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Delphi Survey on Quality of synovial biopsies: Round 2
Please find above the items for Round 2.
Under some items you will find explanations on how and why Items have been added or modified.
As Round 1, every Item shall be rated from 1 (totally disagree) to 5 (totally agree).
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First Part: CLINICAL PRACTICE
1. Biopsy sampling
A minimum of 6 synovial biopsies needs to be retrieved in large joints. *
This item collected 80% agreement. However, regarding the multiple comments that we received, we changed for 6 biopsies. Comments: 1 participant suggested 2-3 biopsies. 1 participant suggested 4 biopsies. 1 participant suggested 5 biopsies. 2 participants suggested 6 biopsies. 1 participant suggested 8 biopsies. 1 participant suggested 20 biopsies.
A minimum of 4 synovial biopsies needs to be retrieved in small joints. *
The initial item suggested 2 biopsies. This item collected under 70% agreement (67%). Regarding the multiple comments that we received, we changed for 4 biopsies. Comments: 2 participants suggested 4 biopsies. 1 participant suggested 3 biopsies. 1 participant suggested 6 biopsies. 1 participant suggested 8 biopsies. 1 participant suggested 20 biopsies.
Biopsies shall be retrieved in different areas of the joint, if possible. *
Initially we proposed 3 items: "Biopsies should be performed in at least 2 different areas of the joint if large.", "Biopsies should be performed in at least 3 different areas of the joint if large." Those 2 items collected under 70% agreement. "Biopsies should be performed in at least 2 different areas of the joint if small." This item collected 80% agreement. Due to the controversial comments we received and the lack of clear literature in this topic, we combined those items in 1.
If it is clinically relevant, bacteriological, fungal and mycobacteriological assessment should be performed. *
The item proposed initially was: Bacteriological, fungal and mycobacteriological assessment should occur in each patient. Most of the participants (11/15) disagreed with this item, assuming that those analysis should occur only if a clinical suspicion exists, so we modified the item accordingly.
Polymerase chain reaction analysis for ARN 16S should be performed if clinically relevant, especially if empiric antibiotic course has been started. *
The item proposed initially was: Polymerase chain reaction analysis for ARN 16S should be performed for each patient. Most of the participants (12/15) disagreed with this item, assuming that those analysis should occur only if a clinical suspicion exists, so we modified the item accordingly.
If it is clinically relevant, Polymerase chain reaction analysis for Lyme and Whipple diseases should be performed. *
The item proposed initially was: Polymerase chain reaction analysis for Lyme and Whipple diseases should be performed for each patient. Most of the participants (12/15) disagreed with this item, assuming that those analysis should occur only if a clinical suspicion exists, so we modified the item accordingly.
2. Biopsy processing
At least 2 biopsies should be formalin-fixed and paraffin-embedded. *
The biopsies should spend 24 hours in formalin 4%. *
The initial item was: "the biopsies should spend 24 hours in formalin". This item was modified as 1 participant suggested to add the % of formalin.
3. Histological criteria
Synovial biopsy surface should be more than 2.5mm2. *
A lining layer should be seen. *
Morphology of the synovial tissue should be preserved. *
This item as first proposed collected 76%. Some participants found the threshold of "100% preserved" too conservative so we modified the item.
4. Staining and Immunohistochemistry (IHC)
H&E staining should always be performed. *
CD68 staining should be performed. *
This initial item "CD68 staining should always be performed" collected 70%. Some participants however found the item too strict so we removed "always".
In particular clinically relevant cases, additional staining should be performed (CD3, CD20, CD138, CD31 or FVIII). *
These items were combined in one and modified according to participants comments (7/15) suggesting that IHC should be performed in clinical practice only in particular clinically relevant situations.
If infectious arthritis is suspected, CD15 staining should be performed. *
This item was added based on the suggestion of 4 participants.
If performed, IHC results can be given using a semi-quantitative score. *
This item initially suggested to use a 0-3 semi-quantitative score. It collected 43% agreement and 2 participants suggested to use a 0-4 semi-quantitative score so we modified accordingly.
5. Biopsies interpretation and Pathologist’s report
A synovitis score should be performed, analyzing: lining layer hyperplasia, inflammatory infiltrate and resident cell activation (Krenn, other). *
This item combines 2 items of the first round. One "A Krenn score should always be performed to assess inflammation." collected 57% agreement and the other one "Other scores for intensity of inflammation should be performed." collected 41% agreement.
Vascularity should be scored. *
The initial item "Absolute number of vessels should be assessed." collected 42% agreement. We modified the item according to 2 participants comments, suggesting that Vascularity in general should be assessed.
Synovial pathotype should be described. *
Presence or absence of lymphoid follicles within the membrane should be described. *
If a semi-quantitative or quantitative analysis is performed for multiple biopsies, an average score should be calculated and given for the analysis of inflammation and vascularization. *
The original item collected 71% agreement. But regarding the different comments we received, we decided to synthesize participants comments in this new item.
If appropriate and possible, the pathologist should mention the likeliest diagnosis. *
The initial item collected 46% agreement. "If possible and appropriate" was added to this item according to comments of 4 participants.
The pathologist should mention the presence of granulomas *
This item was added according to the suggestion of a participant.
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