Advancement of 3D printing technology for the development of a training model in US-guided vesicoamniotic shunting for early LUTO therapy.

INTRODUCTION: Prenatal lower urinary tract obstruction (LUTO) is a rare and challenging condition with potential severe morbidity and mortality. Prenatal shunting methods, specifically vesicoamniotic shunting (VAS) and fetal cystoscopy, aim to manage this condition. However, comprehensive education and training are hindered by the rarity of LUTO. To address this gap, we present a low-cost 3D-printed ultrasound training model for VAS in LUTO fetuses. The aim of the study was to evaluate ultrasound and haptic fidelity of the model. MATERIAL AND METHODS: Ultrasound images of three LUTO fetuses at 12-14 weeks were utilized to create detailed 3D-printed models. Fusion360TM software generated stereo-lithography files, and the Formlabs Form3® printer, using Flexible 80A resin, produced the models. A simulation box mimicking uterine conditions and fetal anatomy was developed for testing. Ultrasound assessments determined model accuracy, and expert evaluations gauged fidelity for VAS placement. RESULTS: The 3D-printed model accurately replicated LUTO fetal anatomy, demonstrating structural integrity and realistic sonographic and haptic feedback during 20 punctures. Macroscopic visualization confirmed the model's durability and authenticity. DISCUSSION: This innovative 3D-printed model addresses the scarcity of LUTO cases and the lack of realistic training tools. Simulation models enhance skills, providing a controlled learning environment that bridges theoretical knowledge and clinical application, potentially improving patient outcomes. CONCLUSIONS: The 3D-printed training model for VAS in LUTO represents a significant advancement in surgical education, offering realistic anatomical simulation and tactile feedback. Future studies should assess its effectiveness in enhancing surgical skills and impacting patient outcomes in clinical practice.

EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update.

OBJECTIVES: To update the EULAR recommendations for the use of imaging modalities in primary large vessel vasculitis (LVV). METHODS: A systematic literature review update was performed to retrieve new evidence on ultrasound, MRI, CT and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis, monitoring and outcome prediction in LVV. The task force consisted of 24 physicians, health professionals and patients from 14 countries. The recommendations were updated based on evidence and expert opinion, iterating until voting indicated consensus. The level of agreement was determined by anonymous votes. RESULTS: Three overarching principles and eight recommendations were agreed. Compared to the 2018 version, ultrasound is now recommended as first-line imaging test in all patients with suspected giant cell arteritis, and axillary arteries should be included in the standard examination. As an alternative to ultrasound, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; FDG-PET, CT or ultrasound are alternatives. Although imaging is not routinely recommended for follow-up, ultrasound, FDG-PET or MRI may be used for assessing vessel abnormalities in LVV patients with suspected relapse, particularly when laboratory markers of inflammation are unreliable. MR-angiography, CT-angiography or ultrasound may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation. CONCLUSIONS: The 2023 EULAR recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with LVV.

The provisional OMERACT ultrasonography score for giant cell arteritis.

OBJECTIVES: To develop an Outcome Measures in Rheumatology (OMERACT) ultrasonography score for monitoring disease activity in giant cell arteritis (GCA) and evaluate its metric properties. METHODS: The OMERACT Instrument Selection Algorithm was followed. Forty-nine members of the OMERACT ultrasonography large vessel vasculitis working group were invited to seven Delphi rounds. An online reliability exercise was conducted using images of bilateral common temporal arteries, parietal and frontal branches as well as axillary arteries from 16 patients with GCA and 7 controls. Sensitivity to change and convergent construct validity were tested using data from a prospective cohort of patients with new GCA in which ultrasound-based intima-media thickness (IMT) measurements were conducted at weeks 1, 3, 6, 12 and 24. RESULTS: Agreement was obtained (92.7%) for the OMERACT GCA Ultrasonography Score (OGUS), calculated as follows: sum of IMT measured in every segment divided by the rounded cut-off values of IMTs in each segment. The resulting value is then divided by the number of segments available. Thirty-five members conducted the reliability exercise, the interrater intraclass correlation coefficient (ICC) for the OGUS was 0.72-0.84 and the median intrareader ICC was 0.91. The prospective cohort consisted of 52 patients. Sensitivity to change between baseline and each follow-up visit up to week 24 yielded standardised mean differences from -1.19 to -2.16, corresponding to large and very large magnitudes of change, respectively. OGUS correlated moderately with erythrocyte sedimentation rate, C reactive protein and Birmingham Vasculitis Activity Score (corrcoeff 0.37-0.48). CONCLUSION: We developed a provisional OGUS for potential use in clinical trials.

Conception and Feasibility of a Digital Tele-Guided Abdomen, Thorax, and Thyroid Gland Ultrasound Course for Medical Students (TELUS study).

PURPOSE: Medical education has been transformed during the COVID-19 pandemic, creating challenges regarding adequate training in ultrasound (US). Due to the discontinuation of traditional classroom teaching, the need to expand digital learning opportunities is undeniable. The aim of our study is to develop a tele-guided US course for undergraduate medical students and test the feasibility and efficacy of this digital US teaching method. MATERIALS AND METHODS: A tele-guided US course was established for medical students. Students underwent seven US organ modules. Each module took place in a flipped classroom concept via the Amboss platform, providing supplementary e-learning material that was optional and included information on each of the US modules. An objective structured assessment of US skills (OSAUS) was implemented as the final exam. US images of the course and exam were rated by the Brightness Mode Quality Ultrasound Imaging Examination Technique (B-QUIET). Achieved points in image rating were compared to the OSAUS exam. RESULTS: A total of 15 medical students were enrolled. Students achieved an average score of 154.5 (SD ±â€Š11.72) out of 175 points (88.29 %) in OSAUS, which corresponded to the image rating using B-QUIET. Interrater analysis of US images showed a favorable agreement with an ICC (2.1) of 0.895 (95 % confidence interval 0.858 < ICC < 0.924). CONCLUSION: US training via teleguidance should be considered in medical education. Our pilot study demonstrates the feasibility of a concept that can be used in the future to improve US training of medical students even during a pandemic.

A 78-year-old female with severe tongue pain: benefit of modern ultrasound.

BACKGROUND: Giant cell arteritis (GCA) is the most common form of systemic vasculitis in persons aged 50 years and older. Medium and large vessels, like the temporal and axillary arteries, are commonly affected. Typical symptoms are headache, scalp tenderness, jaw claudication and ophthalmological symptoms as loss of visual field, diplopia or amaurosis due to optic nerve ischemia. Tongue pain due to vasculitic affection of the deep lingual artery can occur and has so far not been visualized and followed up by modern ultrasound. CASE PRESENTATION: We report the case of a 78-year-old woman with typical symptoms of GCA, such as scalp tenderness, jaw claudication and loss of visual field, as well as severe tongue pain. Broad vasculitic affection of the extracranial arteries, vasculitis of the central retinal artery and the deep lingual artery could be visualized by ultrasound. Further did we observe a relevant decrease of intima-media thickness (IMT) values of all arteries assessed by ultrasound during follow-up. Especially the left common superficial temporal artery showed a relevant decrease of IMT from 0.49 mm at time of diagnosis to 0.23 mm on 6-months follow-up. This is the first GCA case described in literature, in which vasculitis of the central retinal artery and the lingual artery could be visualized at diagnosis and during follow-up using high-resolution ultrasound. CONCLUSION: High-resolution ultrasound can be a useful diagnostic imaging modality in diagnosis and follow-up of GCA, even in small arteries like the lingual artery or central retinal artery. Ultrasound of the central retinal artery could be an important imaging tool in identifying suspected vasculitic affection of the central retinal artery.

Establishment and validation of a didactic musculoskeletal ultrasound course for dermatologists using an innovative handheld ultrasound system - the MUDE study (Musculoskeletal Ultrasound in Dermatology).

BACKGROUND: In the early detection of arthritis, such as psoriatic arthritis, musculoskeletal ultrasound (MSUS) of painful joints plays an important role in diagnosis. Pathological findings can be missed during clinical examination, especially if conducted by physicians who are not trained. The objective of this study was to examine a pilot MSUS course designed specifically for dermatologists, the MUDE protocol. METHODS: To assess the degree of MSUS expertise of the participants, a questionnaire using SurveyMonkey® was completed before the course. The course concept covered only the most important ultrasound sections of all joints and focused on the detection of joint effusion and hyperperfusion. The course consisted of three modules and was carried out over six months. The portable Butterfly IQ® system in combination with an Apple iPad was provided to enable practice between the courses. The final teaching evaluation was carried out as an objective structured clinical examination (OSCE). RESULTS: Twelve dermatologists participated. The survey revealed no prior knowledge of MSUS. The overall score of all participants in the OSCE was 21.86 (87.44 %) out of a total of 25 points, which corresponded to the school grade good. CONCLUSION: The innovative MUDE protocol is thus particularly suitable for the training of dermatologists in MSUS, irrespective of prior knowledge.

Etablierung und Validierung eines didaktischen muskuloskelettalen Ultraschallkurses für Dermatologen unter Verwendung eines innovativen Hand-Ultraschallsystems - die MUDE-Studie (Muskuloskelettaler Ultraschall für Dermatologen).

HINTERGRUND: Der muskuloskelettale Ultraschall (MSUS) schmerzhafter Gelenke spielt bei der Früherkennung der Arthritis, wie zum Beispiel der Psoriasisarthritis, eine wichtige Rolle. Pathologische Befunde können bei der klinischen Untersuchung übersehen werden, insbesondere wenn sie von Ärzten durchgeführt werden, die nicht in der Durchführung geschult sind. Das Ziel dieser Studie war die Untersuchung eines Pilot-MSUS-Kurses anhand des MUDE-Protokolls, welches speziell für Dermatologen entwickelt wurde. METHODIK: Um den Grad der MSUS-Expertise der Teilnehmer zu ermitteln, wurde vor dem Kurs eine Umfrage mittels SurveyMonkey® durchgeführt. Das Kurskonzept umfasste nur die wichtigsten Ultraschallschnitte aller Gelenke und konzentrierte sich auf die Erkennung von Gelenkergüssen und Hyperperfusion der Synovia. Der Kurs bestand aus drei Modulen und wurde über sechs Monate durchgeführt. Das tragbare Butterfly IQ® System in Kombination mit einem Apple iPad wurde allen Teilnehmern zur Verfügung gestellt, um das Üben zwischen den Kursen zu ermöglichen. Die abschließende Lehrevaluation wurde als objective structured clinical examination (OSCE) durchgeführt. ERGEBNISSE: Zwölf Dermatologen nahmen teil. Die Umfrage ergab keine Vorkenntnisse des MSUS. Die Gesamtpunktzahl aller Teilnehmer in der OSCE betrug 21,86 (87,44 %) von insgesamt 25 Punkten, was der Schulnote "gut" entsprach. SCHLUSSFOLGERUNG: Das innovative Lehrkonzept MUDE eignet sich somit, unabhängig von Vorkenntnissen, in besonderer Weise für die Ausbildung von Dermatologen im MSUS.

2019 EULAR recommendations for the generic core competences of health professionals in rheumatology.

BACKGROUND/OBJECTIVES: To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education. METHODS: The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0-10 rating scale). RESULTS: Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda. CONCLUSION: Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.

Imaging for Diagnosis, Monitoring, and Outcome Prediction of Large Vessel Vasculitides.

PURPOSE OF REVIEW: To discuss and summarize the latest evidence on imaging techniques in giant cell arteritis (GCA) and Takayasu arteritis (TAK). This is a report on the performance of ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18-FDG-PET), and other emerging imaging techniques in diagnosis, outcome prediction, and monitoring of disease activity. RECENT FINDINGS: Imaging techniques have gained an important role for diagnosis of large vessel vasculitides (LVV). As signs of vasculitis, US, MRI, and CT show a homogeneous arterial wall thickening, which is mostly concentric. PET displays increased FDG uptake in inflamed artery walls. US is recommended as the initial imaging modality in GCA. MRI and PET/CT may also detect vasculitis of temporal arteries. For TAK, MRI is recommended as the first imaging modality as it provides a good overview without radiation. Extracranial LVV can be confirmed by all four modalities. In addition, MRI and PET/CT provide consistent examination of the aorta and its branches. New techniques such as contrast-enhanced ultrasound, PET/MRI, and auxiliary methods such as "computer-assisted quantitative analysis" have emerged and need to be further validated. Imaging has partly replaced histology for confirming LVV. Provided experience and adequate training, US, MRI, CT, or PET provide excellent diagnostic accuracy. Imaging results need to complement history and clinical examination. Ongoing studies are evaluating the role of imaging for monitoring and outcome measurement.

Impact of esophagogastroduodenoscopy and ileocolonoscopy on diagnosis and therapy in patients with rheumatic diseases-a retrospective cohort study.

OBJECTIVES: Many rheumatic diseases as well as their medications may cause gastrointestinal (GI) pathologies; in addition, some primary GI diseases may contribute or lead to rheumatic disease manifestations. The aim of this study is to analyze the clinical relevance of esophagogastroduodenoscopy (EGD) and ileocolonoscopy (IC) in patients suffering from inflammatory rheumatic diseases. METHODS: A retrospective chart review was performed for all rheumatological inpatients who underwent EGD and/or IC within 2 years. RESULTS: Within 2 years, 456 patients (261 female, 195 male) underwent 752 endoscopic investigations of the GI tract (419 EGDs and 333 ICs). Of all patients, 152 (33.3%) did not report any GI complaints. However, 28 of these asymptomatic patients (18.4%) suffered from esophagitis, a gastric ulcer could be identified in 20 patients (13%), whereas unspecific colitis was diagnosed in 19 patients (12.5%). In addition, 14 patients (9.2%) suffered from clinically unapparent Crohn's disease and two patients from Whipple's disease. In one patient with polymyalgia rheumatica, colon cancer was diagnosed. Altogether 304 patients reported GI complaints. Of these, 292 (39%) endoscopic investigations had impact on the final diagnosis or therapeutic strategy. The antirheumatic medication or the concomitant medication was changed in 18% of the patients due to the endoscopic findings; in 29 patients (6.5%) the initially clinically presumed diagnosis had to be corrected. In 70 patients (15%) with an undefined rheumatic diagnosis prior to endoscopy, endoscopic findings were decisive to establish the final diagnosis. CONCLUSION: EGD and IC have a high diagnostic impact on patients with rheumatic diseases presenting with or without concomitant GI symptoms.

[Diagnostics and treatment of large vessel vasculitis]. / Diagnostik und Therapie von Großgefäßvaskulitiden.

BACKGROUND: Giant cell arteritis (GCA) and Takayasu arteritis (TAK), as the main representatives of large vessel vasculitis, are rheumatological autoimmune disorders associated with inflammatory vessel wall changes in the arterial system that can lead to many types of organ damage. MATERIAL AND METHODS: In this review the current scientific evidence on the diagnostics and treatment of large vessel vasculitis is evaluated and discussed. RESULTS: In addition to the medical history and clinical presentation, imaging techniques nowadays represent the core of large vessel vasculitis diagnostics and have largely replaced the histological confirmation of GCA. After the diagnosis, acute treatment with glucocorticoids should be initiated as rapidly as possible but in the long term this should be tapered out or replaced by a steroid-sparing basic treatment. In contrast to GCA with already available options and other biologic disease-modifying antirheumatic drugs (DMARDs) about to be approved, there are still no approved biologic DMARD treatment options available for the less common TAK. CONCLUSION: In contrast to the substantial progress in imaging diagnostics of large vessel vasculitis and with respect to the treatment of GCA, the much rarer TAK still requires intensive research efforts, especially to improve the treatment situation.

The Meteoritics Trial: efficacy of methotrexate after remission-induction with tocilizumab and glucocorticoids in giant cell arteritis-study protocol for a randomized, double-blind, placebo-controlled, parallel-group phase II study.

BACKGROUND: Glucocorticoids (GC) are the standard treatment for giant cell arteritis (GCA), even though they are associated with adverse side effects and high relapse rates. Tocilizumab (TCZ), an interleukin-6 receptor antagonist, has shown promise in sustaining remission and reducing the cumulative GC dosage, but it increases the risk of infections and is expensive. After discontinuation of TCZ, only about half of patients remain in remission. Additionally, only few studies have been conducted looking at remission maintenance, highlighting the need for alternative strategies to maintain remission in GCA. Methotrexate (MTX) has been shown to significantly decrease the risk of relapse in new-onset GCA and is already a proven safe drug in many rheumatologic diseases. METHODS: This study aims to evaluate the efficacy and safety of MTX in maintaining remission in patients with GCA who have previously been treated with GC and at least 6 months with TCZ. We hypothesize that MTX can maintain remission in GCA patients, who have achieved stable remission after treatment with GC and TCZ, and prevent the occurrence of relapses. The study design is a monocentric, randomized, double-blind, placebo-controlled, parallel-group phase II trial randomizing 40 GCA patients 1:1 into a MTX or placebo arm. Patients will receive 17.5 mg MTX/matching placebo weekly by subcutaneous injection for 12 months, with the possibility of dose reduction if clinically needed. A 6-month follow-up will take place. The primary endpoint is the time to first relapse in the MTX group versus placebo during the 12-month treatment period. Secondary outcomes include patient- and investigator-reported outcomes and laboratory findings, as well as the prevalence of aortitis, number of vasculitic vessels, and change in intima-media thickness during the study. DISCUSSION: This is the first clinical trial evaluating remission maintenance of GCA with MTX after a previous treatment cycle with TCZ. Following the discontinuation of TCZ in GCA, MTX could be a safe and inexpensive drug. TRIAL REGISTRATION: ClinicalTrials.gov, NCT05623592. Registered on 21 November 2022. EU Clinical Trials Register, 2022-501058-12-00. German Clinical Trials Register DRKS00030571.

The Current Situation of Musculoskeletal Ultrasound Education: A Systematic Literature Review.

As a radiation-free and dynamic imaging tool, musculoskeletal ultrasound improves diagnostic and therapeutic safety. With its growing application, the demand for training opportunities rises rapidly. Therefore, this work was aimed at mapping the current state of musculoskeletal ultrasonography education. A systematic literature search was conducted in January 2022 in the medical databases Embase, PubMed and Google Scholar. By use of specifically selected keywords, matching publications were filtered; then abstracts were screened independently by two authors and the inclusion of each publication was checked against pre-defined criteria according to the PICO (Population, Intervention, Comparator, Outcomes) scheme. Full-text versions of included publications were reviewed, and relevant information was extracted. Finally, 67 publications were included. Our results revealed a wide variety of course concepts and programs that have been implemented in different disciplines. Musculoskeletal ultrasonography training especially addresses residents in rheumatology, radiology and physical medicine and rehabilitation. International institutions, such as the European League Against Rheumatism and the Pan-American League of Associations for Rheumatology, have suggested guidelines and curricula to promote standardized ultrasound training. The development of alternative teaching methods incorporating e-learning, peer teaching and distance learning on mobile ultrasound devices and the determination of international guidelines could facilitate overcoming the remaining obstacles still to be passed. In conclusion, it can be stated that there is a broad consensus that standardized musculoskeletal ultrasound curricula would improve training and facilitate the implementation of new training programs.

Development and implementation of a comprehensive ultrasound curriculum for medical students: The Bonn internship point-of-care-ultrasound curriculum (BI-POCUS).

Background: Point-of-care ultrasound (POCUS) is rapidly gaining ground within different areas of applications. Despite the high and increasing relevance of ultrasound, the availability of structured training programs in medical schools is still limited. Therefore, many doctors keep acquiring all their ultrasound skills throughout their postgraduate training. As a result, new residents lack theoretical and practical ultrasound abilities that are critical in everyday clinical practice. In order to improve this, we created and implemented a complete ultrasound curriculum for all medical students throughout their internship year that focuses on hands-on abilities in ultrasound imaging. Methods: We used Kern's six-step model of curricular development comprising (1) problem identification and general needs assessment, (2) needs assessment of the targeted learners, (3) goals and objectives, (4) educational strategies, (5) implementation, and (6) evaluation and feedback by board-certified ultrasound experts. A two rounds Delphi process with multilevel, self-completed questionnaires and individual using a 9-point Likert scale and free text comments was used to identify learning objectives and reach agreement on the content of the curriculum. Results: The curriculum developed is aimed at students with no or little experience in their internship year and will be taught as part of their weekly-based internship training courses consisting of 2 hours of theory and 3 hours of practical training. The training will be conducted within a modular framework focusing on the key requirements of POCUS with increasing levels of complexity in accordance with the recommendations of the German Society for Ultrasound in Medicine (DEGUM), the European Federation of Societies for ultrasound in Medicine and Biology (EFSUMB) and the World Federation for ultrasound in Medicine and Biology (WFUMB). A longitudinal e-learning system will be implemented in addition to the practical and theoretical teaching units to track and examine the progress of the students. Conclusion: Early integration of ultrasound training into medical education as part of a structured and standardized broad ultrasound curriculum enables medical students to acquire basic skills and apply them practically. Fundamental scanning skills are acquired by hands-on exercises in small, supervised groups as part of BI-POCUS. BI-POCUS therefore provides an excellent opportunity to improve the clinical skills of future physicians. More research is needed to analyze the learning outcomes for medical students and the improvement of the patient's outcome by establishing such an ultrasound curriculum.

Updates on the diagnosis and monitoring of giant cell arteritis.

This mini-review offers a critical appraisal of the currently employed imaging or histopathological tools to diagnose and monitor giant cell arteritis (GCA). An overview of the most updated evidence and current application of color duplex ultrasonography (US), temporal artery biopsy (TAB), 18-fluorodeoxyglucose [18F] FDG-PET/CT, magnetic resonance imaging, and computed tomography angiography is provided. The main limitations of each tool, and the most relevant research developments are discussed. The review highlights the complementary value of the available modalities to ensure a correct diagnosis of GCA, and to provide valuable prognostic information. Novel evidence is accumulating to support the role of imaging, and particularly US, as a monitoring tool for the disease, opening new perspectives for the future management of large vessel vasculitis.