Madrid Sonographic Enthesis Index Research Articles

Relationship between tendon elastography and clinical and ultrasound enthesitis scores in patients with psoriasis or psoriatic arthritis

Aim: To determine the existence of a correlation between the elastographic study of the patellar and Achilles tendons and the enthesis evaluation in patients with psoriasis with or without psoriatic arthritis. Methods: Observational, cross-sectional study. Patients with psoriasis, psoriatic arthritis and healthy controls were included. The elastography results of the patellar and Achilles tendons of the non-dominant leg of the three groups were compared and tested for correlation with the Madrid Sonographic Enthesis Index (MASEI) score, as well as an entheses clinical evaluation score [Spondyloarthritis Research Consortium of Canada (SPARCC)]. Results: Forty-eight patients were included, 24 with psoriasis and 24 with psoriatic arthritis, as well as 48 healthy controls. Patients with psoriatic arthritis had a higher clinical enthesitis score than patients with psoriasis (8.0 vs. 1.0, P < 0.001). The mean (standard deviation) or median (25–75 percentile) of control subjects patellar and Achilles’ tendon stiffness, 127.8 kPa (18.5 kPa) and 198.0 kPa (183.2–212.0 kPa) were significantly higher than observed in patients with psoriatic arthritis, 119.2 kPa (19.7 kPa) and 184.8 kPa (175.5–193.9 kPa; P < 0.001 and P = 0.018, respectively). A strong inverse correlation between MASEI score and the patellar and Achilles’ tendon stiffness was also detected (Spearman’s Rho coefficient of –0.813 and –0.941, respectively). Conclusions: Patients with psoriatic arthritis present less stiffness in those load-bearing tendons than healthy controls. There is an inverse correlation between the enthesis involvement demonstrated by ultrasound and the elastography of these tendons. Tendon elastography can be considered a useful quantitative tool in assessing patients with psoriatic disease.

Regression Models of the Ultrasound Score of Madrid Sonographic Enthesis Index in Patients with Spondyloarthritis

Background Machine learning regression models are built by minimizing the generalization error in the prediction while avoiding overfitting. These techniques enhance the models and forecasts of earlier medical research by achieving greater accuracy than traditional econometric techniques. Objectives To predict the Madrid Sonographic Enthesis Index (MASEI) in spondyloarthritis (SpA) patients using the best predictor variables, including disease activity and other factors. Methods There were cross-sectional, descriptive, and observational investigations conducted. We gathered data from 24 SpA patients who received treatment in our clinics from May 2021 to September 2021 and underwent musculoskeletal ultrasonography utilizing the MASEI. Using F-tests and mutual information, we narrowed down the variables to the most important ones. Finally, we used machine learning to estimate a few regression models. Results The predictor variables with higher values in the feature selection tests explaining the MASEI are activity, Ankylosing Spondylitis Disease Activity Score (ASDAS), corticosteroids, enthesophytes, and male sex. The most accurate regression model was the Support Vector Machine model (R-squared=0.81 in validation). Since this model is a black box, we also computed a classical linear regression (R-Squared=0.60 in validation) because it provides an explicit model given by: MASEI=-4.02+2,75 Enthesofites+4.838 ASDAS. Conclusion To date, the correlation between MASEI and disease activity in patients with SpA were known. In order to further examine this relationship, we predicted two regressive models to forecast the MASEI index: a classical linear regression model and a Support Vector Machine model with the lowest estimated Root Mean Square Error among 32 alternative machine learning models.

Sex-Based Differences in Sonographic and Clinical Findings Among Patients With Psoriatic Arthritis.

To investigate sex-based sonographic differences in patients with psoriatic arthritis (PsA). The study population included consecutive prospectively recruited patients with PsA, as determined by the CASPAR (Classification for Psoriatic Arthritis) criteria, who underwent clinical and physical examinations, followed by a detailed ultrasound (US) evaluation (greyscale and Doppler). US evaluation included 52 joints, 40 tendons, and 14 points of entheses (Modified Madrid Sonographic Enthesis Index [MASEI] plus lateral epicondyles) performed by an experienced sonographer blinded to the clinical data. The US score was based on the summation of a semiquantitative score for synovitis, tenosynovitis, and enthesitis. The US enthesitis score was categorized into inflammatory lesions (ie, hypoechogenicity, thickening, bursitis, and Doppler) and structural lesions (ie, enthesophytes/calcifications and erosions). The study population of 158 patients included 70 males and 88 females. The males had higher rates of employment (P = 0.01), Psoriasis Area and Severity Index scores (P = 0.04), and mean swollen joint counts (P = 0.04). The total US score and its subcategory scores-the synovitis and tenosynovitis scores-were similar for both sexes, whereas the total enthesitis score and its subcategory score-the inflammatory enthesitis score-were significantly higher for the males compared to the females (P = 0.01 and P = 0.005, respectively). Hypoechogenicity, thickening, and enthesophytes were more prevalent in males compared to females (P < 0.05). Multivariate ordinal logistic regression models showed that male sex was associated with a higher US inflammatory enthesitis score compared to female sex (odds ratio 1.96, P = 0.02). Sonographic enthesitis was more prevalent in males compared to females with PsA. These differences were not reflected by enthesitis disease activity scores derived from clinical assessment.

Entheseal Involvement in Spondyloarthritis (SpA) and Gout: An Ultrasound Comparative Study.

ObjectiveTo compare the assessment of entheses in subjects with spondyloarthritis (SpA) with patients with gout by the Madrid Sonographic Enthesis Index (MASEI).MethodThis cross-sectional study includes videos of entheses evaluated by ultrasound (US) of 30 patients with SpA diagnosed according to the ASAS criteria and 30 patients with gout established by the presence of monosodium urate crystals. Entheses were evaluated for MASEI in 2 Institutes located in two different countries. Demographic and clinical data were registered. Total MASEI score, MASEI-inflammatory, and MASEI-chronic damage were analyzed. Comparisons between groups were obtained by chi-square test and Student's t-test. An inter-reading US reliability was realized.ResultsPatients with gout were older and had significantly more comorbidities than those with SpA. The total MASEI score was not significantly different among diseases (p = 0.07). MASEI-inflammatory was significantly more prevalent at the Achilles tendon in SpA, while the proximal patellar tendon was in gout. Power Doppler was higher in SpA compared to gout (p = 0.005). MASEI-chronic damage related to calcification/enthesophytes predominated in gout (p = 0.043), while calcaneal erosions did in SpA (p = 0.008). The inter-reader concordance was excellent (0.93, CI 95% 0.87–0.96, p = 0.001).ConclusionsSpA and gout similarly involve entheses according to MASE, however, some inflammatory and chronic lesions differ significantly depending on the underlying disease and tendon scanned.

Interobserver reliability of Masei index validation by a multicenter collaborative group of rheumatologists.

MASEI is the main validated ultrasound score for the evaluation of enthesis. The lack of studies facing the agreement to achieve for the interpretation of the MAdrid Sonographic Enthesis Index (MASEI) among researchers from different centers in multicenter studies is of concern. The aim of this multicenter was to evaluate the interobserver reliability of MASEI. An experienced ultrasonographer-rheumatologist performed ultrasound scans of the areas included in MASEI index in three patients with Ankylosing Spondylitis and Psoriatic Arthritis. Videos were captured. The videos were then evaluated by 24 rheumatologists of the ultrasound working group of the Catalan Society of Rheumatology (EcoCAT). A face-to-face training meeting was held. Ten days after the workshop, the study participants evaluated the videos. A reliability assessment was performed. The ICC for the MASEI scores after the workshop was of 0.97 (95% CI 89-99). Reliability did not vary statistically with examiner experience. Globally, no problems of reliability by structures were seen, and all the ICCs were above 0.90 and improved slightly after the educational program. However, the correlation observed between examiners at plantar aponeursis and triceps tendon was weak. The small variability observed in the results of the index validation in our study, suggests that the MASEI index is reproducible by different observers when those are well trained and show awesome results of the enthesis when examined by ultrasound.

Doppler enthesitis: a potential useful outcome in the assessment of axial spondyloarthritis and psoriatic arthritis.

To analyse the frequency of power Doppler (PD) enthesitis in active axial spondyloarthritis (axSpA) and psoriatic arthritis (PsA) patients and its potential usefulness in clinical practice. A prospective multicentre cross-sectional study in patients with axSpA and PsA with active disease was undertaken. Patients underwent bilateral ultrasound (US) examination of the peripheral entheses according to the Madrid Sonographic Enthesis Index (MASEI). The MASEI and Outcome Measures in Rheumatology (OMERACT) PD enthesitis definitions were checked. An inter-reader analysis of recorded videos was performed to determine reliability. Sixty-four consecutive patients were included. The mean DAS28 (3.9 ± 1.3) for peripheral involvement, mean BASDAI (5.6 ± 2.2) for axial involvement, and CRP values (10 ± 10.9) reflected moderate-high disease activity at baseline. The mean global MASEI score was 29.4 (± 11.4), and 55 patients (86%) scored ≥ 18 (proposed cut-off point to diagnose SpA). At the patient level, abnormal US findings consistent with at least one enthesis showing a PD signal were observed in 52 (81.3%) patients using the MASEI PD definition and 48 (75%) using the OMERACT PD definition, without significant variation between axSpA and PsA. The inter-reader reliability was excellent (kappa = 0.92 for MASEI PD and 0.86 for OMERACT PD). PD enthesitis was found in the majority of patients with active axSpA and PsA, independent of axial or peripheral affectation. Both MASEI and OMERACT PD definitions were useful in detecting active enthesitis. These findings support the usefulness of a PD US evaluation of entheses in the assessment of axSpA and PsA. Key Points • PD enthesitis is a very common finding in patients with active axSpA and PsA • Both MASEI and OMERACT PD definitions are useful to detect active enthesitis • US enthesitis may reveal information in axSpA and PsA.

Updating the use of the Madrid Sonographic Enthesis Index (MASEI): a systematic review of the literature.

To perform a systematic review of the literature to evaluate the use of the enthesis ultrasound Madrid Sonographic Entesis Index (MASEI) from its publication. A systematic search of MEDLINE, EMBASE, and Cochrane Central Register databases was performed. The search strategy was constructed to identify publications containing terms related to enthesis and ultrasound. The only applied filter was studies conducted in humans. One reviewer systematically screened the search. A second reviewer verified the selection. The data extraction was focused on study characteristics, including population and components of the OMERACT filter. Sixty-eight of the 1581 identified studies had used MASEI, including 41 (60%) abstracts and 27 (40%) articles. Of the 27 articles, MASEI was mainly used for spondyloarthritis and related diseases in 12 (44%) articles, followed by both psoriatic arthritis and rheumatoid arthritis in five (19%) articles; however, it was also used in diseases such as Behçet disease, FM, familiar Mediterranean fever, SS, crystal arthropathies and systemic sclerosis. The feasibility of MASEI was reported in three (11%) articles, and the reliability in 12 (44%) with good to excellent values. No article evaluated the responsiveness to treatment. The construct validity of MASEI was assessed using biomarkers in seven (26%) articles, clinical examination in 13 (48%) and imaging procedures (only X-rays) in two (7%). The discriminative validity was assessed in 16 (59%) articles, not only in SpAs. MASEI is a feasible, reliable and valid ultrasound score for the study of enthesis in spondyloarthritis, psoriatic arthritis and other diseases.

Ultrasonography of enthesis in psoriatic arthritis: a descriptive and reliability analysis of elemental lesions and power Doppler subtypes

Objective: To evaluate the reliability and prevalence of enthesis ultrasound (US) elemental lesions in patients with psoriatic arthritis (PsA), using the Madrid Sonographic Enthesis Index (MASEI) and Outcome Measures in Rheumatology (OMERACT) definitions.Methods: The study included 27 PsA patients with metacarpophalangeal joint swelling. An US rheumatologist performed the MASEI examination. Prevalence and reliability of the included elemental lesions [structure, thickness, erosion, enthesophytes, power Doppler (PD), and bursae] were evaluated. In addition, three other PD definitions were checked: PD OMERACT (≤ 2 mm to the bone profile), PD enthesis–tendon (> 2 mm from the bone profile), and PD bursa. Short (3–5 s) videos of US examinations were recorded for reliability assessment.Results: MASEI and all PD definitions showed good to excellent reliability. The best reliability values were found in erosions, bursae, and PD. When present, the PD signal always appeared in more than one location of the evaluated areas. Enthesis Doppler was present in 81.5% of patients. Abnormal tendon structure and enthesophytes were the most prevalent lesions.Conclusion: MASEI demonstrates to be a reliable tool in PsA. All enthesis US Doppler definitions demonstrate to be reliable for its use in PsA with minimal differences, being PD MASEI the most sensitive in active patients.

Peritenon Extensor Tendon Inflammation in Psoriatic Arthritis Is an Enthesitis-related Lesion.

To analyze the association between enthesitis, synovitis, and peritenon extensor tendon inflammation (PTI) in psoriatic arthritis (PsA). PsA patients with swelling of metacarpophalangeal joints were included. Greyscale and power Doppler (PD) were used for synovitis and PTI ultrasound identification. Madrid Sonographic Enthesis Index (MASEI) was used for enthesitis assessment. PD activity was evaluated using PD item of MASEI and PD Outcome Measures in Rheumatology (OMERACT) definition. Synovitis had no association with enthesitis. PTI was associated with PD MASEI and PD OMERACT. Only PD OMERACT showed a positive correlation with PTI. In PsA, PTI is associated to enthesitis, as opposed to synovitis.

Are Ultrasound Findings Similar in Patients with Axial Spondyloarthritis and in Athlete Entheses?

Enthesitis is the spondyloarthritis (SpA) landmark, but can also be seen after entheses overuse, such as during intensive sport. We aimed to compare entheses ultrasound (US) findings in a prospective cross-sectional study of 30 axial SpA cases, 30 athletes, and 29 controls. Mean (SD) MAdrid Sonographic Enthesis Index (MASEI) score was 26.3 (13), 12.2 (7), and 10.4 (6) in patients with SpA, athletes, and non-athlete control groups, respectively (p < 0.0001). The MASEI score was significantly higher in patients with SpA compared with healthy controls, athletes, and non-athletes, and can be of value to distinguish SpA from healthy subjects, whatever their physical activity.

Three-dimensional versus two-dimensional ultrasonographic assessment of peripheral enthesitis in spondylarthritis

To compare the intra- and interobserver reliability of three-dimensional (3D) volumetric versus conventional two-dimensional (2D) power Doppler ultrasonography (US) in the assessment of peripheral enthesitis in spondylarthritis (SpA). Sixteen patients with SpA according to ASAS criteria were included. Two rheumatologists (one experimented in musculoskeletal US (sonographer 1) and one beginner (sonographer 2)) performed independently a 2D US scoring of the enthesis using the Madrid Sonographic Enthesis Index score followed by a 3D acquisition of the same entheseal sites. The reading of the 3D acquisition was performed a minimum of 1week apart. Intraobserver reliability was evaluated by a second reading of the same images. The duration of 2D US scanning, 3D US acquisition and reading was recorded. Intraclass correlation coefficients (ICCs) were used for the reliability analysis. Intraobserver reproducibility was good to excellent for 2D US and good for 3D US (ICC (95%CI) 2D US 0.776 (0.471-0.916) and 0.96 (0.892-0.986) and ICC (95%CI) 3D US 0.796 (0.498-0.921) and 0.703 (0.325-0.886) for sonographer 1 and 2, respectively). Interobserver reliability was slightly better for 3D US than for 2D US (ICC (95%CI) 0.776 (0.471-0.916) for 3D US versus 0.641 (0.221-0.859) for 2D US). The mean time (±SD) for 2D US scanning was 23min (±4) whereas the mean time for 3D US volume acquisition and reading was 16.5min (±2.6) (p < 0.001). 3D US showed good intra- and interobserver reliability in the assessment of enthesitis in SpA and shortened the needed time for scanning. It can be performed by a nonexperienced examiner without loss of reliability.

AB0862 An ultrasonographic study on entheseal involvement in asymptomatic patients with inflammatory bowel disease with or without spondyloarthritis

BackgroundEnthesis is defined as the insertion point of tendons, fascia or joint capsules into bones. This structure is typically affected by inflammatory rheumatic diseases (IRD), such as spondyloarthritis (SpA) [1].Now-a-days,...

AB0755 Entheses ultrasound in patients with ankyosing spondylitis: a controlled study with healthy subjects.

BackgroundInflammation of the entheses (enthesitis) is a characteristic finding of ankylosing spondylitis (AS). Despite the growing interest in rheumatology for musculoskeletal ultrasound (US), there are not many studies evaluating the...

Walking Before an Ultrasound Assessment Increases the Enthesis Score Significantly

To the Editor: Inflammatory enthesis involvement is a characteristic feature of spondyloarthropathies (SpA); it is considered the primary lesion in this disease1. The MAdrid Sonographic Enthesis Index (MASEI) score was recently validated for SpA diagnostic classification2. MASEI scores range from 0 to 136, and a value ≥ 18 was established as the best cutoff point to differentiate between cases and healthy controls (sensitivity of 83.3%, specificity 82.8%). Sporting activities such as running and aerobic exercise are known to result in foot and ankle injuries, such as tendon thickening, edema, and bursitis, that could influence ultrasound (US) assessment of enthesis3. To … Address correspondence to Prof. T. Pham, Department of Rheumatology, Conception Hospital, 147 Boulevard Baille, 13005 Marseille, France. E-mail: thao.pham{at}ap-hm.fr

Seguimiento clínico y ecográfico a 1 año del EStudio PIloto de Derivación de pacientes con Espondiloartritis Precoz (ESPIDEP)

Objectives To characterize a cohort of early spondyloarthritis (SpA) patients, to demonstrate the usefulness of enthesis ultrasonography for the diagnosis and follow up, and to develop a statistical model to predict persitent activity. Patients and methods A 1 year prospective study with clinical, radiological and ultrasonographic evaluations was performed in patients with SpA from the Pilot Study for the Referral of Patients with Early SpA (ESPIDEP). Enthesis ultrasonography was explored by the MAdrid Sonographic Enthesis Index (MASEI), and its diagnostic utility was determined to be a cutoff score of ≥ 18 points. The clinical, radiological and MASEI scores were studied. Finally, a statistical model from factors predicting persitent activity was developed. Results A 1 year follow-up of 32 patients was carried out. The baseline MASEI reached a sensitivity and specificity of 78,12% and 84,37% respectively, positive and negative predictive value was 83,3% and 79,41% respectively, and positive and negative likelihood ratios were 5 and 0,26, respectively. The improvement of BASMI and the MASEI scores were significant (p = 0,001 and p = 0,007, respectively). From the beginning, women had more peripheral affectation, and men had higher axial radiological progression and higher CRP (p < 0,05).The statistical model that best predicted persitent activity was constituted by nocturnal back pain, BASDAI and CRP. Conclusions Enthesis ultrasonography can be useful when begining the evaluation and follow-up of early SpA. Disease patterns are different according to sex. The ability to predict persitent activity in early stages supports the use of more intensive treatments.

One year clinical and ultrasonographic follow up of the Pilot Study for the Referral of Patients with Early Spondyloarthritis (ESPIDEP)

ObjectivesTo characterize a cohort of early spondyloarthritis (SpA) patients, to demonstrate the usefulness of enthesis ultrasonography for the diagnosis and follow up, and to develop a statistical model to predict persitent activity. Patients and methodsA 1 year prospective study with clinical, radiological and ultrasonographic evaluations was performed in patients with SpA from the Pilot Study for the Referral of Patients with Early SpA (ESPIDEP). Enthesis ultrasonography was explored by the MAdrid Sonographic Enthesis Index (MASEI), and its diagnostic utility was determined to be a cutoff score of ≥18 points. The clinical, radiological and MASEI scores were studied. Finally, a statistical model from factors predicting persitent activity was developed. ResultsA 1 year follow-up of 32 patients was carried out. The baseline MASEI reached a sensitivity and specificity of 78.12% and 84.37% respectively, positive and negative predictive value was 83.3% and 79.41% respectively, and positive and negative likelihood ratios were 5 and 0.26, respectively. The improvement of BASMI and the MASEI scores were significant (P=.001 and P=.007, respectively). From the beginning, women had more peripheral affectation, and men had higher axial radiological progression and higher CRP (P<.05). The statistical model that best predicted persitent activity was constituted by nocturnal back pain, BASDAI and CRP. ConclusionsEnthesis ultrasonography can be useful when begining the evaluation and follow-up of early SpA. Disease patterns are different according to sex. The ability to predict persitent activity in early stages supports the use of more intensive treatments