|A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter
|Mandl P, Naredo E, Wakefield RJ, Conaghan PG, D'Agostino MA, OMERACT Ultrasound Task Force
This review concluded that ultrasound could be regarded as a valuable tool for examining the overall extent of synovitis in patients with rheumatoid arthritis; the least number of joints to assess could not be determined. Despite some limitations, the conclusion on the number of joints seems appropriate, but the evidence was insufficient for the value of ultrasound.
To determine the least number of joints, and the appropriate scoring system, to correctly assess patients with rheumatoid arthritis, using ultrasound or ultrasonography.
PubMed and EMBASE were searched for studies published in English, between 1984 and April 2010; search terms were reported. Bibliographies of included studies, reviews and meta-analyses were searched. Conference abstracts were excluded.
Studies reporting data on reliability, validity, responsiveness, or joint count or score, for binary, semi-quantitative or quantitative ultrasound scoring systems, in patients with rheumatoid arthritis, were eligible for inclusion.
In the included studies, the number of ultrasound assessments per patient ranged from one to five. Most studies used both grey-scale and power Doppler ultrasound. Most studies had the same definition for power Doppler; none used colour Doppler. The definition of synovitis varied across studies. All studies reported a semi-quantitative scoring system and a cumulative score; over half reported a binary grade, and approximately 15% of studies reported a quantitative scoring system. All studies included the second and third metacarpophalangeal joints in the assessment. Studies were published between 2003 and 2010. Participant characteristics were not reported.
Studies were selected by one reviewer.
Assessment of study quality
Study quality was assessed for six criteria: patient recruitment described; justification given for the number of joints used; description of the ultrasound technique used; blinding of observers; description and source of synovitis scoring; choice of comparator; and completeness of results. Studies had to meet at least one criterion to be included.
The authors did not state how many reviewers assessed study quality.
The data on the number of joints assessed, and the validity, responsiveness and feasibility of the scoring systems, were extracted. The authors did not state how many reviewers extracted data.
Methods of synthesis
Studies were combined in a narrative synthesis, organised by outcome. Differences between the studies were discussed in the text, and technical characteristics and outcomes were tabulated.
Results of the review
Fourteen studies met the inclusion criteria (1,307 participants; range 24 to 278). Four studies were controlled, all used clinical examination as the comparator for assessing construct validity, 12 also used laboratory results, 13 blinded observers, and 11 described the ultrasound technique. The choice of joint was arbitrary in eight studies.
The number of joints assessed ranged from five to 60. Construct validity, determined by correlation with clinical and laboratory findings, varied across studies, according to the number and size of joints examined. Responsiveness varied across studies, depending on the component tested and the size of the joint examined. Two weeks was the minimum, and 24 weeks was the best, cut-off for identifying a minimal response. As the number of joints examined increased, feasibility decreased, and the evaluation time increased, ranging from 15 to 60 minutes.
Ultrasound could be a valuable tool for examining the overall extent of synovitis in patients with rheumatoid arthritis, but it was difficult to determine the least number of joints that needed to be assessed for a global ultrasound score.
The review addressed a clear research question, supported by reproducible inclusion criteria. Appropriate sources were searched, but inclusion was restricted to studies published in English, so relevant studies could have been missed. The authors stated that the search was verified by a second reviewer, but it was unclear what this involved; there was no report of methods to reduce error and bias in data extraction and quality assessment.
Study quality was assessed, but not all potential areas of bias were included. The decision to combine studies in a narrative synthesis seems to have been appropriate, given the substantial variation in the scoring systems being assessed. Population characteristics were not reported, preventing an assessment of their variation.
Despite limitations to the review, the conclusion on the least number of joints for a global ultrasound score seems appropriate, but the evidence was insufficient for the statement on the value of ultrasound.
Implications of the review for practice and research
Practice: The authors did not state any implications for practice, beyond the main conclusion.
Research: The authors stated that further validation of proposed scores was needed. They reported that their research group was conducting a study to produce a standardised and reliable ultrasound synovitis global scoring system.
Mandl P, Naredo E, Wakefield RJ, Conaghan PG, D'Agostino MA, OMERACT Ultrasound Task Force. A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter. Journal of Rheumatology 2011; 38(9): 2055-2062
Subject indexing assigned by NLM
Arthritis, Rheumatoid /diagnosis /ultrasonography; Cartilage, Articular /pathology /ultrasonography; Humans; Severity of Illness Index; Synovitis /diagnosis /ultrasonography; Ultrasonography, Doppler /methods /standards
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.