Objectives To determine an ultrasound (US) scanning protocol with the best accuracy for the diagnosis of gout and CPPD in patients with acute mono/oligoarthritis of unknown origin. Methods Patients with acute mono/oligoarthritis, in whom a joint aspiration at the most clinically involved joint (target joint) was requested, were consecutively enrolled. US was performed in each patient before the arthrocentesis. The accuracy of different US findings and scanning protocols for the diagnosis of gout and CPPD was calculated. Results 161 subjects were included (32 gout patients, 30 CPPD patients and 99 disease-controls). US findings had a high specificity for gout (0.92-0.96) and CPPD (0.90-0.97), while the sensitivity ranged from 0.73 to 0.85 in gout (double contour sign and tophi, respectively) and from 0.60 to 0.90 in CPPD (hyaline and fibrocartilage deposits, respectively). The US assessment of two joints bilaterally (gout: knees, MTP1js, CPPD: knees, wrists) + the target joint had an excellent diagnostic sensitivity (gout:0.91, CPPD:0.93) and specificity (gout:0.91, CPPD:0.89). This targeted US scanning protocol yielded to higher diagnostic accuracy compared to the US evaluation of the target joint (gout, AUC:0.91 vs AUC:0.84, p = 0.03; CPPD, AUC:0.93, vs AUC:0.84, p = 0.04) unless the target joint was the knee or the MTP1j in gout, and the knee or the wrist in CPPD. Conclusions A targeted US scanning protocol of two joints bilaterally + the target joint (unless this was the knee, MTP1j or the wrist) showed an excellent accuracy (>90%) for the diagnosis of crystal arthritis in patients with acute mono/oligoarthritis.
ObjectiveCalcium pyrophosphate deposition (CPPD) disease is prevalent and has diverse presentations, but there are no validated classification criteria for this symptomatic arthritis. The American College of Rheumatology (ACR) and EULAR have developed the first-ever validated classification criteria for symptomatic CPPD disease.MethodsSupported by the ACR and EULAR, a multinational group of investigators followed established methodology to develop these disease classification criteria. The group generated lists of candidate items and refined their definitions, collected de-identified patient profiles, evaluated strengths of associations between candidate items and CPPD disease, developed a classification criteria framework, and used multi-criterion decision analysis to define criteria weights and a classification threshold score. The criteria were validated in an independent cohort.ResultsAmong patients with joint pain, swelling, or tenderness (entry criterion) whose symptoms are not fully explained by an alternative disease (exclusion criterion), the presence of crowned dens syndrome or calcium pyrophosphate crystals in synovial fluid are sufficient to classify a patient as having CPPD disease. In the absence of these findings, a score>56 points using weighted criteria, comprising clinical features, associated metabolic disorders, and results of laboratory and imaging investigations, can be used to classify as CPPD disease. These criteria had a sensitivity of 92.2% and specificity of 87.9% in the derivation cohort (190 CPPD cases, 148 mimickers), whereas sensitivity was 99.2% and specificity was 92.5% in the validation cohort (251 CPPD cases, 162 mimickers).ConclusionThe 2023 ACR/EULAR CPPD disease classification criteria have excellent performance characteristics and will facilitate research in this field.
Objectives To evaluate whether ultrasound (US) findings indicating monosodium urate (MSU) deposits and US-detected inflammation [i.e. power Doppler (PD) signal] predict gout flares over 12 months. Methods Gout patients on urate-lowering therapy for at least the preceding six months were enrolled consecutively in this 12-month prospective, observational, single-centre study. A nested case-control analysis was performed. Cases were participants with at least one flare in the follow-up period, while controls did not self-report any gout flare. The US assessment included elbows, wrists, 2nd metacarpophalangeal joints, knees, ankles, and 1st metatarsophalangeal joints. The US findings indicating MSU deposits [i.e. aggregates, double contour (DC) sign and tophi] were identified as present/absent according to the Outcome Measure in Rheumatology definitions. PD signal was scored semiquantitatively. Summated scores were calculated for each US finding. Results Eighty-one gout participants were enrolled, and 71 completed the study. Thirty (42.3%) of 71 participants experienced at least one flare over 12 months, with a median of 2.0 flares. Cases had a greater US burden of MSU deposits (6.7 ± 4.7 vs 2.9 ± 2.6, p= 0.01) and PD signal (3.73 ± 3.53 vs 0.82 ± 1.44, p< 0.01) than controls, at baseline. The baseline US scores indicating MSU deposits and US-detected inflammation were significantly associated with the occurrence [total MSU score, adjusted Odds Ratio (aOR):1.75, 95%CI : 1.26–2.43; PD score, aOR : 1.63, 95%CI : 1.12–2.40] and the number (total MSU score, aIRR : 1.17, 95%CI : 1.08–1.26; PD score, aIRR : 1.29, 95%CI : 1.19–1.40) of flares over 12 months in multivariate analyses. Conclusions Baseline US findings indicating MSU deposits and US-detected inflammation are independent predictors of gout flares over 12 months.
ObjectiveCalcium pyrophosphate deposition (CPPD) disease is prevalent and has diverse presentations, but there are no validated classification criteria for this symptomatic arthritis. The American College of Rheumatology (ACR) and EULAR have developed the first‐ever validated classification criteria for symptomatic CPPD disease.MethodsSupported by the ACR and EULAR, a multinational group of investigators followed established methodology to develop these disease classification criteria. The group generated lists of candidate items and refined their definitions, collected de‐identified patient profiles, evaluated strengths of associations between candidate items and CPPD disease, developed a classification criteria framework, and used multi‐criterion decision analysis to define criteria weights and a classification threshold score. The criteria were validated in an independent cohort.ResultsAmong patients with joint pain, swelling, or tenderness (entry criterion) whose symptoms are not fully explained by an alternative disease (exclusion criterion), the presence of crowned dens syndrome or calcium pyrophosphate crystals in synovial fluid are sufficient to classify a patient as having CPPD disease. In the absence of these findings, a score >56 points using weighted criteria, comprising clinical features, associated metabolic disorders, and results of laboratory and imaging investigations, can be used to classify as CPPD disease. These criteria had a sensitivity of 92.2% and specificity of 87.9% in the derivation cohort (190 CPPD cases, 148 mimickers), whereas sensitivity was 99.2% and specificity was 92.5% in the validation cohort (251 CPPD cases, 162 mimickers).ConclusionThe 2023 ACR/EULAR CPPD disease classification criteria have excellent performance characteristics and will facilitate research in this field.
Objective To explore the spectrum of articular and peri-articular ultrasound (US) findings at metacarpophalangeal (MCP) joints in calcium pyrophosphate (CPP) deposition disease (CPPD). Methods Consecutive CPPD patients (chronic CPP crystal inflammatory arthritis or osteoarthritis (OA) with CPPD), and age- and sex-matched controls with rheumatoid arthritis (RA) were prospectively enrolled. Patients underwent bilateral US examination of MCP joints. CPP deposits, synovial inflammation, osteophytes, cartilage damage, and bone erosions were recorded. Results Sixty CPPD patients (33, 55.0% with osteoarthritis with CPPD and 27, 45.0% with chronic CPP crystal inflammatory arthritis) and 40 RA patients were enrolled. CPP deposits were detected in 24 (40.0%) CPPD patients and in 3 (7.5%) RA patients (p< 0.01). In CPPD patients, different types of CPP deposits were identified at MCP joints: 17 (28.3%) patients had dorsal capsuloligamentous deposits, 14 (23.3%) intra-cartilaginous deposits, 13 (21.7%) lateral capsuloligamentous deposits, 12 (20.0%) intra-articular deposits, 8 (13.3%) double contour sign, and 5 (8.3%) flexor digitorum tendons’ deposits. CPPD patients with chronic CPP crystal inflammatory arthritis showed more US findings indicating synovial inflammation and CPP deposits than those with osteoarthritis with CPPD. Conversely, a higher prevalence of US features indicating structural damage was noted in this latter phenotype. CPP deposits and bone erosions were the US findings with the highest value for diagnosing chronic CPP crystal inflammatory arthritis and RA, respectively. Conclusion This study provides pictorial evidence of the broad spectrum of US findings indicating CPP deposits at MCP joints in CPPD. Furthermore, we reported different US patterns in different CPPD phenotypes.
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