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Rheumatology (Oxford). 2016 May;55(5):883-90. doi: 10.1093/rheumatology/kev441. Epub 2016 Feb 3.

An EULAR study group pilot study on reliability of simple capillaroscopic definitions to describe capillary morphology in rheumatic diseases.

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Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, Ghent University, Ghent, Belgium,
Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, Ghent University, Ghent, Belgium.
Centre for Musculoskeletal Research, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
Biostatistics Unit, Department of Public Health, Ghent University, Ghent, Belgium.
Division of Rheumatology, University Hospital Zurich, Zurich, Switzerland.
Hamburg Centre for Pediatric and Adolescent Rheumatology, Centre for Treatment of Scleroderma and Uveitis in Childhood and Adolescence, Teaching Unit of the Asklepios Campus of the Semmelweis Medical School, Budapest, An der Schön Klinik Hamburg Eilbek, Hamburg, Germany.
Division of Rheumatology, Istituto Gaetano Pini, Department of Clinical Sciences & Community Health, University of Milano, Milano, Italy.
Rheumatology and Clinical Immunology, University of Giessen/Kerckhoff-Klinik, Bad Nauheim, Germany.
Department of Internal Medicine and Medical Specialities, University Sapienza Rome, Rome, Italy.
Clinic of Rheumatology, University of Luebeck, Luebeck, Germany.
Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy and.
Department of Rheumatology, VU University Medical Center, Amsterdam, The Netherlands.



To propose simple capillaroscopic definitions for interpretation of capillaroscopic morphologies and to assess inter-rater reliability.


The simple definitions proposed were: normal--hairpin, tortuous or crossing; abnormal--not hairpin, not tortuous and not crossing; not evaluable--whenever rater undecided between normal and abnormal. Based upon an aimed kappa of 0.80 and default prevalences of normal (0.4), abnormal (0.4) and not evaluable (0.2) capillaries, 90 single capillaries were presented to three groups of raters: experienced independent raters, n = 5; attendees of the sixth EULAR capillaroscopy course, n = 34; novices after a 1-h course, n = 11. Inter-rater agreement was assessed by calculation of proportion of agreement and by kappa coefficients.


Mean kappa based on 90 capillaries was 0.47 (95% CI: 0.39, 0.54) for expert raters, 0.40 (95% CI: 0.36, 0.44) for attendees and 0.46 (95% CI: 0.41, 0.52) for novices, with overall agreements of 67% (95% CI: 63, 71), 63% (95% CI: 60, 65) and 67% (95% CI: 63, 70), respectively. Comparing only normal vs the combined groups of abnormal and not evaluable capillaries did increase the kappa: 0.51 (95% CI: 0.37 ,: 0.65), 0.53 (95% CI: 0.49, 0.58) and 0.55 (95% CI: 0.49, 0.62). On the condition that the capillaries were classifiable, the mean kappa was 0.62 (95% CI: 0.50, 0.74) for expert raters (n = 65), 0.76 (95% CI: 0.69, 0.83) for attendees (n = 20) and 0.81 (95% CI: 0.74, 0.89) for novices (n = 44).


This multicentre, international study showed moderate reliability of simple capillaroscopic definitions for describing morphology of capillaries by rheumatologists with varying levels of expertise. Novices were capable of distinguishing normal from abnormal capillaries by means of a 1-h training session. In future studies, the class not evaluable may be obsolete.


EULAR study group on microcirculation; capillaroscopy; definitions; experts; morphology; novices; reliability; trainees

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