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Is the Madrid Sonographic Enthesitis Index Useful for Differentiating Psoriatic Arthritis from Psoriasis Alone and Healthy Controls?

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Is the Madrid Sonographic Enthesitis Index Useful for Differentiating Psoriatic Arthritis from Psoriasis Alone and Healthy Controls? Is the Madrid Sonographic Enthesitis Index Useful for Differentiating Psoriatic Arthritis from Psoriasis Alone and Healthy Controls? Lihi Eder, Jai Jayakar, Arane Thavaneswaran, Amir Haddad, Vinod Chandran, David Salonen, Cheryl F. Rosen, and Dafna D. Gladman ABSTRACT. Objective. To assess the usefulness of the MAdrid Sonographic Enthesitis Index (MASEI) in classi- fying patients as having psoriatic arthritis (PsA) and comparing entheseal abnormalities between patients with PsA, psoriasis alone (PsC), and healthy controls (HC). Methods. Patients with PsC were assessed to exclude inflammatory arthritis. The MASEI scoring system was used to quantify the extent of ultrasonographic (US) entheseal abnormalities. The total MASEI score was categorized into items that reflected inflammatory abnormalities (MASEI-inflam- matory) and chronic damage (MASEI-damage). Nonparametric tests were used to compare MASEI scores across the groups. A cutoff point of MASEI ≥ 20 was used to calculate the sensitivity and specificity of the MASEI to classify patients as having PsA. Results. Patients with PsA (n = 50), PsC (n = 66), and HC (n = 60) were assessed. Total MASEI scores were higher in patients with PsA than in those with PsC, and both those groups were higher than HC (p < 0.0001). MASEI-inflammatory showed a similar trend (p < 0.0001). MASEI-damage was higher in patients with PsA compared to both patients with PsC and HC (p < 0.0001); however, no difference was observed between patients with PsC and HC. No significant difference in MASEI scores was found across the 3 groups in patients with a body mass index > 30. The sensitivity of the MASEI score to correctly classify patients as having PsA was 30% and the specificity was 95% when compared to HC and 89% when compared to PsC. Conclusion. The severity of US entheseal abnormalities is highest in patients with PsA followed by PsC and is lowest in healthy controls. MASEI can specifically classify patients as having PsA. (First Release Feb 1 2014; J Rheumatol 2014;41:466–72; doi:10.3899/jrheum.130949) Key Indexing Terms: ULTRASOUND ENTHESITIS SPONDYLOARTHRITIS PSORIASIS Enthesitis is considered the primary lesion in spondy- Rheumatology (OMERACT) 7 consensus definition for US loarthritis (SpA), including psoriatic arthritis (PsA)1. The enthesopathy includes abnormalities that reflect both active clinical diagnosis of enthesitis is neither specific nor inflammation and structural damage3. Hypoechogenicity sensitive and often relies on typical abnormalities found in and thickening of the tendon/ligament resulting from edema ultrasound (US) or MRI studies2. The Outcome Measures in and increased power Doppler signal at the enthesis that From the Psoriatic Arthritis Program, Centre for Prognosis Studies in the Studies in the Rheumatic Diseases, Toronto Western Hospital; Rheumatic Diseases, Toronto Western Hospital, Toronto; Western V. Chandran, MBBS, MD, DM, PhD, Assistant Professor, Co-director, University, London; Division of Rheumatology, Department of Medicine, Psoriatic Arthritis Program, Centre for Prognosis Studies in the University of Toronto; Department of Medical Imaging, University of Rheumatic Diseases, Toronto Western Hospital, and Division of Toronto; Musculoskeletal Imaging, Mount Sinai Hospital; Department of Rheumatology, Department of Medicine, University of Toronto; Medical Imaging, University of Toronto; Division of Dermatology, D. Salonen, MD, Associate Professor, Department of Medical Imaging, Toronto Western Hospital and University Health Network Hospitals; University of Toronto, and Staff Radiologist, Musculoskeletal Imaging, Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Mount Sinai Hospital and the University Health Network, Department of Hospital, University of Toronto Psoriatic Arthritis Clinic, Toronto, Medical Imaging; C.F. Rosen, MD, FRCPC, Professor of Medicine, Ontario, Canada. University of Toronto, Head of Division of Dermatology, Toronto Western Funded by a grant from Abbvie Canada. Jai Jayakar was supported by a Hospital and University Health Network Hospitals; D.D. Gladman, MD, Canadian Rheumatology Association-Roche Summer Research FRCPC, Professor of Medicine, University of Toronto, Senior Scientist Studentship Award. The Psoriatic Arthritis Program is funded in part by Toronto Western Research Institute, Director, Psoriatic Arthritis Program, The Arthritis Society, Canadian Institutes of Health Research and the Centre for Prognosis Studies in The Rheumatic Diseases, Toronto Western Krembil Foundation. Hospital. L. Eder, MD, PhD, Postdoctoral Fellow, Psoriatic Arthritis Program, Address correspondence to Dr. D.D. Gladman, Centre for Prognosis Centre for Prognosis Studies in the Rheumatic Diseases, Toronto Western Studies in Rheumatic Disease, Toronto Western Hospital, Hospital; J. Jayakar, Medical Student, Western University; 399 Bathurst, 1E-410B, Toronto, Ontario M5T 2S8, Canada. A. Thavaneswaran, MMath, Research Associate; A. Haddad, MD, Clinical E-mail: [email protected] Research Fellow, Psoriatic Arthritis Program, Centre for Prognosis Accepted for publication October 25, 2013. Personal non-commercial use only. The Journal of Rheumatology Copyright © 2014. All rights reserved. 466 The Journal of Rheumatology 2014; 41:3; doi:10.3899/jrheum.130949 Downloaded on September 28, 2021 from www.jrheum.org represents hypervascularization are considered active matory arthritis. The collected information included demographic infor- inflammatory findings, while bone erosions, calcifications, mation, comorbid conditions, medications, height, weight, and dis- ease-related information including age at diagnosis of psoriasis and PsA; and enthesophytes reflect irreversible damage that counts of tender, swollen, and damaged joints; and current psoriasis 4,5 occasionally coexists with active inflammation . activity, determined by using the Psoriasis Area and Severity Index. The Because of the limitations of clinical assessment of the study was approved by the University Health Network Research Ethics entheses, there is increasing interest in using US to improve Board and all participants gave informed consent. the diagnosis of enthesitis and thus facilitate early diagnosis US assessment. US scanning of the entheses was performed by 2 rheuma- of SpA. In PsA, a potential window of opportunity allows tologists trained in musculoskeletal ultrasound (LE, AH) using a MyLab 70XVG scanner (Esaote) equipped with a 6–18 MHz linear transducer early diagnosis by identifying patients with psoriasis and (Esaote). The following enthesis sites that are included in the MASEI scoring subclinical inflammatory features that may subsequently system were scanned bilaterally: patella (at insertions of the quadriceps evolve to clinical arthritis. Several semiquantitative scoring femoris and patellar tendons), Achilles tendon and plantar fascia insertions on systems have been developed to quantify the extent of a the calcaneus, and triceps tendon insertion to the olecranon process. Each patient’s enthesitis. The MAdrid Sonographic Enthesitis tendon was scanned in both longitudinal and transverse planes, and the scan images were stored. Each examination took about 20 min. The patients were Index (MASEI) scores greyscale abnormalities and power placed in a supine position to assess the patellar and quadriceps entheses. The Doppler signal in 6 entheseal sites, mostly in the lower knee was placed in 70° flexion to assess greyscale abnormalities and in full 6 limbs . De Miguel, et al reported that at a cutoff point of 20 extension to assess vascularization. Then the patients were placed in a prone or more, MASEI correctly classified patients as having SpA position with the feet over the end of the examination table for assessment of with a sensitivity of 53% and a specificity of 83.3% among the Achilles tendon and plantar fascia entheses. The triceps tendon enthesis 7 was assessed with the elbow flexed to 90°. a group of patients with mixed probability of having SpA . All of the following greyscale US findings indicative of enthesopathy The development and validation of MASEI was conducted according to MASEI were documented (Figure 1): thickening and struc- on patients with SpA, but the performance of the method tural changes of the tendon insertion, calcific deposits at the tendon among patients with PsA has not been extensively assessed. insertion, bony changes including erosions and enthesophyte formation as 6 Complicating matters, entheseal lesions are commonly defined . To simplify matters, ossifications and enthesophytes at the found in patients with psoriasis who do not have clinical enthesis were also termed calcifications. Bursitis was defined as a 8,9,10 well-circumscribed, localized anechoic or hypoechoic area at the site of an signs of enthesitis or synovitis . The significance of such anatomical bursa, which was compressible by the transducer. The thickness abnormalities is unclear because other factors, such as age of the enthesis was measured at the insertion of the deeper tendon margin and obesity, may contribute to the development of these into the bone in a longitudinal axis. Vascularization was assessed at the changes. A small study suggested that subclinical enthesitis cortical bone insertion because this site is more specific for enthesitis compared to the presence of a signal at other sites, such as the bursa and the among patients with psoriasis may predict the development 15 11 tendon . Power Doppler settings were standardized with a Doppler
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