Ultrasound composite scores for the assessment of inflammatory and structural pathologies in Psoriatic Arthritis (PsASon-Score)

Anja Ficjan, Rusmir Husic, Judith Gretler, Angelika Lackner, Winfried B Graninger, Marwin Gutierrez, Christina Duftner, Josef Hermann, Christian Dejaco, Anja Ficjan, Rusmir Husic, Judith Gretler, Angelika Lackner, Winfried B Graninger, Marwin Gutierrez, Christina Duftner, Josef Hermann, Christian Dejaco

Abstract

Introduction: This study was performed to develop ultrasound composite scores for the assessment of inflammatory and structural lesions in Psoriatic Arthritis (PsA).

Methods: We performed a prospective study on 83 PsA patients undergoing two study visits scheduled 6 months apart. B-mode and Power Doppler (PD) findings were semi-quantitatively scored at 68 joints (evaluating synovia, perisynovial tissue, tendons and bone) and 14 entheses. We constructed bilateral and unilateral (focusing the dominant site) ultrasound composite scores selecting relevant sites by a hierarchical approach. We tested convergent construct validity, reliability and feasibility of inflammatory and structural elements of the scores as well as sensitivity to change for inflammatory items.

Results: The bilateral score (termed PsASon22) included 22 joints (6 metacarpophalangeal joints (MCPs), 4 proximal interphalangeal joints (PIPs) of hands (H-PIPs), 2 metatarsophalangeal joints (MTPs), 4 distal interphalangeal joints (DIPs) of hands (H-DIPs), 2 DIPs of feet (F-DIPs), 4 large joints) and 4 entheses (bilateral assessment of lateral epicondyle and distal patellar tendon). The unilateral score (PsASon13) compromised 13 joints (2 MCPs, 3 H-PIPs, 1 PIP of feet (F-PIP), 2 MTPs, 1 H-DIP and 2 F-DIPs and 2 large joints) and 2 entheses (unilateral lateral epicondyle and distal patellar tendon). Both composite scores revealed a moderate to high sensitivity (bilateral composite score 43% to 100%, unilateral 36% to 100%) to detect inflammatory and structural lesions compared to the 68-joint/14-entheses score. The inflammatory and structural components of the composite scores correlated weakly with clinical markers of disease activity (corrcoeffs 0 to 0.40) and the health assessment questionnaire (HAQ, corrcoeffs 0 to 0.39), respectively. Patients with active disease achieving remission at follow-up yielded greater reductions of ultrasound inflammatory scores than those with stable clinical activity (Cohen's d effect size ranging from 0 to 0.79). Inter-rater reliability of bi- and unilateral composite scores was moderate to good with ICCs ranging from 0.42 to 0.96 and from 0.36 to 0.71, respectively for inflammatory and structural sub-scores. The PsASon22 and PsASon13 required 16 to 26 and 9 to 13 minutes, respectively to be completed.

Conclusion: Both new PsA ultrasound composite scores (PsASon22 and PsASon13) revealed sufficient convergent construct validity, sensitivity to change, reliability and feasibility.

Figures

Figure 1
Figure 1
Joints and entheses included in ultrasound composite scores. Illustration depicts joints (circles) and entheses (arrows) included in the 68-joint/14-entheses score, and the bilateral 22-joint/4-entheses (PsASon22) and the unilateral 13-joint/2-entheses composite scores (PsASon13). For the unilateral score the dominant site is investigated (for example, the right site as shown in the figure). Solid circles indicate that both, palmar and dorsal sites (suprapatellar, medial and lateral scans for the knee) are assessed, whereas striped circles mark sites investigated by dorsal scans only.
Figure 2
Figure 2
Sensitivity to change of ultrasound composite scores. Change (Δscore 6-month visit – score baseline) of global ultrasound inflammatory subscores (global ultrasound inflammation score (GUI-score)) in patients without a change in clinical disease activity (that is, active or remission at both baseline and follow-up visits) (no change DA) and patients who were active at baseline and achieved remission according to the evaluating physician (A), active-remission) or minimal disease activity (B) (active-MDA) at 6 months follow-up. Whiskers box plots show the median and 50% of cases within the boxes and all data excluding mavericks between the end points of the whiskers. Differences were tested by the Mann-Whitney U-test.

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