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Validation of a screening strategy for psoriatic arthritis based on musculoskeletal ultrasound by dermatologists, second interim results from the multicentric observational DerminUS study
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Veröffentlicht: | 18. September 2024 |
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Introduction: In daily clinical practice, accurately distinguishing between patients presenting with arthralgia and psoriasis versus those with psoriatic arthritis (PsA) is crucial. However, due to a shortage of rheumatologists in Germany, patients frequently have to wait for months before seeing a rheumatologist. The study design of DerminUS was adapted and upscaled from the local MUDE and PSOSONE study [1], [2]), which included a standardized musculoskeletal ultrasound (MSUS) training curriculum designed for dermatologists. These studies demonstrated a marked enhancement in the specificity of PsA screening, escalating from 54.4% without MSUS application to 90.4% when MSUS was utilized. DerminUS is an ongoing, cross-sectional study of planned 600 patients, that aims to enroll approximately 600 patients who have both psoriasis and arthralgia. Its primary objective is to validate the efficacy of MSUS, when conducted by dermatologists, as a screening tool for PsA [3]. Protocol changes were implemented in DerminUS to adjust for real life conditions. An interim analysis at an advanced stage was performed to assess the effect of protocol deviations to the MUDE and PSOSONE study.
Methods: We established a network of eleven clusters throughout Germany, each comprising one rheumatologic center and up to eight associated dermatologists. In these clusters, dermatologists receive training in MSUS using a handheld ultrasound probe connected to an iPad (9. generation, China). This training employs the MUDE-training framework [1], and each session is led by an experienced tutor alongside a local rheumatologist proficient in MSUS. The training sessions were shortened, compared to the MUDE protocol, to about 4–5 hours including practical training in small groups of 2–3 dermatologists per tutor. Following their training, dermatologists begin screening patients with any form of psoriasis and arthralgia in two or more joints for joint lesions and perform an additional MSUS. The respective patients will be referred to the corresponding rheumatologist. The results of dermatological examinations, as well as the final rheumatological diagnosis, are documented.
Results: At the time of the data cut for the interim analysis (October 2023) nine networks have included 208 patients. For 135 (64.9%) patients a visit at the rheumatologist was documented (Figure 1 [Fig. 1]).
Outcomes of dermatological assessments: Signs of an active PsA were found in 72.4% (144/199 patients, 9 missing values) of the included patients at the dermatologic visit. Joint lesions detected by MSUS were reported in 61.2% (120/196 patients, 12 missing values). Table 1 [Tab. 1] shows the distribution of joint lesions detected by MSUS per patient. In 79 patients (61.2%), suspected PsA was confirmed by the MSUS on the basis of the classic examination method, while this was not the case in 22 patients (17.1%). In 10 patients (7.8%) there was no suspicion of PsA on the basis of the classic examination method, but PsA was suspected with the help of the MSUS. In 18 patients (14.0%), the classic examination method did not reveal any evidence of PsA, which was confirmed by the MSUS.
Outcomes of rheumatological assessments: The results of the rheumatologic examination were documented for 135 patients (64.9%) at the time of the data cutoff. The referring dermatologists suspected PsA in 89 of the referred patients based on MSUS screening. Rheumatologists confirmed active PsA as the final diagnosis in 37 patients. This represents a 41.6% hit-ratio for the detection of PsA by MSUS screening, the same ratio without MSUS was 41.7%.
Conclusion: Despite its interim status and the fact that only about one-third of the targeted patient cohort has been enrolled, preliminary findings from this study indicate that dermatologists can effectively employ MSUS as a screening tool for PsA. Greater efficacy of MSUS in earlier localized studies is likely attributable to the abbreviated MSUS training protocol employed in DerminUS. Nonetheless, it is important to highlight that the use of MSUS in DerminUS has resulted in more selective patient referrals compared to scenarios where MSUS was not utilized. The primary insight from this interim assessment underscores the potential of enhancing MSUS screening accuracy through the provision of additional training and feedback to dermatologists. We will implement this during the data collection period and evaluate the impact of these measurements.
Disclosure: Financial support was received from Novartis for the MUDE und PSOSONE study.
References
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