Joint Bone Spine 82 (2015) 139–140

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Editorial

Why are rheumatologists still reluctant to perform joint-fluid analysis?

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Keywords: Synovial fluid Joint diseases Arthritis Crystals Gout

The work by Pollet et al. published in this issue of Joint Bone Spine provides important information: agreement is good between joint-fluid analyses performed by rheumatologists and by hospital laboratories [1]. We hope this information will contribute to increase self-confidence among rheumatologists regarding their joint-fluid analysis skills, thus encouraging them to perform this test themselves, given its crucial importance for the diagnosis of joint diseases. Another strong point of this study is its carefully chosen design, which efficiently tests the practical feasibility of joint-fluid analysis by rheumatologists, since the test was performed by a single rheumatologist, who was unaware of the clinical data and laboratory findings and whose training had consisted only in two workshops. Nevertheless, the study has a number of biases. For instance, we do not know how the rheumatologist who performed the tests was chosen, and neither do we have any information on the experience of the pathologist who performed the joint-fluid analyses in the laboratory. An extremely satisfactory finding is the good agreement between the manual cell count performed by the rheumatologist and the automated cell count done at the laboratory to classify the joint-fluid samples as mechanical or inflammatory. However, the level of experience of the laboratory physician in charge of crystal detection is not reported. Conceivably, for a given level of training, rheumatologists may be more likely to obtain findings of assistance in establishing the diagnosis than laboratory physicians, who have no information on the patient or disease [2]. However, this argument does not apply to laboratories associated with rheumatology departments, whose experience with joint-fluid analysis is extensive. The reluctance of rheumatologists to perform joint-fluid analysis is difficult to understand, since this test is still the reference standard for diagnosing gout and calcium pyrophosphate deposition disease [3–8]. In addition, these are the most common inflammatory joint diseases in the general population and may well be the most amenable to a cure. The EULAR recommendations are particularly emphatic, since both the 2006 version [5]

and the updated version issued in 2014 [8] indicate that joint-fluid analysis for monosodium urate crystals should be performed not only when gout is suspected, but also when the joint fluid exhibits inflammatory properties and no diagnosis has been established. The reluctance of rheumatologists to use a highly specialized tool in order to definitively confirm or infirm a diagnosis considerably damages the confidence of primary-care physicians in the ability of rheumatologists to efficiently carry out their role as specialists, most notably in the field of gout. This situation calls to mind a statement by Hamburger et al. in their 2011 recommendations for the diagnosis and management of gout and hyperuricemia established with a group of US rheumatologists [9]. These authors state that, although monosodium urate crystal detection remains the reference standard for diagnosing gout, routine monosodium urate crystal detection to diagnose gout is not feasible for the family physicians, given their heavy workload, and finding a reference laboratory capable of performing high-quality crystal detection in joint fluid may prove difficult. Should the family physicians want to perform joint fluid aspiration and analysis themselves, these would be limiting factors [9]. In addition, even for rheumatologists, the time from joint fluid collection to arrival at the laboratory, which may be located at some distance, may lead to the loss of valuable information. These considerations have prompted a search for clinical alternatives involving a long list of questionnaires and evaluation criteria whose reliability is at times almost laughable. Thus, the likelihood ratio is 567 for monosodium urate crystals seen under the microscope and 5 at the most for the best performing clinical indices [5,9]. Another major point is the 100% specificity of monosodium urate crystals, a value that is difficult to achieve using other diagnostic markers available in medicine. Thus, the decision by a rheumatologist to refrain from performing joint-fluid analysis should be viewed as absurd, illogical, and even suicidal. In addition to microcrystal detection, joint-fluid analysis has other uses. It can help to diagnose other forms of arthritis, including septic arthritis, which is an extremely serious condition [10,11]. At present, joint-fluid analysis is even more necessary in patients with polyarthritis or spondyloarthritis treated with biological agents [12]. The increasing availability of ultrasound machines in rheumatology departments makes joint fluid collection possible even in the most difficult cases [13]. In terms of opportunity and diagnostic yield, a rheumatologist who does not perform joint-fluid analysis can be compared to a cardiologist who refuses to record electrocardiograms. A particularly surprising fact is that this situation is not confined to a small number of countries. Possible

http://dx.doi.org/10.1016/j.jbspin.2015.01.001 1297-319X/© 2015 Published by Elsevier Masson SAS on behalf of the Société Française de Rhumatologie.

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Editorial / Joint Bone Spine 82 (2015) 139–140

explanations may include difficulties in carrying out the test, a risk of errors due to insufficient competence, the disproportion in some countries between rheumatologist fees and the time needed to perform the test, and the cost of the equipment needed for the test. Furthermore, rheumatologists may be more likely than other specialists to lack confidence in their ability to perform complex diagnostic procedures. Several studies have shown fairly high error rates for joint-fluid analysis in clinical laboratories, most notably regarding crystal detection, when quality-control procedures are inadequate [2,3,14]. Nevertheless, once properly trained, rheumatologists are more than capable of obtaining very satisfactory and reproducible results, provided they perform the test often [1–3]. Regarding the time needed, in our experience, the microscopic examination to determine the leukocyte count and detect crystals requires 15 minutes at the most. If the test is confined to crystal detection, the time is even shorter. These estimates are valid only if the required equipment is at hand. The reluctance of rheumatologists to perform diagnostic procedures of limited or minimal invasiveness is probably among the reasons for the limited appeal of rheumatology to students in some countries until now. In a Canadian study of factors associated with the choice of subspecialties by internal medicine residents, the least often chosen were rheumatology, immunology, and endocrinology [15]. Responses to a questionnaire showed that men tended to choose subspecialties involving the performance of procedures or instruments, not only for financial reasons but also because of doubts regarding their manual abilities. Procedure-based subspecialties such as cardiology, gastroenterology, emergency medicine, and pulmonology were the most frequently chosen specialties [15]. The already considerable and steadily growing popularity of ultrasonography among young rheumatologists, together with the effectiveness of intraarticular injections, indicate clearly that modern rheumatology is changing, and that joint-fluid analysis cannot be excluded from this trend. Furthermore, in this setting, potential medicolegal implications should be increasingly borne in mind. In patients with joint effusions identified by ultrasonography or during an intraarticular injection and no clear diagnosis, rheumatologists will find it difficult to explain why they deemed joint-fluid analysis unnecessary. Relevant to this discussion is the European Rheumatology Curriculum Framework drawn up by the European Board of Rheumatology (EBR), which represents rheumatologists within the European Union of Medical Specialists (EUMS) The goal of this document is to increase the uniformity of the training delivered to rheumatologists across the European Union [16]. Among the key technical skills that must be acquired, those considered mandatory include synovial-fluid aspiration from joints and bursae, injections into joints and soft tissues, joint-fluid analysis including crystal detection under polarized light, and the ability to interpret radiological musculoskeletal signs [16]. Both the EULAR and the French Society for Rheumatology (SFR) offer workshops on crystal detection at their yearly meetings. The Italian Society for Rheumatology (SIR) organizes a yearly training session on joint-fluid aspiration and analysis. The microscopes used during these sessions are simple and affordable. Such microscopes are clearly sufficient to obtain optimal diagnostic performance, as shown in the study by Pollet et al. [1]. The availability in some centers of more sophisticated equipment such as phase-contrast microscopes and microphotography are chiefly useful for research purposes. Schumacher HR et al. have emphasized the desirability of achieving an international consensus on the type of training and level of trainer skill that should be required to obtain a reliability certificate [2]. However, some

of the criteria required to obtain these certificates are excessively sophisticated and stringent and may, therefore, constitute a further obstacle to the acquisition of the necessary skills and create the misconception that performing high-quality joint-fluid analysis should be restricted to a limited group of highly specialized rheumatologists. This possibility constitutes an additional reason to disseminate the data obtained by Pollet et al. [1]. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. References [1] Pollet S, Coiffier G, Albert JD, et al. Concordance between fresh joint fluid analysis by the rheumatologist and joint fluid analysis at the laboratory: prospective single-center study of 180 samples. Joint Bone Spine 2015, http://dx.doi.org/10.1016/j.jbspin.2014.11.005. [2] Schumacher HR, Chen LX, Mandell BF. The time has come to incorporate more teaching and formalized assessment of skills in synovial fluid analysis into rheumatology training programs. Arthritis Care Res 2012;9:1271–3. [3] Swan A, Amer H, Dieppe P. The value of synovial fluid assays in the diagnosis of joint disease: a literature survey. Ann Rheum Dis 2002;61:493–8. [4] Pascual E, Sivera F, Andres M. Synovial fluid analysis for crystals. Curr Opin Rheumatol 2011;23:161–9. [5] Zhang W, Doherty M, Pascual E, et al. EULAR evidence based recommendations for gout - part I: diagnosis. Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT). Ann Rheum Dis 2006;65:1301–11. [6] Zhang W, Doherty M, Bardin T, et al. European League against Rheumatism recommendations for calcium pyrophosphate deposition. Part I: terminology and diagnosis. Ann Rheum Dis 2011;70:563–70. [7] Landewé RBM, Günther KP, Lukas C, et al. EULAR-EFORT for the diagnosis and initial management of patients with acute or recent onset swelling of knee. Ann Rheum Dis 2010;69:12–9. [8] Richette P, Pascual E, Doherty M, et al. Updated EULAR evidence-based recommendations for the diagnosis of gout. Ann Rheum Dis 2014;73:783–4. [9] Hamburger M, Baraf HSB, Adamson TC, et al. 2011 recommendations for the diagnosis and the management of gout and hyperuricemia. Postgrad Med 2011;123:s3–36. [10] Garcia-Arias M, Balsa A, Mola EM. Septic arthritis. Best Best Pract Res Clin Rheumatol 2011;25:407–21. [11] Courtney P, Doherty M. Joint aspiration and injection and synovial fluid analysis. Best Pract Res Clin Rheumatol 2013;27:137–69. [12] Oliviero F, Scanu A, Galozzi P, et al. Prevalence of calcium pyrophosphate and monosodium urate crystals in synovial fluid of patients with previously diagnosed joint diseases. Joint Bone Spine 2013;80:287–90. [13] Punzi L, Oliviero F. Arthrocentesis and synovial fluid analysis in clinical practice. Value of sonography in difficult cases. Ann NY Acad Sci 2009;1154:152–8. [14] McGill NW, York HF. Reproducibility of synovial fluid examination for crystals. Aust N Z J Med 1991;21:710–3. [15] Horn L, Tzanetos K, Thorpe K, et al. Factors associated with subspecialty choices of internal medicine residents in Canada. BMC Med Educ 2008;8:37. [16] Faarvang KL, Da Silva JA. Competencies in Rheumatology: a European framework. Best Best Pract Res Clin Rheumatol 2009;23:145–60.

Leonardo Punzi ∗ Roberta Ramonda Francesca Oliviero Service de rhumatologie, département de médecine interne DIMED, université de Padova, Via Giustiniani 2, 35128 Padua, Italy ∗ Corresponding

author. Rheumatology Unit, Department of Medicine (DIMED, Padova University, Via Giustiniani 2, 35128 Padua, Italy. Tel.: +39 049 8212190; fax: +39 049 8212191. E-mail address: [email protected] (L. Punzi) Accepted 13 January 2011 Available online 9 February 2015

Why are rheumatologists still reluctant to perform joint-fluid analysis?

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