced the Registered Physician in Vascular Interpretation (RPVI) credential in 2006 to provide a certification process that focuses more on interpretation of vascular ultrasound tests than on performing the examinations. The RPVI credential is open to all qualified physicians and is not restricted to vascular surgeons.

"The advantage of the RPVI is that it is a national, standardized credential that is available to all physicians with an interest in vascular testing," said Dr. Gene Zierler, a member of the National Ultrasound Faculty and professor of surgery at the University of Washington, Seattle. "So that means it can document expertise in vascular ultrasound across multiple specialties and training programs."

Starting in 2014, the RPVI will be a requirement for vascular surgery board certification, a decision supported by the Society for Vascular Surgery.

Trauma Surgery

Ultrasound is the quickest and most reliable diagnostic tool under emergency conditions, according to Dr. Frankel.

"We work with very time-sensitive injuries. Ultrasound in my specialty is absolutely necessary. We image trauma patients this way. We can’t wait for a radiologist to come in," she said.

Dr. Frankel, who began using ultrasound in 1994, echoed her colleagues who said that technology has improved over time. Her hospital has begun using ultrasound in the intensive care unit, and "our residents are starting to use it early on. And medical students are picking it up," she said.

Whether surgeons are permitted to use ultrasound in the hospital varies by system or institution. Hospitals may require board-certified surgeons to perform a certain number of ultrasound procedures before granting them certification or to show certain certification or credentialing in ultrasound, experts said.

"There’s no science [to show] how many of these procedures I should have done to get credentialed by the hospital to use ultrasound," Dr. Frankel said.

She and other surgeons predicted that the individual surgical societies will ultimately specify the training, certification, or accreditation requirements for performing ultrasound. In the meantime, ultrasound seems to be finding its place in surgery, and surgeons who have been using it say they wouldn’t practice without it.

"It adds to the joy of practicing medicine," said Dr. Sofferman. "It makes it enjoyable for us to be able to see everything. That’s a definite advantage. I couldn’t be as efficient and as accurate without it."

None of the surgeons reported any relevant disclosures.

Ultrasound, a technology that was once mainly in the purview of radiologists, is becoming an integral part of the surgeon’s toolbox.

Across specialties, an increasing number of surgeons are incorporating ultrasound into their practices, whether in the office or in the operating room, especially as procedures become less invasive.

The once-cumbersome machines have gotten smaller over the past three decades, the technology has improved dramatically, and – compared with some other types of imaging – ultrasound is more cost-effective and affordable, experts say.

"It’s a technology that I think is going to expand in use," said Dr. Jay K. Harness, an early adopter of ultrasound in breast surgery and coauthor of the textbook "Ultrasound in Surgical Practice." "I started using it in the 1990s, and it’s like we’ve gone from analog TV to digital."

Dr. Heidi Frankel, chair of American College of Surgeons’ (ACS) National Ultrasound Faculty, compared the developments in use of ultrasound in surgery to laparoscopy.

"Ultimately, the patients and the market pushed the need for it," said Dr. Frankel, professor of surgery at University of Maryland Shock Trauma Center, Baltimore. "Surgeons who didn’t do it had to learn to do it, and it became part of surgical training. I suspect the same thing is going to happen with ultrasound."

And while training and certification requirements vary widely, the surgeons currently using ultrasound predict that guidelines may ultimately become somewhat standardized within and across specialties.

Breast Surgery

Dr. Harness, who is also a member of the ACS National Ultrasound Faculty and the past-president of the American Society of Breast Surgeons (ASBS), was among the first to incorporate ultrasound into his practice. Today, he said, "for the contemporary breast surgeon, [ultrasound] is a fundamental tool ... Ultrasound is our stethoscope."

In breast surgery, ultrasound is an adjunctive tool for the physical exam, said Dr. Harness. It is used for diagnostic biopsy, and it can speed up the diagnostic process. Ultrasound also is used in the operating room, notably for procedures such as lumpectomies. And finally, ultrasound can help guide the placement of partial breast brachyradiation therapy devices.

Breast surgeons can obtain ultrasound certification through ASBS, although becoming certified is not a requirement. "A major goal of the Society’s breast ultrasound certification program is to improve the quality of care for patients with breast disease by encouraging education and training to advance expertise and clinical competency for surgeons who use ultrasound and ultrasound-guided procedures in their practices," according to the ASBS website.

Dr. Harness said that ultrasound combined with other imaging techniques such as MRI provides the most complete imaging possible, given that there’s no single technology that captures everything.

Abdominal Surgery

In the 1980s, not many surgeons used ultrasound in their day-to-day practice and there were few publications on the topic, said Dr. Junji Machi. At that time, x-rays were commonly used to check areas such as the bile duct for stones. "But, it was cumbersome and took 15-30 minutes. So we used ultrasound instead. It was quicker, and the results were accurate," said Dr. Machi, professor of surgery at University of Hawaii, and director of the Abdominal Ultrasound Module at the ACS.

Dr. Machi has published a number of studies on cases and findings, and he uses ultrasound, especially during liver, biliary, and pancreatic surgery.

"For liver surgery, intraoperative ultrasound is a must," he said. "Without it, we consider the procedure suboptimal, because we may miss lesions and cannot perform the best operations."

Among the indications for ultrasound use in abdominal surgery were laparoscopic procedures, which were introduced in the 1990s, he said. "You can see, but not touch, the tissue," said Dr. Machi. "So we needed something to evaluate under the surface. ... With ultrasound, we can see without much dissection."

Surgeons could be discouraged from using ultrasound because the learning curve is steep (usually several months’ experience is needed) and because the equipment is relatively expensive. Yet, "once you learn it, it’s much more cost effective," he said, adding that this imaging technique does not expose the patient and operative team to radiation.

There’s no specialty limitation in the use of ultrasound, and abdominal surgeons can perform it once they master ultrasound. The ACS ultrasound course is an excellent way to learn, said Dr. Machi. Surgeons receive a certificate upon completion of a course.

Indeed, "the training issues are really paramount," said Dr. Ellen Hagopian, who did her liver training in France, and studied with radiologists and surgeons. Ultrasound is used much more frequently in Europe than in the United States, she said. "I sit on the education and training committee of Americas Hepato-Pancreato-Biliary Association [AHPBA], and I think ultrasound training throughout the fellowship programs needs to be more consistent."

Dr. Hagopian, who sits on ACS’s National Ultrasound Faculty board, coordinated and taught the first advanced ultrasound course in hepato-pancreato-biliary surgery at the AHPBA Annual Meeting in March. The course will be given again this year at the ACS Clinical Congress in San Francisco. Surgeons receive a certification of completion.

"Feedback and interest at AHPBA was excellent," said Dr. Hagopian. "There were many more surgeons who wanted to take the course than we could accommodate." She anticipates that similar interest will be shown during the ACS Clinical Congress.

Head and Neck Surgery

"Basically, the best way to evaluate the thyroid gland is ultrasound," said Dr. Robert Sofferman, an otolaryngologist who does thyroid and parathyroid surgery as part of his practice. "It’s cheaper and incredibly accurate."

Dr. Sofferman, professor emeritus of surgery at the University of Vermont in Burlington, said that some 15 years ago, ultrasound machines were too big and didn’t have good resolution. But over time, the equipment has become smaller, better, portable, and less expensive, he said. He predicts that the machines will eventually shrink to the size of an iPad.

"We operate in the neck on a daily basis," said Dr. Sofferman. "Ultrasound is very helpful for us. I couldn’t do my work without it."

Having the imaging available in the office is also convenient for the patients. "We arrange everything before the patient comes in. We do the physical exam. We do the ultrasound exam. We do ultrasound-guided biopsy, so the patient is done in one visit."

He said ultrasound can be used to evaluate the size and characteristics of a tumor before deciding whether to operate or to monitor the tumor’s response to treatment. "It’s a technology that has some advantages. It’s an extension of our physical examination."

It also comes with a few drawbacks. Aside from the price, which can be upwards of $30,000, ultrasound can slow down the day, and it does have a moderate learning curve, according to Dr. Sofferman.

Neither the ACS nor American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) require certification for the use of ultrasound. However, the ACS offers training in thyroid/parathyroid ultrasound to all surgeons who do neck surgery, either during the annual Clinical Congress or in other courses. Participants who complete training receive certification from the ACS.

Vascular Surgery

Ultrasound is a major component of vascular surgery training and practice, and many vascular surgeons have obtained the Registered Vascular Technologist (RVT) credential from the American Registry for Diagnostic Medical Sonography (ARDMS.)

While the RVT credential has been available since the 1980s, the ARDMS introduced the Registered Physician in Vascular Interpretation (RPVI) credential in 2006 to provide a certification process that focuses more on interpretation of vascular ultrasound tests than on performing the examinations. The RPVI credential is open to all qualified physicians and is not restricted to vascular surgeons.

"The advantage of the RPVI is that it is a national, standardized credential that is available to all physicians with an interest in vascular testing," said Dr. Gene Zierler, a member of the National Ultrasound Faculty and professor of surgery at the University of Washington, Seattle. "So that means it can document expertise in vascular ultrasound across multiple specialties and training programs."

Starting in 2014, the RPVI will be a requirement for vascular surgery board certification, a decision supported by the Society for Vascular Surgery.

Trauma Surgery

Ultrasound is the quickest and most reliable diagnostic tool under emergency conditions, according to Dr. Frankel.

"We work with very time-sensitive injuries. Ultrasound in my specialty is absolutely necessary. We image trauma patients this way. We can’t wait for a radiologist to come in," she said.

Dr. Frankel, who began using ultrasound in 1994, echoed her colleagues who said that technology has improved over time. Her hospital has begun using ultrasound in the intensive care unit, and "our residents are starting to use it early on. And medical students are picking it up," she said.

Whether surgeons are permitted to use ultrasound in the hospital varies by system or institution. Hospitals may require board-certified surgeons to perform a certain number of ultrasound procedures before granting them certification or to show certain certification or credentialing in ultrasound, experts said.

"There’s no science [to show] how many of these procedures I should have done to get credentialed by the hospital to use ultrasound," Dr. Frankel said.

She and other surgeons predicted that the individual surgical societies will ultimately specify the training, certification, or accreditation requirements for performing ultrasound. In the meantime, ultrasound seems to be finding its place in surgery, and surgeons who have been using it say they wouldn’t practice without it.

"It adds to the joy of practicing medicine," said Dr. Sofferman. "It makes it enjoyable for us to be able to see everything. That’s a definite advantage. I couldn’t be as efficient and as accurate without it."

None of the surgeons reported any relevant disclosures.

Ultrasound, a technology that was once mainly in the purview of radiologists, is becoming an integral part of the surgeon’s toolbox.

Across specialties, an increasing number of surgeons are incorporating ultrasound into their practices, whether in the office or in the operating room, especially as procedures become less invasive.

The once-cumbersome machines have gotten smaller over the past three decades, the technology has improved dramatically, and – compared with some other types of imaging – ultrasound is more cost-effective and affordable, experts say.

"It’s a technology that I think is going to expand in use," said Dr. Jay K. Harness, an early adopter of ultrasound in breast surgery and coauthor of the textbook "Ultrasound in Surgical Practice." "I started using it in the 1990s, and it’s like we’ve gone from analog TV to digital."

Dr. Heidi Frankel, chair of American College of Surgeons’ (ACS) National Ultrasound Faculty, compared the developments in use of ultrasound in surgery to laparoscopy.

"Ultimately, the patients and the market pushed the need for it," said Dr. Frankel, professor of surgery at University of Maryland Shock Trauma Center, Baltimore. "Surgeons who didn’t do it had to learn to do it, and it became part of surgical training. I suspect the same thing is going to happen with ultrasound."

And while training and certification requirements vary widely, the surgeons currently using ultrasound predict that guidelines may ultimately become somewhat standardized within and across specialties.

Breast Surgery

Dr. Harness, who is also a member of the ACS National Ultrasound Faculty and the past-president of the American Society of Breast Surgeons (ASBS), was among the first to incorporate ultrasound into his practice. Today, he said, "for the contemporary breast surgeon, [ultrasound] is a fundamental tool ... Ultrasound is our stethoscope."

In breast surgery, ultrasound is an adjunctive tool for the physical exam, said Dr. Harness. It is used for diagnostic biopsy, and it can speed up the diagnostic process. Ultrasound also is used in the operating room, notably for procedures such as lumpectomies. And finally, ultrasound can help guide the placement of partial breast brachyradiation therapy devices.

Breast surgeons can obtain ultrasound certification through ASBS, although becoming certified is not a requirement. "A major goal of the Society’s breast ultrasound certification program is to improve the quality of care for patients with breast disease by encouraging education and training to advance expertise and clinical competency for surgeons who use ultrasound and ultrasound-guided procedures in their practices," according to the ASBS website.

Dr. Harness said that ultrasound combined with other imaging techniques such as MRI provides the most complete imaging possible, given that there’s no single technology that captures everything.

Abdominal Surgery

In the 1980s, not many surgeons used ultrasound in their day-to-day practice and there were few publications on the topic, said Dr. Junji Machi. At that time, x-rays were commonly used to check areas such as the bile duct for stones. "But, it was cumbersome and took 15-30 minutes. So we used ultrasound instead. It was quicker, and the results were accurate," said Dr. Machi, professor of surgery at University of Hawaii, and director of the Abdominal Ultrasound Module at the ACS.

Dr. Machi has published a number of studies on cases and findings, and he uses ultrasound, especially during liver, biliary, and pancreatic surgery.

"For liver surgery, intraoperative ultrasound is a must," he said. "Without it, we consider the procedure suboptimal, because we may miss lesions and cannot perform the best operations."

Among the indications for ultrasound use in abdominal surgery were laparoscopic procedures, which were introduced in the 1990s, he said. "You can see, but not touch, the tissue," said Dr. Machi. "So we needed something to evaluate under the surface. ... With ultrasound, we can see without much dissection."

Surgeons could be discouraged from using ultrasound because the learning curve is steep (usually several months’ experience is needed) and because the equipment is relatively expensive. Yet, "once you learn it, it’s much more cost effective," he said, adding that this imaging technique does not expose the patient and operative team to radiation.

There’s no specialty limitation in the use of ultrasound, and abdominal surgeons can perform it once they master ultrasound. The ACS ultrasound course is an excellent way to learn, said Dr. Machi. Surgeons receive a certificate upon completion of a course.

Indeed, "the training issues are really paramount," said Dr. Ellen Hagopian, who did her liver training in France, and studied with radiologists and surgeons. Ultrasound is used much more frequently in Europe than in the United States, she said. "I sit on the education and training committee of Americas Hepato-Pancreato-Biliary Association [AHPBA], and I think ultrasound training throughout the fellowship programs needs to be more consistent."

Dr. Hagopian, who sits on ACS’s National Ultrasound Faculty board, coordinated and taught the first advanced ultrasound course in hepato-pancreato-biliary surgery at the AHPBA Annual Meeting in March. The course will be given again this year at the ACS Clinical Congress in San Francisco. Surgeons receive a certification of completion.

"Feedback and interest at AHPBA was excellent," said Dr. Hagopian. "There were many more surgeons who wanted to take the course than we could accommodate." She anticipates that similar interest will be shown during the ACS Clinical Congress.

Head and Neck Surgery

"Basically, the best way to evaluate the thyroid gland is ultrasound," said Dr. Robert Sofferman, an otolaryngologist who does thyroid and parathyroid surgery as part of his practice. "It’s cheaper and incredibly accurate."

Dr. Sofferman, professor emeritus of surgery at the University of Vermont in Burlington, said that some 15 years ago, ultrasound machines were too big and didn’t have good resolution. But over time, the equipment has become smaller, better, portable, and less expensive, he said. He predicts that the machines will eventually shrink to the size of an iPad.

"We operate in the neck on a daily basis," said Dr. Sofferman. "Ultrasound is very helpful for us. I couldn’t do my work without it."

Having the imaging available in the office is also convenient for the patients. "We arrange everything before the patient comes in. We do the physical exam. We do the ultrasound exam. We do ultrasound-guided biopsy, so the patient is done in one visit."

He said ultrasound can be used to evaluate the size and characteristics of a tumor before deciding whether to operate or to monitor the tumor’s response to treatment. "It’s a technology that has some advantages. It’s an extension of our physical examination."

It also comes with a few drawbacks. Aside from the price, which can be upwards of $30,000, ultrasound can slow down the day, and it does have a moderate learning curve, according to Dr. Sofferman.

Neither the ACS nor American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) require certification for the use of ultrasound. However, the ACS offers training in thyroid/parathyroid ultrasound to all surgeons who do neck surgery, either during the annual Clinical Congress or in other courses. Participants who complete training receive certification from the ACS.

Vascular Surgery

Ultrasound is a major component of vascular surgery training and practice, and many vascular surgeons have obtained the Registered Vascular Technologist (RVT) credential from the American Registry for Diagnostic Medical Sonography (ARDMS.)

While the RVT credential has been available since the 1980s, the ARDMS introduced the Registered Physician in Vascular Interpretation (RPVI) credential in 2006 to provide a certification process that focuses more on interpretation of vascular ultrasound tests than on performing the examinations. The RPVI credential is open to all qualified physicians and is not restricted to vascular surgeons.

"The advantage of the RPVI is that it is a national, standardized credential that is available to all physicians with an interest in vascular testing," said Dr. Gene Zierler, a member of the National Ultrasound Faculty and professor of surgery at the University of Washington, Seattle. "So that means it can document expertise in vascular ultrasound across multiple specialties and training programs."

Starting in 2014, the RPVI will be a requirement for vascular surgery board certification, a decision supported by the Society for Vascular Surgery.

Trauma Surgery

Ultrasound is the quickest and most reliable diagnostic tool under emergency conditions, according to Dr. Frankel.

"We work with very time-sensitive injuries. Ultrasound in my specialty is absolutely necessary. We image trauma patients this way. We can’t wait for a radiologist to come in," she said.

Dr. Frankel, who began using ultrasound in 1994, echoed her colleagues who said that technology has improved over time. Her hospital has begun using ultrasound in the intensive care unit, and "our residents are starting to use it early on. And medical students are picking it up," she said.

Whether surgeons are permitted to use ultrasound in the hospital varies by system or institution. Hospitals may require board-certified surgeons to perform a certain number of ultrasound procedures before granting them certification or to show certain certification or credentialing in ultrasound, experts said.

"There’s no science [to show] how many of these procedures I should have done to get credentialed by the hospital to use ultrasound," Dr. Frankel said.

She and other surgeons predicted that the individual surgical societies will ultimately specify the training, certification, or accreditation requirements for performing ultrasound. In the meantime, ultrasound seems to be finding its place in surgery, and surgeons who have been using it say they wouldn’t practice without it.

"It adds to the joy of practicing medicine," said Dr. Sofferman. "It makes it enjoyable for us to be able to see everything. That’s a definite advantage. I couldn’t be as efficient and as accurate without it."

None of the surgeons reported any relevant disclosures.

Musculoskeletal ultrasound is an efficient, noninvasive method for evaluating inflammatory and destructive changes in bone, cartilage, tendons, ligaments, and surrounding soft tissue of patients with psoriatic arthritis. The bedside technology allows the monitoring of all peripheral joints as frequently as needed in the management of early, active disease. Power Doppler ultrasound, in particular, can estimate increases in synovium, tendon sheaths, bursae, and enthesis. Thus it provides invaluable insight into disease status and progression, according to Dr. Marwin Gutierrez, assistant professor of rheumatology at Università Politecnica delle Marche in Ancona. Italy.

Despite its value, "[ultrasound] imaging is not firmly established in the assessment of treatment efficacy and monitoring of patient outcome in daily practice," said Dr. Gutierrez. And although joint, tendon, enthesis, skin, and nail involvement has been widely described by the different subset criteria as aspects to consider in psoriatic arthritis, "ultrasound research in the disease has relatively lagged behind that of rheumatoid arthritis [RA], with scarce validated imaging outcome measures," he said.

In this month’s column, Dr. Gutierrez discusses both the role of ultrasound imaging in the assessment of psoriatic arthritis (PsA) and his group’s development of a preliminary power Doppler ultrasound composite score for monitoring treatment of the disease (Rheumatology 2012 Feb. 29 [doi:10.1093/rheumatology/kes014]).

Question: What tools are currently being used for the global assessment of PsA?

Dr. Gutierrez: There are a variety of clinical instruments for measuring disease activity and treatment response in patients with PsA, including the Disease Activity Index for PsA (DAPSA), the PsA Response Criteria (PsARC), and the Disease Activity Score using 28 joint counts (DAS28), which was originally developed for patients with RA. The main weakness of the majority of these tools is that they are focused only on joint involvement and do not include measures of other key PsA targets, such as tendons, skin, and nails. Recently, the Composite Psoriatic Disease Activity Index (CPDAI) has been proposed, which includes multiple clinical domains – joints, tendons, and the spine – in its assessment. This tool provides more comprehensive information regarding disease activity, but it is limited by the absence of imaging findings, which offer a more objective measure of the global condition of the PsA patient.

Because a composite ultrasound score does not exist at present for PsA, we tested the possibility of using power Doppler ultrasound as a global measure of the inflammatory process to detect perfusion changes induced by tumor necrosis factor (TNF)-alpha antagonist, which have been shown in recent studies to be effective in improving functional outcomes and to arrest disease progression.

Question: How are the existing tools and measures insufficient? How would the power Doppler ultrasound composite score that your group has developed fill in the gaps?

Dr. Gutierrez: PsA is a chronic inflammatory disease. Its heterogeneity is such that the term "psoriatic disease" has been recently suggested to encompass the involvement at different tissue levels, including joints, tendons, enthesis, skin, and nails. Due to the high variability in the clinical course both within one patient and between patients, as well as the variability in the outcomes of PsA, no single measure can provide accurate information regarding disease activity and responsiveness in these patients.

The main disadvantage of the most commonly used clinical measures in the assessment of PsA is that they do not provide information on the real-time activity of the psoriatic disease. Rather, they provide information confined to the assessment of single domains separately. The alternative is individual evaluation of all targets. However, such an approach is associated with methodological and statistical problems, especially when these targets are employed as end points in clinical trials.

High-frequency ultrasound can detect not only structural abnormalities but also minimal blood flow changes at the superficial soft tissue level, making it a great tool for the global assessment of disease activity in psoriatic arthritis, in which persistently active disease plays a major role in causing anatomical damage and physical functional disability. Furthermore, the ability to measure global disease activity over time is important in assessing treatment efficacy in clinical trials and monitoring the patient’s course in daily care.

Additionally, pooling individual domains of disease activity into a composite ultrasound score offers a picture of disease activity along a continuous scale, and facilitates more consistency in the assessment and communication of disease activity and treatment response in research settings and clinical practice.

Question: Of the various imaging technologies, why is ultrasound the modality of choice for this application?

Dr. Gutierrez: Early detection and careful characterization of the inflammatory process in PsA play a key role in both diagnostic and therapeutic procedures. Ultrasound technology has the essential qualities to satisfy these fundamental necessities, including high- and variable-frequency probes and very sensitive power Doppler. These capabilities permit the study of structural changes with a resolution power of 0.1 mm and the sensitive detection of blood flow even in the small vessels of superficial tissues.

In addition to being sensitive enough to assess anatomical changes, disease activity, and therapeutic efficacy, ultrasound is safe, noninvasive, patient friendly, free of ionizing radiation, and less expensive than other imaging methods. It also allows multiple target assessment in real time without the need for external referral. Compared with conventional radiography, magnetic resonance imaging (MRI), or computed tomography (CT), power Doppler ultrasound can simultaneously reflect a change in inflammatory activity by accurately measuring blood flow changes and assess the progression of anatomical damage.

Question: What are the strengths and weaknesses of the preliminary power Doppler ultrasound composite score?

Dr. Gutierrez: Our preliminary composite score, called Five Targets Power Doppler for Psoriatic Disease (5TPD), includes the assessment of changes in joints, tendons with synovial sheath, entheses, skin, and nails. It represents a feasible, reliable, and comprehensive approach for multitarget monitoring of PsA.

The score is based on the simple arithmetic sum of the scores regarding the five clinical targets. Power Doppler for each target is graded from 0 to 3 on the basis of the semiquantitative scoring systems previously suggested. The maximum total score of 5TPDis 15. In our study, the instrument was found to possess both face and content validity, and it exhibited good responsiveness. By documenting these key measurement properties, we have shown that the 5TPD is a useful instrument for the assessment of disease activity and responsiveness in PsA patients and is, therefore, potentially applicable in standard clinical care, observational studies, and clinical trials.

The 5PTD is feasible and easy to perform in the hands of expert sonographers. The baseline assessment takes an average of 10.5 minutes. The follow-up complete examination, including calculating the score, averages no more than 7 minutes, which makes it quite practical in busy clinical settings.

The main limitation of the score currently is that it was tested in a small cohort of patients, which does not allow for an accurate evaluation in terms of the sensitivity and specificity needed to support our results more strongly. Also, we need to consider the ceiling effect. For example, high composite ultrasound scores denote the involvement of multiple target areas of psoriatic disease, and they can be shared by patients with relevant differences in terms of the extent of the inflammatory involvement at each specific target area. In other words, a severe inflammation of a single joint showing a power Doppler grade of 3 gives the maximum contribution to the final score; an equally severe inflammation in terms of power Doppler appearance, but polyarticular involvement, cannot provide more than 3 and thus would be easily underestimated. We are currently developing steps aimed at defining a linear cutoff value point for any single domain of 5TPD to resolve this aspect.

It is important to remember that this composite score was designed to monitor PsA disease activity in daily practice after a complete clinical examination, and not to replace other well-established and accepted ultrasound assessments.

Question: What is next for the 5TPD?

Dr. Gutierrez: Investigations are ongoing to assess the advantages and limitations of the formula in wider cohorts of patients. The composite score needs further development and concurrent and discriminate validation through randomized controlled trials and longitudinal observational studies. The tool is currently being evaluated prospectively as part of a larger multicenter study, as well as in a study comparing it with the CPDAI for the assessment of disease activity and responsiveness.

–Interview by Diana Mahoney

Dr. Gutierrez is scientific director of the Pan-American League of Associations for Rheumatology (PANLAR) Ultrasound Group. He reported having no financial conflicts of interest.

Musculoskeletal ultrasound is an efficient, noninvasive method for evaluating inflammatory and destructive changes in bone, cartilage, tendons, ligaments, and surrounding soft tissue of patients with psoriatic arthritis. The bedside technology allows the monitoring of all peripheral joints as frequently as needed in the management of early, active disease. Power Doppler ultrasound, in particular, can estimate increases in synovium, tendon sheaths, bursae, and enthesis. Thus it provides invaluable insight into disease status and progression, according to Dr. Marwin Gutierrez, assistant professor of rheumatology at Università Politecnica delle Marche in Ancona. Italy.

Despite its value, "[ultrasound] imaging is not firmly established in the assessment of treatment efficacy and monitoring of patient outcome in daily practice," said Dr. Gutierrez. And although joint, tendon, enthesis, skin, and nail involvement has been widely described by the different subset criteria as aspects to consider in psoriatic arthritis, "ultrasound research in the disease has relatively lagged behind that of rheumatoid arthritis [RA], with scarce validated imaging outcome measures," he said.

In this month’s column, Dr. Gutierrez discusses both the role of ultrasound imaging in the assessment of psoriatic arthritis (PsA) and his group’s development of a preliminary power Doppler ultrasound composite score for monitoring treatment of the disease (Rheumatology 2012 Feb. 29 [doi:10.1093/rheumatology/kes014]).

Question: What tools are currently being used for the global assessment of PsA?

Dr. Gutierrez: There are a variety of clinical instruments for measuring disease activity and treatment response in patients with PsA, including the Disease Activity Index for PsA (DAPSA), the PsA Response Criteria (PsARC), and the Disease Activity Score using 28 joint counts (DAS28), which was originally developed for patients with RA. The main weakness of the majority of these tools is that they are focused only on joint involvement and do not include measures of other key PsA targets, such as tendons, skin, and nails. Recently, the Composite Psoriatic Disease Activity Index (CPDAI) has been proposed, which includes multiple clinical domains – joints, tendons, and the spine – in its assessment. This tool provides more comprehensive information regarding disease activity, but it is limited by the absence of imaging findings, which offer a more objective measure of the global condition of the PsA patient.

Because a composite ultrasound score does not exist at present for PsA, we tested the possibility of using power Doppler ultrasound as a global measure of the inflammatory process to detect perfusion changes induced by tumor necrosis factor (TNF)-alpha antagonist, which have been shown in recent studies to be effective in improving functional outcomes and to arrest disease progression.

Question: How are the existing tools and measures insufficient? How would the power Doppler ultrasound composite score that your group has developed fill in the gaps?

Dr. Gutierrez: PsA is a chronic inflammatory disease. Its heterogeneity is such that the term "psoriatic disease" has been recently suggested to encompass the involvement at different tissue levels, including joints, tendons, enthesis, skin, and nails. Due to the high variability in the clinical course both within one patient and between patients, as well as the variability in the outcomes of PsA, no single measure can provide accurate information regarding disease activity and responsiveness in these patients.

The main disadvantage of the most commonly used clinical measures in the assessment of PsA is that they do not provide information on the real-time activity of the psoriatic disease. Rather, they provide information confined to the assessment of single domains separately. The alternative is individual evaluation of all targets. However, such an approach is associated with methodological and statistical problems, especially when these targets are employed as end points in clinical trials.

High-frequency ultrasound can detect not only structural abnormalities but also minimal blood flow changes at the superficial soft tissue level, making it a great tool for the global assessment of disease activity in psoriatic arthritis, in which persistently active disease plays a major role in causing anatomical damage and physical functional disability. Furthermore, the ability to measure global disease activity over time is important in assessing treatment efficacy in clinical trials and monitoring the patient’s course in daily care.

Additionally, pooling individual domains of disease activity into a composite ultrasound score offers a picture of disease activity along a continuous scale, and facilitates more consistency in the assessment and communication of disease activity and treatment response in research settings and clinical practice.

Question: Of the various imaging technologies, why is ultrasound the modality of choice for this application?

Dr. Gutierrez: Early detection and careful characterization of the inflammatory process in PsA play a key role in both diagnostic and therapeutic procedures. Ultrasound technology has the essential qualities to satisfy these fundamental necessities, including high- and variable-frequency probes and very sensitive power Doppler. These capabilities permit the study of structural changes with a resolution power of 0.1 mm and the sensitive detection of blood flow even in the small vessels of superficial tissues.

In addition to being sensitive enough to assess anatomical changes, disease activity, and therapeutic efficacy, ultrasound is safe, noninvasive, patient friendly, free of ionizing radiation, and less expensive than other imaging methods. It also allows multiple target assessment in real time without the need for external referral. Compared with conventional radiography, magnetic resonance imaging (MRI), or computed tomography (CT), power Doppler ultrasound can simultaneously reflect a change in inflammatory activity by accurately measuring blood flow changes and assess the progression of anatomical damage.

Question: What are the strengths and weaknesses of the preliminary power Doppler ultrasound composite score?

Dr. Gutierrez: Our preliminary composite score, called Five Targets Power Doppler for Psoriatic Disease (5TPD), includes the assessment of changes in joints, tendons with synovial sheath, entheses, skin, and nails. It represents a feasible, reliable, and comprehensive approach for multitarget monitoring of PsA.

The score is based on the simple arithmetic sum of the scores regarding the five clinical targets. Power Doppler for each target is graded from 0 to 3 on the basis of the semiquantitative scoring systems previously suggested. The maximum total score of 5TPDis 15. In our study, the instrument was found to possess both face and content validity, and it exhibited good responsiveness. By documenting these key measurement properties, we have shown that the 5TPD is a useful instrument for the assessment of disease activity and responsiveness in PsA patients and is, therefore, potentially applicable in standard clinical care, observational studies, and clinical trials.

The 5PTD is feasible and easy to perform in the hands of expert sonographers. The baseline assessment takes an average of 10.5 minutes. The follow-up complete examination, including calculating the score, averages no more than 7 minutes, which makes it quite practical in busy clinical settings.

The main limitation of the score currently is that it was tested in a small cohort of patients, which does not allow for an accurate evaluation in terms of the sensitivity and specificity needed to support our results more strongly. Also, we need to consider the ceiling effect. For example, high composite ultrasound scores denote the involvement of multiple target areas of psoriatic disease, and they can be shared by patients with relevant differences in terms of the extent of the inflammatory involvement at each specific target area. In other words, a severe inflammation of a single joint showing a power Doppler grade of 3 gives the maximum contribution to the final score; an equally severe inflammation in terms of power Doppler appearance, but polyarticular involvement, cannot provide more than 3 and thus would be easily underestimated. We are currently developing steps aimed at defining a linear cutoff value point for any single domain of 5TPD to resolve this aspect.

It is important to remember that this composite score was designed to monitor PsA disease activity in daily practice after a complete clinical examination, and not to replace other well-established and accepted ultrasound assessments.

Question: What is next for the 5TPD?

Dr. Gutierrez: Investigations are ongoing to assess the advantages and limitations of the formula in wider cohorts of patients. The composite score needs further development and concurrent and discriminate validation through randomized controlled trials and longitudinal observational studies. The tool is currently being evaluated prospectively as part of a larger multicenter study, as well as in a study comparing it with the CPDAI for the assessment of disease activity and responsiveness.

–Interview by Diana Mahoney

Dr. Gutierrez is scientific director of the Pan-American League of Associations for Rheumatology (PANLAR) Ultrasound Group. He reported having no financial conflicts of interest.

Musculoskeletal ultrasound is an efficient, noninvasive method for evaluating inflammatory and destructive changes in bone, cartilage, tendons, ligaments, and surrounding soft tissue of patients with psoriatic arthritis. The bedside technology allows the monitoring of all peripheral joints as frequently as needed in the management of early, active disease. Power Doppler ultrasound, in particular, can estimate increases in synovium, tendon sheaths, bursae, and enthesis. Thus it provides invaluable insight into disease status and progression, according to Dr. Marwin Gutierrez, assistant professor of rheumatology at Università Politecnica delle Marche in Ancona. Italy.

Despite its value, "[ultrasound] imaging is not firmly established in the assessment of treatment efficacy and monitoring of patient outcome in daily practice," said Dr. Gutierrez. And although joint, tendon, enthesis, skin, and nail involvement has been widely described by the different subset criteria as aspects to consider in psoriatic arthritis, "ultrasound research in the disease has relatively lagged behind that of rheumatoid arthritis [RA], with scarce validated imaging outcome measures," he said.

In this month’s column, Dr. Gutierrez discusses both the role of ultrasound imaging in the assessment of psoriatic arthritis (PsA) and his group’s development of a preliminary power Doppler ultrasound composite score for monitoring treatment of the disease (Rheumatology 2012 Feb. 29 [doi:10.1093/rheumatology/kes014]).

Question: What tools are currently being used for the global assessment of PsA?

Dr. Gutierrez: There are a variety of clinical instruments for measuring disease activity and treatment response in patients with PsA, including the Disease Activity Index for PsA (DAPSA), the PsA Response Criteria (PsARC), and the Disease Activity Score using 28 joint counts (DAS28), which was originally developed for patients with RA. The main weakness of the majority of these tools is that they are focused only on joint involvement and do not include measures of other key PsA targets, such as tendons, skin, and nails. Recently, the Composite Psoriatic Disease Activity Index (CPDAI) has been proposed, which includes multiple clinical domains – joints, tendons, and the spine – in its assessment. This tool provides more comprehensive information regarding disease activity, but it is limited by the absence of imaging findings, which offer a more objective measure of the global condition of the PsA patient.

Because a composite ultrasound score does not exist at present for PsA, we tested the possibility of using power Doppler ultrasound as a global measure of the inflammatory process to detect perfusion changes induced by tumor necrosis factor (TNF)-alpha antagonist, which have been shown in recent studies to be effective in improving functional outcomes and to arrest disease progression.

Question: How are the existing tools and measures insufficient? How would the power Doppler ultrasound composite score that your group has developed fill in the gaps?

Dr. Gutierrez: PsA is a chronic inflammatory disease. Its heterogeneity is such that the term "psoriatic disease" has been recently suggested to encompass the involvement at different tissue levels, including joints, tendons, enthesis, skin, and nails. Due to the high variability in the clinical course both within one patient and between patients, as well as the variability in the outcomes of PsA, no single measure can provide accurate information regarding disease activity and responsiveness in these patients.

The main disadvantage of the most commonly used clinical measures in the assessment of PsA is that they do not provide information on the real-time activity of the psoriatic disease. Rather, they provide information confined to the assessment of single domains separately. The alternative is individual evaluation of all targets. However, such an approach is associated with methodological and statistical problems, especially when these targets are employed as end points in clinical trials.

High-frequency ultrasound can detect not only structural abnormalities but also minimal blood flow changes at the superficial soft tissue level, making it a great tool for the global assessment of disease activity in psoriatic arthritis, in which persistently active disease plays a major role in causing anatomical damage and physical functional disability. Furthermore, the ability to measure global disease activity over time is important in assessing treatment efficacy in clinical trials and monitoring the patient’s course in daily care.

Additionally, pooling individual domains of disease activity into a composite ultrasound score offers a picture of disease activity along a continuous scale, and facilitates more consistency in the assessment and communication of disease activity and treatment response in research settings and clinical practice.

Question: Of the various imaging technologies, why is ultrasound the modality of choice for this application?

Dr. Gutierrez: Early detection and careful characterization of the inflammatory process in PsA play a key role in both diagnostic and therapeutic procedures. Ultrasound technology has the essential qualities to satisfy these fundamental necessities, including high- and variable-frequency probes and very sensitive power Doppler. These capabilities permit the study of structural changes with a resolution power of 0.1 mm and the sensitive detection of blood flow even in the small vessels of superficial tissues.

In addition to being sensitive enough to assess anatomical changes, disease activity, and therapeutic efficacy, ultrasound is safe, noninvasive, patient friendly, free of ionizing radiation, and less expensive than other imaging methods. It also allows multiple target assessment in real time without the need for external referral. Compared with conventional radiography, magnetic resonance imaging (MRI), or computed tomography (CT), power Doppler ultrasound can simultaneously reflect a change in inflammatory activity by accurately measuring blood flow changes and assess the progression of anatomical damage.

Question: What are the strengths and weaknesses of the preliminary power Doppler ultrasound composite score?

Dr. Gutierrez: Our preliminary composite score, called Five Targets Power Doppler for Psoriatic Disease (5TPD), includes the assessment of changes in joints, tendons with synovial sheath, entheses, skin, and nails. It represents a feasible, reliable, and comprehensive approach for multitarget monitoring of PsA.

The score is based on the simple arithmetic sum of the scores regarding the five clinical targets. Power Doppler for each target is graded from 0 to 3 on the basis of the semiquantitative scoring systems previously suggested. The maximum total score of 5TPDis 15. In our study, the instrument was found to possess both face and content validity, and it exhibited good responsiveness. By documenting these key measurement properties, we have shown that the 5TPD is a useful instrument for the assessment of disease activity and responsiveness in PsA patients and is, therefore, potentially applicable in standard clinical care, observational studies, and clinical trials.

The 5PTD is feasible and easy to perform in the hands of expert sonographers. The baseline assessment takes an average of 10.5 minutes. The follow-up complete examination, including calculating the score, averages no more than 7 minutes, which makes it quite practical in busy clinical settings.

The main limitation of the score currently is that it was tested in a small cohort of patients, which does not allow for an accurate evaluation in terms of the sensitivity and specificity needed to support our results more strongly. Also, we need to consider the ceiling effect. For example, high composite ultrasound scores denote the involvement of multiple target areas of psoriatic disease, and they can be shared by patients with relevant differences in terms of the extent of the inflammatory involvement at each specific target area. In other words, a severe inflammation of a single joint showing a power Doppler grade of 3 gives the maximum contribution to the final score; an equally severe inflammation in terms of power Doppler appearance, but polyarticular involvement, cannot provide more than 3 and thus would be easily underestimated. We are currently developing steps aimed at defining a linear cutoff value point for any single domain of 5TPD to resolve this aspect.

It is important to remember that this composite score was designed to monitor PsA disease activity in daily practice after a complete clinical examination, and not to replace other well-established and accepted ultrasound assessments.

Question: What is next for the 5TPD?

Dr. Gutierrez: Investigations are ongoing to assess the advantages and limitations of the formula in wider cohorts of patients. The composite score needs further development and concurrent and discriminate validation through randomized controlled trials and longitudinal observational studies. The tool is currently being evaluated prospectively as part of a larger multicenter study, as well as in a study comparing it with the CPDAI for the assessment of disease activity and responsiveness.

–Interview by Diana Mahoney

Dr. Gutierrez is scientific director of the Pan-American League of Associations for Rheumatology (PANLAR) Ultrasound Group. He reported having no financial conflicts of interest.

CHICAGO – Patients given a look at their coronary artery calcium CT scans are more likely to undertake cardiovascular risk reduction measures.

Further, the more abnormal the coronary artery calcium (CAC) score and its corresponding cardiac CT scan, the better the subsequent patient adherence with recommended risk reduction measures. So CAC scores are useful not only for risk stratification, but also for improving adherence to measures aimed at lowering risk, according to Dr. Nove Kalia of the University of Saskatchewan, Saskatoon.

He presented two related studies showing that patients who viewed their own CAC CT scan and had an elevated CAC score were more likely to lose weight and to adhere to prescribed statin therapy. He carried out both studies at Harbor-UCLA Medical Center in Torrance, Calif.

The weight loss study included 518 subjects followed for a mean of 3 years after their initial CAC CT scan. All participants were shown their scans and the significance of their CAC score was explained to them.

Any measurable weight loss at 3 years of follow up was present in 22% of subjects with a CAC score of 0, in 36% of those with a score of 1-99, in 32% of those with a score of 100-399, and in 38% of those with a score of 400 or above.

Compared to patients with a CAC score of 0, the likelihood of weight loss was 2.0-fold greater in patients with a CAC score of 1-99, 3.6-fold greater in those with a score of 100-399, and 3.3-fold greater in patients with a CAC score of 400 or above.

The higher the CAC score, the greater the average weight loss, ranging from 5 pounds in those with a score of 1-99 to 15 pounds with a score of 400 or greater.

"I think visualizing these coronary artery calcium images may be an important means of motivating patients even in an era of economic austerity," Dr. Kalia asserted. "The extra motivation you get from visualizing these images is helpful and probably translates into reduced long-term effects of coronary artery disease."

The statin adherence study involved 2,100 patients. At a mean follow up of 3 years, responses to a comprehensive patient questionnaire revealed that 36% of patients with a CAC score of 0 were compliant with their prescribed statin therapy, as compared to 52% of those with a CAC score of 1-99, 57% with a score of 100-399, and 59% with a CAC score of 400 or greater.

Compared to those with a CAC score of 0, adherence to statin therapy was 2.0-fold greater in patients with a score of 1-99, 2.4-fold greater with a score of 100-399, and 2.6-fold greater with a score of 400 or more.

Dr. Kalia reported having no financial conflicts.

CHICAGO – Patients given a look at their coronary artery calcium CT scans are more likely to undertake cardiovascular risk reduction measures.

Further, the more abnormal the coronary artery calcium (CAC) score and its corresponding cardiac CT scan, the better the subsequent patient adherence with recommended risk reduction measures. So CAC scores are useful not only for risk stratification, but also for improving adherence to measures aimed at lowering risk, according to Dr. Nove Kalia of the University of Saskatchewan, Saskatoon.

He presented two related studies showing that patients who viewed their own CAC CT scan and had an elevated CAC score were more likely to lose weight and to adhere to prescribed statin therapy. He carried out both studies at Harbor-UCLA Medical Center in Torrance, Calif.

The weight loss study included 518 subjects followed for a mean of 3 years after their initial CAC CT scan. All participants were shown their scans and the significance of their CAC score was explained to them.

Any measurable weight loss at 3 years of follow up was present in 22% of subjects with a CAC score of 0, in 36% of those with a score of 1-99, in 32% of those with a score of 100-399, and in 38% of those with a score of 400 or above.

Compared to patients with a CAC score of 0, the likelihood of weight loss was 2.0-fold greater in patients with a CAC score of 1-99, 3.6-fold greater in those with a score of 100-399, and 3.3-fold greater in patients with a CAC score of 400 or above.

The higher the CAC score, the greater the average weight loss, ranging from 5 pounds in those with a score of 1-99 to 15 pounds with a score of 400 or greater.

"I think visualizing these coronary artery calcium images may be an important means of motivating patients even in an era of economic austerity," Dr. Kalia asserted. "The extra motivation you get from visualizing these images is helpful and probably translates into reduced long-term effects of coronary artery disease."

The statin adherence study involved 2,100 patients. At a mean follow up of 3 years, responses to a comprehensive patient questionnaire revealed that 36% of patients with a CAC score of 0 were compliant with their prescribed statin therapy, as compared to 52% of those with a CAC score of 1-99, 57% with a score of 100-399, and 59% with a CAC score of 400 or greater.

Compared to those with a CAC score of 0, adherence to statin therapy was 2.0-fold greater in patients with a score of 1-99, 2.4-fold greater with a score of 100-399, and 2.6-fold greater with a score of 400 or more.

Dr. Kalia reported having no financial conflicts.

CHICAGO – Patients given a look at their coronary artery calcium CT scans are more likely to undertake cardiovascular risk reduction measures.

Further, the more abnormal the coronary artery calcium (CAC) score and its corresponding cardiac CT scan, the better the subsequent patient adherence with recommended risk reduction measures. So CAC scores are useful not only for risk stratification, but also for improving adherence to measures aimed at lowering risk, according to Dr. Nove Kalia of the University of Saskatchewan, Saskatoon.

He presented two related studies showing that patients who viewed their own CAC CT scan and had an elevated CAC score were more likely to lose weight and to adhere to prescribed statin therapy. He carried out both studies at Harbor-UCLA Medical Center in Torrance, Calif.

The weight loss study included 518 subjects followed for a mean of 3 years after their initial CAC CT scan. All participants were shown their scans and the significance of their CAC score was explained to them.

Any measurable weight loss at 3 years of follow up was present in 22% of subjects with a CAC score of 0, in 36% of those with a score of 1-99, in 32% of those with a score of 100-399, and in 38% of those with a score of 400 or above.

Compared to patients with a CAC score of 0, the likelihood of weight loss was 2.0-fold greater in patients with a CAC score of 1-99, 3.6-fold greater in those with a score of 100-399, and 3.3-fold greater in patients with a CAC score of 400 or above.

The higher the CAC score, the greater the average weight loss, ranging from 5 pounds in those with a score of 1-99 to 15 pounds with a score of 400 or greater.

"I think visualizing these coronary artery calcium images may be an important means of motivating patients even in an era of economic austerity," Dr. Kalia asserted. "The extra motivation you get from visualizing these images is helpful and probably translates into reduced long-term effects of coronary artery disease."

The statin adherence study involved 2,100 patients. At a mean follow up of 3 years, responses to a comprehensive patient questionnaire revealed that 36% of patients with a CAC score of 0 were compliant with their prescribed statin therapy, as compared to 52% of those with a CAC score of 1-99, 57% with a score of 100-399, and 59% with a CAC score of 400 or greater.

Compared to those with a CAC score of 0, adherence to statin therapy was 2.0-fold greater in patients with a score of 1-99, 2.4-fold greater with a score of 100-399, and 2.6-fold greater with a score of 400 or more.

Dr. Kalia reported having no financial conflicts.

CHICAGO – Triaging chest-pain patients with cardiac CT angiography increased direct emergency room discharges and shortened hospital stays, but did not reduce costs, compared with a standard emergency department evaluation, in the prospective, randomized ROMICAT-II trial.

There were no missed cases of acute coronary syndrome with either strategy in ROMICAT II, the Rule Out Myocardial Infarction using Computer Assisted Computed Tomography II trial.

Patrice Wendling/IMNG Medical Media

Incorporating cardiac computed tomography angiography (CCTA) early into an emergency department (ED) evaluation strategy improves clinical decision making for ED triage compared to current practice and is safe, principal investigator Dr. Udo Hoffmann said at the annual meeting of the American College of Cardiology.

ROMICAT II evenly randomized 1,000 patients, aged 40-74 years, with suspected acute coronary syndrome to the CCTA-based strategy or standard ED evaluation. Their mean age was 54 years and half had 2-3 major cardiovascular risk factors.

The average time to diagnosis was shortened by 8 hours with CCTA from 18.7 hours with a standard evaluation to 10.4 hours. A diagnosis could not be made in 4% of CT scans.

The average length of stay, the study’s primary end point, was significantly shorter at 23 hours vs. 31 hours with a standard evaluation. This was driven largely by patients without ACS as a final diagnosis, who averaged 17 hours in the hospital with CCTA vs. 27 hours with a standard evaluation, said Dr. Hoffmann, a cardiac radiologist at Massachusetts General Hospital in Boston.

Patients with an ACS diagnosis had similar lengths of stay, averaging 86.3 hours vs. 84 hours, respectively. ROMICAT I reported an 8% prevalence of ACS in acute chest-pain patients at low to intermediate risk of ACS.

"An interesting data point here is that it took about 8 hours to discharge 50% of patients in the CT arm, while it took about 18 hours longer to discharge 50% of patients in the standard-of-care arm," he said.

The number CCTA patients discharged directly from the emergency department was triple that of the standard-evaluation group (46.7% vs. 12.4%), with no missed ACS. At 28 days, major adverse cardiovascular events were similar, reported in two CCTA and five standard-care patients. In all, 13 CCTA patients and 19 standard-care patients returned to the ED, with seven repeat hospitalizations in both groups.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Matthew Budoff, director of the University of California, Los Angeles BioMed CT Reading Center, observed that similar trends were just reported at the meeting from the American College of Radiology Imaging Network PA 4005 trial and were reported last year from the CT-STAT (Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment trial. (J. Am. Coll. Cardiol. 2011;58:1414-22).

"We’re now garnering significant clinical evidence with three randomized trials that are all very consistent," he said.

Financial Costs

While cost analyses are still awaited from American College of Radiology Imaging Network PA 4005, hospital billing data from a subset of patients in ROMICAT II showed that ED costs with the CCTA strategy were significantly lower, at 19% less per patient at a mean of $2,053 vs. $2,532 with a standard evaluation, Dr. Hoffmann reported. Hospital costs, however, were 50% higher with the CCTA strategy ($1,950 vs. $1,297), driven largely by significantly more diagnostic testing during the index stay and more invasive coronary angiography (12% vs. 8%).

Dr. Hoffmann said Medicare data have shown a doubling in procedures and costs after CCTA. He described the absence of an increase in costs as "a major step forward," but also acknowledged "there’s always room for improvement."

He went on to say that CCTA may become more cost effective as technology evolves and the effectiveness of CT increases and as emergency room experience with CCTA improves. ROMICAT II was conducted at centers without ED CCTA experience, and required training by Dr. Hoffmann and a coauthor was not included in the cost analysis, he acknowledged.

Dr. Michael Crawford, professor of medicine and chief of clinical cardiology at the University of California, San Francisco Medical Center, pointed out that CCTA use in ROMICAT II was very contained since enrollment was limited to patients coming to the emergency room on weekday business hours only.

"So if you expand this to 24/7 coverage, the cost has to go up," he told reporters. "The question of what you save downstream by avoiding further tests remains to be shown in the future."

Radiation Costs

Invited discussant Dr. Elliott Antman expressed concerns about the cost of radiation exposure, noting that there was roughly a threefold increase in the cumulative radiation dose with the CCTA strategy (14.3 5.3 mSv vs. 5.3 mSv), and that chest-pain patients often present to different emergency departments.

"If in fact one adopts a strategy using cardiac CT, there is the potential for patients to have repeated exposures," said Dr. Antman, professor of medicine at Harvard University and senior faculty member in the cardiovascular division at Brigham and Women’s Hospital in Boston.

Dr. Hoffmann said there is a cost to performing a CT and to being able to discharge patients early, but also noted the collateral effect early discharge of chest-pain patients can have on getting other patients seen in the emergency room.

Dr. Budoff commented that there have been less repeat visits with CCTA in the three trials to date, and thus if one looked at cumulative radiation exposure over the subsequent year, "it might actually start to balance a little better."

This study was sponsored by Massachusetts General Hospital. Dr. Hoffmann reported research grants from the National Institutes of Health and Siemens Medical Systems. Five of his coauthors reported consulting and research funding from a variety of sources.

CHICAGO – Triaging chest-pain patients with cardiac CT angiography increased direct emergency room discharges and shortened hospital stays, but did not reduce costs, compared with a standard emergency department evaluation, in the prospective, randomized ROMICAT-II trial.

There were no missed cases of acute coronary syndrome with either strategy in ROMICAT II, the Rule Out Myocardial Infarction using Computer Assisted Computed Tomography II trial.

Patrice Wendling/IMNG Medical Media

Incorporating cardiac computed tomography angiography (CCTA) early into an emergency department (ED) evaluation strategy improves clinical decision making for ED triage compared to current practice and is safe, principal investigator Dr. Udo Hoffmann said at the annual meeting of the American College of Cardiology.

ROMICAT II evenly randomized 1,000 patients, aged 40-74 years, with suspected acute coronary syndrome to the CCTA-based strategy or standard ED evaluation. Their mean age was 54 years and half had 2-3 major cardiovascular risk factors.

The average time to diagnosis was shortened by 8 hours with CCTA from 18.7 hours with a standard evaluation to 10.4 hours. A diagnosis could not be made in 4% of CT scans.

The average length of stay, the study’s primary end point, was significantly shorter at 23 hours vs. 31 hours with a standard evaluation. This was driven largely by patients without ACS as a final diagnosis, who averaged 17 hours in the hospital with CCTA vs. 27 hours with a standard evaluation, said Dr. Hoffmann, a cardiac radiologist at Massachusetts General Hospital in Boston.

Patients with an ACS diagnosis had similar lengths of stay, averaging 86.3 hours vs. 84 hours, respectively. ROMICAT I reported an 8% prevalence of ACS in acute chest-pain patients at low to intermediate risk of ACS.

"An interesting data point here is that it took about 8 hours to discharge 50% of patients in the CT arm, while it took about 18 hours longer to discharge 50% of patients in the standard-of-care arm," he said.

The number CCTA patients discharged directly from the emergency department was triple that of the standard-evaluation group (46.7% vs. 12.4%), with no missed ACS. At 28 days, major adverse cardiovascular events were similar, reported in two CCTA and five standard-care patients. In all, 13 CCTA patients and 19 standard-care patients returned to the ED, with seven repeat hospitalizations in both groups.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Matthew Budoff, director of the University of California, Los Angeles BioMed CT Reading Center, observed that similar trends were just reported at the meeting from the American College of Radiology Imaging Network PA 4005 trial and were reported last year from the CT-STAT (Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment trial. (J. Am. Coll. Cardiol. 2011;58:1414-22).

"We’re now garnering significant clinical evidence with three randomized trials that are all very consistent," he said.

Financial Costs

While cost analyses are still awaited from American College of Radiology Imaging Network PA 4005, hospital billing data from a subset of patients in ROMICAT II showed that ED costs with the CCTA strategy were significantly lower, at 19% less per patient at a mean of $2,053 vs. $2,532 with a standard evaluation, Dr. Hoffmann reported. Hospital costs, however, were 50% higher with the CCTA strategy ($1,950 vs. $1,297), driven largely by significantly more diagnostic testing during the index stay and more invasive coronary angiography (12% vs. 8%).

Dr. Hoffmann said Medicare data have shown a doubling in procedures and costs after CCTA. He described the absence of an increase in costs as "a major step forward," but also acknowledged "there’s always room for improvement."

He went on to say that CCTA may become more cost effective as technology evolves and the effectiveness of CT increases and as emergency room experience with CCTA improves. ROMICAT II was conducted at centers without ED CCTA experience, and required training by Dr. Hoffmann and a coauthor was not included in the cost analysis, he acknowledged.

Dr. Michael Crawford, professor of medicine and chief of clinical cardiology at the University of California, San Francisco Medical Center, pointed out that CCTA use in ROMICAT II was very contained since enrollment was limited to patients coming to the emergency room on weekday business hours only.

"So if you expand this to 24/7 coverage, the cost has to go up," he told reporters. "The question of what you save downstream by avoiding further tests remains to be shown in the future."

Radiation Costs

Invited discussant Dr. Elliott Antman expressed concerns about the cost of radiation exposure, noting that there was roughly a threefold increase in the cumulative radiation dose with the CCTA strategy (14.3 5.3 mSv vs. 5.3 mSv), and that chest-pain patients often present to different emergency departments.

"If in fact one adopts a strategy using cardiac CT, there is the potential for patients to have repeated exposures," said Dr. Antman, professor of medicine at Harvard University and senior faculty member in the cardiovascular division at Brigham and Women’s Hospital in Boston.

Dr. Hoffmann said there is a cost to performing a CT and to being able to discharge patients early, but also noted the collateral effect early discharge of chest-pain patients can have on getting other patients seen in the emergency room.

Dr. Budoff commented that there have been less repeat visits with CCTA in the three trials to date, and thus if one looked at cumulative radiation exposure over the subsequent year, "it might actually start to balance a little better."

This study was sponsored by Massachusetts General Hospital. Dr. Hoffmann reported research grants from the National Institutes of Health and Siemens Medical Systems. Five of his coauthors reported consulting and research funding from a variety of sources.

CHICAGO – Triaging chest-pain patients with cardiac CT angiography increased direct emergency room discharges and shortened hospital stays, but did not reduce costs, compared with a standard emergency department evaluation, in the prospective, randomized ROMICAT-II trial.

There were no missed cases of acute coronary syndrome with either strategy in ROMICAT II, the Rule Out Myocardial Infarction using Computer Assisted Computed Tomography II trial.

Patrice Wendling/IMNG Medical Media

Incorporating cardiac computed tomography angiography (CCTA) early into an emergency department (ED) evaluation strategy improves clinical decision making for ED triage compared to current practice and is safe, principal investigator Dr. Udo Hoffmann said at the annual meeting of the American College of Cardiology.

ROMICAT II evenly randomized 1,000 patients, aged 40-74 years, with suspected acute coronary syndrome to the CCTA-based strategy or standard ED evaluation. Their mean age was 54 years and half had 2-3 major cardiovascular risk factors.

The average time to diagnosis was shortened by 8 hours with CCTA from 18.7 hours with a standard evaluation to 10.4 hours. A diagnosis could not be made in 4% of CT scans.

The average length of stay, the study’s primary end point, was significantly shorter at 23 hours vs. 31 hours with a standard evaluation. This was driven largely by patients without ACS as a final diagnosis, who averaged 17 hours in the hospital with CCTA vs. 27 hours with a standard evaluation, said Dr. Hoffmann, a cardiac radiologist at Massachusetts General Hospital in Boston.

Patients with an ACS diagnosis had similar lengths of stay, averaging 86.3 hours vs. 84 hours, respectively. ROMICAT I reported an 8% prevalence of ACS in acute chest-pain patients at low to intermediate risk of ACS.

"An interesting data point here is that it took about 8 hours to discharge 50% of patients in the CT arm, while it took about 18 hours longer to discharge 50% of patients in the standard-of-care arm," he said.

The number CCTA patients discharged directly from the emergency department was triple that of the standard-evaluation group (46.7% vs. 12.4%), with no missed ACS. At 28 days, major adverse cardiovascular events were similar, reported in two CCTA and five standard-care patients. In all, 13 CCTA patients and 19 standard-care patients returned to the ED, with seven repeat hospitalizations in both groups.

Patrice Wendling/IMNG Medical Media

Invited discussant Dr. Matthew Budoff, director of the University of California, Los Angeles BioMed CT Reading Center, observed that similar trends were just reported at the meeting from the American College of Radiology Imaging Network PA 4005 trial and were reported last year from the CT-STAT (Computed Tomography for Systematic Triage of Acute Chest Pain Patients to Treatment trial. (J. Am. Coll. Cardiol. 2011;58:1414-22).

"We’re now garnering significant clinical evidence with three randomized trials that are all very consistent," he said.

Financial Costs

While cost analyses are still awaited from American College of Radiology Imaging Network PA 4005, hospital billing data from a subset of patients in ROMICAT II showed that ED costs with the CCTA strategy were significantly lower, at 19% less per patient at a mean of $2,053 vs. $2,532 with a standard evaluation, Dr. Hoffmann reported. Hospital costs, however, were 50% higher with the CCTA strategy ($1,950 vs. $1,297), driven largely by significantly more diagnostic testing during the index stay and more invasive coronary angiography (12% vs. 8%).

Dr. Hoffmann said Medicare data have shown a doubling in procedures and costs after CCTA. He described the absence of an increase in costs as "a major step forward," but also acknowledged "there’s always room for improvement."

He went on to say that CCTA may become more cost effective as technology evolves and the effectiveness of CT increases and as emergency room experience with CCTA improves. ROMICAT II was conducted at centers without ED CCTA experience, and required training by Dr. Hoffmann and a coauthor was not included in the cost analysis, he acknowledged.

Dr. Michael Crawford, professor of medicine and chief of clinical cardiology at the University of California, San Francisco Medical Center, pointed out that CCTA use in ROMICAT II was very contained since enrollment was limited to patients coming to the emergency room on weekday business hours only.

"So if you expand this to 24/7 coverage, the cost has to go up," he told reporters. "The question of what you save downstream by avoiding further tests remains to be shown in the future."

Radiation Costs

Invited discussant Dr. Elliott Antman expressed concerns about the cost of radiation exposure, noting that there was roughly a threefold increase in the cumulative radiation dose with the CCTA strategy (14.3 5.3 mSv vs. 5.3 mSv), and that chest-pain patients often present to different emergency departments.

"If in fact one adopts a strategy using cardiac CT, there is the potential for patients to have repeated exposures," said Dr. Antman, professor of medicine at Harvard University and senior faculty member in the cardiovascular division at Brigham and Women’s Hospital in Boston.

Dr. Hoffmann said there is a cost to performing a CT and to being able to discharge patients early, but also noted the collateral effect early discharge of chest-pain patients can have on getting other patients seen in the emergency room.

Dr. Budoff commented that there have been less repeat visits with CCTA in the three trials to date, and thus if one looked at cumulative radiation exposure over the subsequent year, "it might actually start to balance a little better."

This study was sponsored by Massachusetts General Hospital. Dr. Hoffmann reported research grants from the National Institutes of Health and Siemens Medical Systems. Five of his coauthors reported consulting and research funding from a variety of sources.