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The systemic large vessel vasculitides consist mainly of giant cell arteritis and Takayasu arteritis. Both diseases affect the large blood vessels and can lead to ischemia and end-organ damage. Ultrasound is an imaging technique that can depict inflammation of the vessel wall in large and medium vessel vasculitis. In this article, we critically review the current evidence for the clinical use of ultrasound for systemic large vessel vasculitides, regarding the clinical applicability, technical requirements, challenges, and cost. A roadmap for the development of a fast-track ultrasound clinic for giant cell arteritis is also provided.

Accurate clavicular length measurement is considered important for the selection of patients requiring surgical treatment after a midclavicular fracture. As radiographic length measurements can be inaccurate to varying degrees, new measurement methods are needed. Use of novel technology, navigation ultrasound, to deliver accurate measurements seems promising. To examine the reliability and validity of navigation ultrasound for length measurements of the clavicle, a study was performed using length measurements performed before forensic autopsies from 2012 to 2013. In total, 38 bodies with a median age of 52.5 (range: 21–78 y) were included. Navigation ultrasound exhibited high reliability (intra-class correlation coefficient: 0.942–0.997, standard error of the mean: 0.7–2.9 mm, minimal detectable change: 2.3–8.1 mm) and validity (measurement error: 1.3%–1.8%, limits of agreement (95% confidence interval): approximately ± 7.5 mm, Pearson's correlation R : 0.948–0.974). Navigation ultrasound can measure clavicular length with an intra-rater reliability matching that of 3-D rendered computed tomography scans and with high validity. Its use could spread to other fields requiring accurate musculoskeletal length measurements.

Background Ultrasound (US) examination of the entheses is increasingly used to document pathological changes in e.g. psoriasis arthritis and spondyloarthritis. Grey-scale (GS) US is used to assess morphological changes and Doppler US to assess increased blood flow. The OMERACT expert group has agreed on the following elementary components when assessing the entheses on US examination; hypoechogenicity, increased thickness, enthesophytes/ calcifications, erosions, and Doppler activity (1). Little is known about US assessment of the entheses in asymptomatic persons, thus the frequency and distribution of the above components between genders and age groups is uncertain. Objectives To investigate the frequency of enthesitis components in the entheses of the lower limb in a group of healthy subjects. Methods We recruited 64 subjects (32 women and 32 men), eight women and eight men in four decades, from 20 to 59 years. None of the subjects had previous or present signs of tendon or joint disease in the lower extremities. None of the participants took any kind of medication. All subjects were examined by a rheumatologist and blood samples were collected to rule out any clinical signs of tendon or joint disease e.g. swollen and tender entheses or increased inflammatory markers in the blood. The dominant leg was examined with US using a Logiq 9 (GE Medical, Milwaukee, WI, USA) with a ML 6–15 MHz transducer and a fixed pre-set with Doppler settings optimised for inflammatory flow. Both GS and Doppler examination were made. The entheses were examined for hypoechogenicity, increased thickness, enthesophytes/ calcifications, erosions, and Doppler activity. Results No subjects had clinical signs of tendon or joint disease. Seven displayed various degrees of hypermobility and seven had various degrees of flatfoot; some in combination. None of the blood tests indicated any pathology. On US erosions were only seen in one Achilles insertion (not shown in table). The Doppler activity was not measured in plantar fascia due to attenuation of the heel fad pad. All other US pathology present is seen in the table below. Conclusions Only minor pathological findings in the entheses of the lower limb were present in an age stratified cohort of healthy persons. The changes most frequently seen were bony changes in the insertion of the quadriceps and Achilles tendons. A weak tendency toward more pathological findings was seen in this cohort among men, compared to women, and additionally, with increasing age. The findings suggest that US can be used to diagnose/examine subjects for pathological changes of the entheses although with caution regarding enthesophytes of the quadriceps and Achilles tendon. References Terslev L et al. Defining enthesitis in spondyloarthritis by ultrasound: results of a Delphi process and of a reliability reading exercise. Arthritis Care Res 2014 May;66:741–8. Disclosure of Interest None declared

Aim The aim of this study was to compare the assessment of tenosynovitis by ultrasound (US) and magnetic resonance imaging (MRI) using the image fusion technique and to investigate whether US B-flow imaging (BFI) is an alternative to Doppler US when assessing tenosynovitis. Materials and Methods 15 patients with rheumatoid arthritis (RA) had US-verified tenosynovitis in the wrist/hand. An MRI was performed of the wrist/hand with subsequent repeated US and image fusion. Images were compared in three steps: 1. Visual image comparison, 2. Quantitative measurement of transverse areas of the affected tendon and tendon sheath, using two tendon measures on MRI, area 1 and area 2, excluding and including partial volume artifacts, respectively, 3. Assessment using the OMERACT semi-quantitative scoring systems for US and MRI. Furthermore, BFI was assessed as: 0: No flow, 1: Focal flow, 2: Multifocal flow, 3: Diffuse flow, in the tendon sheath. Results The median areas on US and MRI (areas 1 and 2) were 0.16 cm2 (25;75 pctl: 0.10; 0.25), 0.9 cm2 (0.06; 0.18) and 0.13 cm2 (0.10; 0.25), respectively, for included tendons and 0.18 cm2 (0.13; 0.26), 0.27 cm2 (0.20; 0.45) and 0.23 cm2 (0.16; 0.40) for tendon sheaths. No statistically significant difference was found between US tendon area and MRI tendon area 2 (Wilcoxon’s test; p = 0.47). Overall, the agreement between grayscale and color Doppler (CD) US and MRI tenosynovitis visualization and scoring was good, but not between CD and BFI. Conclusion US and MRI have high agreement using image fusion for the assessment of tenosynovitis when partial volume artifacts are taken into account. BFI is not an alternative to CD for the measurement of slow flow in tenosynovitis.

OBJECTIVES: Little is known regarding the association between ultrasound-determined pathological synovial blood flow and synovial pathology in rheumatoid arthritis (RA). We therefore examined the association between colour Doppler ultrasound imaging and synovitis assessed by histopathology and specific cell markers by immunohistochemistry in patients with RA.METHODS: 81 synovial sites from wrist and finger joints from 29 RA patients were evaluated by ultrasound colour Doppler and subsequently biopsied by needle arthroscopy. The association between ultrasound colour fraction and an overall synovitis score and immunohistochemical staining for CD3, CD68, Ki67 and von Willebrand factor was investigated, including repeated samples from the same patients. The overall synovitis score (total 0-9) assessed synovial lining hyperplasia (0-3), stromal activation (0-3) and inflammatory infiltration (0-3). Data were clustered within patients, thus a linear mixed model was applied for the statistical tests. Parsimony in the statistical models was achieved omitting covariates from the model in the case of what was judged no statistical significance (p>0.1).RESULTS: Doppler colour fraction showed an association with the overall synovitis score (approximated Spearman, approximately r=0.43, p=0.003). The density of all immunohistochemical stainings showed a significant association with Doppler colour fraction: von Willebrand factor (approximately r=0.44, p=0.01), CD68 (approximately r=0.53, p=0.02), Ki67 (approximately r=0.57, p=0.05) and CD3 (approximately r=0.57, p=0.0003).CONCLUSIONS: Colour Doppler activity is associated with the extent of inflammation present in the synovial biopsies from RA patients. However, synovial pathology was also seen in biopsies taken from Doppler negative sites.

Background Subacromial pain syndrome (SAPS) accounts for around 50 % of all cases of shoulder pain. The most commonly used treatments are glucocorticosteroid (steroid) injections and exercise therapy; however, despite treatment SAPS patients often experience relapse of their symptoms. Therefore the clinical effect of combining steroid and exercise therapy is highly relevant to clarify. The aim of this randomized controlled trial was to investigate if exercise therapy added to steroid injection in patients with SAPS will improve the effect of the injection therapy on shoulder pain. Methods In this two-arm randomized trial running over 26 weeks, patients with unilateral shoulder pain (> 4 weeks) and thickened subacromial bursa (> 2 mm on US) were included. At baseline all participants received two steroid injections into the painful shoulder with an interval of one week. Subsequently they were randomized (1:1) to either 10 weeks exercise of the involved shoulder (intervention group) or exercise of the uninvolved shoulder (control group). The patients were re-examined after the exercise program (at week 13) and again at week 26. The primary outcome assessed after 26 weeks was change in shoulder pain analyzed using the intention-to-treat principle (non-responder imputation). Results Ninety-nine SAPS patients (58 female) participated (49 intervention/50 control). At both follow up visits (week 13 and 26) no statistically significant between-group differences in pain changes on a visual analog scale (mm) were seen (13 weeks: pain at rest 1.7 (95 % CI –3.6 to 7.0; P = 0.53); pain in activity 2.2 (95 % CI –6.5 to 10.9; P = 0.61), 26 weeks: rest 5.6 (95 % CI –0.9 to 12.1; P = 0.09); activity 2.2 (95 % CI –6.8 to 11.2; P = 0.62). The reduction in pain was most evident in the control group at all four pain measurements. The only difference between groups was seen by US examination at week 13, where fewer participants with impingement were observed in the intervention group compared with the controls (9 vs. 19 participants; P = 0.03). Conclusion Exercise therapy in the painful shoulder in SAPS patients did not improve the effectiveness of steroid injections for shoulder pain in patients with unilateral SAPS and enlarged subacromial bursa on US examination. Trial registration ClinicalTrials.gov (NCT01506804). Registration date 5 May 2011. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1002-5) contains supplementary material, which is available to authorized users.

Topical application of NSAIDs is an alternative route to systemic administration when a local anti-inflammatory effect of the underlying tissue is a treatment option. The aim of the present microdialysis study was to assess and compare plasma and tissue levels of diclofenac when topically applied with or without iontophoresis in healthy adults. Fourteen healthy adults (26±9.4 years) were randomized to diclofenac applied by iontophoresis, or by a gel, in a crossover design. Diclofenac concentrations were measured in plasma and in microdialysis perfusates from the underlying tissues. Iontophoretic application resulted in the highest plasma concentration of 3.4±0.5ng/ml (SEM given) compared to 0.4ng/ml (at the detection limit) with gel, whereas no differences were observed between tissue concentrations for the two application methods, both being very low, below or around the detection limit. Iontophoresis caused skin reactions in 25% of the participants. Iontophoresis of diclofenac as compared to traditional topical application was not superior in order to increase the NSAID concentration locally and appears to have a higher frequency of skin reactions.

PURPOSE: The aim of this study was to show the number of cases in which the use of fusion-guided ultrasonography (US) provided conclusive diagnosis of lesions in the liver seen on CT or MRI or PET/CT. A lesion is defined as a region that has suffered damage due to injury or disease. MATERIALS AND METHODS: Forty patients of whom 34 had confirmed neoplastic disease, referred to US evaluation or US-guided biopsy of liver lesions seen on CT (n = 35), MRI (n = 2) or PET/CT (n = 3), were prospectively included in the study. We used a LOGIQ prototype system with incorporated software for fusion imaging, and a convex-array 4 MHz transducer (GE Healthcare, Chalfont St. Giles, UK). All patients were initially examined with B-mode US, then by fusion-guided US and for some patients also with CEUS. All patients received follow-up after at least one year. RESULTS: Twenty-six lesions were initially indistinguishable with US. Of these, 9 became visible with fusion-guided US and another 4 became visible with CEUS, which facilitated a final diagnosis in 11 of these 13 patients. The median tumor size for all lesions included in the study was 1.5 cm (interquartile range: 1.0 - 2.4). There was no statistically significant difference in tumor size between the groups. CONCLUSION: We have successfully demonstrated an increase in the characterization of liver lesions by using fusion-guided US compared with conventional B-mode US.

Aim: Doppler ultrasound was used to evaluate the day-to-day variation in inflammatory activity in rheumatoid arthritis patients on stable TNF alpha blocker treatment. Materials & methods: A total of 16 patients with rheumatoid arthritis were included in the study, according to the American College of Rheumatology criteria of unaltered etanercept dosage for the last 3 months. All patients had a stable total TNF-binding capacity during the examination period. The most swollen joint was chosen as the target joint (11 wrist joints and five metacarpophalangeal joints) and was examined by ultrasound the morning before injection of 25 mg etanercept at day 0, and the same time on days 1, 2 and 3 after the injection. Color Doppler and spectral Doppler were used to estimate the inflammation. The C reactive protein was measured at each visit. Results: The disease activity was assessed only at baseline. Mean disease activity score 28 was 3.97. Only slight changes in ultrasound variables were seen over the 4 day period. Overall, there was no statistically significant effect of time, and all pairwise comparisons were nonsignificant (p > 0.14). No changes were found for C reactive protein and TNF-binding capacity between the individual visits (time effect: p = 0.85 and p = 0.23, respectively). Conclusion: There was no significant day-to-day variation in Doppler parameters in patients on stable etanercept treatment. Ultrasound may therefore be performed at any time between two etanercept injections and significant alterations in Doppler activity may be a potential indicator of change in disease activity.

Purpose Early repair of rotator cuff tears leads to superior results. To detect symptomatic full-thickness tears of the supraspinatus tendon at an early stage, we conducted a prospective study to evaluate the value of clinical examination with and without subacromial lidocaine within the first weeks after an acute injury to the shoulder. Methods Of 104 patients included in a prospective investigation, 52 patients were selected to evaluate the diagnostic accuracy of clinical tests in acute full-thickness tears of the supraspinatus tendon. Clinical tests and ultrasound examination were performed at a median of 13 days (range, 3 to 49 days) after the initial injury. The study group consisted of 29 patients (median age, 56 years [range, 39 to 75 years]) who all had an acute complete tear of the supraspinatus tendon verified by ultrasound and arthroscopy. The control group consisted of 23 patients who all had an intact tendon confirmed by ultrasound (median age, 38 years [range, 19 to 73 years]). Results The Hawkins sign (0.83) and the painful arc test (0.97) had high sensitivity but low specificity (0.23 and 0.05, respectively). The external rotation lag sign (ERLS) and the drop-arm test (DAT) had a sensitivity of 0.39 and 0.37, respectively, and specificity of 0.91 and 0.86, respectively, in diagnosing acute full-thickness tears of the rotator cuff. After a subacromial lidocaine injection, sensitivity of all lag sign tests was reduced, whereas specificity and likelihood ratios of the Jobe test, the ERLS, and the DAT improved. Active abduction was significantly reduced in the full-thickness tear group. Conclusions A positive lag sign (ERLS or DAT) is indicative of a full-thickness supraspinatus tear, but a negative lag sign does not preclude a tear. After a subacromial injection of lidocaine, the specificity improves whereas the sensitivity is reduced. Overall, in patients with suspected acute rotator cuff tear, clinical tests cannot stand alone in the evaluation the first weeks after an acute injury. Level of Evidence Level I, diagnostic study—testing of previously developed criteria in a series of consecutive patients (by use of arthroscopy and ultrasound as the gold standard).

The purpose of our study was to test the accuracy of sonographically guided biopsies in a phantom of structures not visible on sonography but shown on MRI by using commercially available sonography systems with image fusion software.A previously recorded MRI examination from a custom-made phantom was loaded into the sonography system. The phantom contained spheres that were invisible to sonography and contained red dye. The red dye was visible in the biopsy if it was successful. The images were coregistered using structures visible on both sonography and MRI, and biopsies were taken. The biopsy procedure was continued until a biopsy was successful, and the number of needle passes and time spent were registered.A total of 130 targets were hit. Ten minutes was used for loading the MRI data set and the coregistration; 94 of the 130 biopsies (72.3%) were successful at the first needle pass. The median number of needle passes until a successful biopsy was obtained was one (range, 1-7).The described method was successful in obtaining an adequate sample in a phantom.

To quantify the border versus centre enhancement of malignant breast tumours on dynamic magnetic resonance mammography.Fifty-two women diagnosed with primary breast cancer underwent dynamic magnetic resonance mammography (Omniscan 0.2 mmol/kg bodyweight) on a midfield scanner (0.6 T), prior to surgery. The following five variables were recorded from the border and centre regions of the tumours: Early Enhancement, Time to Peak, Wash-in rate, Wash-out rate and Area under Curve. Information on histology type, oestrogen and progesterone receptor status was collected. Statistical analysis was performed in SAS 9.1 as paired samples t-tests.Fifty of 52 malignant tumours displayed a faster Early Enhancement in the border region compared to the centre (p0.0001). Significant differences between the border and centre values were found for Time to Peak, Wash-in rate, Wash-out rate and Area under Curve. Hormone receptor positive tumours displayed an over-all highly significant difference between border and centre enhancement, whereas no significant differences for any of the five variables were recorded in neither oestrogen nor progesterone hormone receptor negative tumours.The border/centre enhancement difference in malignant breast tumours is easily visualized on midfield dynamic magnetic resonance mammography. The dynamic behaviour is significantly correlated to histological features and receptor status of the tumours.

BackgroundThe aim was to investigate the presence of feeding vessels in or in close proximity to extensor and flexor tendon sheaths at the wrists level and in finger flexor tendon sheaths in healthy controls, using 3D ultrasound (US), which may cause pitfalls, in order to ensure correct interpretation of Doppler signals when diagnosing tenosynovitis.MethodForty healthy participants (20 women and 20 men age 23-67 years) without prior history of arthritis, tendon diseases or present pain in their hands were included. Twenty participants had 3D Doppler US of the second and third finger and twenty of the right wrist. US was carried out using a GE Logiq E9 unit with a 3D US probe. The colour Doppler settings were to published recommendation.ResultsThe feeding vessels in or in close proximity to the tendon sheaths were found in the flexor and extensor tendons sheaths at least once in each participant. No significant difference in feeding vessels was seen between the radial and carpal level in the wrist (p = 0.06) or between the second and third flexor tendon sheath (p = 0.84).ConclusionDoppler findings in or in close proximity to the tendon sheaths were common in wrists and fingers in healthy participants. These feeding vessels can be a source of error, not only due to their presence but also because they may be interpreted as being inside the tendon sheath due to blooming and reverberations artefacts. These vessels should be taken into consideration when diagnosing Doppler tenosynovitis.

The paper explains the most important parameters for the use of colour and power Doppler in rheumatology. Recommendations for machine settings are given. The commonly encountered artefacts and their importance for image interpretation are explained.

PURPOSE The purpose of this study is to see if changes in patient positioning result in significant changes in Doppler findings. MATERIALS AND METHODS 30 consecutive patients with jumper's knee in the proximal portion of the patellar tendon formed the study group. The patellar tendon was scanned in the longitudinal plane with colour and spectral Doppler with the knee fully extended as well as, flexed at 15 degrees and 20 degrees . All subjects were randomised to either extension or 20 degrees flexion as the initial position. The amount of colour Doppler activity inside the tendon was expressed with the colour fraction (colour pixels/total pixels) in the proximal portion of the tendon. With spectral Doppler, the resistive index was measured ((peak systolic velocity--end-diastolic velocity)/ peak systolic velocity). RESULTS The mean (+/- SE) colour fraction in the fully extended position and 20 degrees flexion was 36.7 +/- 3.4% and 13.3 +/- 3.4%, respectively (p

PURPOSE Grey-scale ultrasound may be used to visualise the amount of synovial tissue in patients with rheumatoid arthritis (RA). Different scoring systems have been developed. None of the scoring systems have been tested on a larger group of healthy joints, and it is therefore unknown to what extent synovial tissue is seen on grey-scale ultrasound in healthy joints. The objective of this study was to test two scoring systems on healthy volunteers. MATERIALS AND METHODS 24 healthy men and women between 30 and 54 years underwent scanning of the MCP, PIP and DIP joints of their dominant hand. Each person was scanned in 69 positions. The images were graded on a scale from 0 to 4 with two scoring systems (I and II). Scores 0 - 1 were defined as normal and 2 - 4 as pathological. With scoring system I, only markedly hypoechoic synovium was graded. With scoring system II, marked hypoechogenicity was not a criterion. RESULTS With system I, 89 % of the joints obtained at least one pathological score. With system II, 95 % of the joints obtained at least one pathological score. With both systems, women obtained higher scores than men, and the number of high scores increased with increasing age. CONCLUSION An unacceptably high number of joints obtained pathological scores with both scoring systems in healthy volunteers. This indicates that many of the scores interpreted as pathological in patients with RA may just be normal findings, with increasing numbers in older patients.

The aim of this study was to evaluate the epidemiologic data of patients with an acute soft-tissue injury to the shoulder, with an emphasis on improving the early diagnosis of acute rotator cuff tears. This study included 104 patients, with a median age of 49 years (range, 19-75 years). The patients were evaluated clinically and with ultrasonography at a median of 13 days (range, 3-49 days) after the injury. A total of 60 patients (58%) had some degree of cuff lesion on the ultrasonographic examination. Of these patients, 33 (32%) had a full-thickness rotator cuff tear, 14 (13%) had a partial-thickness cuff tear in the tendon substance, and 13 (13%) had a partial cuff tear at the insertion site on the major tubercle. The injury mechanism or activity at the moment of injury did not correlate with the presence of a rotator cuff lesion, but we found a strong age correlation, with a prevalence of any rotator cuff tear, above 50%, for patients aged above 50 years and with a prevalence of full-thickness tears of 50% in the groups aged 50 to 59 years and aged 60 to 69 years. In conclusion, this study found a high incidence of rotator cuff lesions by further evaluation of patients undergoing consultation at the emergency department, with an inability to perform active abduction above 90 degrees and normal radiographs, after an acute shoulder trauma.

Background The most frequent injuries in badminton players are in the lower extremities, especially in the Achilles tendon. Hypothesis The game of badminton may be related to abnormal intratendinous flow in the Achilles tendon as detected by color Doppler ultrasound. To a certain extent, this blood flow might be physiological, especially when examined after match. Study Design Cohort study (prevalence); Level of evidence, 3. Methods Seventy-two elite badminton players were interviewed regarding Achilles tendon pain (achillodynia) in the preceding 3 years. Color Doppler was used to examine the tendons of 64 players before their matches and 46 players after their matches. Intratendinous color Doppler flow was graded from 0 to 4. The Achilles tendon was divided into dominant (eg, right side for right-handed players and vice versa) and nondominant side and classified as midtendon, preinsertional, and calcaneal areas. Results Of 72 players, 26 had experienced achillodynia in 34 tendons, 18 on the dominant side and 16 on the nondominant side. In 62% of the players with achillodynia, the problems had begun slowly, and the median duration of symptoms was 4 months (range, 0-36 months). Thirty-five percent had ongoing pain in their tendons for a median duration of 12 months (range, 0-12 months). Achillodynia was not associated with the self-reported training load or with sex, age, weight, singles or doubles players, or racket side. Forty-six players were scanned before and after match. At baseline, color Doppler flow was present in the majority of players, and only 7 (16%) players had no color Doppler flow in either tendon. After match, all players had some color Doppler flow in 1 or both tendons. Achillodynia and color Doppler flow were related in the nondominant Achilles tendon (chi-square, P =. 008). The grades of Doppler flow also increased significantly after match in the preinsertional area in both the nondominant (P =. 0002) and dominant (P =. 005) side tendons. Conclusion A large proportion of the players had experienced achillodynia and habitually played with a degree of pain that demanded medication. The self-reported pain was associated with increased intratendinous color Doppler flow in the nondominant Achilles tendon. Doppler flow was found in most players before and in all players after the match and therefore may in part be a physiological response to activity.

Resume Cette etude avait pour objectif de tester l'innocuite de l'injection intra-articulaire d'anti-TNFa dans de petites articulations siege d'une arthrite. Une dose de 2–8 mg d'etanercept etait injectee sous controle echographique (US) dans une articulation donnee, siege d'une arthrite, (16 poignets, deux coudes, deux chevilles, six articulations des doigts), chez 26 patients. Le critere principal d'evaluation etait l'analyse radiographique par des investigateurs independants : les mesures doppler etaient realisees chez tous les patients avant et apres injection et l'IRM avant et apres etait obtenue pour neuf patients. Le seul evenement indesirable etait un cas de gonflement de la main durant deux jours apres l'infiltration d'un poignet. Deux patients eurent une injection supplementaire de glucocorticoides et furent exclus de l'analyse d'efficacite apres quatre jours et trois semaines respectivement. L'EVA douleur decroissait apres une semaine pour 23 des 25 patients (mediane 0,62), et apres un mois pour 14 des 24 patients (mediane 0,60). Pas de modification significative de la VS ou de la CRP n'etait observee. Sur l'IRM, les neuf sujets analyses avaient une reduction de l'epaisseur synoviale ( p = 0,008) et les signaux doppler diminuaient apres traitement (RI p = 0,02, pixels p = 0,09). En conclusion, l'injection intra-articulaire d'etanercept n'a conduit a aucun effet indesirable notoire.

Background: Intratendinous Doppler activity has been interpreted as an equivalent of neovessels in the Achilles tendon and as a sign of tendinosis (AT). Aim: To evaluate the vascular response as indicated by color Doppler activity after repeated loading of both symptomatic and non-symptomatic Achilles tendons. Material and methods: Ten non-trained, healthy subjects ran 5 km. Ultrasound (US) Doppler activity was determined before and after the exercise. Eleven patients with chronic AT performed 3 × 15 heavy-load eccentric exercise. The Achilles tendons were scanned before and immediately after the exercise. Results: Non-symptomatic: six Achilles tendons in five subjects had intratendinous Doppler activity before the exercise. All but two subjects (80%) had intratendinous Doppler activity after running. Symptomatic: all patients had Doppler activity in the tendons, with a median color fraction before eccentric exercise of 0.05 (range 0.01–0.33). The Doppler activity did not disappear after exercise. Tendons with a color fraction below the median at baseline increased significantly after the exercise (P=0.02). Conclusion: The mere presence of Doppler in the Achilles tendon does not per se indicate disease. Eccentric exercise does not extinguish the flow during or after one training session in patients with chronic AT.

A case report of a 62-year-old man with a 20-year history of tendon problems, who presented with a swollen and tender left Achilles tendon. Ultrasound (US) revealed a 2 x 1 x 0.9 cm intra-tendinous substance with acoustic shadowing. On a radiogram, ossification was found. Colour Doppler activity was present in both the bursa and the tendon. A US-guided injection of 40 mg Depomedrol was applied into the retrocalcaneal bursa. On follow-up two months later, the patient had no symptoms and US showed total regression of Doppler activity. The ossification was unchanged. US colour Doppler may be recommended for guidance and monitoring of treatment.

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid-portion Achilles tendinosis. A unipolar coagulation device was used.One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were "cured" after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0-10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months' follow up (p0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid-tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.

Objective: To evaluate the intra-reader and inter-reader agreements of ultrasonographic assessments of hip joints in patients with hip osteoarthritis. Design: Ultrasonography was performed on 100 patients with hip osteoarthritis at 14 MHz using a 8–15 MHz linear probe. Dynamic sweeps of the hip and representative still images were used for the analysis. A semiquantitative grading score was introduced in the evaluation of the ultrasound pictures and compared with an overall ultrasound evaluation. The evaluation was performed by a specialist in ultrasonography and a rheumatologist trained in musculoskeletal ultrasound examination. Clinical pain assessment and joint aspiration were obtained in parallel with the ultrasonography. Results: Intraobserver agreement represented by intraclass correlation coefficients (ICC) (exact agreement in percentage; unweighted κ values) showed good to excellent correlation, 0.8 with regard to the osteophyte score, 0.78 with regard to the femoral head score, 0.71 with regard to the fluid score and 0.69 with regard to the synovial profile score. Interobserver agreement was fair to good with corresponding ICC 0.65, 0.63, 0.45 and 0.6, respectively. In comparison, the ICC for the global osteoarthritis and synovial assessments were 0.7 and 0.72, respectively, for the intraobserver rating and 0.56 and 0.58, respectively, for the interobserver rating. Conclusions: This study suggests that ultrasound is a reproducible method for the assessment of changes in the osseous surface and synovium-related inflammation. The semiquantitative scoring system presented seemed to match the global assessment of a trained ultrasound investigator and might be used by less-trained investigators.

UNLABELLED The sensitivity of ultrasound Doppler has now reached a level at which perfusion can be detected even in normal, resting musculoskeletal tissues. To be able to distinguish normal from abnormal flow, the resistive index (RI) determined by spectral Doppler may be of value. Inflammation is associated with low RI values and a value of 1.00 is normal. PURPOSE In tissues with no detectable flow, it has been assumed that RI may be defined as 1.00. This study was performed to test if normal tendinous vessels could be visualised with a contrast agent, and if such vessels had normal RI. MATERIALS AND METHODS Ultrasound (US) was performed with a 14 MHz linear transducer. 22 asymptomatic tendons in 12 subjects were scanned, and only 5 ultrasonically normal tendons in 5 subjects were identified. In these 5 normal tendons, SonoVue was used to make vessels visible. The Achilles tendons and the peritendinous tissues were evaluated clinically. RESULTS In all 5 ultrasonically normal tendons, arteries could be detected with Doppler after contrast injection and in all cases with normal RI values. All vessels were located in the mid-portion of the tendon. 18 tendons were categorised as normal by the clinician. CONCLUSION After administration of a contrast agent, all Achilles tendons could be demonstrated to have arteries present in the mid-portion. The flow profile of these arteries was fully normal without diastolic component and with an RI of 1.00. This finding has implications for criteria of normality of tendons, which cannot be based exclusively on the presence or absence of Doppler activity. The majority of the tendons in this study had ultrasound abnormalities both on gray-scale and colour Doppler. It can be speculated that the abnormalities may be age-related degenerative changes and that age-stratified normal materials are needed to define normality. There was no consistency between US and clinical diagnosis.

Objective: To examine the effect of contrast agents on Doppler ultrasound findings in the synovial membrane in the wrist and fingers of healthy volunteers. Material and methods: Eleven healthy subjects were included in the study (5 women and 6 men, mean age 38 years, range (20–60)). They had no clinical signs of inflammatory or degenerative joint diseases. A total of 66 joints were examined—6 joints for each subject: wrist and metacarpophalangeal (MCP) joints 1–5—before contrast injection and after Levovist and SonoVue injection with a 30 minute interval. Results: Colour Doppler activity was detected in 10/55 (18%) MCP joints before contrast injection and in 29/55 (53%) and 28/55 (51%) joints after Levovist (p

Background: It is debated as to whether Achilles tendonitis (AT) has an inflammatory component. The intratendinous hyperaemia demonstrated with colour Doppler has been interpreted as neovascularisation. Glucocorticoid injection around the tendon is a common therapeutic procedure. Hypotheses: The intratendinous hyperaemia seen with ultrasound (US) colour Doppler represents an inflammatory background. Glucocorticoid injections will be effective if administered inside the tendon where the inflammation seems to be. Study design: An uncontrolled, prospective study with a minimum follow-up of 3 months. Methods: Six tendons in five patients were evaluated with grey-scale US and colour Doppler before and after US-guided intratendinous glucocorticoid injection. Pain at rest and at activity was evaluated on a visual analogue scale. Results: With colour Doppler all tendons had intratendinous flow. Pain and colour Doppler activity decreased during a mean follow-up of 182 days (range 92–309 days). One tendon relapsed after 199 days. Conclusion: Intratendinous glucocorticoid injections seem to have a marked effect on both symptoms and colour Doppler findings, which may be taken as an indication of an inflammatory component in the disease. Colour Doppler adds significant information to grey-scale US with regard to diagnosis, location and follow-up of AT.

Objective To compare the quantitative and qualitative information obtained by Doppler ultrasound (US) measurements of the wrist joints and the small joints of the hand with the information obtained by postcontrast magnetic resonance imaging (MRI) and to correlate the imaging results with clinical observations in patients with rheumatoid arthritis (RA). Methods Twenty-nine consecutive RA patients were studied; 196 joints (29 wrist and 167 finger joints) were examined by both US and MRI. Parameters of inflammation were the color fraction and the resistance index (RI) obtained with color Doppler US and the thickness of enhanced synovium (in mm) and the MRI score obtained with postcontrast MRI. Clinical examination and measurements of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were performed on the same day as the imaging studies. Results There was a highly significant association between US indices of inflammation and postcontrast MRI scores. The mean values for both the color fraction and the RI were significantly different in the group without joint swelling compared with the other groups. The mean RI values were significantly different in the group without joint tenderness compared with the other groups. The mean thickness of enhanced synovium on postcontrast MRI was significantly different between the group without joint swelling and the other groups, but this difference was statistically significant only for the comparison of the group without joint tenderness versus the group with maximum tenderness. No association between the MRI or US estimates of inflammation and values on the visual analog scale for pain, Health Assessment Questionnaire, duration of morning stiffness, ESR, or CRP was found. Conclusion Estimates of synovial inflammatory activity by Doppler US and postcontrast MRI were comparable. Estimation of synovial inflammatory activity by the RI and color fraction parameters of US appears to be a promising method of detecting and monitoring inflammatory activity in patients with RA.

Blood velocity estimation is complicated by the strong echoes received from tissue surrounding the vessel under investigation. Proper blood velocity estimation necessitates use of a filter for separation of the different signal components. Development of these filters and new estimators requires RF-data, where the tissue component is known. In vivo RF-data does not have this property. Instead simulated data incorporating all relevant features of the measurement situation can be employed. One feature is the motion in the surrounding tissue induced by pulsation, heartbeat, and breathing. This study has developed models for the motions and incorporated them into the RF simulation program Field II, thereby obtaining realistic simulated data. A powerful tool for evaluation of different filters and estimators is then available. The model parameters can be varied according to the physical situation with respect to scan-site and the individual to be scanned. The nature of pulsation is discussed, and a relation between the pressure in the carotid artery and the experienced vessel wall motion is derived.

to estimate and visualise the efficacy of treatment with etanercept (Enbrel) in patients with rheumatoid arthritis (RA) using colour Doppler and spectral Doppler ultrasonography to determine the possible changes in synovial perfusion during a one year observation period.Eleven patients from the European multicentre trial of the efficacy and safety of etanercept were included in this study when transferred into the open label, long term safety, and efficacy study. Before a scheduled dosage increase to 50 mg/week they were examined clinically, serologically, and by ultrasonography using the colour Doppler pixels and the spectral Doppler resistance index (RI) as indicators of inflammation. The patients were re-examined at two weeks and at one year follow upThe clinical activity decreased significantly from baseline to week 2, but no significant changes were seen from baseline to one year. The number of coloured pixels in each region of interest decreased from baseline to week 2 with a median reduction of 60% (p=0.005). This effect on the perfusion in the synovium could not be found after one year of treatment. During the initial treatment we detected an increase in synovial RI by spectral Doppler. The median increase in peripheral resistance from baseline to week 2 as estimated by the mean RI was 22.6% (p=0.005). The increase in peripheral resistance was maintained to some extent after one year (mean RI increased by 18.8% p=0.074).Ultrasonography seems to be a promising tool for the detection of treatment response using spectral Doppler and pixel estimation.

Introduction: This study aimed to assess the utility of musculoskeletal ultrasound (MSUS) in patients with joint symptoms using a probabilistic approach. Methods: One hundred and three patients without prior rheumatologic diagnosis and referred to our clinic for evaluation of inflammatory arthritis were included. Patients were assessed clinically including joint examination, laboratory testing including acute-phase reactants, rheumatoid factor (RF) and anti citrulinated protein antibody (ACPA), and radiographs of hands and feet if clinically indicated. A diagnostic assessment was then performed by the responsible rheumatologist where the probability of a) any inflammatory arthritis and b) rheumatoid arthritis was given on a 5-point scale ranging from 0 to 20% up to 80 to 100% probability. Subsequently, an ultrasound examination of the wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) joints 2 to 5 in both hands, metatarsophalangeal (MTP) joints 2 to 5 in both feet and any symptomatic joints was performed and the results presented to the same rheumatologist. The latter then assessed the diagnostic probabilities again, using the same scale. Results: The rheumatologists’ certainty for presence/absence of inflammatory arthritis and rheumatoid arthritis was increased significantly following ultrasound performance. The proportion of patient for whom diagnostic certainty for inflammatory arthritis was maximal was 33.0% before and 71.8% after musculoskeletal ultrasound (P

Introduction: Despite the widespread use of magnetic resonance imaging (MRI) and Doppler ultrasound for the detection of rheumatoid arthritis (RA) disease activity, little is known regarding the association of imaging-detected activity and synovial pathology. The purpose of this study was to compare site-specific release of inflammatory mediators and evaluate the corresponding anatomical sites by examining colour Doppler ultrasound (CDUS) and MRI scans.Methods: RA patients were evaluated on the basis of CDUS and 3-T MRI scans and subsequently underwent synovectomy using a needle arthroscopic procedure of the hand joints. The synovial tissue specimens were incubated for 72 hours, and spontaneous release of monocyte chemoattractant protein 1 (MCP-1), interleukin 6 (IL-6), macrophage inflammatory protein 1β (MIP-1β) and IL-8 was measured by performing multiplex immunoassays. Bone marrow oedema (BME), synovitis and erosion scores were estimated on the basis of the rheumatoid arthritis magnetic resonance imaging score (RAMRIS). Mixed models were used for the statistical analyses. Parsimony was achieved by omitting covariates with P > 0.1 from the statistical model.Results: Tissue samples from 58 synovial sites were obtained from 25 patients. MCP-1 was associated with CDUS activity (P = 0.009, approximate Spearman's ρ = 0.41), RAMRIS BME score (P = 0.01, approximate Spearman's ρ = 0.42) and RAMRIS erosion score (P = 0.03, approximate Spearman's ρ = 0.31). IL-6 was associated with RAMRIS synovitis score (P = 0.04, approximate Spearman's ρ = 0.50), BME score (P = 0.04, approximate Spearman's ρ = 0.31) and RAMRIS erosion score (P = 0.03, approximate Spearman's ρ = 0.35). MIP-1β was associated with CDUS activity (P = 0.02, approximate Spearman's ρ = 0.38) and RAMRIS synovitis scores (P = 0.02, approximate Spearman's ρ = 0.63). IL-8 associations with imaging outcome measures did not reach statistical significance.Conclusions: The association between imaging activity and synovial inflammatory mediators underscores the high sensitivity of CDUS and MRI in the evaluation of RA disease activity. The associations found in our present study have different implications for synovial mediator releases and corresponding imaging signs. For example, MCP-1 and IL-6 were associated with both general inflammation and bone destruction, in contrast to MIP-1β, which was involved solely in general synovitis. The lack of association of IL-8 with synovitis was likely underestimated because of a large proportion of samples above assay detection limits among the patients with the highest synovitis scores. © 2014 Andersen et al.; licensee BioMed Central Ltd.

Objective To develop and assess a stable method for ascertaining the placement of intraarticular injections for osteoarthritis (OA) in the hip and knee. Methods Injections into the hip or knee joint with e.g. hyaluaronan or cortisone were performed under the guidance of ultrasound. For this purpose an Acuson Sequoia apparatus and a 8–15MHz transducer were used. After perforation of the capsule with a 21G needle, 0.5–1ml of asmospheric air and 1ml lidocain 1% was injected with simultaneous recording of the ultrasound signals. This procedure was undertaken before the injection of the medication through the in situ needle. Results In the hip joint the injected air could readily ascertain the placement of the injection with a sharp echoic contrast forming on the ultrasound picture respecting the joint cavity. In the knee joint the procedure gave the best results in joints which have a small amount of fluid in either the suprapatellar bursa or in a pouch regularly observed over the lateral joint margin. However, also in some so-called ‘dry' knee joints the air could be traced in the bursa by ultrasound. Conclusion By the injection of air, it is possible to test the placement of intraarticular injections in both hip and knee joints. This procedure will give a supplementary documentation of the injection as compared to a mere ultrasonographic demonstration of the position of the needle in the joint. The method is proposed as a tool for both learning purposes and quality assurance in daily therapy.

Objective: to examine a group of high risk athletes, for signs of inflammation in jumper's knee (JK) by gray-scale ultrasonography (US) and color/Power Doppler findings in JK. Subjects and methods: eighteen high-elite basketball players participated in the investigation after a match. Seven players were examined by ultrasound before the match as well. The players were clinically examined for signs of JK and filled in a questionnaire concerning previous and present knee symptoms. Results: clinical signs of JK were found in 13 knees. Of these knees, ten had hypoechoic areas and six had Power Doppler flow. Four players reported symptoms of JK and clinical examination suspected the same. Three of them had both hypoechoic areas and Power Doppler flow. Fourteen players were asymptomatic at the time of examination but both hypoechoic areas and Power Doppler flow was found in the patellar tendons of four players. No correlation was found between clinical findings, symptoms of JK and US findings — including Power Doppler. The risk of type II error in this material is considerable. Conclusion: an association between gray-scale US and color/Power Doppler was found in JK which may suggest an inflammatory component to be a part of the pathogenesis of JK.

Introduction Chronic pain is common in rheumatoid arthritis (RA) and may still persist despite regression of objective signs of inflammation. This has led researchers to hypothesise that central pain sensitisation may play a role in the generation of chronic pain in RA. Application of the disease activity score DAS28 can classify some patients with active RA solely based on a high tender joint count and poor patient global health score. In such cases, intensified treatment with anti-inflammatory drugs would be expected to yield poorer results than in cases with DAS28 elevation due to a high score for swollen joints and C reactive protein (CRP). Evaluation of central pain sensitisation in patients with few inflammatory indices may be a predictive tool regarding the effect of anti-inflammatory treatment. Computerised pneumatic cuff pressure algometry (CPA) is a method for assessing temporal summation (ie, degree of central sensitisation). The main objective of this study was to examine the prognostic values of pressure pain-induced temporal summation, ultrasound Doppler activity and the interaction between them in relation to treatment response (DAS28-CRP change) in patients with RA initiating any anti-inflammatory therapy. Method and analysis 120 participants ≥18 years of age will be recruited. Furthermore, they must be either (1) diagnosed with RA, untreated with disease-modifying antirheumatic drugs for at least 6 months and about to initiate disease-modifying antirheumatic drug treatment or (2) about to begin or switch treatment with any biological drug for their RA. Data (clinical, imaging, blood samples, patient reported outcomes and CPA measurements) will be collected from each participant at baseline and after 4 months of anti-inflammatory treatment. Ethics and dissemination This study has been approved by the ethics committee for the Copenhagen region (H-4-2013-007). Dissemination will occur through presentations and publication in international peer-reviewed journals.

Objective: To determine how settings for power and color Doppler ultrasound sensitivity vary on different high- and intermediate-range ultrasound machines and to evaluate the impact of these changes on Doppler scoring of inflamed joints. Methods: Six different types of ultrasound machines were used. On each machine, the factory setting for superficial musculoskeletal scanning was used unchanged for both color and power Doppler modalities. The settings were then adjusted for increased Doppler sensitivity, and these settings were designated study settings. Eleven patients with rheumatoid arthritis (RA) with wrist involvement were scanned on the 6 machines, each with 4 settings, generating 264 Doppler images for scoring and color quantification. Doppler sensitivity was measured with a quantitative assessment of Doppler activity: color fraction. Higher color fraction indicated higher sensitivity. Results: Power Doppler was more sensitive on half of the machines, whereas color Doppler was more sensitive on the other half, using both factory settings and study settings. There was an average increase in Doppler sensitivity, despite modality, of 78% when study settings were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, the grades for each of 7 of the patients varied between 0 and 3, while the grades for each of the other 4 patients varied between 0 and 2. Conclusion: The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation by ultrasound in RA patients, and this must be taken into account in multicenter studies.

Copyright (c) 1997 Elsevier Science Ireland Ltd. All rights reserved. Objective: Breast ultrasound and US-guided interventional procedures of the breast are increasingly being applied and integrated in the diagnostic work-up and management of breast patients. The aim of the study was to assess the reliability of ultrasound-guided (US-guided) needle core biopsy of palpable breast masses with a 1.2 mm needle (18 gauge) in a fully automated firing device as an alternative to the existing surgical routine, i.e. surgical excision or palpation-guided Tru-Cut biopsy with a 2.0 mm needle (14 gauge) in a semi-automated device. Method: US-guided biopsy of palpable breast masses was prospectively, consecutively and openly compared to open surgical biopsy in a design closely connected to the routine diagnostic work-up of these patients. Results: 106 Patients with a palpable mass in one of their breasts were included in this study. The final diagnosis was the histological result of the open surgical biopsies, which were: 49 malignant lesions, 14 fibroadenomas, and 43 cases of fibrocystic disease. Forty-six malignant tumors were detectable ultrasonically and US-guided biopsy was performed, yielding adequate and correctly positive diagnoses in 41 cases (89%). Three US-guided samples were adequate for diagnosis but yielded a false-negative result. Two samples were excessively fragmented and thus inadequate for diagnosis. All 14 fibroadenomas were correctly diagnosed ultrasonically and US-guided sampling yielded a correct diagnosis in all but one case which was inadequate. The remaining 43 cases showed no abnormality on the sonogram and open biopsy yielded fibrocystic disease. Conclusion: US-guided biopsy of palpable breast masses can obviate open surgical biopsy whenever a mass is ultrasonically visible and it is strongly advocated to implement the procedure in the diagnostic work-up of these patients. © 1997 Elsevier Science Ireland Ltd.

Rationale and Objectives. Radiofrequency (RF) tissue ablation with a cooled needle electrode (probe) can produce large lesions. By using this technique on ex vivo calf livers, the authors evaluated the role of ultrasound (US), dose response, and temperature course with time. Methods. RF ablation was produced with a 14-gauge probe with a 2-cm exposed tip. The lesions were examined with US and macroscopically after various treatment durations. Tissue temperature was measured with thermosensors inserted 1, 2, and 3 cm from the probe. Results. Before treatment the tip of the probe was easy to visualize with US, but during treatment microbubbles obscured the lesion and probe. After treatment, the lesions appeared hypoechoic. Lesion size was underestimated based on US findings. Lesion size was logarithmically correlated to treatment duration. Lesion temperature increased at an increased rate with higher wattage applied and with decreased distance from the probe. Conclusion. US is useful for probe placement before treatment and might be of value after treatment. Lesion size increases reproducibly with treatment duration.

The aim of this paper is to investigate sensitivity to change (SRM), predictive validity and discriminative ability of a quantitative (QS) and a semi-quantitative (SQS) Doppler ultrasound scoring systems in patients with rheumatoid arthritis (RA) treated with anti-TNF-α therapy.RA patients with wrist joint affection treated with TNF-α inhibitor were followed for one year. The wrist was examined with Doppler before initiating therapy and after one year. DAS28 was determined at both visits. One person trained in the SQS system and one in the QS system evaluated the anonymised images. The SRM, predictive validity and discriminative ability for both systems were calculated using DAS28 as the measure of disease improvement.Fourty-six patients with RA (80% females) were included. The mean Doppler activity at baseline was QS:24.4% (SD=17.7%) and SQS:2.0 (SD=0.6). A decrease in Doppler activity was seen for both systems after anti-TNF-α therapy. Sensitivity to change was seen, SRM=-0.52 (95%CI; -0.83 to -0.21; QS) and -0.24 (-0.53 to -0.05; SQS). Predictive value was poor (QS rs=-0.24; SQS rs=-0.05). Construct validity was; QS: rs=0.29, SQS: rs=0.23.Both systems were to some extent sensitive to change. Predictive validity and discriminate capacity of both systems showed only a weak association to DAS 28 in the study population. The QS was a little superior to the SQS. The results do not necessarily reflect Doppler evaluation as being ineffective, but may be caused by DAS28 not being a perfect marker of inflammation.

In order to optimize and standardize musculoskeletal ultrasonography education for rheumatologists, there is a need for competency assessments addressing the required training and practical and theoretical skills. This paper describes how these competency assessments for rheumatologists were developed and what they contain.

Purpose: To test the reliability and validity of a 3D US erosion score in RA using MRI as the gold standard. Materials and Methods: RA patients were examined with 3D US and 3 T MRI over the 2 nd and 3 rd metacarpophalangeal joints. 3D blocks were evaluated by two investigators. The erosions were estimated according to a semi-quantitative score (SQS) (0 – 3) and a quantitative score (QS) (mm 2 ). MRI was evaluated according to the RAMRIS score. For the estimation of reliability, intra-class correlation coefficients (ICC) were used. Validity was tested using Spearman’s rho (r s ). The sensitivity and specificity were also calculated. Results: 28 patients with RA were included. The ICC for the inter-observer reliability in the QS was 0.41 and 0.13 for the metacarpal bone and phalangeal bone, respectively, and 0.86 and 0.16, respectively, in the SQS. The ICC for the intra-observer reliability in the QS was 0.75 and 0.48 for the metacarpal bone and phalangeal bone, respectively, and 0.83 and 0.60, respectively, in the SQS. The correlation with MRI for the metacarpal bone was significant, with values of 0.73 (p = 0.0001) (SQ) and 0.74 (p = 0.0001) (SQS). For the phalangeal bone, bad correlation was found: 0.28 (p = 0.145) (SQ) and 0.26 (p = 0.57) (SQS). The sensitivity and specificity for the metacarpal bone were 86 % and 85 % respectively. For the phalangeal bone they were 60 % and 97 %, respectively. Conclusion: Good inter- and intra-observer reliability and correlation with MRI were seen in the assessment of erosions with 3D US in the metacarpal bone, while the results were low and insignificant for the phalangeal bone, indicating that 3D US still has room for improvement.

A retrospective study was designed to compare the diagnostic yield of US-guided (FNAB) fine needle aspiration biopsy (N = 92) from clearly defined hepatic lesions with diameters of 2 cm or larger, when one, two or three needle passes were performed. No significant diagnostic loss was detected when the number of needle passes was reduced from three to two (Sensitivity = 0.985, Specificity = 1.0, Pos. predictive value (PPV) = 1.0, Neg. predictive value (NPV) = 0.81). However, an unacceptable diagnostic loss was seen when only one needle pass was evaluated (Sensitivity = 0.81, Specificity = 1.0, PPV = 1.0, NPV = 0.69). We conclude that two needle passes can be recommended as a standard procedure for US-guided fine needle aspiration biopsy from hepatic lesions larger than 2 cm in diameter provided the procedure is performed routinely.

SummaryIn an animal study, we have tested a special loop electrode for ultrasound-guided percutaneous interstitial tissue ablation using monopolar radiofrequency (RF) electrosurgery. The loop electrode with a radius of 1 cm was inserted into calf livers via an insulated introducer cannula. Monopolar RF current in the cut mode was applied to the loop electrode which was rotated a full turn. During this, a lesion was cut off interstitially. In three sedated calves a total of seven liver lesions were made percutaneously or during laparotomy. The procedure was guided and monitored by ultrasono-graphy including colour Doppler imaging. Autopsy was performed on day 0 or day 8 post treatment and included gross sectional examination and microscopic evaluation (light microscopy and electron microscopy). In the first animal, the lesions were incomplete because of insufficient voltage setting. In the second and third animal, however, four spherical lesions with a diameter of 2 cm were cut off without clinical complic...

OBJECTIVE.: To assess pain sensitivity and spreading hyperalgesia in lateral epicondylalgia (LE). SUBJECTS.: Twenty-two women with LE, and 38 controls were included. OUTCOME MEASURES.: Computerized cuff pressure algometry was used for assessment of pressure-pain threshold and tolerance. The stimulus was applied using a single (stimulation-area: 241 cm(2) ) or double-chambered (stimulation-area: 482 cm(2) ) tourniquet on the arm and leg. Spatial summation was expressed as the ratio between pressure-pain thresholds to single and double cuff-chamber stimulation. During 10-minute constant pressure stimulation at intensity relative to the individual pain threshold, the pain intensity was continuously recorded using an electronic visual analogue scale (VAS), and from this the degree of temporal summation was estimated. For LE, a Doppler ultrasound examination of the elbow was made to identify inflammation. RESULTS.: In LE compared with controls the pressure-pain threshold and tolerance were on average reduced by respectively 31% (nonsignificant) and 18% (nonsignificant) on the lower arm and by 32% (P < 0.05) and 22% (P < 0.05) on the lower leg (spreading sensitization). Within the LE group, pressure-pain thresholds were on average reduced by 20% (P < 0.05) and pain tolerance by 10% (nonsignificant) on the painful compared with the asymptomatic side. Spatial summation (P < 0.01) and temporal summation (P < 0.05) was facilitated in LE compared with controls. In LE patients without signs of peripheral inflammation assessed by Doppler ultrasound, temporal summation was significantly stronger than in patients with ongoing inflammation (P < 0.01). CONCLUSION.: Patients with LE may be subgrouped based on pain hypersensitivity and Doppler ultrasound into clinically meaningful subgroups with varying duration of symptoms and different degrees of central sensitization. These groups may require different pain management strategies.

In 90% of patients with rheumatoid arthritis (RA), the joints of the hand are affected. Studies of grip strength training have not indicated a negative effect on disease activity after training. Introduction of ultrasound Doppler (USD) to measure increased blood flow induced by inflammation has made it possible to investigate the direct effect on blood supply in the synovium after training. In this case-control study, 24 patients with RA with USD activity in the wrist joint participated. The USD activity was measured by the color fraction (CF) (CF = colored pixels/total number of pixels in ROI). Twenty-four patients were assigned to an 8-week grip strength training program. At baseline and after 8 weeks of training, an USD examination of the wrist joint was performed. In the training group, we measured grip strength and pain in the wrist joint. Six patients withdrew from the training because of pain or change in medication. Eighteen patients served as control group. There was a modest, not significant, decrease in the CF in response to training (1.86%; P = 0.08). Grip strength increased 8.8% after training (P = 0.055). Pain in motion deceased after training (P = 0.04). No difference in the CF was seen between the training and control groups, neither at baseline nor at follow-up (P = 0.82 and P = 0.48). Patients withdrawing from training had a significantly higher CF than the other patients (P > 0.001). The results in this study might indicate that the flow in the synovium assessed by USD is not affected by grip strength training.

Objective: The purpose of the study was to assess the value of ultrasound in detecting focal lesions of the breast, in differentiating between benign and malignant lesions and in detecting axillary dissemination of a malignant disease, and to assess the clinical impact of the implementation of breast ultrasound in symptomatic patients. Materials and methods: A prospective, consecutive, blinded study was conducted, comparing the results of the ultrasonic examination of the breast with those of mammography. One hundred and ninety nine patients with a mean age of 48 years (range: 19–80 years) were examined according to a strict methodological design. All these patients were referred for X-ray mammography as they were suspected of having a malignant disease of the breast; they were all affiliated to the general surgery ward (responsible for breast surgery). Specified analytic criteria (tumor shape and margins, architectural distortion and retrotumoral acoustic effect) were used to assess the findings. Results: There were 28 cancers. Ultrasound detected 27, whereas mammography detected 22. McNemar's test yielded a P value of 0.037 for patients with malignant disease, thereby showing a tendency towards breast ultrasound being a better diagnostic method than X-ray mammography. The same tendency applies to the benign findings. Conclusion: In this study, breast ultrasound had better results than mammography in detecting focal lesions, in differentiating the nature of the lesions, as well as detecting dissemination of malignant disease. A more liberal use of breast ultrasound is advocated.