The synovitis clinic: Diagnoses and interventions
Dr Claire Masih, Dr Gary Meenagh, Dr James Burns, Dr Esme Whitehead, Dr Auleen Millar
Department of Rheumatology, Antrim Area Hospital, Northern Ireland
The importance of early assessment of patients with potential inflammatory arthritis is increasingly recognised. A new synovitis clinic was set up to enable rapid assessment of these patients after appropriate grading of referrals. The first 60 patients assessed in this fortnightly synovitis clinic were audited.
We aimed to assess whether grading of referrals to the synovitis clinic was appropriate. We recorded whether the patients did have an inflammatory condition and the diagnosis after initial assessment. We also recorded the interventions from the clinic, in terms of medication changes, DMARD commencement, IM and IA injections, imaging requests and referrals to other specialties.
The first 10 clinics were reviewed with potentially 60 new patients. Eight patients were excluded as they were routine patients seen during service start up while sufficient synovitis patients were accrued. There was one DNA leaving 51 patients which were audited in a retrospective chart review.
We recorded age, sex, source and urgency of initial referral, time to assessment from referral date, diagnosis and interventions performed.
Patients were described as 'inflammatory', 'non-inflammatory' or 'possibly inflammatory.'
There were 32 females and 19 males with a mean age of 54 and age range 19 to 81years.
Most referrals were from GPs with six requests for routine assessment and 39 for urgent.
The mean time from referral to appointment was 32 days.
Diagnoses were 39 inflammatory conditions and 9 non-inflammatory with 7 possibly inflammatory diagnoses in progress. Inflammatory diagnoses included seropositive RA (9), seronegative arthritis (7), spondyloarthropathy (5), gout (4), palindromic rheumatism (3), psoriatic arthritis (3) and one each of GPA, Sjogrens syndrome, CPPD and erosive osteoarthritis.
Interventions included 13 DMARD commencements and 18 other prescriptions including prednisolone (6) and NSAIDs (8).
Eight patients received IM steroid and eight had joint injections, of which 2 had 2 joints injected.
Imaging requests included 3 MRIs, 2 CTs and 1 US. Xray requests were not recorded.
Twelve referrals to different specialties were made, excluding MDT referrals.
The clinic ran smoothly with all required resources present. Grading of patients for synovitis clinic was excellent with 79% of patients having inflammatory conditions. Of the patients with inflammatory arthritis 59% commenced DMARD at the first attendance. This is lower than recommendations suggest. Reasons for not commencing DMARDs were not formally recorded but included deranged LFTs, requirement to liaise with other specialties and time needed for patient consideration.
The clinic also proved to be an excellent resource for teaching and training with a high concentration of musculoskeletal pathology.