Clinical, Laboratory, and Imaging Features Between Men and Women With Axial Spondyloarthritis in a Specialized Center in Argentina.

OBJECTIVES: The aims were to estimate the frequency of axial spondyloarthritis (axSpA) in women and to analyze the clinical, laboratory, and imaging differences with respect to men at the time of diagnosis. METHODS: Consecutive patients older than 18 years with a diagnosis of axSpA admitted to the "Reumacheck" SpA program were included between 2017 and 2022. At baseline, all patients underwent clinical assessment, laboratory tests including C-reactive protein and human leukocyte antigen B27, and imaging (plain radiography and magnetic resonance imaging of sacroiliac joints, and ultrasound of heel entheses). All evaluators were blinded to the results of the other evaluations. RESULTS: One hundred sixteen patients with a diagnosis of axSpA were included. The frequency at diagnosis in women was 61.55%. In the univariate analysis, the significant differences between women and men at diagnosis of axSpA were good response to nonsteroidal anti-inflammatory drugs, elevated C-reactive protein, New York Criteria (+), enthesis ultrasound (+), years of education, number of swollen joints, erythrosedimentation rate, and the very low frequency of bone bridges in the magnetic resonance imaging of the sacroiliac joints. In the logistic regression analysis, the dependent variable was "men," and the only feature that was independently associated was having radiographic compromise according to the New York criteria (odds ratio, 2.6). CONCLUSIONS: The frequency of axSpA in women was 61.55%; clinical, laboratory, and imaging differences were observed. Women experienced less radiographic compromise.

Difficult to treat rheumatoid arthritis in a comprehensive evaluation program: frequency according to different objective evaluations.

Difficult-to-treat Rheumatoid Arthritis (RA-D2T) is a condition in which patients do not achieve the treatment target despite multiple advanced therapies, more others features. Aims: to estimate the frequency of RA-D2T in a cohort comprehensively evaluated (clinical, serology, imaging), and to analyze the associated characteristics. In a second part, the frequency of RA-D2T after 1 year of follow-up, analyzing the predictive variables at baseline and therapeutic behavior. Cross-sectional and prospective study, consecutive RA were included, then those who completed the one-year follow-up were evaluated. RA-D2T frequency was estimated (DAS28-CDAI-SDAI-Ultrasonography (US)-HAQ) at baseline and 1 year. The variables associated and those baseline predictive characteristics of D2T at 1 year, and their independent association by logistic regression were analyzed. The treatment approach was described. Two hundred seventy-six patients completed the evaluation, frequency of RA-D2T (all scores): 27.5%. Anemia, RF high titers and higher HAQ score were independent associated. At year, 125 competed follow-up. RA-D2T (all scores): 33%, D2T-US and D2T-HAQ were 14 and 18.4% (p 0.001). Predictive baseline characteristics D2T (all score): ACPA + (OR: 13.7) and X-ray erosion (OR: 2.9). D2T-US: X-ray erosion (OR: 19.7). Conventional DMARDs, corticosteroids and TNF-blockers were the drugs most used by D2T patients, Jaki were the most used in the switch. We showed different frequencies of RA-D2T according to different objective parameters (scores, images) and their association with patient characteristics. In turn, predictive variables (erosions-ACPA) for RA-D2T at 1 year were analyzed. It was shown that the Jaki were the most used drug in these patients.

The Role of HLA-B27 in Argentinian Axial Spondyloarthritis Patients.

BACKGROUND: The prevalence of human leukocyte antigen B27 (HLA-B27) is variable around the world. Our objectives were to estimate the frequency of HLA-B27 in an Argentinian cohort of axial spondyloarthritis (axSpA), to evaluate the differences between HLA-B27-positive and HLA-B27-negative patients, and to analyze its performance as a diagnostic biomarker. METHODS: Observational study including patients older than 18 years, with axSpA diagnosis assessed in a fast track program (Reuma-Check SpA). All patients underwent the following: blood tests, HLA-B27, sacroiliac images, and enthesitis ultrasound. Sociodemographic data and SpA symptoms were also collected. The clinical assessor was blinded to complementary studies. For the sensitivity and specificity analysis, patients with chronic low back pain without axSpA who performed the same circuit in the same period were used as control, paired 1:1 (sex and age). RESULTS: One hundred fifty patients were included, 75 axSpA and 75 controls. The frequency of HLA-B27 was 43% (95% confidence interval [CI], 30-53). The differences between HLA-B27-positive and HLA-B27-negative patients were observed in age of low back pain onset (36 vs 46 years), BASFI (Bath Ankylosing Spondylitis Functional Index) (4 vs 5), and extra-articular SpA features such as uveitis and inflammatory bowel disease (29% vs 50%). When this frequency was compared (low back pain control group), the difference was 43% versus 9% (odds ratio, 7.7; 95% CI, 2.8-24), and HLA-B27 had a sensitivity of 43%, specificity of 91%, positive predictive value of 85%, negative predictive value of 58%, and likelihood ratio of 4.9 (95% CI, 3-8). CONCLUSIONS: The frequency of HLA-B27 in axSpA was 43%; positive patients had an earlier age of onset (36), a higher BASFI, and more SpA features. For the diagnosis of SpA, HLA-B27 had a good specificity but low sensitivity.

"Reuma-Check": Performance of a Comprehensive Fast-Track Program for the Diagnosis of Axial Spondyloarthritis in South America.

OBJECTIVES: The aim of this study was to evaluate the performance of a comprehensive diagnosis program called "Reuma-check" for the diagnosis of axial spondyloarthritis (SpA) in patients with low back pain (LBP). METHODS: This is a cross-sectional study. Patients with LBP aged 18 years or older were preselected, and those with at least 1 SpA feature completed the circuit. They were referred after 2 strategies: education for orthopedists and a campaign on social networks. All patients underwent a clinical evaluation, laboratory testing, and imaging (including human leukocyte antigen B27 evaluation and magnetic resonance imaging). The diagnosis of axial SpA was established by an expert rheumatologist opinion. Time from onset of symptoms to "Reuma-check," time from patient referral to admission of the checkup, and time from "Reuma-check" to diagnosis were evaluated. RESULTS: A total of 175 of 246 patients were included, most of them came from the social media campaign (55%). Seventy-five (43%) of 175 patients were diagnosed as axial SpA. The median time from referral (or self-referral) to access to the program was 1.3 months. The median time from symptoms onset to access to the program was 31.7 months, and the median time from the performance of "Reuma-check" to final diagnosis was 2 weeks. Features associated with a diagnosis of axial SpA were as follows: inflammatory LBP (odds ratio [OR], 6.64; 95% confidence interval [CI], 1.6-28), clinical enthesopathy (OR, 4.56; 95% CI, 1.1-18.4), positive human leukocyte antigen B27 (OR, 23.02; 95% CI, 3.5-58), and positive magnetic resonance imaging (OR, 14.34; 95% CI, 3.5-58). CONCLUSIONS: "Reuma-check" allowed a high frequency of axial SpA diagnosis and improved access to rapid diagnosis, shortening the time from referral to diagnosis with a shorter acquisition time for the ancillary studies. Patients with a final diagnosis of axial SpA presented distinctive features.

Reliability of OMERACT ultrasound elementary lesions in gout: results from a multicenter exercise.

The aim of this study was to evaluate the reliability of the outcome measures in rheumatology (OMERACT) definitions for ultrasound (US) elementary lesions in gout through an image reading exercise. Images from patients with gout (static images and videos) were collected. As an initial step, we carried out a image reading exercise within the experts of the Pan-American League of Associations for Rheumatology (PANLAR) US Study Group (n = 16). The following step consisted in a web-based exercise with the participation of larger number of sonographers (n = 63) from different centers. Images were rated evaluating the presence/absence of any US elementary lesion. Inter- and intra-reader reliabilities were analyzed using kappa coefficients. Participants were stratified according to their level of experience. In the first exercise, inter-reader kappa values were 0.45 for aggregates, 0.57 for tophus, 0.69 for erosions, and 0.90 for double contour (DC). Intra-reader kappa values were 0.86, 0.76, 0.80, and 0.90, respectively. The web-based exercise showed inter-reader kappa values for aggregates, tophus, erosions, and DC of 0.42, 0.49, 0.69, and 0.79, respectively. The intra-reader kappa values were 0.62, 0.69, 0.77, and 0.85, respectively. Reliability was not influenced by the sonographer's level of experience. The reliability of the new OMERACT US definitions for elementary lesions in gout ranged from moderate to excellent, depending on the type of lesion.

Does a Simplified 6-Joint Ultrasound Index Correlate Well Enough With the 28-Joint Disease Activity Score to Be Used in Clinical Practice?

OBJECTIVE: Ultrasound (US) has become an important tool in the management of rheumatoid arthritis (RA) but it is time consuming in clinical practice. We compared 3 US indices (with different numbers of joints) with disease activity measured by the 28-Joint Disease Activity Score (DAS28) in order to find the most parsimonious index still useful in clinical practice. METHODS: Sixty consecutive RA patients were included. The DAS28 score was calculated by the attending rheumatologist, and later in the day, they underwent US examination by another rheumatologist trained in US (bilateral gray-scale and power Doppler examination of the wrist and metacarpophalangeal and proximal interphalangeal joints). Three different US indices were constructed: index A (22 joints), index B (10 joints), and index C (6 joints). RESULTS: All 3 US indices were significantly higher in patients with active disease versus inactive disease (P < 0.05 for all 3). Ultrasound index C showed the best correlation with DAS28 (rho = 0.5020, P < 0.0001) and a very good discriminative value for moderate to high disease activity (DAS28 >3.2) and for absence of remission (DAS28 >2.6) (areas under receiver operating characteristic curve = 0.75 and 0.80, respectively). A cutoff value of 3 in US index C showed sensitivity of 88.89% and specificity of 66.67% for absence of remission. Correlation between the 3 US indices was excellent. CONCLUSIONS: A US index of 6 joints (both wrists and second and third metacarpophalangeal joints bilaterally) correlated well with disease activity measured by DAS28 and may be used to evaluate RA patients in daily practice.

General applications of ultrasound in rheumatology: why we need it in our daily practice.

Ultrasound (US) is a noninvasive imaging technique that continues to gain interest among rheumatologists because of its undoubted utility for the assessment of a wide range of abnormalities in rheumatic diseases. It also has a great potential to be used at the time of consultation as an extension of the clinical examination.Current data demonstrate that the standard clinical approach could result in an insensitive assessment of some the different aspects of the various rheumatic diseases for which US has become a feasible and effective imaging modality that allows early detection of anatomical changes, careful guidance for the aspiration and/or local treatment, and short- and long-term therapy monitoring at the joint, tendon, enthesis, nail, and skin levels. The spectrum of pathological conditions for which US plays a crucial role continues to increase over time and includes rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal-related arthropathies, connective tissue disorders, and vasculitis.It is expected that the inclusion of more longitudinal studies with a larger number of patients and more rigorous methodological approach will undoubtedly provide a better understanding of the significance of the abnormal US findings detected in order to provide the proper diagnostic and/or therapeutic approaches. In this article, we analyze the current potential applications of US in rheumatology and discuss the evidence supporting its use in the daily rheumatologic practice.

Psoriatic Arthritis: Differential Features at the Time of Clinical Presentation in a Large Cohort of Patients with Polyarthralgia.

OBJECTIVE: Most patients with psoriatic arthritis begin with cutaneous psoriasis, which is why all early detection strategies are based on screening in the dermatological consultation and referral to a rheu matologist. However, there are cases of patients who consult initially for musculoskeletal symptoms, mostly joint pain, regardless of family and/or personal history of psoriasis. This study aimed to esti mate the frequency of psoriatic arthritis in a cohort of patients who consulted for polyarthralgia and to determine the differential features, at the time of clinical presentation, in relation to both patients with final diagnosis other than psoriatic arthritis and patients with diagnosis of rheumatoid arthritis. METHODS: Consecutive patients with polyarthralgia (including arthralgia of the hands) were included. Clinical examination, laboratory tests, ultrasound with power Doppler of both hands, and radiography of both hands and feet were performed at baseline. All patients were followed up and the definitive diagnosis of psoriatic arthritis was established. RESULTS: A total of 1055 were included, 88 (8.3%) ended with diagnosis of psoriatic arthritis. Diagnosis of psoriatic arthritis was positively associated with a family history of psoriasis (odds ratio=4.14), pso riasis (odds ratio=78.94), radiographic erosions (odds ratio=5.74), and ultrasound with at least 1 joint with positive power Doppler (odds ratio=7.11). In comparison with rheumatoid arthritis patients, diagnosis of psoriatic arthritis was positively associated with psoriasis (odds ratio=433.42) and family history of psoriasis (odds ratio=41.63). On the other hand, it was negatively associated with positivity, for both rheumatoid factor (odds ratio=0.03) and anti-cyclic citrullinated peptide antibodies (odds ratio=0.06). CONCLUSION: The frequency of psoriatic arthritis was 8.3% and was associated with a personal and/or family history of psoriasis, radiographic erosions, and inflammatory involvement by Power Doppler Ultrasound (PDUS). In comparison with rheumatoid arthritis patients, psoriatic arthritis was associated with a personal and/or family history of psoriasis, while the presence of both rheumatoid factor and/ or anti-cyclic citrullinated peptide antibodies was shown to be a protective factor for the diagnosis of psoriatic arthritis.

Ultrasound tenosynovitis: A differential feature of patients with seronegative rheumatoid arthritis.

OBJECTIVE: To identify differential features between patients with seropositive and seronegative rheumatoid arthritis (RA). METHOD: Prospective cohort study, including patients who were admitted for polyarthralgia. At baseline was performed: laboratory studies, X-rays of hands and feet, ultrasound of both hands with power Doppler technique, clinical data and clinimetry. In subsequent visits the definitive diagnosis of RA was established or not. It was considered as seronegative RA when patients were negative for both RF and ACPAs. RESULTS: 746 patients were included, of which 128 (17.1%) ended with a final diagnosis of RA. Of these 128 patients, 87 (67.9%) were seropositive RA, while 41 (32%) were seronegative RA. The only feature that showed significant differences was the presence of tenosynovitis detected by ultrasound with a positive power Doppler signal, 13.7% of the patients with seropositive RA vs 41.6% of the patients with seronegative RA (p=0.0028). CONCLUSION: The only differential feature of patients with seronegative RA was the higher proportion of tenosynovitis detected by ultrasound.

The emerging role of ultrasound in detecting interstitial lung disease in patients with rheumatoid arthritis.

OBJECTIVE: To investigate the potential role of US in the detection of ILD in a cohort of patients with RA. METHODS: Patients with diagnosis of RA were consecutively enrolled. All patients underwent pulmonary examination, laboratory data, DLCO measure, chest HRCT and radiographs, and US examination. A healthy group was included as control group. US was performed according the 14-intercostal space scanning protocol using the following semiquantitative scale [0=normal (≤5 B-lines); 1=slight (≥6 and ≤15 B-lines); 2=moderate, (≤16 and ≥30 B-lines); 3=severe (≥30 B-lines)]. RESULTS: A total of 74 RA patients and 74 healthy controls were included. Thirty of 74 patients (40.5%) showed US signs of ILD with respect to the healthy controls (3 subjects, 4.1%) (P<0.001); whereas HRCT showed ILD in 27 (36.4%) of 74 patients. Among the 30 patients that showed US findings of ILD, 17 (56.6%) were asymptomatic from respiratory view-point. The sensitivity and specificity of US were 92% and 89% respectively. A positive correlation between US and HRCT findings were found (P<0.001) whereas no correlation was found with chest radiographs and DLCO findings. Positive association between US findings and DAS28-ESR, anti-CCP and RF (P<0.01 for each respectively) was found. Feasibility, represented by the mean time spent to perform the pulmonary US assessment was 7.8minutes (±SD 1.2, range 6 to 10minutes). CONCLUSIONS: Our results support the potential of US in detect accurately ILD in patients with RA and provide a rationale to consider it as a friendly screening tool to be implemented in early phases of the disease.

Inter-observer reliability of high-resolution ultrasonography in the assessment of bone erosions in patients with rheumatoid arthritis: experience of an intensive dedicated training programme.

OBJECTIVE: The present study was aimed at testing the ability of a rheumatologist without experience in ultrasound (US) who attended an intensive 4-week training programme focused on US assessing bone erosions in the hands and feet in patients with RA. METHODS: Twenty patients diagnosed with RA according to the ACR criteria were included in the study. All US examinations were performed bilaterally by two investigators (with different experience in the field of musculoskeletal US) at the following sites: the dorsal, lateral and volar aspect of the second metacarpal, ulnar and fifth metatarsal head; and the dorsal and volar aspect of the third metacarpal and second proximal heads. Each quadrant was scanning in longitudinal and transverse scans for assessing the qualitative, semiquantitative and quantitative US findings indicative of bone erosions according the OMERACT preliminary definition. RESULTS: Both κ-values and overall agreement percentages of qualitative and semiquantitative assessments showed moderate to excellent agreement between the two investigators. Similar results were obtained for the quantitative assessment with the concordance correlation coefficient value always significant. The only exception was the volar aspects, in particular those of the fifth metatarsal head. CONCLUSION: Our study suggests that after a 4-week dedicated training programme, a rheumatologist without experience in US is able to detect and score bone erosions in the hands and feet of patients with RA.

Prevalence of subclinical enthesopathy in patients with spondyloarthropathy: an ultrasound study.

BACKGROUND: Ultrasound has demonstrated to be a highly sensitive tool in the evaluation of entheses in spondyloarthropathy (SpA) patients and improves the ability of clinical examination to detect enthesopathy. OBJECTIVES: The objectives of the study were to determine the prevalence of subclinical enthesopathy in SpA patients and to evaluate the reliability of ultrasound in the detection of abnormal findings indicative of enthesopathy. METHODS: Six hundred lower-limb entheses were assessed in 60 SpA patients without known history of entheseal involvement. Sixty rheumatoid arthritis patients and 30 control subjects were included as control groups. Clinical examination and ultrasound were consecutively performed at each of the entheses to detect signs indicative of enthesopathy. Images from 20 SpA patients were stored and afterward evaluated to determine the reliability of abnormal ultrasound findings. RESULTS: Ultrasound detected a high prevalence of enthesopathy in SpA patients with respect to both rheumatoid arthritis patients and control subjects (P < 0.001 for both comparisons). In SpA patients, clinical examination detected enthesopathy in 56 (9.3%) of 600 entheses. In the remainder 544 clinically asymptomatic entheses (90.7%) (not painful and not swollen), ultrasound detected in 331 (60.8%) at least 1 ultrasound sign of enthesopathy. The intrareader and interreader agreement for all ultrasound abnormal findings was good to excellent. CONCLUSION: The present study demonstrates a higher sensitivity of ultrasound with respect to physical examination in the detection of signs indicative of enthesopathy in SpA patients with an adequate interreader and intrareader reliability. Further study is needed about the prognostic value of the ultrasound findings for predicting clinical onset of entheseal involvement.

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists.

OBJECTIVE: To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas. METHODS: A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level. RESULTS: General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions. CONCLUSION: A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.

Recognition of spondyloarthritis lesions on magnetic resonance imaging: Results of an educational intervention.

BACKGROUND: Magnetic resonance imaging (MRI) is a fundamental diagnostic tool in axial spondyloarthritis (SpA), allowing us an earlier diagnosis of the disease compared to radiography. OBJECTIVE: To compare the performance of a recognition test on SpA MRI lesions and theoretical knowledge, before and after carrying out an educational intervention (hands-on workshop). We also evaluated whether the successes in the tests were associated with the individual characteristics of the participants. METHODS: A test was carried out involving 10 questions (seven for image recognition and three for theoretical knowledge) before and after the attendance to an MRI workshop in SpA performed in different cities in Argentina. The number of correct answers was assessed before and after the workshop; good performance was defined as the achievement of 6 correct answers on average between the pre- and post-test. Participants' characteristics were collected. RESULTS: A total of 106 participants were evaluated. Average of correct answers before and after the workshop were 5.3 and 6.8, respectively (P = .0001); 65% of participants achieved good performance. Performance is not associated with the characteristics of trained physicians. CONCLUSION: MRI training workshops in SpA allow rheumatologists to improve recognition of acute inflammatory and structural lesions. The long-term effects of such training need further evaluation.

EULAR definition of "arthralgia suspicious for progression to rheumatoid arthritis" in a large cohort of patients included in a program for rapid diagnosis: role of auto-antibodies and ultrasound.

OBJECTIVES: To evaluate the performance of the European League Against Rheumatism (EULAR) definition of arthralgias suspicious for progression to RA in patients with hand arthralgias and to estimate the added value of both auto-antibodies and ultrasound (US) with power Doppler (PD). METHODS: Consecutive patients admitted for hand arthralgias to "Reuma-check" ® program were included. This program includes the following at baseline: clinical assessment, laboratory tests, US with PD of both hands, and radiography of both hands and feet. All patients were followed-up after baseline evaluation by their treating rheumatologists, and a definitive diagnosis of RA (ACR/EULAR 2010 criteria) was established or not. RESULTS: A total of 465 consecutive patients were included. During follow-up, 44 (9.4%) were diagnosed with RA. Mean of baseline EULAR features describing arthralgia suspicious for progression to RA was 4.1 in patients with final diagnosis of RA vs 2.3 in non-RA patients (p < 0.0001). The AUC for the EULAR defined features describing arthralgia suspicious for progression to RA for the final diagnosis of RA was 0.7827, while adding US with PD, rheumatoid factor (RF), and anti-cyclic citrullinated peptide antibodies (ACPA) data, the AUC was 0.9172 (p < 0.0001). In the multivariate regression logistic analysis, baseline features associated with a final diagnosis of RA were difficulty with making a fist, RF, ACPA, and US with PD. CONCLUSIONS: EULAR definition of arthralgia suspicious for progression to RA had an acceptable performance to predict the future development of RA and improves adding information of both RF, ACPA and US with PD data.Key Points• Clinically suspect arthralgia may trigger rheumatologists to monitor patients closely for an early diagnosis.• EULAR definition of arthralgia suspicious for progression to RA predicts future development of arthritis.• Auto-antibodies and ultrasound improve EULAR definition of arthralgia suspicious for progression to RA.

Performance of Ultrasonography Compared to Conventional Radiography for the Diagnosis of Osteoarthritis in Patients With Knee Pain.

Purpose: To investigate the performance of ultrasonography (US) for the detection of knee osteoarthritis (OA) in patients suffering from knee pain, compared to conventional radiographs. Methods: Cross-sectional study performed at a university teaching hospital. Consecutive patients complaining of unilateral or bilateral mechanical knee pain who signed an informed consent were included. All patients underwent simultaneously an ultrasonographic and a radiographic evaluation of the knee. Exclusion criteria were age under 18 years, prior diagnosis of knee OA, diagnosis of inflammatory arthritis, history of knee surgery or trauma, severe knee deformities, and corticosteroid injection within the last 2 months. The diagnostic properties of US for the detection of knee OA were evaluated using radiological data as the reference method. Evaluated test properties were sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and the positive and negative likelihood ratio (LR+ and LR-). Results: Three-hundred twenty-two knees (281 patients) were included. Radiographic degenerative changes were present in 56.8% (183) of the evaluated knees. Regarding the diagnostic properties of the US, the presence of either osteophytes or the compromise of the femoral hyaline cartilage had the best sensitivity to detect OA (95%), with a NPV of 92% and a LR- of 0,07, while the combined identification of osteophytes and compromise of the femoral hyaline cartilage had the best specificity (94%), with 94% PPV and a LR+ of 13. Conclusion: US demonstrated an excellent sensitivity with an adequate specificity for the detection of radiographic knee OA.

Value of Color Doppler Ultrasound Assessment of Sacroiliac Joints in Patients with Inflammatory Low Back Pain.

OBJECTIVE: To evaluate the diagnostic value of color Doppler ultrasound (CDUS) for the detection of sacroiliitis, in patients with inflammatory back pain (IBP). METHODS: Consecutive patients with IBP and suspected axial spondyloarthritis (SpA), but without a definitive diagnosis, were included. Consecutive patients with defined SpA and axial involvement were included as a control group. All patients underwent clinical evaluation, magnetic resonance imaging (MRI), and CDUS of sacroiliac joints (SIJ) within the same week. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the diagnosis of sacroiliitis by CDUS were calculated, using MRI as the gold standard. RESULTS: There were 198 SIJ evaluated in 99 patients (36 with previous SpA). There were 61 men (61.6%), with a mean age of 39.8 years (SD 11.3) and median disease duration of 24 months (IQR 12-84). At the patient level, CDUS had a sensitivity of 63% (95% CI 48.7-75.7%) and a specificity of 89% (95% CI 76-96%). The PPV was 87.2% (95% CI 72.6-95.7%) and the NPV was 66.7% (95% CI 53.3-78.3%). At joint level, CDUS had a sensitivity of 60% (95% CI 49-70%) and a specificity of 93% (95% CI 88-98%). The PPV was 83% (95% CI 78-95%) and the NPV was 43% (95% CI 33-56%). The sensitivity of CDUS for the diagnosis of axial SpA was 54% (95% CI 36.6-71.2%), specificity was 82% (95% CI 63.1-93.9%), PPV was 79% (95% CI 57.8-92.9%), and NPV was 59% (95% CI 42.1-74.4%). CONCLUSION: CDUS showed adequate diagnostic properties for detection of sacroiliitis and is a useful tool in patients with IBP.

Chronic intestinal pseudo-obstruction in patients with systemic lupus erythematosus: report of four cases.

Chronic intestinal pseudo-obstruction (CIPO), a recently recognized manifestation of systemic lupus erythematosus (SLE) with only 23 cases reported in the English literature, may appear as a complication or as the initial presentation of SLE and usually occurs during the setting of an active lupus. The pathogenic mechanism in SLE is unknown. We describe four additional cases with clinical, radiological, and manometric features of CIPO. As SLE-related CIPO usually responds to treatment with high doses of corticosteroids and/or immunosuppressive and prokinetic agents, a high level of awareness of this complication is needed to avoid unnecessary surgical intervention.

The value of power Doppler ultrasound in patients with rheumatoid arthritis in clinical remission: Reclassifying disease activity? / Valor de la ecografía con Doppler de poder en pacientes con artritis reumatoide en remisión clínica: ¿reclasificación de la actividad de la enfermedad?

OBJECTIVES: The aim of the present study was to describe the ultrasound (US) findings in patients with rheumatoid arthritis (RA) in clinical remission, and to evaluate the ability of power Doppler (PD) US to reclassify disease activity in these patients. MATERIAL AND METHODS: We included consecutive patients with RA according to 2010 American College of Rheumatology/European League Against Rheumatism criteria, who were in clinical remission by the Disease Activity Score (DAS28<2.6). Twenty joints of both hands were assessed by US. PD signal was evaluated on a semi-quantitative scale from 0 to 3. Three different US-modified DAS28 (US-DAS28) were constructed, replacing the clinical swollen joint count by the PD US joint count using PD score ≥1, ≥2 or ≥3, respectively. RESULTS: Eighty-six patients were included. Twenty-three (26.7%) patients had at least one joint with abnormal US-positive PD signal. Thirteen percent of patients were reclassified to low disease activity by applying the US-DAS28 when joints were considered active with a PD signal ≥1; 12%, when a PD signal ≥2 was considered, and 2% of the patients were reclassified when a PD score of 3 was considered. No patients were reclassified to a level of moderate or high activity applying US-DAS28. CONCLUSIONS: Although around a quarter of patients with RA in clinical remission showed PD US features indicating residual activity, only a small percentage were reclassified to a state of low activity and none to a level of moderate or high activity, applying the proposed US-DAS28.