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To determine the prevalence and distribution of the ultrasound (US) findings indicating cartilage and bone damage at the metacarpal head (MH) in a group of healthy subjects (HS), and their association with the clinical and US data. We also aimed to provide standard reference values of cartilage thickness.US scans of the dorsal aspect of the metacarpophalangeal joints (MCPj) from 2nd to 5th finger of both hands were performed in 179 HS. The presence of cartilage damage, osteophytes and bone erosions was recorded.Cartilage damage, osteophytes and bone erosions were found in at least one MCPj in 30 (16.8%), 17 (9.5%) and 4 (2.2%) out of 179 HS, respectively. Signs of cartilage damage were found in 91 out of 1432 MHs (6.4%). Blurring of the chondrosynovial margin, minimal and severe thinning were detected in 73.7%, 26.3% and 0% of the 91 MHs, respectively. Osteophytes and bone erosions were found in 31 (2.2%) and in 4 (0.3%) MCPjs. The thickness of the MH cartilage ranged between 0.41 and 1.10 mm in males and between 0.36 and 1.03 mm in females. A significant association was found between cartilage thickness and age (r=-0.33, p0.001), sex (rpb=0.42, p0.001), height (r=0.39, p0.001) and osteophytes in the same joint (v=-0.54, p0.001) and between working condition and osteophytes (v=0.31, p=0.021).This cross-sectional study reports the prevalence of US findings of joint damage in a large cohort of HS. Moreover, standard reference values of the MH cartilage thickness in HS are provided.

In psoriatic arthritis (PsA), ultrasonography (US) plays a growing role in the differential diagnosis and in monitoring treatment response.1 PsA is a heterogeneous disease with different domains and peculiar sites involved.2 Therefore, a dedicated US composite score is needed to monitor disease activity and to identify structural damage progression. A recently published Systematic Literature Review (SLR) identified only two US scores specifically developed for PsA (ie, 5TPD and PsA-Son) and, although these had a good sensitivity to detect inflammation and a good feasibility, they have not been validated in other series.1 3 4 Recently, the Study Group for US of the Italian Society of Rheumatology promoted the Ultrasound in PSoriatic Arthritis TREAtMent (UPSTREAM) study (registered at ClinicalTrial.gov, NCT03330769). UPSTREAM is a multicentre observational prospective cohort study and it represents the first …

Objective.To test the reliability of the consensus-based ultrasound (US) definitions of elementary gout lesions in patients.Methods.Eight patients with microscopically proven gout were evaluated by 16 sonographers for signs of double contour (DC), aggregates, erosions, and tophi in the first metatarsophalangeal joint and the knee bilaterally. The patients were examined twice using B-mode US to test agreement and inter- and intraobserver reliability of the elementary components.Results.The prevalence of the lesions were DC 52.8%, tophus 61.1%, aggregates 29.8%, and erosions 32.4%. The intraobserver reliability was good for all lesions except DC, where it was moderate. The best reliability per lesion was seen for tophus (κ 0.73, 95% CI 0.61–0.85) and lowest for DC (κ 0.53, 95% CI 0.38–0.67). The interobserver reliability was good for tophus and erosions, but fair to moderate for aggregates and DC, respectively. The best reliability was seen for erosions (κ 0.74, 95% CI 0.65–0.81) and lowest for aggregates (κ 0.21, 95% CI 0.04–0.37).Conclusion.This is the first step to test consensus-based US definitions on elementary lesions in patients with gout. High intraobserver reliability was found when applying the definition in patients on all elementary lesions while interobserver reliability was moderate to low. Further studies are needed to improve the interobserver reliability, particularly for DC and aggregates.

To develop the first ultrasound scoring system of tendon damage in rheumatoid arthritis (RA) and assess its intraobserver and interobserver reliability.We conducted a Delphi study on ultrasound-defined tendon damage and ultrasound scoring system of tendon damage in RA among 35 international rheumatologists with experience in musculoskeletal ultrasound. Twelve patients with RA were included and assessed twice by 12 rheumatologists-sonographers. Ultrasound examination for tendon damage in B mode of five wrist extensor compartments (extensor carpi radialis brevis and longus; extensor pollicis longus; extensor digitorum communis; extensor digiti minimi; extensor carpi ulnaris) and one ankle tendon (tibialis posterior) was performed blindly, independently and bilaterally in each patient. Intraobserver and interobserver reliability were calculated by κ coefficients.A three-grade semiquantitative scoring system was agreed for scoring tendon damage in B mode. The mean intraobserver reliability for tendon damage scoring was excellent (κ value 0.91). The mean interobserver reliability assessment showed good κ values (κ value 0.75). The most reliable were the extensor digiti minimi, the extensor carpi ulnaris, and the tibialis posterior tendons. An ultrasound reference image atlas of tenosynovitis and tendon damage was also developed.Ultrasound is a reproducible tool for evaluating tendon damage in RA. This study strongly supports a new reliable ultrasound scoring system for tendon damage.

Objective. To assess the intra- and interobserver reproducibility of musculoskeletal ultrasonography (US) in detecting inflammatory shoulder changes in patients with rheumatoid arthritis, and to determine the agreement between US and the Shoulder Pain and Disability Index (SPADI) and the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, using magnetic resonance imaging (MRI) as a gold standard.Methods. Eleven rheumatologists investigated 10 patients in 2 rounds independently and blindly of each other by US. US results were compared with shoulder function tests and MRI.Results. The positive and negative predictive values (NPVs) for axillary recess synovitis (ARS) were 0.88 and 0.43, respectively, for posterior recess synovitis (PRS) were 0.36 and 0.97, respectively, for subacromial/subdeltoid bursitis (SASB) were 0.85 and 0.28, respectively, and the NPV for biceps tenosynovitis (BT) was 1.00. The intraobserver kappa was 0.62 for ARS, 0.59 for PRS, 0.51 for BT, and 0.70 for SASB. The intraobserver kappa for power Doppler US (PDUS) signal was 0.91 for PRS, 0.77 for ARS, 0.94 for SASB, and 0.53 for BT. The interobserver maximum kappa was 0.46 for BT, 0.95 for ARS, 0.52 for PRS, and 0.61 for SASB. The interobserver reliability of PDUS was 1.0 for PRS, 0.1 for ARS, 0.5 for BT, and 1.0 for SASB. P values for the SPADI and DASH versus cuff tear on US were 0.02 and 0.01, respectively; all other relationships were not significant.Conclusion. Overall agreements between gray-scale US and MRI regarding synovitis of the shoulder varied considerably, but excellent results were seen for PDUS. Measures of shoulder function have a poor relationship with US and MRI. Improved standardization of US scanning technique could further reliability of shoulder US.

Objective:The objective of this study was to draw up a set of recommendations for the format and content of the musculoskeletal ultrasonography (MSUS) report in rheumatology. METHODS: A panel of rheumatologists, members of the MSUS Study Group of the Italian Society of Rheumatology, met in order to identify the main discrepancies in the MSUS report. A set of 15 recommendations was then defined, aimed at resolving the main discrepancies. They consisted of information about the motivations for the MSUS examination, the equipment, the US modalities and scanning technique, a list of the examined structures and findings, the scoring/grading systems, the number of images and main findings to include and conclusions. Subsequently a Delphi-based procedure was started in order to obtain agreement on a core set of recommendations. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS: Three complete rounds were performed. The response rate was 85.2% for the first round, 78.3% for the second and 88.9% for the third. Finally, consensus was obtained for 14 of 15 statements. These 14 statements represent the recommendations of the group for the format and content of the report and documentation in MSUS in rheumatology. CONCLUSION: To the best of our knowledge, our group has produced the first recommendations for the format and content of the report and documentation in MSUS in rheumatology. The report is an integral part of the MSUS examination and its use in a homogeneous form can help in the correct interpretation of the findings.

Objective.To summarize the work performed by the Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group on the validation of US as a potential outcome measure in gout.Methods.Based on the lack of definitions, highlighted in a recent literature review on US as an outcome tool in gout, a series of iterative exercises were carried out to obtain consensus-based definitions on US elementary components in gout using a Delphi exercise and subsequently testing these definitions in static images and in patients with proven gout. Cohen’s κ was used to test agreement, and values of 0–0.20 were considered poor, 0.20–0.40 fair, 0.40–0.60 moderate, 0.60–0.80 good, and 0.80–1 excellent.Results.With an agreement of > 80%, consensus-based definitions were obtained for the 4 elementary lesions highlighted in the literature review: tophi, aggregates, erosions, and double contour (DC). In static images interobserver reliability ranged from moderate to almost perfect, and similar results were found for the intrareader reliability. In patients the intraobserver agreement was good for all lesions except DC (moderate). The interobserver agreement was poor for aggregates and DC but moderate for the other components.Conclusion.These first steps in evaluating the validity of US as an outcome measure for gout show that the reliability of the definitions ranged from moderate to excellent in static images and somewhat lower in patients, indicating that a standardized scanning technique may be needed, before testing the responsiveness of those definitions in a composite US score.

Objectives: To investigate the prevalence of ultrasound (US) detectable inflammation in hips of patients with ankylosing spondylitis (AS) and the relationship between US and measures of disease activity and severity. Methods: Consecutive patients with AS attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US examination of bilateral hips was performed at the same time, evaluating anterior longitudinal scan to search for synovial hypertrophy (SH), joint effusion (JE) or power Doppler (PD) positive synovitis. Results: A total of 56 patients were included, median age (interquartile range, IQR) 49 (39, 59.5), median disease duration 98 (72, 204) months, 80.3% were treated with TNF-α inhibitors, median BASDAI 2.65 (1.96, 3.95), 30.3% had hip tenderness. US JE was found in 26.7% of patients, US SH in 16%, no patient had detectable PD. The concordance between clinical findings and US abnormalities was moderate, with a kappa of 0.44. Patients with detectable US abnormalities had higher median visual analogue scale (VAS) pain and C-reactive protein (CRP), while there was no significant association with other measures of disease activity and disability. In the subgroup of patients with no hip tenderness, US alterations were still significantly related to higher CRP levels, while in patients with hip tenderness and no US abnormalities CRP was not higher than in the asymptomatic patients. Conclusions: US assessment of hip joint in AS patients can be considered of value, as suggested by the correlation with relevant clinical and laboratory measures. In asymptomatic patients, US examination might provide further information on subclinical involvement. © Clinical and Experimental Rheumatology 2012.

Psoriatic arthritis (PsA) is an arthropathy associated with psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving the small joints of hands, feet (the involvement of which seems to be very common, ranging from 50 to 100% of patients), wrists, ankles and knees. Other common features are represented by the inflammation of enthesis and tendons. Its exact prevalence, in Italy, should be about 30% in psoriatic subjects or 0.42% when considering the general population. The aims of our study were to investigate, by US examination, the prevalence and the features of foot involvement in PsA and to describe their correlations with clinical findings. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 14 MHz. One hundred and eighty feet were investigated in a total of 101 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the feet) and swelling. US finding indicative of metatarsophalangeal joint inflammation were obtained in 77 (76.2%) patients, while only 34 (33.7%) patients were positive to the clinical examination. This study demonstrates that US detected a higher number of inflamed joints with respect to clinical assessment in PsA patients.

Objectives. To investigate the ability of ultrasonography (US) to detect synovitis in metatarsophalangeal joints (MTP) in patients with suspicion of early arthritis, and to discriminate between diagnoses. Methods. Patients referred to early arthritis clinics for differential diagnosis were enrolled, and clinical and laboratory measures were recorded. Ultrasonography of MTPs was performed searching for synovial hypertrophy (SH), joint effusion (JE) and power Doppler (PD), graded from 0 to 3 on a semi-quantitative scale. Patients were classified according to definite classification criteria, or as undifferentiated arthritis or non-inflammatory pathology. US findings were compared across different diagnoses and diagnostic accuracy was calculated taking clinical diagnosis as reference.Results. Out of 427 patients (71% rheumatoid arthritis (RA), 20% undifferentiated arthritis (UA), 15% spondyloarthritides (SpA), 13% non-inflammatory), 307 (71.9%) showed SH, 120 (25.5%) JE, 77(18.0%) PD. RA patients had median JE, SH and PD scores significantly higher than non-inflammatory and other diseases. Patient with UA and SpA had higher scores of SH and JE compared to non-inflammatory, no significant differences were present among different diagnosis. In RA, SH and JE were more frequently detected in the second MTP, and PD in the fifth. Crystal-related arthritis showed a tendency towards a more frequent involvement of the first MTP. The diagnostic accuracy of single US measures was moderate, but the detection of a PD of 2 or more provided a high specificity for the diagnosis of RA. Conclusions. US can be used as additional information in patients evaluated in an early arthritis setting. High scores of JE, SH and PD, together with the pattern of involvement are suggestive of RA.

Objective: The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with rheumatoid arthritis (RA) and to compare them with the clinical findings. Methods: One hundred RA patients were enrolled in the study. Bilateral US examination of metatarsophalangeal (MTP) joints, proximal interphalangeal (PIP) joints, midfoot joints (talonavicular, calcaneo-cuboid, medial, intermediate and lateral navicularcuneiform and cuneiform-metatarsal joints and cuboid-4th and 5th metatarsal joints) were examined for synovitis and erosion. In addition the plantar fascia and the insertion of the anterior and posterior tibialis and peroneous brevis tendons were imaged. Results: Effusion with synovial proliferation was visualised only at MTP joints in 84 out of 200 (42%) feet, at MTP plus at least one joint of the midfoot in other 41 out of 200 (20%) feet (making a total of 125 out of 200 (62%) MTP joints) exclusively in one or more joints of the midfoot in 7 out 200 (3%) feet, in the PIP joint of the 2nd and 3rd toes in 3 (1.5%) and 4 (2%) feet respectively, while no effusion with synovial proliferation was visualised in the PIP joint of the 4th and 5th toes. Synovitis was present most frequently in the 2nd MTP joint whilst erosions were most frequently imaged in the 5th MTP joint. Conclusion: US examination appears to be a useful imaging technique to study joint and tendon involvement of the foot in RA patients. Moreover, US examination of the foot is more sensitive than clinical examination in the detection of joint inflammation and allows for a better understanding of the features and the progression of the disease. © Clinical and Experimental Rheumatology 2011.

The aims of our study were to investigate the prevalence of ultrasound (US) pathologic abnormalities and to compare them with the clinical findings in the knee of rheumatoid arthritis (RA) patients. One hundred RA patients were enrolled in the study. Bilateral US examination of the knee was performed to visualise the presence of effusion, synovial proliferation, bone erosions, femoral cartilage abnormalities, quadricipital and/or patellar enthesopathy. The popliteal fossa and the calf region were also evacuate to detect popliteal cyst. We observed joint effusion in 140 out of 200 (70%) knees. Synovial hypertrophy was present in 115 out of 140 (82%) knees associated with effusion and in 22 out of 115 (19%) knees intra-articular power Doppler (PD) signal was found. Hyperechoic spots within the cartilage layer, suggestive of pyrophosphate crystals deposit, were detected in the knees of 3 patients. US signs of quadricipital and/or patellar enthesopathy were detected in 53 out 200 (26%) knees. Bone erosions were visualised in 16 out 200 (8%) knees. Popliteal cyst was found in 66 out of 200 (33%) joints. US examination of the knee is more sensitive than clinical examination in the detection of joint inflammation and allows for the identification of different patterns of pathologic changes at knee level, including morphostructural changes at both cartilage and tendon level.

Objective: To assess the impact of the knee joint inflammation, detected by ultrasonography (US), on functional disability in patients with recent-onset inflammatory polyarthritis (IP). Methods: We included patients who had IP for less than 12 months and who had more than 5 swollen joints. All patients were assessed clinically at baseline. US was used to identify joint inflammation at multiple joint sites including: hands, wrists, elbows, shoulders, knees, ankles and feet. Joint group involvement was defined when at least one joint showed intra-articular signs of inflammation (synovial fluid abnormalities and/or synovial hypertrophy), according to the OMERACT definitions. Functional disability was measured using the health assessment questionnaire (HAQ) score. All patients with complete clinical and US data were included in the analysis. Results: Patients with US knee involvement showed more active and severe disease at baseline. The mean difference of HAQ between patients with and without US knee inflammation was 0.42 (95%CI 0.22, 0.62; p

Objective. To investigate the prevalence and severity of sonographic-detected abnormalities in knee osteoarthritis (OA) and to correlate ultrasound (US) findings with clinical data. Methods. Outpatients with chronic, painful knee OA according to the ACR criteria were consecutively recruited and underwent clinical and US examinations. An expert rheumatologist recorded the presence of knee joint pain, swelling and tenderness, patient's global assessment of knee pain using visual analogue scale (VAS), and Lequesne Index of severity for knee OA.A second rheumatologist, blinded to the clinical data, performed the knee US examination using a Logiq9 machine equipped with a 12MHz linear probe and registering the presence of joint effusion, synovial proliferation, power Doppler (PD) signal, Baker's cyst, osteophytes and femoral cartilage abnormalities. Results. One hundred and sixty-four knees of 82 patients (53 women, 29 men) were studied; mean age was 63.2 ±8.1 SD years, mean disease duration was 4.3±5.6 SD years. All patients complained of at least one knee joint pain during physical activity. Mean patient's VAS for knee pain was 48.4±19.9 SD mm, mean Lequesne Index was 8.2 ±4.4 SD. Knee swelling was present in 39% of the patients and tenderness was found in 65.8%. US showed: joint effusion in 43.3% of the patients, synovial proliferation in 22.1%, PD signal in 2.9%, Baker's cysts in 6.6%, cartilage abnormalities in 79%, osteophytes in 100%. In all patients US findings were present at least at the level of one knee. Statistically significant correlations were demonstrated between a composite inflammatory score and both VAS (p=0.004) and Lequesne Index (p

Psoriatic arthritis (PsA) is an arthropathy associated to psoriasis, which is part of the spondyloarthropathy family, and which may present with various forms, from mono-oligoarthritis to symmetric polyarthritis mimicking rheumatoid arthritis. In longstanding disease, the symmetric polyarthritis is the most common pattern of PsA, involving small joint of hands, feet, wrists, ankles and, very frequently, knees. Other common features are represented by the inflammation of enthesis and tendons. Ultrasound (US) examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 10-14 MHz. One-hundred and sixty-six knee joints were investigated in a total of 83 patients. Prior to US assessment, all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/absence of pain, tenderness (detected by palpation and/or active or passive mobilisation of the knee), and knee swelling. Sixty-two (74.7%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 70 (84.3%) knee joints. In the 59% of the patients we noticed synovial hypertrophy. Enthesitis was present in 39.7% of the subjects studied. This study demonstrated that US detected a higher number of inflamed knee joints and enthesis with respect to clinical assessment in PsA patients.

The knee is a frequent target for gout and calcium pyrophosphate dihydrate (CPPD) disease with involvement of both articular and peri-articular structures. The aims of the present study were to investigate the relationship between clinical and ultrasound (US) findings and to describe the prevalence and distribution of crystal deposits in the knee in patients with gout and CPPD disease. Thirty patients with gout and 70 patients with CPPD disease were enrolled in the study. Prior to US assessment all patients underwent a clinical examination by an expert rheumatologist who recorded the presence/ absence of pain, tenderness (evocated by palpation and/or active or passive mobilisation of the knee), and knee swelling. US examinations were performed using a Logiq 9 (General Electric Medical Systems, Milwaukee, WI) equipped with a multifrequency linear probe, working at 9 MHz. Two hundred knee joints were investigated in a total of 100 patients. Fifty-one (25.5%) knee joints were found clinically involved, while at least one US finding indicative of joint inflammation was obtained in 73 (36.5%) knee joints. The most frequent US finding indicative of knee joint inflammation was joint effusion, detected in 21 (35%) out of 60 knees and in 52 (37%) out of 140 knees, in gout and CPPD disease, respectively. Ten (17%) out of 60 knees and 21 (15%) out of 140 knees were found positive for synovial hypertrophy with or without intra-articular power Doppler, in gout and CPPD disease respectively. Sonographic evidence of crystal deposition within joint cartilage (hyaline and fibrocartilage) was more frequently seen than in the soft tissue in the knee. This study demonstrated that US detected a higher number of inflamed knee joints than clinical assessment in patients with crystal related arthropathies and that the distribution of crystal deposits at joint cartilage level permitted distinction between gout and CPPD disease. Further studies are required to investigate both sensitivity and specificity of US features indicative of crystal aggregates at both tendon and entheseal level.

The field of inflammatory arthritis owes much to the advances in imaging technology which have enlightened not only clinical specialists but also researchers worldwide. The most exciting developments in recent decades have centred upon rheumatoid arthritis (RA) and more specifically the ultrasound (US) and magnetic resonance imaging (MRI) findings at various stages of the natural history of this condition. Investigation of RA using the standard techniques of plain radiography (x-ray) and more sophisticated computerised tomography (CT) have now been superseded by the exponential growth of use of US and MRI and this has been born out by the profusion of scientific papers published on these subjects.This paper aims to review the array of imaging modalities available as investigative tools to the rheumatologist when presented with various clinical scenarios by patients with RA.

Objective. To study the frequency and features of joint and tendon involvement in the hand of patients with primary Sjögren's syndrome (pSS) by musculoskeletal ultrasound (US) examination. Methods. Forty-eight patients with pSS diagnosed according to the preliminary classification criteria proposed by the American-European Classification Criteria Group were enrolled in the study. Bilateral US examination of the 1st-5th metacarpophalangeal (MCP), 2nd-5th proximal interphalangeal (PIP) joints and of flexor tendons were performed. A semi-quantitative grading method (0 to 3) for scoring joint effusion, synovial proliferation and intra-articular power Doppler (PD) signal was used. Results. We observed clear evidence of inflammatory arthritis in 9 (18.7%) patients. Bone erosions at MCP and/or PIP joint were visualized in 6 out of 48 (12.5%) patients. In 10 (20.8%) patients we imaged flexor tenosynovitis which appeared more frequent than in healthy subjects even if no statistically significant difference was detected. Conclusion. US examination appears to be a useful imaging technique to study joint and sofi tissue involvement in connective tissue diseases. The presence of bone erosions in pSS patients is unexpected. Future studies will hopefully concentrate more on defining the erosive capability of connective tissue disorders together with inflammatory involvement of tendons. © Copyright Clinical and Experimental Rheumatology 2009.

Three-dimensional (3D) US is a new sonographic modality which represents a promising tool in the assessment of joint and periarticular tissues abnormalities in rheumatic diseases. The available literature has recently underlined its advantages mainly related to the virtual operator independence due to image acquisition of infinite 3D data sets obtained by transducer automated sweeping. Shortening of the US examination time represents another notable advantage over conventional two-dimensional (2D) US. The aim of the present study was to investigate the validity of 3D US in assessing Achilles tendon enthesitis by comparing it with 2D US. US examinations were performed by using a Logiq 9 (General Electrics Medical Systems, Milwaukee, WI) equipment with a high-frequency (8-15 MHz) volumetric probe. One hundred and eighty-six Achilles tendon enthesis of 93 SpA patients were examined. The analysis of each basic US finding demonstrated from good to excellent agreement rates between 3D and 2D US, both in dichotomous assessment of sonographic lesions and in the use of semi-quantitative grading. Excellent agreement between the two modalities was demonstrated in the assessment of both inflammatory changes and structural lesions. Our study for the first time demonstrated that 3D US is a valid imaging modality for the assessment of Achilles tendon enthesitis.

Systemic lupus erhthematosus (SLE) is an autoimmune multisystem disorder characterised by frequent musculoskeletal manifestations. Joint involvement in SLE is usually not erosive or destructive but some patients develop hand erosive arthritis or deforming arthropathy of the hand (respectively "rhupus" hand and Jaccoud arthritis). To date, few studies, evaluated joint and tendon involvement in SLE patients by US. We studied wrist and hand structure, using ultrasound, in 50 patients affected by SLE, detecting inflammatory joint involvement in 80% of them at the wrist and in 50% at the hand. Tenosynovitis was visualised in 14 patients, while structural damage was present in 12% of the SLE group. Those results reinforce the importance of including musculoskeletal ultrasound in the patient assessment, especially in those cases in which physical examination is not conclusive.

Enthesitis represents a characteristic features of spondyloarthritis (SpA) and, in the context of the early management of the disease, its reliable assessment has emerged as a central issue. Musculoskeletal ultrasonography (US) has proven to be of value in the assessment of peripheral entheses. Our aim was to systematically review the literature from 2010 to 2013 in order to summarise the evidence on the evaluation of entheses by US in patients with diagnosed or suspected SpA.PubMed and Embase were searched developing a search strategy based on terms related to SpA and US. The target population were patients with SpA or suspected SpA, the intervention was entheseal US, the outcomes were the prevalence of US abnormalities, the reliability, the diagnostic accuracy, the sensitivity to change. The possible comparators were clinical evaluation and other imaging techniques. Cohort studies (cross-sectional or longitudinal), case-control studies, diagnostic accuracy studies, systematic literature reviews and meta-analyses were eligible for inclusion.Out of 3368 retrieved references, 34 papers were finally included. 22 of which reported information on the prevalence of US findings, yielding highly variable results. US was sufficiently reliable, as reported in 6 papers. A minority of studies reported data on sensitivity to change, which was good, and on the application of US for differential diagnosis and diagnosis of SpA, thus demonstrating the value of US also in this context.US confirms its validity and reliability in the assessment of entheseal involvement in patients with SpA. Further application in the help of diagnosis will be provided by future research.

OBJECTIVE—To demonstrate the diagnostic efficacy of ultrasonography in depicting erosions in patients with rheumatoid arthritis and to compare sonographic and radiographic findings. METHODS—Sonographic images were obtained with an AU-4 Idea Esaote Biomedica (Genoa, Italy) equipped with a 13 MHz linear transducer. RESULTS—The images reported in this essay are representative examples of the ability of ultrasonography to detect and characterise even minimal bone margin changes in rheumatoid arthritis. CONCLUSION—Ultrasonography with very high frequency transducers can depict bone erosions in early target areas of bone resorption. However, further studies are needed to validate this technique and to evaluate the relation between sonographic findings and those obtained with other imaging techniques (standard radiology, magnetic resonance).

One of the largest challenges to the field of musculoskeletal ultrasonography is attempting to accurately quantify the changes seen in chronic arthritis. With advances in ultrasound technology, researchers have been increasingly exploring ways of more accurately assessing these changes and attempting to reach consensus with agreed scoring systems. This review presents the main scoring systems developed for quantifying sonographic findings indicative of synovitis and joint damage in patients with rheumatoid arthritis. Further investigation is required to attain international consensus on such scoring systems and to evaluate their impact on therapeutic decision-making.

To investigate the prevalence of ultrasonographic (US) shoulder abnormalities in patients with rheumatoid arthritis (RA) and to investigate the relationship between US findings and demographic and clinical features.Consecutive patients attending the rheumatology units involved in this study were enrolled. Clinical and demographical data were recorded. US of bilateral shoulders was performed at the same time, examining tendons, bursae, gleno-humeral and acromion-clavicular joints. The presence of signs of inflammation, bone erosions or rotator cuff pathology was evaluated.A total of one hundred patients were enrolled, mean age (SD) 59.6 (14.7) years, median disease duration (IQR) 56.5 (34.7, 96.5) months, 98% of them were on DMARDs and 22% on biologics. Shoulder tenderness was reported by 44% of patients. 34% of patients showed at least one sign of inflammatory involvement, and 25% of them presented with humeral head erosions. Signs of rotator cuff pathology were seen in 49% of patients. Agreement between the presence of spontaneous pain and US inflammatory abnormalities was moderate (kappa 0.501). Patients with inflammatory involvement of the shoulders had significantly higher DAS28, HAQ, VAS pain, acute phase reactants and disease duration compared to patient with no inflammatory signs, they were more frequently RF positive and reported more frequently spontaneous pain.US assessment of the shoulder in RA patients can be considered of value, especially in patients with relevant indicators of disease activity and severity.

To investigate the prevalence of shoulder ultrasound (US) detectable abnormalities in asymptomatic individuals of various ages and to correlate the US findings with clinical data.97 healthy subjects were enrolled in the present study. They were subgrouped according to their age, as follows: group I (20-29 years); group II (30-39 years); group III (40-49 years); group IV (50-59 years); group V (60 years). A physical examination of both shoulders, based on a series of provocative maneuvers, was carried out. The US assessment was performed by using a Logiq9 machine equipped with a multi-frequency linear probe working at 12MHz and included the study of a number of structures for the evaluation of local abnormalities, as follows: the long head of biceps tendon (synovial effusion (SE), synovial hypertrophy (SH), power Doppler (PD) signal); the subacromion-subdeltoid and sub-scapularis bursae (SE, SH, PD signal); the rotator cuff tendons (tendinosis, calcifications, tears, impingement); the acromionclavicular (ACJ) and gleno-humeral joints (SE, SH, PD signal, osteophytes, erosions, fibrocartilage calcifications, cartilage abnormalities, tophaceous deposits). In addition, deltoid, throchite and throchine enthesopathy were searched for.194 shoulders were studied in total. A low but variable percentage of joints of healthy individuals (3.1-13.4%) showed positive provocative maneuvers. 138 shoulders (71.1%) did not show any US abnormalities. The most frequent changes were SE of ACJ (25.5%), osteophytes of ACJ (23.3%), and supraspinatus tendinosis (20.6%). The prevalence of abnormalities progressively increased with age. Sub-clinical involvement was present in most cases, being provocative maneuvers positive only in a low percentage of joints.The present study demonstrated the presence of a wide set of US-detectable changes in healthy subjects, that were more frequently present in elderly individuals. The absence of any clinical sign of local pathology cannot exclude the presence of local abnormalities.

Musculoskeletal ultrasonography (US) has lately been applied to patients with polymyalgia rheumatica for the examination of shoulders and hip, and included in the 2012 PMR classification criteria. We aimed to perform a comprehensive overview of the literature on this topic with a systematic review.We searched PubMed, Embase, the Cochrane library and the proceedings from EULAR and ACR congresses (2011-2012). We included studies evaluating patients with confirmed or suspected PMR, undergoing US of shoulders and/or hips. The diagnosis of PMR could be based on expert opinion or diagnostic criteria. Cohort, case-control, diagnostic accuracy studies and case-series were eligible for inclusion. The features of the included studies were presented. When available, sensitivities and specificities were calculated for primary studies.Out of 1736 papers identified by our search, 13 articles and 1 abstract were finally included in the review. Eight studies focused on shoulder US, 1 on hip US, 4 on both. Studies were extremely variable in terms of population, US examination, reference standard and control population. In general, at the shoulder, pathological bilateral US findings in most studies were more prevalent in patients with PMR compared to controls. When sensitivity and specificity could be calculated, bilateral findings were more sensitive. Notably, less information was available on hip US.US (especially in shoulder examination) is confirmed to be a potentially useful instrument to integrate clinical information in the management of patients with PMR. Its additional value in conjunction with the new classification criteria should be further tested.

The aims of this study were to investigate the prevalence of ultrasound (US) pathologic abnormalities in the shoulders of psoriatic arthritis (PsA) patients and to compare them with the main clinical findings.Ninety-seven PsA patients were enrolled in the study. The subacromial/subdeltoid bursa, the sheath of the long biceps tendon, the glenohumeral joint and the acromion-clavicular joint were examined for the presence of synovial effusions and synovial hypertrophy. Rotator cuff tendons (supraspinatus, subscapularis, infraspinatus) were imaged for tendinosis, calcifications and total or partial tears, while deltoid enthesis were evaluated for local enthesitis and the lesser and greater tuberosity of the humerus for the presence of enthesophytes.Tendinosis represented the most frequent abnormal finding. Supraspinatus tendinosis was detected more often than subscapularis and infraspinatus tendinosis. When considering tendon tear, supraspinatus was also the most frequently involved anatomical structure. Clinical examination frequently failed to detect abnormalities in patients in whom US examination showed pathological findings. This is particularly true for tendon involvement, i.e. effusion within the sheath of the biceps tendon was imaged in 43 shoulders but clinical assessment reported abnormalities only in 22 shoulders (p0.0001).US examination appears to be a useful and sensitive imaging technique, specifically in identifying joint and tendon involvement of the shoulder.

Fibromyalgia syndrome (FMS) is a common form of non-inflammatory rheumatism within the general population with symptoms often mimicking those of arthritis or muscle disorders. Arthralgic symptoms in the region of the hip are commonly mentioned by patients with FMS and one of the diagnostic trigger points for the condition is found around the greater trochanter. To date, no formal imaging studies using ultrasound (US) have been performed in FMS. This study describes the correlation between clinical and US findings in patients presenting with primary FMS to rheumatology clinics. In the majority of the patients, no significant pathological US abnormalities were detected.

Hip pain is a common complaint in daily practice and the identification of the underlying pathologic condition is the first step for an adequate treatment. In this review, we discuss the available evidence for the application of conventional radiography, computed tomography and magnetic resonance imaging in rheumatologic patients with painful hip, presenting the main imaging findings due to osteoarthritis, inflammatory arthritis (rheumatoid arthritis and spondyloarthritides), osteonecrosis and some other soft tissue involvement (bursitis and synovial cyst) that could be the cause of hip pain. Because different imaging techniques show different sensitivity and specificity, the choice of technique to use depends on the type and stage of the disease itself.

Objective.The OMERACT Ultrasound Task Force is currently developing a global synovitis score (GLOSS) with the objective of feasibly measuring global disease activity in patients with rheumatoid arthritis (RA). In order to determine the minimal number of joints to be included in such a scoring system, and to analyze the metric properties of proposed global (i.e., patient level) ultrasound (US) scoring systems of synovitis in RA, a systematic analysis of the literature was performed.Methods.A systematic literature search of Pubmed and Embase was performed (January 1, 1984, to March 31, 2010). Original research reports written in English including RA, ultrasound, Doppler, and scoring systems were included. The design, subjects, methods, imaging protocols, and performance characteristics studied were analyzed, as well as the ultrasound definition of synovitis.Results.Of 3004 reports identified, 14 articles were included in the review. We found a lack of clear definition of synovitis as well as varying validity data with respect to the proposed scores. Scoring systems included a wide range and number of joints. All analyzed studies assessed construct validity and responsiveness by using clinical examination, laboratory findings, and other imaging modalities as comparators. Both construct validity and responsiveness varied according to the number and size of joints examined and according to the component of synovitis measured [i.e., gray-scale (GS) or power Doppler (PD) alone or in combination]. With regard to feasibility, time of evaluation varied from 15 to 60 min and increased with the number of joints involved in the examination.Conclusions.Ultrasound can be regarded as a valuable tool for globally examining the extent of synovitis in RA. However, it is presently difficult to determine a minimal number of joints to be included in a global ultrasound score. Further validation of proposed scores is needed.

Introduction An increasing number of studies have applied ultrasound to the evaluation of entheses in spondyloarthritis patients. However, no clear agreement exists on the definition of enthesitis, on the number and choice of entheses to examine and on ultrasound technique, which may all affect the results of the examination. The objectives of this study were to first determine the level of homogeneity in the ultrasound definitions for the principal lesions of enthesitis in the published literature and second, to evaluate the metric properties of ultrasound for detecting enthesitis according to the OMERACT filter. Methods Search was performed in PUBMED and EMBASE. Both grey-scale and Doppler definitions of enthesitis, including describing features of enthesitis, were collected and metrological qualities of studies were assessed. Results After selection, 48 articles were analyzed. The definition of ultrasound enthesitis and elementary features varied among authors. Grey-scale enthesitis was characterized by increasing thickness (94% of studies), hypoechogenicity (83%), enthesophytes (69%), erosions (67%), calcifications (52%), associated bursitis (46%) and cortical irregularities (29%). Only 46% of studies reported the use of Doppler. High discrepancies were observed on frequency, type of probe and Doppler mode used. Face and content validity were the most frequently evaluated criteria (43%) followed by reliability (29%) and responsiveness (19%). Conclusions Ultrasound has evidence to support face, content validity and reliability for the evaluation of enthesitis, though there is a lack of well-reported methodology in most of the studies. Consensus on elementary lesions and standardization of exam is needed to determine the ultrasound definition of enthesitis in grey-scale and in Doppler for future applications.

The aims of our study were to investigate the prevalence of ultrasound (US) abnormalities in the foot of patients with osteoarthritis (OA) and to compare them with clinical findings.Consecutive patients with foot OA were investigated by clinical and US examinations. Bilateral US of the midfoot and forefoot joints was performed by using a Logiq9 machine, equipped with a multi-frequency linear probe, operating at 14 MHz; in addition, power Doppler was applied (frequency 7.5 MHz; gain 50%; PRF 750 Hz). Clinical evaluation included the registration of demographic data, disease duration, current treatment undergone, joint swelling and tenderness. US study included the assessment of both inflammatory (joint effusion, synovial hypertrophy, local pathologic vascularisation at PD, big-toe bursitis) and structural (osteophytes, MTP joints subluxation) abnormalities.One hundred patients were studied. At midfoot level, clinical examination demonstrated signs suggestive for joint inflammation (tenderness and/or swelling) in at least one joint in 43/200 feet (21.5%) of 23 patients; US showed inflammatory abnormalities in 87/200 feet (43.5%) of 63 patients and structural lesions in 100/200 feet (50%) of 70 patients. At forefoot level, clinical examination found inflammatory signs in at least one joint in 128 feet (64%) of 64 patients; US showed inflammatory abnormalities in at least one joint in 176 feet (88%) of 88 patients and structural lesions in 189 feet (86%) of 86 patients.US is a useful imaging tool for analysing both inflammatory and structural damage lesions at foot joints level in OA. In addition, it demonstrated to be more sensitive than clinical examination in the detection of inflammatory abnormalities.

Background: The optimal management of patients with cryptogenic ischemic stroke found to have a patent foramen ovale (PFO) at diagnostic workup remains unclear. The aims of this observational multicenter study were to evaluate: (1) the risk of recurrent cerebrovascular events in patients with cryptogenic minor ischemic stroke or transient ischemic attack (TIA) and PFO who either underwent percutaneous PFO closure or received only medical treatment, and (2) the risk factors associated with recurrent events. Methods: Consecutive patients (aged 55 years or less) with first-ever cryptogenic minor ischemic stroke or TIA and PFO were recruited in 13 Italian hospitals between January 2006 and September 2007 and followed up for 2 years. Results: 238 patients were included in the study (mean age 42.2 ± 10.0 years; 118 males); 117 patients (49.2%) received only antithrombotic therapy while 121 patients underwent percutaneous PFO closure (50.8%). Stroke as the qualifying event was more common in the medical treatment group (p = 0.01). The presence of atrial septal aneurysm and evidence of 20 bubbles or more on transcranial Doppler were more common in the PFO closure group (p = 0.002 and 0.02). Eight patients (6.6%) experienced a nonfatal complication during PFO closure. At the 2-year follow-up, 17 recurrent events (TIA or stroke; 3.6% per year) were observed; 7 of these events (2.9% per year) occurred in the percutaneous PFO closure group and 10 events (4.2% per year) in the medical treatment group. The rate of recurrent stroke was 0.4% per year in patients who underwent percutaneous closure (1 event) and 3.4% per year in patients who received medical treatment (8 events). On multivariate analysis, percutaneous closure was not protective in preventing recurrent TIA or stroke (OR = 0.1, 95% CI = 0.02–1.5, p = 0.1), while it was barely protective in preventing recurrent stroke (OR = 0.1, 95% CI = 0.0–1.0, p = 0.053). Conclusions: The results of this observational, nonrandomized study suggest that PFO closure might be superior to medical therapy for the prevention of recurrent stroke. Periprocedural complications were the trade-off for this clinical benefit. Controlled randomized clinical trials comparing percutaneous closure with medical management are required.

Objective:To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.Methods:A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.Results:Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver κ was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, −0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver κ for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.Conclusions:US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

Over the last few years, a large number of studies have emphasized the fundamental role of ultrasonography (US) in the clinical evaluation of patients affected by rheumatic disorders. However, not all rheumatic diseases have been studied by US. To date, very few reports exist on the use of US in the assessment of articular, periarticular structures and blood vessels in vasculitis. In this review we provide an overview of the current data regarding the role of US in vasculitis. Sonographic evaluation of cardiac or renal involvement in these disorders will not be covered.

Ultrasound (US) role is becoming more and more relevant in the assessment of rheumatic diseases but there are still some almost unexplored fields and, surely, one of these is represented by the great family of connective tissue diseases (CTD). In this review we provide an update of the available data regarding some applications of US in CTD. Besides an overview of the role of US in their musculoskeletal involvement, we will report data on the use of US in the evaluation of skin and lung in systemic sclerosis and of salivary glands in Sjögren's syndrome. US assessment of heart, kidney or vascular involvement in CTD will not be the subjects of this paper.

Ultrasound (US) is a relatively new imaging modality in rheumatology that offers great potential as a diagnostic and management tool. In 2004, an OMERACT Ultrasound Special Interest Group was formed to address the metric qualities of US as a potential outcome measure. A preliminary systematic review highlighted the deficiencies in the literature, particularly with regard to the reliability of interpreting and acquiring images; as a consequence, a number of exercises were proposed to address these issues. This report describes a series of iterative studies that have resulted in improved intra- and inter-reader reliability for detecting and scoring synovitis from both static and real-time images of the hand joints of patients with rheumatoid arthritis. The reliability of acquiring images was also enhanced using standardized positions. Future studies will assess the value of US in clinical trials.

The present review provides an update of the available data and discusses research issues relating to ultrasound (US) imaging in osteoarthritis (OA). Currently, the principal indications for using US in OA include: delineation of changes within articular cartilage (AC) and demonstration of synovial and adjacent soft tissue pathology together with injection into OA joints under US guidance. US has been proposed as a possible imaging tool for following the progression of OA. The main priorities requiring the attention of researchers include: addressing difficulties surrounding consensus on definitions of pathology in OA, charting the natural history of AC change in site specific OA, investigation of the link between inflammation and OA and the use of three-dimensional (3D) US in OA.

Musculoskeletal ultrasound (US) has an increasingly important role in the assessment of spondyloarthritis (SpA) not only for its ability to detect synovial and tendon involvement but also for the accurate imaging of enthesitis, the clinical hallmark feature of SpA. As already known, most cases of enthesitis are subclinical in SpA and US is an effective technique used to detect them. Also, in cases of dactylitis, US can accurately delineate the underlying pathology. US allows clinicians to guide needle positioning within inflamed joints, tendon sheaths and entheses in order to inject steroids or other drugs. This is particularly important for patients with SpA, because of the frequency of mono or oligoarthritis, tendon and entheseal involvement, who may have great benefit from intrarticular or intralesional therapy. The clinical application of US in SpA extends to the monitoring of therapy efficacy, particularly when coupled with power Doppler imaging. Very slight changes in vascularity are easily detected in joints, entheses or tendons, aiding the rheumatologist in the assessment of the effects of local or systemic therapies. The present review provides an update of the available data and discusses research issues of US imaging in SpA.

Over the last few years, technological advances have resulted in dramatic improvements in quality and resolution of ultrasonography (US), allowing it to become a very powerful tool in rheumatological clinical practice. Despite the fact that the impact of US on final diagnosis or therapeutic options for rheumatic patients has not yet been defined, there is now growing evidence that US improves clinical diagnosis and intervention skills. This review discusses the most important issues connected with the practice of US in rheumatology including: basic requirements, scanning technique, clinical applications, training and future developments. Moreover, it provides a general overview of both US anatomy and pathology relevant for the rheumatologist.

Ultrasonography (US) is a reliable and useful diagnostic tool for the assessment of hip pathology. It depicts changes within the coxo-femoral joint (synovitis, erosions, osteophytes) and in the adjacent peri-articular tissues (calcifications, tendonitis, enthesitis, bursitis) in many rheumatic diseases (rheumatoid arthritis, spondyloarthritis, osteoarthritis, polymyalgia rheumatica ) and in some orthopaedic disorders (septic arthritis, trauma, abscess, painful hip after arthroplasty). It is commonly used both in adults and in children. In the assessment of hip joint pathology, US exerts considerable diagnostic supremacy over physical examination. In fact, by virtue of its size and position, reliable physical examination of the hip is often difficult thus making US particularly useful as a bedside tool for the evaluation of a painful hip. Hip US has also proven to be of great practical benefit when performing aspiration and injection within the joint and in the periarticular soft tissues. The relatively limited acoustic windows available to the US beam is the principal limitation to hip US thereby making detailed examination of some important structures impossible together with the interpretation of power Doppler signal sometimes unreliable. In addition, the deep location of the hip can confer further problems to US scanning in obese or particularly muscular subjects.

Ultrasonography (US) has proved to be a useful diagnostic tool in patients with shoulder pain and/or limited range of motion. It allows careful assessment of a wide range of changes involving many different anatomic structures of the shoulder girdle, such as the rotator cuff tendons (tendonitis, tendon tears and calcific deposits), the long head of the biceps tendon (tenosynovitis, tendonitis, tears, rupture and displacement), the bursae (bursitis), the soft tissues of the gleno-humeral (synovial proliferation, joint effusion) and acromioclavicular joints (synovial proliferation and joint effusion). In addition, it is also a reliable tool in the evaluation of bony profiles detecting the presence of erosions and osteophytes. The use of high quality equipment and the application of a standard scanning protocol are mandatory for reliable US assessment of shoulder pathology.

Ultrasound (US) examination of the elbow and parasternal joints is very useful to detect synovitis, degenerative changes, intrarticular calcification or soft tissue abnormalities. More recently new fields of research involving the sacroiliac and temporomandibular (TM) joints have evolved. Moreover, important information has been obtained about vascularization of the synovial joint in the sacroiliac region and structural modification such as internal derangement in the TM joint.. In this paper, we review and discuss the role of US in the evaluation of elbow, sacroiliac, parasternal and TM joint pathology.

To evaluate the ability of high resolution ultrasonography (US) in the diagnosis of erosive osteoarthritis (OA).We enrolled 110 patients with signs and symptoms of inflammatory OA. Radiographs of both hands were performed in all patients; 22 were diagnosed as having erosive OA and 88 classical OA on the basis of typical erosive/non-erosive patterns. Distal and proximal interphalangeal joints of all patients were evaluated by US by 2 independent operators blinded to patient data. The examination was performed with a multiplanar scan technique, with joints in both maximal extension and flexion, using either a 14 MHz or 8-16 MHz broadband linear probe. The presence of articular bone surface irregularities defined as either marginal osteophytes or central erosions was recorded. Sensitivity, specificity, and likelihood ratios on the presence of erosions were calculated.Central erosions were detected by US in 16 of 22 (72.7%) patients with erosive OA and in none of 88 patients with classical hand OA. Sensitivity and specificity for the detection of central erosions by US were 73% and 100%, respectively. The positive and negative likelihood ratios were 100% and 94%.This is the first study to evaluate the presence of erosions in patients with erosive OA by US. Our results showed good concordance between US and radiography in detecting central joint erosions. We believe US may be considered a useful technique for the differential diagnosis between erosive OA and classical hand OA.

In the rheumatology literature, most of the available evidence on three-dimensional ultrasound (3D US) is related to the acquisition process and highlights the virtual operator independence and shortening of the US examination time. The main aim of this study was to compare 3D US using a high-frequency volumetric probe and conventional 2D US at the wrist and hand in patients with rheumatoid arthritis (RA). The 3D US examinations were performed using a Logiq 9 (General Electrics Medical Systems, Milwaukee, WI) with a high-frequency (8-15 MHz) volumetric probe. Overall, there is good-to-excellent agreement between the two modalities relating to both joint inflammation and bone erosion. This study is an initial step towards establishing a methodology necessary for developing multi-centre US studies which are aimed at assessing hand involvement in patients with RA.

The knee joint is a frequent focus of attention for rheumatologists when assessing patients presenting to a clinic and may represent underlying intra-articular inflammatory pathology or involvement of the surrounding soft tissues. This study describes the correlation between clinical and ultrasound findings in patients presenting with a variety of rheumatic disorders and knee pain. US imaging provides for a sensitive and detailed identification of different intra- and peri-articular pathology responsible for knee pain.

The foot is increasingly the focus of attention for rheumatologists when assessing patients presenting to a clinic and may represent underlying intra-articular inflammatory pathology or involvement of the surrounding soft tissues. This study describes the correlation between clinical and ultrasound (US) findings in patients presenting with a variety of rheumatic disorders linked with foot pain. Poor correlation was found between conventional clinical examination and US in cases with joint inflammation, tendonitis and, more particularly, those cases with enthesopathy.

To evaluate by clinical, laboratory, and sonographic assessment the effects of adalimumab therapy in patients with rheumatoid arthritis (RA) over 24 months of treatment.Twenty-five patients with RA were commenced on adalimumab therapy. Before the beginning of the therapy (Time 0) and after 3 (T1), 12 (T2), and 24 (T3) months we evaluated erythrocyte sedimentation rate, C-reactive protein, physician and patient visual analog scale for disease activity, number of tender and swollen joints, Health Assessment Questionnaire, and Disease Activity Score in 28 joints. In addition, musculoskeletal ultrasound (US) was performed bilaterally in the 2nd and 5th metacarpophalangeal, 3rd interphalangeal, wrist, and knee joints and in the tendon sheaths and bursae of those areas. A semiquantitative score (0 3) was used to indicate the presence of a localized inflammatory process and/or structural damage. The summed total was used as an indicator of global change in each joint (single joint score). The sum of the single joint scores was used as an indicator of overall polyarticular involvement in each patient (total score).Patients who did not submit to the planned examinations strictly on time were excluded from the study. Then 25 patients were examined at T0 and T1, 20 at T2, and 9 at T3. All clinical and laboratory measures as well as the US scores were significantly reduced during the followup.A positive response to treatment with adalimumab was demonstrated by clinical, laboratory, and US evaluation by both short- and longterm followup.