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Objective.To define the ultrasonographic characteristics of calcium pyrophosphate crystal (CPP) deposits in joints and periarticular tissues and to evaluate the intra- and interobserver reliability of expert ultrasonographers in the assessment of CPP deposition disease (CPPD) according to the new definitions.Methods.After a systematic literature review, a Delphi survey was circulated among a group of expert ultrasonographers, who were members of the CPPD Ultrasound (US) Outcome Measures in Rheumatology (OMERACT) subtask force, to obtain definitions of the US characteristics of CPPD at the level of fibrocartilage (FC), hyaline cartilage (HC), tendon, and synovial fluid (SF). Subsequently, the reliability of US in assessing CPPD at knee and wrist levels according to the agreed definitions was tested in static images and in patients with CPPD. Cohen’s κ was used for statistical analysis.Results.HC and FC of the knee yielded the highest interobserver κ values among all the structures examined, in both the Web-based (0.73 for HC and 0.58 for FC) and patient-based exercises (0.55 for the HC and 0.64 for the FC). Kappa values for the other structures were lower, ranging from 0.28 in tendons to 0.50 in SF in the static exercise and from 0.09 (proximal patellar tendon) to 0.27 (triangular FC of the wrist) in the patient-based exercise.Conclusion.The new OMERACT definitions for the US identification of CPPD proved to be reliable at the level of the HC and FC of the knee. Further studies are needed to better define the US characteristics of CPPD and optimize the scanning technique in other anatomical sites.

Objective.To test the learning curve of rheumatologists with different experience in videocapillaroscopy (VCP) attending an intensive training program focused on interpretation of the main capillary nailfold abnormalities, the scleroderma (systemic sclerosis, SSc) pattern, and the normal pattern, and to determine their interreader agreement with an experienced investigator.Methods.Five investigators (1 senior, 1 junior, and 3 beginners) participated in the exercise. The study was composed of 2 steps. First, an independent investigator selected representative VCP images of normal patterns and capillary abnormalities. The second step included the training program, which ran 4 hours per day for 7 days. The senior rheumatologist taught investigators to recognize and interpret the normal pattern, the capillary abnormalities, and the different types of SSc pattern. These abnormalities were considered: homogeneously enlarged capillaries, giant capillaries, irregularly enlarged capillaries, microhemorrhages, neoangiogenesis, avascular areas, and capillary density.Results.A total of 300 VCP images were read from all the investigators. Both κ values and overall agreement percentages of qualitative and quantitative assessments showed progressive improvement from poor to excellent from the beginning to the end of the exercise. The sensitivity and specificity of the participants in the assessment of SSc pattern at the last lecture session were high.Conclusion.Our pilot study suggests that after an intensive 1-week training program, novice investigators with little or no experience in VCP are able to interpret the main capillary abnormalities and SSc pattern and to achieve good interreader agreement rates.

To the Editor: Calcium pyrophosphate deposition (CPPD) disease is a metabolic arthropathy caused by the deposition of calcium pyrophosphate (CPP) crystals in and around joints, especially in hyaline and fibrous cartilage. CPPD disease is generally categorized into sporadic, familial, and secondary (metabolic) forms. Prevalence increases with age; indeed, radiographic evidence of CPPD is found in up to 40% of elderly subjects. The sporadic form is the most common. Secondary CPPD disease is an infrequent condition related to a variety of metabolic causes including hyperparathyroidism, hypomagnesemia, hypophosphatasia, and hemochromatosis. Familial CPPD disease is characterized by distinctive clinical and radiographic features, but its prevalence is unknown1,2,3,4. Diagnosis requires detection of CPP crystals in synovial fluid1; however, an increasing body of evidence indicates a role for ultrasound (US) as a bedside procedure to improve diagnostic accuracy and clinical decision making in routine rheumatological practice. US possesses some ideal features for assessing crystalline arthropathies. … Address correspondence to Dr. Di Geso; E-mail: lucadigeso{at}libero.it

Objective.Dactylitis, a characteristic feature of the spondyloarthropathies, occurs in up to 48% of patients with psoriatic arthritis (PsA). No clear consensus on the underlying components and pathogenesis of dactylitis exists in the literature. We undertook a systematic review of ultrasound (US) and magnetic resonance imaging (MRI) literature to better define imaging elements that contribute to the dactylitic digit seen in PsA. Our objectives were to determine first the level of homogeneity of each imaging modality’s definition of the components of dactylitis, and second, to evaluate the metric properties of each imaging modality according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) filter.Methods.Searches were performed in PUBMED and EMBASE for articles pertaining to MRI, US, and dactylitis. Data regarding the reported features of dactylitis were collected and categorized, and the metrological qualities of the studies were assessed.Results.The most commonly described features of dactylitis were flexor tendon tenosynovitis and joint synovitis (90%). Extratendinous soft tissue thickening and extensor tendonitis were described nearly equally as being present and absent. Discrepancy exists as to whether entheses proper contribute to the etiology of dactylitis. An increasing number of studies categorize abnormalities in several tissue compartments including the soft tissue, tendon sheaths, and joints, as well as ligaments.Conclusion.The understanding of which tissues contribute to dactylitic inflammation has evolved. However, there is a lack of literature regarding the natural history of these abnormalities. This systematic review provides guidance in defining elementary lesions that may discriminate dactylitic digits from normal digits, leading to development of a composite measure of activity and severity of dactylitis.

Objective.To investigate the correlation between ultrasound (US) B-lines and high-resolution computed tomography (HRCT) findings in the assessment of pulmonary fibrosis (PF) in patients with connective tissue disorders (CTD).Methods.Thirty-four patients with a diagnosis of CTD were included. Each patient underwent clinical examination, pulmonary function test (PFT), chest HRCT, and lung US by an experienced radiologist or rheumatologist. A second rheumatologist carried out US examinations to assess interobserver agreement. In each patient, US B-line lung assessment including 50 intercostal spaces (IS) was performed. For the anterior and lateral chest, the IS were the second to the fifth along the parasternal, mid-clavicular, anterior axillary, and medial axillary lines (the left fifth IS of the anterior and lateral chest was not performed because of the presence of the heart, which limits lung visualization). For the posterior chest, the IS assessed were the seventh to the eighth along the posterior-axillary and subscapular lines. The second to eighth IS were assessed in the paravertebral line. In each IS, the number of US B-lines under the transducer was recorded, summed, and graded according to the following semiquantitative scoring: grade 0 = normal (< 10 B-lines); grade 1 = mild (11 to 20 B-lines); grade 2 = moderate (21 to 50 B-lines); and grade 3 = marked (> 50 B-lines).Results.A total of 1700 IS in 34 patients were assessed. A significant linear correlation was found between the US score and the HRCT score (p < 0.001; correlation coefficient ρ = 0.875). A positive correlation was found between US B-line assessments and values of DLCO (p = 0.014). Both κ values and overall percentages of interobserver agreement showed excellent agreement.Conclusion.Our study demonstrates that US B-line assessment may be a useful and reliable additional imaging method in the evaluation of PF in patients with CTD.

The enthesis, a 1-millimeter universe, is an area of great interest for the spondyloarthritis (SpA) research community. Our understanding of this critical anatomical area has dramatically improved over the past few years, but much remains to be learned. Ultrasonography (US) provides an innovative approach to the investigation of this still mysterious point of union between bone and other anatomical structures (tendon, ligament, aponeurosis, capsule)1,2,3,4,5,6,7,8. Entheses appear to be perfect targets for US because most of them are superficial and can be explored with very high frequency probes9,10,11,12. The availability of high-resolution equipment has opened up new and fascinating possibilities in the assessment of minimal details of tendons, fibrocartilage, and bone surface. The level of spatial resolution of widely available 18 MHz probes has broken the 0.1-mm barrier, allowing access to an impressive amount of otherwise unobtainable images of the various phases of early and late inflammatory and degenerative changes involving the enthesis. This plethora of images can be problematic. US researchers are facing the challenge of how best to interpret, organize, and classify an incredibly wide range of new findings. These challenges are similar to those … Address correspondence to Prof. Grassi. E-mail: walter.grassi{at}univpm.it

Seronegative spondyloarthropathy (SpA) is a chronic inflammatory disease that includes a heterogeneous group of diseases such as psoriatic arthritis (PsA), ankylosing spondylitis (AS), reactive arthritis, arthritis associated with inflammatory bowel disease, and undifferentiated SpA. Enthesis and tendon involvement are 2 important aspects of SpA1. There is strong evidence that demonstrates the role of ultrasound (US) with power Doppler (PD) technique and its higher sensitivity, compared to the clinical examination, in the detection of signs of entheseal involvement in both late and early stages2. One of its main limits is operator dependency. A minimal change in the transducer position or an erroneous setting can provide completely different information, easily leading to misinterpretations. The importance of the patient’s position during the US assessment has not been well studied3,4. We investigated the effect of this phenomenon at different enthesis levels in 4 patients with SpA. US images were obtained with a MyLab 70 XVG US system (Esaote Biomedica, Genoa, Italy) with a 6–18 MHz linear transducer B-mode frequency of 18 MHz and a Doppler frequency of 9.1 …

Psoriasis is a chronic inflammatory skin disease affecting 1% to 3% of the world’s population1. A considerable proportion of patients with psoriasis will develop a form of inflammatory arthritis known as psoriatic arthritis (PsA). More rarely, PsA develops before the psoriatic lesions. The prevalence of PsA in patients with psoriasis varies from 7.6% to 36% according to the different populations studied2. The inadequate response to treatment and the toxicity of traditional treatments opened the doors to the development of new therapeutic alternatives such as tumor necrosis factor-α (TNF-α) antagonists, which are utilized in patients with PsA and psoriasis for reducing the proinflammatory cell infiltration (macrophages, monocytes, keratinocytes, Langerhan’s cells, dermal dendritic cells, mast cells, and activated T cells) at the skin and synovial level3,4. Some authors have demonstrated the utility of ultrasound (US) in PsA5,6, but to our knowledge no studies have aimed at assessing the potential of this technique in anti-TNF-α therapy …

There is a consistent body of evidence supporting the role of ultrasound in patients with rheumatoid arthritis (RA)1,2. More recently, ultrasound is gaining interest among rheumatologists for the assessment of calcium pyrophosphate dihydrate (CPPD) disease3,4,5, because it has demonstrated high specificity in the detection of pathological findings indicative of pyrophosphate crystal deposits6,7,8. The definite diagnosis of CPPD disease requires identification of CPPD crystals in the synovial fluid by polarizing light microscopy. However, aspiration of the synovial fluid is not always possible for many reasons. In those cases, imaging modalities are important as surrogate diagnostic tools. We describe 2 cases showing the diagnostic potential of ultrasound in the detection of pyrophosphate crystal deposits in patients with negative radiographic evidence of cartilage calcifications. A 58-year-old woman presented to our clinic for a history of recurrent attacks of monoarthritis at right knee level, associated …