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Objective. The journey to a diagnosis of spondyloarthritis (SpA) can be difficult for women, who often experience delays in receiving the correct diagnosis as their symptoms are frequently misinterpreted due to other conditions like osteoarthritis, fibromyalgia, or other psychosomatic disorders. The purpose of this article is to examine the challenges in the diagnosis of SpA in women and the possible role of musculoskeletal ultrasound in early diagnosis and in avoiding misdiagnosis. Methods. We have performed a narrative review of the currently available literature on the subject. Results. The complexity of diagnosing SpA in women is compounded by the misconception that the disease predominantly affects men. To facilitate early diagnosis and prevent misdiagnosis, it is crucial not to overlook gender differences in the clinical presentation of SpA. Since women have more peripheral and enthesitic involvement, performing an ultrasound of entheses, tendons, and joints in women with musculoskeletal symptoms that could refer to SpA may help both in the early and differential diagnosis. Conclusions. There is a need to increase awareness among physicians of the existence of a different clinical presentation of SpA between men and women. The use of musculoskeletal ultrasound, which allows the detection of even subclinical inflammation and structural damage since early disease at the level of joints, tendons, and entheses can help make an early diagnosis and avoid misdiagnosis. Early diagnosis and timely treatment of SpA are crucial to reducing irreversible damage.

The aim of this study was to evaluate the accuracy of synovial fluid analysis in the identification of calcium pyrophosphate dihydrate crystals compared to microscopic analysis of joint tissues as the reference standard. This is an ancillary study of an international, multicentre cross-sectional study performed by the calcium pyrophosphate deposition disease (CPPD) subgroup of the OMERACT Ultrasound working group. Consecutive patients with knee osteoarthritis (OA) waiting for total knee replacement surgery were enrolled in the study from 2 participating centres in Mexico and Romania. During the surgical procedures, synovial fluid, menisci and hyaline cartilage were collected and analysed within 48 hours from surgery under transmitted light microscopy and compensated polarised light microscopy for the presence/absence of calcium pyrophosphate crystals. All slides were analysed by expert examiners on site, blinded to other findings. A dichotomic score (absence/ presence) was used for scoring both synovial fluid and tissues. Microscopic analysis of knee tissues was considered the gold standard. Sensitivity, specificity, accuracy, positive and negative predictive values of synovial fluid analysis in the identification of calcium pyrophosphate crystals were calculated. 15 patients (53% female, mean age 68 yo ± 8.4) with OA of grade 3 or 4 according to Kellgren-Lawrence scoring were enrolled. 12 patients (80%) were positive for calcium pyrophosphate crystals at the synovial fluid analysis and 14 (93%) at the tissue microscopic analysis. The overall diagnostic accuracy of synovial fluid analysis compared with histology for CPPD was 87%, with a sensitivity of 86% and a specificity of 100%, the positive predictive value was 100% and the negative predictive value was 33%. In conclusion synovial fluid analysis proved to be an accurate test for the identification of calcium pyrophosphate dihydrate crystals in patients with advanced OA.

We present a case report of a rheumatoid arthritis patient, who underwent a PET scan, which revealed inflammation of multiple joints, which was missed by both physical and ultrasound examinations. A 55-year old woman with a long-term rheumatoid arthritis, who had undergone arthroplasty of the left knee in the past, consulted with the rheumatologist for pain in the left knee. The physical examination revealed signs of inflammation in the left knee and right elbow. The inflammatory parameters were high. Ultrasound showed intraarticular effusion without signs of active synovitis in the left knee. The ultrasound assessment of the other joints (hands, wrists and feet) was also negative for active synovitis, while positron-emission tomography (PET) revealed increased glucose metabolism at the level of the medial side of the left knee, left radio-ulno-carpal joint, I-II-III metacarpo-phalangeal joints bilaterally, right II metatarso-phalangeal joint, and left II-III metatarso-phalangeal joints. This case report demonstrates that PET might be more sensitive than ultrasound in detecting subclinical joint inflammation.

Shoulder pain is a common condition in the rheumatologist’s practice, yet there are no guidelines on how to report shoulder ultrasound (US) examinations. The aim of this study was to compare scanning and reporting techniques performed by radiologists and rheumatologists and identify any discrepancies between the two. The participants in this study were five rheumatologists and two radiologists specialized in musculoskeletal US. The study was divided in 2 phases. In the first phase, each participant performed an US of 3 patients and reported the findings without knowing the patient diagnosis and the findings reported by the other operators. Other three investigators reported the US technique of each operator. Reports and images were subsequently compared to identify any discrepancies and reach consensus on a common approach. In the second phase, a US scan was performed on a fourth patient in a plenary session to assess feasibility and efficacy of the common approach The US scanning technique was similar for all operators. The differences in reporting emerged in the description of the rotator cuff disease. Radiologists provided a detailed description of lesions (measurements along 2 axis and scoring of lesions), whereas rheumatologists described carefully the inflammatory changes. The experts concluded that lesions should be measured along 2 axes and the grade of degeneration and the age of the lesion should be reported. Another difference emerged in the description of the irregularities of the bone surface. The experts concluded that the term erosion should be used only when an inflammatory joint disease is suspected. This study led to the clarification of some inconsistencies in US reporting, and represented an interesting collaborative experience between radiologists and rheumatologists.

Sjögren’s syndrome (SS) is a chronic inflammatory disease with an autoimmune etiology, that affects exocrine glands, in particular salivary and lacrimal glands. Among the diagnostic criteria of SS, imaging tecniques play an important role. The aim of our study is to compare three imaging tecniques, such as sonography, scintigraphy and sialography in the evaluation of major salivary glands. The use of the these tecniques is of great importance for the diagnosis of SS. Sonography is the most frequently used for its prompt execution, non invasivity, great acceptance by the patient and low cost. In the diagnostic patient management of SS, sonography results are eventually confirmed by the other imaging tecniques, sialography and scintigraphy.

Objectives: To evaluate, using musculoskeletal ultrasound (MSUS), the effects of Etanercept therapy in patients with rheumatoid arthritis (RA) over 3 months of treatment. Methods: Eighteen consecutive patients, 3 male and 15 female, affected by RA (ACR criteria) who were non-responders or partial responders to DMARDs therapy were commenced on Etanercept treatment. MSUS was performed bilaterally in the 2nd and 5th metacarpophalangeal, 3rd interphalangeal, wrist and knee joints, using a Philips/HP Image Point HX machine with a 7,5 MHz linear probe for knee joints and a 14 MHz probe for the hands and wrists. In addition, power Doppler was used with the following settings: PRF 700-1000Hz, gain 60-65 dB, low filter. For all the changes a semi-quantitative score (0-3) was used to indicate the presence of a localised inflammatory process (synovitis, tenosynovitis). An overall score was then calculated based on the sum of the single scores in order to obtain a comprehensive score indicative of the global pathological change. Results: The overall score significantly (p

The Musculoskeletal Ultrasound Study Group of the Italian Society of Rheumatology (SIR) was founded during the 68th SIR Congress, on November 2011. The request of activation of this group was based on the increasing interest and the widespread diffusion of ultrasound in the scientific rheumatology community and on the solid experience of some Italian rheumatologists in the field. The aims of the Study Group are to stimulate the applications and use of ultrasound in the clinical practice at the level of the Italian rheumatology units and, in addition, to develop research projects at a national level...

Brucellosis is a zoonosis commonly present in many areas of the world; in some Mediterranean countries it is endemic. The disease is usually transmitted to humans by ingestion of contaminated food; rarely it may be transmitted either by direct penetration through skin lesions or conjunctival mucosa or even by inhalation of aerosols. The disease may be asymptomatic, but in some occasions acute or chronic symptoms are present. Among localised forms of the disease spinal involvement is rare but it should be suspected in many Mediterranean areas where brucellosis is endemic. In particular, the extension of the brucellar abscess within the epidural space with contemporaneous muscular involvement is unusual. The authors report a case of a patient with multiple spinal brucellar abscesses of exceptional dimensions, extending in the epidural space and within paravertebral and psoas muscles and causing compression of the lumbar nerve roots. The exact localisation and extension of the abscess have been accurately defined by MRI.

About 10% of the Italian general population is affected by rheumatic diseases (RD). Due to their chronic and disabling nature, RD are cause of an annual economic burden evaluated in about 17,000 billions italian lire. In Italy, rheumatoid arthritis (RA) affects nearly 400,000 people. One hundred RA patients answered to a questionnaire concerning hospitalization during the first ten years of disease. Seventy-two patients needed hospitalization with a total of 147 hospital admissions. Eleven patients were admetted thrice to the hospital, 53 patients twice, and 8 patients only once with a mean number of hospital admissions per patients of 1.8. Hospitalization costs were calculated on the basis of the cost of the DRG for RA and inferred for the total population of Italian RA patients. The result was about 350 billions italian lire. Two methods were used in order to evaluate the economic impact of RA including both direct and indirect costs. First, internationally accepted criteria for cost assessment were applied to the Italian system. Second, different evaluations were performed by the authors. With the first method, direct and indirect costs were 3,000 and 3,500 billions Italian lire, respectively. With the second method, based on a more precise assesment of costs including the costs of wager from a reduction or cessation of work, the total costs for RA was between 3,100 and 3,600 billions Italian lire. Since psychological and social problems often influence patients with RA in relation to their families and society, the issue of intangible costs has also been addressed.

Sjögren's syndrome (SS) is a chronic inflammatory disease with an autoimmune etiology, that affects exocrine glands, in particular salivary and lacrimal glands. Among the diagnostic criteria of SS, imaging techniques play an important role. The aim of our study is to compare three imaging techniques, such as sonography, scintigraphy and sialography in the evaluation of major salivary glands. The use of the these techniques is of great importance for the diagnosis of SS. Sonography is the most frequently used for its prompt execution, non invasivity, great acceptance by the patient and low cost. In the diagnostic patient management of SS, sonography results are eventually confirmed by the other imaging techniques, sialography and scintigraphy.

Objectives: To evaluate, using musculoskeletal ultrasound (MSUS), the effects of Etanercept therapy in patients with rheumatoid arthritis (RA) over 3 months of treatment., Methods: Eighteen consecutive patients, 3 male and 15 female, affected by RA (ACR criteria) who were non-responders or partial responders to DMARDs therapy were commenced on Etanercept treatment. MSUS was performed bilaterally in the 2nd and 5th metacarpophalangeal, 3rd interphalangeal, wrist and knee joints, using a Philips/HP Image Point HX machine with a 7,5 MHz linear probe for knee joints and a 14 MHz probe for the hands and wrists. In addition, power Doppler was used with the following settings: PRF 700-1000Hz, gain 60-65 dB, low filter. For all the changes a semi-quantitative score (0-3) was used to indicate the presence of a localised inflammatory process (synovitis, tenosynovitis). An overall score was then calculated based on the sum of the single scores in order to obtain a comprehensive score indicative of the global pathological change., Results: The overall score significantly (p<10-5) reduced between T0 (8,5) and T3 (5). Even the most part of the local joint scores significantly reduced., Conclusions: A positive response to treatment with Etanercept was demonstrated by MSUS examination of several joints. The results of our study are supportive of those presented in other reports where MSUS was used to monitor disease activity. We were able however to demonstrate this in a wider range of anatomical targets than in previous studies. MSUS is a useful tool in the monitoring of biologic therapy in RA.

Brucellosis is a zoonosis commonly present in many areas of the world; in some Mediterranean countries it is endemic. The disease is usually transmitted to humans by ingestion of contaminated food; rarely it may be transmitted either by direct penetration through skin lesions or conjunctival mucosa or even by inhalation of aerosols. The disease may be asymptomatic, but in some occasions acute or chronic symptoms are present. Among localised forms of the disease spinal involvement is rare but it should be suspected in many Mediterranean areas where brucellosis is endemic. In particular, the extension of the brucellar abscess within the epidural space with contemporaneous muscular involvement is unusual. The authors report a case of a patient with multiple spinal brucellar abscesses of exceptional dimensions, extending in the epidural space and within paravertebral and psoas muscles and causing compression of the lumbar nerve roots. The exact localisation and extension of the abscess have been accurately defined by MRI.

About 10% of the Italian general population is affected by rheumatic diseases (RD). Due to their chronic and disabling nature, RD are cause of an annual economic burden evaluated in about 17,000 billions italian lire. In Italy, rheumatoid arthritis (RA) affects nearly 400,000 people. One hundred RA patients answered to a questionnaire concerning hospitalization during the first ten years of disease. Seventy-two patients needed hospitalization with a total of 147 hospital admissions. Eleven patients were admitted thrice to the hospital, 53 patients twice, and 8 patients only once with a mean number of hospital admissions per patients of 1.8. Hospitalization costs were calculated on the basis of the cost of the DRG for RA and inferred for the total population of Italian RA patients. The result was about 350 billions italian lire. Two methods were used in order to evaluate the economic impact of RA including both direct and indirect costs. First, internationally accepted criteria for cost assessment were applied to the Italian system. Second, different evaluations were performed by the authors. With the first method, direct and indirect costs were 3,000 and 3,500 billions Italian lire, respectively. With the second method, based on a more precise assessment of costs including the costs of wager from a reduction or cessation of work, the total costs for RA was between 3,100 and 3,600 billions Italian lire. Since psychological and social problems often influence patients with RA in relation to their families and society, the issue of intangible costs has also been addressed.

We evaluated the effectiveness and the tolerability of a new non steroidal antiinflammatory drug (NSAID), nabumetone (1 g/daily for at least 8 days), in 20 patients (10 males and 10 females), 4 with rheumatoid arthritis and 16 with osteoarthritis. During the treatment we observed a progressive reduction of pain and swelling with improvement of articular movements. Our results showed an appreciable effectiveness of nabumetone treatment in 75% of patients. Excluding two patients with transient mild side effects (gastric and cutaneous symptoms), the tolerability has been satisfactory.

Twenty patients, 10 males and 10 females, age range 32-76, mean age 57.80 years, with diagnoses of acute multiple joint disorders (9 cases), flare-ups of rheumatoid arthritis (4 cases), low back pain due to lumbosacral disc pathology (4 cases), osteoarthritis of large joints (3 cases), all with severe pain and corresponding functional limitation of the joints involved, were treated with a nabumetone preparation (1 g capsules; one capsule at night before going to bed) for 8-12 days. During treatment, symptoms subsided gradually with adequate recovery of joint function. Parameters concerning general tolerability did not reveal clinically relevant changes compared to baseline. Local tolerability was mostly satisfactory. Two patients complained of mild side effects (gastric pain and skin phenomena). Treatment was considered effective in 15 cases, scarsely effective in 4, and ineffective in one.