Robert Fairchild, MD, PhD specializes in the diagnosis, evaluation and management of rheumatologic diseases utilizing rheumatologic ultrasonography. He is the Director of Stanford’s Rheumatology Ultrasound Diagnostic and Interventional Clinic which he began five years ago. Since that time, the ultrasound clinic has seen tremendous growth and referrals for imaging and procedural intervention are now core components of Stanford Rheumatology’s clinical practice. In addition, Dr. Fairchild developed and instituted a comprehensive rheumatology ultrasound fellowship training curriculum and is engaged in a variety of ultrasound research studies. Outside of his ultrasound pursuits, Dr. Fairchild also serves as the Medical Director for Stanford’s Value Based Care program which focuses on initiatives aimed at delivering high quality care at lower cost.
Dr. Fairchild received his PhD from Georgetown University, and his M.D. from Columbia University college of Physicians and Surgeons. He completed internship and residency in the Department of Medicine at Stanford and continued on for rheumatology fellowship training in the Division of Immunology and Rheumatology at Stanford. Dr. Fairchild trained in rheumatologic ultrasonography through the USSONAR program and is certified in this technique through the American College of Rheumatology (RhMSUS certification).
Dr. Fairchild’s research interests in ultrasonography focus on unique applications of ultrasonography in rheumatology disease. He has performed extensive research in systemic sclerosis (scleroderma), using ultrasound to study arthritis and tendinopathy, vascular disease, calcinosis, and skin disease. He also spent considerable focus on interstitial lung disease in adult and pediatric rheumatologic disease and recently leveraged this knowledge to study pulmonary disease in SARS-CoV-2 infected patients. Dr. Fairchild is engaged in the development of ultrasonographic outcome measures for research studies and uses ultrasonographic assessments of the salivary gland to measure disease response in clinical trials in Sjogren’s Syndrome. Dr. Fairchild is also engaged in synovial biopsy research to further our understanding of the underlying immunologic pathways and drivers in rheumatologic disease.
- Diagnostic and Interventional Rheumatologic Ultrasonography
Clinical Assistant Professor, Medicine - Immunology & Rheumatology
Fellowship: Stanford University Immunology and Rheumatology Fellowship (2017) CA
Board Certification: American Board of Internal Medicine, Rheumatology (2017)
Board Certification: American Board of Internal Medicine, Internal Medicine (2015)
Residency: Stanford University Internal Medicine Residency (2015) CA
Internship: Stanford University Internal Medicine Residency (2013) CA
Medical Education: Columbia University College of Physicians and Surgeons (2012) NY
PhD, Georgetown University, Host-Guest and Organometallic Chemistry (2008)
Current Research and Scholarly Interests
Dr. Fairchild’s research interests center on novel applications of ultrasonography in rheumatologic disease. Current active research endeavors include using ultrasound 1) to evaluate articular and soft tissue manifestations of systemic sclerosis, 2) to screen, detect and monitor of connective tissue disease associated interstitial lung disease, 3) and to examine the incidence of immune checkpoint inhibitor related adverse events and inflammatory arthritis. Additionally, Dr. Fairchild is engaged in collaborative work with other rheumatologic ultrasonographers nationally helping to develop consensus on ultrasonography protocols and fellowship training guidelines.
Ultrasound evaluation of the hands and wrists in patients with systemic sclerosis: Osteophytosis is a major contributor to tender joints.
Seminars in arthritis and rheumatism
2021; 51 (4): 735-740
OBJECTIVE: To evaluate the prevalence and clinical associations of ultrasound (US) findings of inflammatory arthritis and joint and soft tissue pathology in patients with systemic sclerosis (SSc).METHODS: The hands and wrists of 43 SSc patients and 35 age-balanced controls were evaluated by clinical exam and musculoskeletal US. Synovial and tenosynovial pathology were assessed using semi-quantitative Gray Scale (GS) and Power Doppler (PD) scoring. US evaluation for osteophytes, erosions, ulnar artery occlusion, and median nerve cross-sectional areas was performed. Tender joints (TJ), swollen joints (SJ), modified Rodnan skin score (mRSS), digital ulcers, contractures, and calcinosis were evaluated. Concordance between US and physical exam findings at each joint region were assessed, and associations between their severity were analyzed.RESULTS: TJs and SJs were present in 44.2% and 62.8% of SSc patients, respectively. Inflammatory arthritis, defined as having both GS>0 and PD>0, was observed in 18.6% of SSc patients and no controls. There was a high concordance by joint region between GS synovial hypertrophy and osteophytes (kappa=0.88) as well as TJs (kappa=0.72). SSc patients had more osteophytes compared to controls (48.8% vs 22.9%, p=0.018) as well as higher osteophyte severity (p=0.033).CONCLUSIONS: Despite a high percentage of tender and swollen joints, less than 20% of SSc patients met criteria for inflammatory arthritis on US. The high concordance of osteophytes with GS synovial hypertrophy and tender joints suggest that osteophytosis may be a significant contributor to joint pain in SSc patients.
View details for DOI 10.1016/j.semarthrit.2021.04.020
View details for PubMedID 34144383
A narrative review of imaging in calcinosis associated with systemic sclerosis.
Calcinosis is dystrophic calcification of the soft tissue which can lead to painful and debilitating disease. It is commonly seen in patients with systemic sclerosis (SSc). Imaging can assist in diagnosis, quantification of disease, and better pathophysiologic understanding of calcinosis. Traditionally, X-rays have been the most frequently used imaging modality for diagnosis; however, advances in ultrasound (US), computed tomography (CT), positron emission tomography (PET), and magnetic resonance imaging (MRI) have led to greater ability to characterize these lesions and surrounding structures. This narrative review aims to describe the use of imaging for calcinosis in patients with SSc. Key Points Imaging is useful in the diagnosis of calcinosis, assessment of disease severity, and disease monitoring. X-ray is commonly used and offers high sensitivity and specificity, but both ultrasound and CT-scans are alternatives when greater anatomic detail is sought regarding surrounding structures. Investigational imaging modalities include dual energy CT-scans, cinematic rendering CT-scans, and PET- CT scans. Conventional MRI scans have less sensitivity and specificity for detection of calcinosis.
View details for DOI 10.1007/s10067-021-05696-6
View details for PubMedID 33755836
Prevalence and significance of pulmonary disease on lung ultrasonography in outpatients with SARS-CoV-2 infection.
BMJ open respiratory research
2021; 8 (1)
The majority of patients with SARS-CoV-2 infection are diagnosed and managed as outpatients; however, little is known about the burden of pulmonary disease in this setting. Lung ultrasound (LUS) is a convenient tool for detection of COVID-19 pneumonia. Identifying SARS-CoV-2 infected outpatients with pulmonary disease may be important for early risk stratification.To investigate the prevalence, natural history and clinical significance of pulmonary disease in outpatients with SARS-CoV-2.SARS-CoV-2 PCR positive outpatients (CV(+)) were assessed with LUS to identify the presence of interstitial pneumonia. Studies were considered positive based on the presence of B-lines, pleural irregularity and consolidations. A subset of patients underwent longitudinal examinations. Correlations between LUS findings and patient symptoms, demographics, comorbidities and clinical outcomes over 8 weeks were evaluated.102 CV(+) patients underwent LUS with 42 (41%) demonstrating pulmonary involvement. Baseline LUS severity scores correlated with shortness of breath on multivariate analysis. Of the CV(+) patients followed longitudinally, a majority showed improvement or resolution in LUS findings after 1-2 weeks. Only one patient in the CV(+) cohort was briefly hospitalised, and no patient died or required mechanical ventilation.We found a high prevalence of LUS findings in outpatients with SARS-CoV-2 infection. Given the pervasiveness of pulmonary disease across a broad spectrum of LUS severity scores and lack of adverse outcomes, our findings suggest that LUS may not be a useful as a risk stratification tool in SARS-CoV-2 in the general outpatient population.
View details for DOI 10.1136/bmjresp-2021-000947
View details for PubMedID 34385149
View details for PubMedCentralID PMC8361701
Ultrasound Detection of Calcinosis and Association with Ulnar Artery Occlusion in Patients with Systemic Sclerosis.
Arthritis care & research
To investigate the ability of ultrasound (US) compared to radiographs in detecting calcinosis in hands/wrists of systemic sclerosis (SSc) patients, and assess US markers of pathologic perfusion.SSc patients were evaluated for calcinosis in the hands/wrists by X-ray and US. Presence or absence of calcinosis was recorded by patient, hand, and anatomical zone; sensitivity and specificity for calcinosis detection by US versus X-ray was determined. Bilateral US vascular measurements of ulnar artery occlusion (UAO) and finger pulp blood flow (FPBF) were obtained. For each hand, associations between markers of pathologic blood flow (UAO, FPBF, and a composite severity score of UAO and FPBF) and presence of calcinosis were assessed using generalized estimating equations.Of 43 SSc patients (19 diffuse, 24 limited), 39.5% had calcinosis on X-ray compared to 30.2% on US. Sensitivity and specificity for US was 61% and 95% by zone, 78% and 98% by hand, and 76% and 100% by patient, respectively. UAO was seen in 30% and 28% of left and right hands, respectively; FPBF was absent in ≥1 digit of the left and right hands in 49% and 44%, respectively. UAO was associated with X-ray identified calcinosis by hand (OR 8.08, 95% CI 2.45-26.60, p<0.001), whereas FPBF and the composite severity score were not significant. UAO was associated with calcinosis even in the absence of digital ulcers (OR 33.00, 95% CI 3.39-321.09, p=0.003).US was sensitive and highly specific in detecting calcinosis in SSc. UAO was strongly associated with X-ray identified calcinosis.
View details for DOI 10.1002/acr.24327
View details for PubMedID 32475057
Development and Assessment of a Novel Lung Ultrasound Interpretation Criteria for the Detection of Interstitial Lung Disease in Systemic Sclerosis.
Arthritis care & research
Interstitial lung disease (ILD) is a frequent complication of systemic sclerosis (SSc), and ILD screening, characterization, and monitoring are important for therapeutic decision-making and prognostication. Lung ultrasonography (LUS) is a potential alternative imaging modality for ILD detection. In this study, we develop and test a novel LUS examination technique and interpretation criteria for detecting SSc-ILD.LUS acquisition was performed by collecting short ultrasound movies at 14 lung positions. LUS interpretation criteria for SSc-ILD detection focused on visualized pleural changes. To assess the performance of our methodology for SSc-ILD detection, we prospectively enrolled SSc patients with high resolution computed tomography (HRCT) imaging within 3 months of LUS. LUS exams were scored independently by two blinded readers (one ultrasonographer and one non-ultrasonographer). The sensitivity and specificity for SSc-ILD detection was assessed and agreement was measured with Cohen's Kappa statistic.To test the performance of our LUS acquisition technique and interpretation criteria, 20 SSc patients were evaluated by LUS (278 lung zones) and HRCT. HRCT confirmed ILD in 9 patients (45%). LUS was positive for SSc-ILD in 11 patients (55%) with a sensitivity of 100% and specificity of 82% versus HRCT, with perfect agreement between the two readers (κ=1). Analysis by individual lung zones found excellent agreement between readers with 93.8% concordance and κ=0.82.We developed a novel LUS examination technique and interpretation criteria that are highly sensitive and specific for SSc-ILD detection in an SSc cohort, affording perfect agreement between ultrasonographer and non-ultrasonographer readers.
View details for DOI 10.1002/acr.24338
View details for PubMedID 32475026
Strongyloides Hyperinfection After Immunosuppression in an Immigrant From El Salvador A Case for Early Diagnosis and Treatment
JCR-JOURNAL OF CLINICAL RHEUMATOLOGY
2021; 27 (4): E128-+
View details for Web of Science ID 000657235500003
Comparison of Adverse Events Among Home- vs Facility-Administered Biologic Infusions, 2007-2017.
JAMA network open
2021; 4 (6): e2110268
Importance: Infusion reactions occur in 7% to 20% of patients receiving biologics. Home infusions are convenient and incur lower costs but may be associated with more adverse events; the safety of receiving biologic infusions for immune-mediated diseases at home remains unclear.Objective: To assess whether patients receiving home biologic infusions have increased adverse events requiring emergency department (ED) or hospital admission compared with patients receiving facility infusions.Design, Setting, and Participants: This retrospective cohort study used administrative claims data from a large national insurer for adult patients who received biologic infusions for immune-mediated disease between January 2007 and December 2017. Patients with hematologic malignant neoplasms or bone marrow transplantation were excluded. Data were analyzed from August 2019 to October 2020.Main Outcomes and Measures: ED or hospital admission on the same or next day after administration of a biologic infusion at home vs at a facility; secondary outcomes included discontinuation of the biologic after an ED or hospital admission and postinfusion mortality.Results: Of a total of 57 220 patients (mean [SD] age, 50.1 [14.8] years; 512 314 [68.1%] women) who received 752 150 biologic infusions (34 078 home infusions [4.5%] to 3954 patients and 718 072 facility infusions [95.5%] to 54 770 patients), patients who received home infusions were younger (mean [SD] age, 43.2 [13.2] vs 51.3 [14.8] years), more likely to be men (14 031 [41.2%] vs 225 668 [31.4%]), and had a lower Charlson comorbidity score compared with patients who received facility infusions (mean [SD] score, 0.5 [1.0] vs 1.1 [1.3]). Home infusions were associated with 25% increased odds of ED or hospital admission on the same or next day after the infusion (odds ratio [OR], 1.25; 95% CI, 1.09-1.44; P=.002) and 28% increased odds of discontinuation of the biologic after the ED or hospital admission (OR, 1.28; 95% CI, 1.08-1.51; P=.005). There was no difference in postinfusion mortality between home or facility infusions. The rates of adverse events were highest with home infusions of tocilizumab (48 of 481 infusions [10.0%]), vedolizumab (150 of 2681 infusions [5.6%]), and infliximab (1085 of 20 653 infusions [5.3%]), although the number of tocilizumab and vedolizumab infusions was low.Conclusions and Relevance: In this study, biologic infusions administered at home, compared with those administered at a facility, were associated with increased adverse events requiring escalation of care. Because the number of home infusions has increased and is expected to continue to rise, the safety implications of administering biologic infusions at home needs to be further assessed.
View details for DOI 10.1001/jamanetworkopen.2021.10268
View details for PubMedID 34081140
North American musculoskeletal ultrasound scanning protocol of the hip, knee, ankle, and foot: update of a Delphi consensus study.
BACKGROUND/OBJECTIVE: A North American rheumatology consensus on tiered-mastery designation for anatomic views was developed in 2011 for course and fellowship teaching. This study updates the lower extremity joint scanning protocols aiming to inform musculoskeletal ultrasound curriculum development for the American College of Rheumatology affiliated Fellowship Programs.METHODS: Three Delphi rounds were conducted to reach consensus for tiered-level mastery designation for hip, knee, ankle, and foot scanning views. The survey was disseminated (Qualtrics) to 101 potential participants with ultrasound teaching experience. High agreement was defined as ≥ 85% consensus and final tier designation as having >50% agreement for the preferred tier. Response changes were evaluated by McNemar's chi-square test.RESULTS: Consensus regarding tier designations was reached for 80% of the views. Three knee views (anterior transverse suprapatellar, medial, and lateral longitudinal) and 2 ankle views (anterior and posterior transverse) achieved upgrades to tier 1 from 2. The transverse sacroiliac hip joint was downgraded from tier 2 to 3. The lateral longitudinal hip view was added with a tier 1 designation.CONCLUSION: Updated scanning protocols support modifications reflecting current scanning methods delivered by North American rheumatologists performing point of care ultrasound that may inform educators involved in rheumatology ultrasound. Key Points The anterior transverse suprapatellar, medial, and lateral longitudinal knee views; the anterior and posterior transverse ankle views; and the lateral longitudinal view hip view were perceived as important to master and perform routinely. The transverse sacroiliac joint view was suggested to be performed based on practice focus.
View details for DOI 10.1007/s10067-021-05716-5
View details for PubMedID 33821367
Ultrasound Doppler and tenosynovial fluid analysis in tenosynovitis.
Annals of the rheumatic diseases
To assess Doppler ultrasound (US) and tenosynovial fluid (TSF) characteristics in tenosynovitis within common rheumatic conditions, as well as their diagnostic utility.Subjects with tenosynovitis underwent Doppler US and US-guided TSF aspiration for white cell count (WCC) and crystal analysis. Tenosynovial Doppler scores (DS) were semiquantitatively graded. TSF WCC and DS were compared using Kruskal-Wallis tests and logistic regression between non-inflammatory conditions (NIC), inflammatory conditions (IC) and crystal-related conditions (CRC). Receiver operating curves, sensitivity and specificity assessed the ability of WCC and DS to discriminate IC from NIC.We analysed 100 subjects from 14 sites. The mean age was 62 years, 65% were female, and the mean TSF volume was 1.2 mL. Doppler signal was present in 93.7% of the IC group and was more frequent in IC than in NIC group (OR 6.82, 95% CI 1.41 to 32.97). The TSF median WCC per 109/L was significantly higher in the IC (2.58, p<0.001) and CRC (1.07, p<0.01) groups versus the NIC group (0.38). A TSF cut-off of ≥0.67 WCC per 109/L optimally discriminated IC versus NIC with a sensitivity and specificity each of 81.3%. In the IC group, 20 of 48 (41.7%) subjects had a TSF WCC <2.00 per 109/L.A negative DS helps rule out IC in tenosynovitis, but a positive DS is non-specific and merits TSF testing. Unlike synovial fluid, a lower TSF WCC better discriminates IC from NIC. US guidance facilitates aspiration of minute TSF volume, which is critical for diagnosing tenosynovial CRC.
View details for DOI 10.1136/annrheumdis-2020-216927
View details for PubMedID 32213497
- Painful Panniculitis and Polyarthritis in Pancreatic Adenocarcinoma: A Case Report. Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases 2020
Development and Preliminary Validation of a Novel Lung Ultrasound Interpretation Criteria for the Detection of Interstitial Lung Disease in Patients with Systemic Sclerosis
View details for Web of Science ID 000507466904514
Tenosynovial Aspiration by Ultrasound Guidance: Correlation and Diagnostic Implications of Tenosynovial Analysis and Ultrasound Doppler Signal
View details for Web of Science ID 000507466903201
Ultrasound Evaluation of the Hands in Patients with Systemic Sclerosis: Osteophytosis Is a Major Contributor to Tender Joints
View details for Web of Science ID 000507466901134
Ultrasound Detection of Calcinosis and Correlation with Ulnar Artery Occlusion in Patients with Systemic Sclerosis
View details for Web of Science ID 000507466904371
Musculoskeletal Ultrasound Scanning Protocol Consensus Statements on Scanning Conventions and Documentation in the U.S.
Arthritis care & research
There has been increased engagement with ultrasound in rheumatology (RhUS) in the United States with more physicians being trained and certified, its inclusion in fellowship training curricula, and as criteria in the evaluation of rheumatic disease patients. European rheumatology and Radiology-determined standards have largely driven the execution of RhUS; how this translates to American rheumatology practice has not been examined. A 2011 rheumatology-driven consensus on documentation, scanning conventions, and tiered-mastery designation for anatomic region views was developed, which served as the framework for training, and clinical research validation. This study aims to update this consensus to reflect current utilization of musculoskeletal RhUS evaluation in the United States.A 3-round Delphi method study was conducted using a 96-item questionnaire sent via Qualtrics® to 101 respondents experienced in RhUS education and scholarship. The target participant number was 38. High agreement was defined as ≥ 85% agreement on each item. McNemar's chi-square statistic tested for changes in agreement in responses. Comments were reviewed for content analysis.46 respondents completed all three rounds. 80% and 100% of documentation and scanning convention statements, respectively, reached high agreement. Comments reflected the need for rheumatology-defined and disease-specific "complete scan" and "limited scan" definitions, separate from radiology-defined definitions.Many scanning conventions from 2011 remain relevant in current practice. There is a need to determine rheumatology-defined descriptions for common procedural terminology codes for "complete" and "limited" scans that accurately reflect the current state of RhUS. This article is protected by copyright. All rights reserved.
View details for DOI 10.1002/acr.24005
View details for PubMedID 31199596
Consensus Statements on Scanning Conventions and Documentation in Musculoskeletal Ultrasound
View details for Web of Science ID 000447268902292
Strongyloides Hyperinfection After Immunosuppression in an Immigrant From El Salvador: A Case for Early Diagnosis and Treatment.
Journal of clinical rheumatology : practical reports on rheumatic & musculoskeletal diseases
View details for PubMedID 30074914
Consensus-Building on a Rheumatology Musculoskeletal Ultrasound Scanning Protocol for Rheumatology Fellowship Programs
View details for Web of Science ID 000411824100110
Utility of B-type natriuretic peptides in the assessment of patients with systemic sclerosis-associated pulmonary hypertension in the PHAROS registry
CLINICAL AND EXPERIMENTAL RHEUMATOLOGY
2017; 35 (4): S106–S113
View details for Web of Science ID 000418419000015
Utility of B-type natriuretic peptides in the assessment of patients with systemic sclerosis-associated pulmonary hypertension in the PHAROS registry.
Clinical and experimental rheumatology
To assess the utility of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) in detecting and monitoring pulmonary hypertension (PH) in systemic sclerosis (SSc).PHAROS is a multicenter prospective cohort of SSc patients at high risk for developing pulmonary arterial hypertension (SSc-AR-PAH) or with a definitive diagnosis of SSc-PH. We evaluated 1) the sensitivity and specificity of BNP≥64 and NT-proBNP≥210 pg/mL for the detection of SSc-PAH and/ or SSc-PH in the SSc-AR-PAH population; 2) baseline and longitudinal BNP and NT-proBNP levels as predictors of progression to SSc-PAH and/or SSc-PH; 3) baseline BNP≥180, NT-proBNP≥553 pg/mL, and longitudinal changes in BNP and NT-proBNP as predictors of mortality in SSc-PH diagnosed patients.172 SSc-PH and 157 SSc-AR- PAH patients had natriuretic peptide levels available. Median BNP and NT-proBNP were significantly higher in the SSc-PH versus SSc-AR-PAH group. The sensitivity and specificity for SSc-PAH detection using baseline BNP≥64 pg/mL was 71% and 59%; and for NT-proBNP≥210 pg/mL, 73% and 78%. NT-proBNP showed stronger correlations with haemodynamic indicators of right ventricular dysfunction than BNP. Baseline creatinine, RVSP > 40 mmHg, and FVC%:DLco% ratio ≥1.8 were associated with progression from SSc-AR-PAH to SSc-PH but no association with individual or combined baseline BNP and NT-proBNP levels was observed. Baseline and follow-up BNP or NT-proBNP levels were not predictive of death, however, a composite BNP/NT-proBNP group predicted mortality (HR 3.81 (2.08-6.99), p<.0001).NT-proBNP may be more useful than BNP in the detection and monitoring of PAH in SSc patients, but additional studies are necessary.
View details for PubMedID 27908301