Ultrasound ability in early diagnosis of metatarsal stress fractures.

Stress fractures are common in young and active individuals, associated with aggressive or repetitive physical activity and their early detection is fundamental to optimise patient care, decrease complications and avoid unnecessary exams. Currently, magnetic resonance imaging is the standard of care for detecting these lesions. Recently, ultrasound has been getting an increasing interest for the detection of stress fractures. In this article, we describe a clinical case that involved a second metatarsal stress fracture diagnosed by ultrasound and review the literature regarding the use of ultrasound in the diagnosis of stress fractures, particularly of the metatarsals.

Cancer-associated myositis before and after the COVID-19 pandemic onset: a changing trend.

OBJECTIVES: During the COVID-19 pandemic, there was a significant impact on the management of non-COVID-19 related diseases, potentially increasing the incidence of paraneoplastic syndromes such as cancer-associated myositis (CAM).The aim of this study is to determine the incidence of CAM in our cohort before and after the COVID-19 pandemic onset. METHODS: We included patients with idiopathic inflammatory myopathy (IIM), diagnosed between June 2016 and June 2023. The patients were divided into two groups according to the date of IIM diagnosis. RESULTS: We included 132 patients; 65.1% (n=86) were diagnosed prior to and 34.9% (n=46) after the COVID-19 pandemic. The most common IIM was dermatomyositis (DM) before and after the COVID-19 pandemic onset (p=0.750). The most frequent myositis-specific antibody (MSA) before the COVID-19 pandemic was anti-Mi2 (15.1%). After the COVID-19 pandemic onset, anti-TIF1γ was the most common MSA (21.7%), with a significantly higher relative prevalence (p=0.006). The incidence of CAM was significantly higher after the COVID-19 pandemic onset (11 vs. 3 new cases, p<0.002). Patients with CAM more frequently had anti-TIF1γ-positivity (p<0.001) and a diagnosis after the pandemic (p=0.001) than non-CAM-IIM patients. No significant differences were found regarding vaccination status or previous COVID-19 infection in CAM and non-CAM-IIM patients. Diagnosis after the COVID-19 pandemic was an independent predictor of CAM among IIM patients (OR 0.012, 95% CI 0.000-0.400, p=0.013), regardless of age, sex or previous COVID-19 infection. CONCLUSIONS: There was a significant increase in the incidence of CAM after the COVID-19 pandemic. IIM diagnosis after the COVID-19 pandemic was an independent predictor of CAM.

Ultrasound exploration of the elbow: A user-friendly approach.

Ultrasound is a strong diagnostic and therapeutic tool for the elbow joint. Existing guidelines and protocols list relevant structures to be scanned but lack some logical connection and intermediate exploration manoeuvres to link each step, which we consider crucial from an operator's perspective that aims to be efficient in regular clinical practice. We present thirteen steps that are described in detail and accompanied by forty-seven ultrasound images, logically linked in what we believe is the best balance between detail and a real-world applicable protocol to perform an ultrasound of the elbow joint.

Ultrasound features of a pulley strain in a sport climber: a discussion based on a case report.

Ruptures of the annular pulleys of the finger flexor tendons are not common in the general population. In sport climbing, these structures can be abnormally stressed, mainly because of the so-called crimped position, an extreme flexion of the proximal interphalangeal joint, levering an abnormal tension by flexor tendons. Complete pulley tears manifest with explicit pain and an inability, but strains or minor tears might only be perceived by individuals like professional climbers, since they can bring total disability to crucial grip positions. Complete tears of one or more pulleys have already been characterized by ultrasound and magnetic resonance, but no imaging features were described for strains or smaller partial tears. We describe the case of a climber with symptoms of an A2-pulley injury, in whom ultrasound imaging revealed reversible features of fusiform thickening and hypoechogenicity, which resemble the strains that we find in similar structures like tendons and other ligaments.

Safety of intra-articular glucocorticoid injections - state of the art.

Intra-articular glucocorticoid injection (IAGCI) is frequently used to treat joint pain and inflammation. While its efficacy has been extensively studied, there are not as many detailed descriptions regarding safety. This review aimed to describe the immediate-, short- and long-term complications of IAGCI and their predictors. Most studies mainly report mild and self-limited adverse events with an incidence similar to placebo. However, the reported incidences vary significantly and are mostly inferred from retrospective data. Septic arthritis is the most feared adverse event due to its association with high mortality. Other short-term local complications include injection site pain, post-injection flare, skin hypopigmentation and atrophy, and tendon rupture. Systemic side effects are common, including vasovagal reactions, flushing, increased appetite and mood changes, hyperglycemia in diabetic patients, and bleeding in high-risk patients. Few predictors of complications have been systematically evaluated. However, male gender, advanced age, and pre-existing joint disease have been suggested in retrospective studies to correlate with infection risk. Overall, in most studies, only severe adverse event rates are reported, with no systematic prospective evaluations of safety and no report of predictors of complications. Therefore, since IAGCI is a routinely used treatment, more detailed knowledge of adverse events and complications is warranted.

Ultrasound halo sign as a potential monitoring tool for patients with giant cell arteritis: a prospective analysis.

OBJECTIVES: To assess the sensitivity to change of ultrasound halo features and their association with disease activity and glucocorticoid (GC) treatment in patients with newly diagnosed giant cell arteritis (GCA). METHODS: Prospective study of patients with ultrasound-confirmed GCA who underwent serial ultrasound assessments of the temporal artery (TA) and axillary artery (AX) at fixed time points. The number of segments with halo and maximum halo intima-media thickness (IMT) was recorded. Time points in which >80% of patients were assessed were considered for analysis. Halo features at disease presentation and first relapse were compared. RESULTS: 49 patients were assessed at 354 visits. Halo sensitivity to change was assessed at weeks 1, 3, 6, 12 and 24 and showed a significant standardised mean difference between all time points and baseline for the TA halo features but only after week 6 for the AX halo features. The number of TA segments with halo and sum and maximum TA halo IMT showed a significant correlation with erythrocyte sedimentation rate (0.41, 0.44 and 0.48), C reactive protein (0.34, 0.39 and 0.41), Birmingham Vasculitis Activity Score (0.29, 0.36 and 0.35) and GC cumulative dose (-0.34, -0.37 and -0.32); no significant correlation was found for the AX halo features. Halo sign was present in 94% of first disease relapses but with a lower mean number of segments with halo and sum of halo IMT compared with disease onset (2.93±1.59 mm vs 4.85±1.51 mm, p=0.0012; 2.01±1.13 mm vs 4.49±1.95 mm, p=0.0012). CONCLUSIONS: Ultrasound is a useful imaging tool to assess disease activity and response to treatment in patients with GCA.

Ultrasound-Guided Synovial Biopsy: A Review.

Ultrasound-guided synovial biopsy is a safe, well-tolerated, and effective method to collect good-quality synovial tissue from all types of joints for clinical and research purposes. Although synovial biopsy cannot be used to distinguish between types of inflammatory rheumatic disease, analysis of synovial tissue has led to remarkable advances in the understanding of the pathobiology of rheumatoid arthritis and other inflammatory rheumatic diseases. Synovitis is the hallmark of these diseases; hence, accessing the core of the pathological process, synovial tissue, provides an opportunity to gather information with potential diagnostic and prognostic utility.

Musculoskeletal ultrasound among rheumatologists in Portugal: state of practice and training.

Over the last years, musculoskeletal ultrasound (MSUS) has been increasingly integrated by rheumatologists into clinical practice. Nowadays, it is considered an important imaging modality for the diagnosis, monitoring, and prognosis of various rheumatic diseases, along with its role in the guidance of interventional procedures. Formal training is needed to ensure a skilled and safe MSUS practice. Data regarding the use of MSUS by Portuguese rheumatologists is, however, lacking. Herein, we present a study on the current state of practice and training of MSUS in Portugal.

Rheumatology practice amidst the COVID-19 pandemic: a pragmatic view.

The coronavirus disease 2019 (COVID-19) pandemic has come with many challenges for healthcare providers and patients alike. In addition to the direct burden it has placed on societies and health systems, it had a significant impact in the care of patients with chronic diseases, as healthcare resources were deployed to fight the crisis, and major travel and social restrictions were adopted. In the field of rheumatology, this has required notable efforts from departments and clinicians to adapt to the novel status quo and assure the follow-up of patients with rheumatic and musculoskeletal diseases. In the present viewpoint, we provide a practical approach to tackle this reality. Key measures include setting up preventive team management strategies, optimising communication with patients and reorganising patient care in all its dimensions. We then anticipate the nuances of rheumatology practice as restrictive measures are progressively lifted, while an effective vaccine is still pending. This includes the need to reimpose the same strategy as further waves unfold. Finally, we look ahead and address the lessons we can incorporate into post-COVID-19 rheumatology.

Efficacy, Safety, and Sample Quality of Ultrasound-Guided Synovial Needle Biopsy in Clinical Practice and Research: A Prospective Observational Study.

OBJECTIVE: To study the efficacy, tolerability, safety, and sampling variation of ultrasound (US)-guided synovial biopsies performed in clinical practice and research. METHODS: We included all patients who had a US-guided synovial needle biopsy from November 2013 to January 2018. Patients were evaluated for procedure safety and tolerability. Usefulness of synovial biopsy was considered based on contribution for achieving the proposed aims. We analyzed samples for presence and quality of synovial tissue, synovitis score/grade, and pathotype. Variation across patients, samples, section levels, and sampling order was assessed. RESULTS: A total of 64 US-guided synovial biopsies were performed (n = 52 in clinical practice, n = 12 in research). Patient tolerability (70% no/mild discomfort) was remarkably high. There was no significant aggravation of symptoms or US synovitis in the biopsied joint. Procedures were overall safe, with few minor, 2 moderate, and no major adverse events. Usefulness of US-guided synovial biopsies was high, both in clinical practice (37% direct diagnostic impact, 100% positive/95% negative predictive values for infection) and in research (92% success). Synovial tissue was retrieved in 88% of biopsies, with a median of 75% gradable samples. There was significant variation in sample quality and synovitis features across patients and samples, but not between different section levels. Samples collected later in the procedure had a lower frequency of synovial tissue and were poorly concordant in pathotype with those collected earlier. CONCLUSION: US-guided synovial needle biopsy is an effective, safe, and well-tolerated means to collect good quality synovial tissue for clinical and research purposes. Samples collected for different aims should be retrieved in parallel, rather than sequentially.

Portuguese recommendations for the use of ultrasound in rheumatology.

INTRODUCTION: Ultrasound (US) is a relatively cheap, easily available and reliable method to improve the care of rheumatic patients. However, its use in rheumatology practice is very heterogeneous and needs to be standardized. OBJECTIVES: To develop recommendations for the use of US in rheumatic diseases endorsed by the Portuguese Society of Rheumatology. METHODS: A systematic literature review of the available recommendations on the use of ultrasound in rheumatic diseases was performed and presented in a Portuguese Society of Rheumatology meeting to a subgroup of rheumatologists and rheumatology trainees with special interest in the subject. The most important topics to be addressed were selected and assigned to subgroups for literature review and draft recommendations. Following an iterative process of consensus, the final recommendations were developed, and their level of agreement voted anonymously online. A recommendation was approved when the average level of agreement was ≥ 7.5 in a 10-point Likert scale. RESULTS: Fourteen recommendations were produced regarding nine rheumatology topics: rheumatoid arthritis, spondyloarthritis, connective tissue diseases, polymyalgia rheumatica, vasculitis, crystal-deposition diseases, soft tissue rheumatism, osteoarthritis and ultrasound-guided procedures. CONCLUSION: We developed an up-to-date guidance in the form of recommendations for the use of US in nine different areas of rheumatology. As ultrasound is an important imaging modality with increasing use in the rheumatology setting, and there are frequent technological advances in the ultrasound machines and probes, in parallel with continuous associated research, these recommendations should be regularly updated.

Reevaluating the initial impact of John Broadus Watson on American psychology: The necessity of comparative parameters.

In recent decades, various studies have challenged the traditional view that John Broadus Watson's Behaviorist Manifesto prompted a psychological revolution. However, methodological hindrances underlie all these attempts to evaluate the impact of Watson's study, such as the absence of comparative parameters. This article remedies this problem by conducting a comparative citation analysis involving Watson and eight other representative psychologists of the time: J. R. Angell, H. Carr, J. M. Cattell, J. Dewey, G. S. Hall, W. James, E. L. Thorndike, and E. B. Titchener. Eight important American journals were scrutinized for the period between 1903 and 1923, a decade before and a decade after the publication of Watson's Manifesto. The results suggest that even if Watson's study cannot be taken as revolutionary, it had an impact between 1914 and 1923 that was close to Dewey's, Titchener's, and Thorndike's and higher than Angell's, Carr's, Cattell's, and Hall's, although distant from James's. Finally, some methodological implications of this study are discussed.

A low fermentable oligo-di-mono-saccharides and polyols (FODMAP) diet is a balanced therapy for fibromyalgia with nutritional and symptomatic benefits

INTRODUCTION: Fibromyalgia is a chronic rheumatic disease producing widespread pain, associated to a major comorbidity -irritable bowel syndrome. Low FODMAPS diet (low fermentable oligo-di-mono-saccharides and polyols diet) has been effective in controlling irritable bowel syndrome symptoms. Overweight is an aggravating factor for fibromyalgia. We studied effects of low fermentable oligo-di-mono-saccharides and polyols diets on fibromyalgia symptoms and weight status. METHODS: A longitudinal study was performed on 38 fibromyalgia patients using a four-week, repeated assessment as follow: M1 = first assessments/presentation of individual low fermentable oligo-di-mono-saccharides and polyols diet; M2 = second assessments/reintroduction of FODMAPs; M3 = final assessments/nutritional counselling. The assessment instruments applied were: Fibromyalgia Survey Questionnaire (FSQ); Severity Score System (IBS-SSS); visual analogic scale (VAS). Body mass-index/composition and waist circumference (WC) were also measured. Daily macro-micronutrients and FODMAP intake were quantified at each moment of the study. RESULTS: The studied cohort was 37% overweight, 34% obese (average body mass-index 27.4 ± 4.6; excess fat mass 39.4 ± 7%). Weight, body mass-index and waist circumference decreased significantly (p < 0.01) with low fermentable oligo-di-mono-saccharides and polyols diet, but no significant effect on body composition was observed. All fibromyalgiasymptoms, including somatic pain, declined significantly post-LFD (p < 0.01); as well for severity of fibromyalgia [Fibromyalgia survey questionnaire: M1 = 21.8; M2 = 16.9; M3 = 17.0 (p < 0.01)]. The intake of essential nutrients (fiber, calcium, magnesium and vitamin D) showed no significant difference. The significant reduction in FODMAP intake (M1 = 24.4 g; M2 = 2.6g; p < 0.01) reflected the "Diet adherence" (85%). "Satisfaction with improvement of symptoms" (76%), showed correlating with "diet adherence" (r = 0.65; p < 0.01). CONCLUSIONS: Results are highly encouraging, showing low fermentable oligo-di-mono-saccharides and polyols diets as a nutritionally balanced approach, contributing to weight loss and reducing the severity of FM fibromyalgiasymptoms.

O impacto da obra de J. B. Watson na psicologia norte-americana: Alguns parâmetros de comparação / The impact of J. B. Watson's work on American Psychology: Some comparison parameters / El impacto de la obra de J. B. Watson en la psicología norteamericana: Algunos parámetros de comparación

O impacto da obra de J. B. Watson tem sido explorado na historiografia da psicologia. Neste âmbito, destacam-se estudos que utilizam como método a análise bibliométrica. Tais pesquisas, no entanto, não utilizam parâmetros comparativos que possam indicar de forma mais precisa o grau de impacto daquela obra. O presente estudo busca preencher tal lacuna por meio de uma análise bibliométrica comparativa das referências às obras de Watson e outros três relevantes psicólogos do período: Edward B. Titchener, Edward L. Thorndike e William James. A pesquisa foi realizada em cinco importantes periódicos norte-americanos da área, entre os anos 1903 e 1923 ­ uma década antes e uma década após a publicação do Manifesto Behaviorista. Os resultados permitem concluir que, embora não possa ser tomada propriamente como um marco revolucionário, a obra de Watson teve, na década posterior à publicação do Manifesto Behaviorista (1914-1923), um impacto próximo ao de Titchener e maior do que o de Thorndike, ainda que distante da influência exercida por James. (AU)

The impact of J. B. Watson's work has been explored in the historiography of psychology. In this context, bibliometric analysis has been often used as a methodological strategy. However, such studies do not present comparative parameters that may indicate more precisely its degree of impact. The goal of this paper is to fill this gap, by making a comparative bibliometric analysis of citations to Watson and three other representative psychologists at that time: Edward B. Titchener, Edward L. Thorndike and William James. Five important American journals were scrutinized for the period between 1903 and 1923, a decade before and a decade after the publication of Watson's Behaviorist Manifesto. The results suggest that, even if it cannot be taken as a revolutionary milestone, Watson's work had, in the first decade after the publication of the Behaviorist Manifesto (1914-1923), an impact similar to Titchener's and higher than Thorndike's, although still distant from James's influence. (AU)

El impacto de la obra de J. B. Watson ha sido investigado en la historiografía de la psicología. En este contexto, se destacan los estudios que utilizan el análisis bibliométrico como método. Sin embargo, estos estudios no utilizan parámetros comparativos que pueden indicar con mejor precisión el grado de impacto del autor. El objetivo de este estudio es llenar este vacío por medio de un análisis bibliométrico comparativo de las citas de las obras de Watson y de otros tres sicólogos importantes en este período: Edward B. Titchener, Edward Thorndike y William James. La búsqueda se realizó en cinco periódicos norteamericanos importantes entre los años 1903 y 1923, una década antes y una década después de la publicación del Manifiesto Conductista de Watson. Los resultados permiten concluir que, aún que no pueda ser tomada propiamente como un hito revolucionario, la obra de Watson tuvo, en la década después de la publicación del Manifiesto Conductista (1914-1923), un impacto próximo al de Titchener y más alto que el de Thorndike, aún que muy distante de la influencia ejercida por James. (AU)

A low fermentable oligo-di-mono saccharides and polyols (FODMAP) diet reduced pain and improved daily life in fibromyalgia patients.

BACKGROUND AND AIMS: Fibromyalgia (FM) is a chronic, rheumatic disease characterized by widespread myofascial pain, of unknown aetiology, having a major impact on quality of life (QOL). Available pharmacotherapy for FM is marginally effective. FM is associated with co-morbidities of gastrointestinal (GI) disorders and Irritable Bowel Syndrome (IBS). There is growing evidence that diets low in FODMAPs, "fermentable oligo-, di- or mono-saccharides and polyols" [Low FODMAP Diet (LFD)], are effective in treating IBS. The aim of this pilot study was to examine the effects of LFDs on symptoms of FM, especially with regard to pain, QOL and GI disorders. METHODS: A longitudinal study using LFD intervention was performed on 38, 51±10 year-old, female patients diagnosed with FM for an average of 10 years, based on ACR (American College of Rheumatology) 2010 criteria. The study was conducted from January through May, 2015, using a four-week, repeated-assessment model, as follows: Moment 0 - introduction of the protocol to participants; Moment 1 - first assessment and delivery of individual LFD dietary plans; Moment 2 - second assessment and reintroduction of FODMAPs; Moment 3 - last assessment and final nutritional counselling. Assessment tools used were the following: RFIQ (Revised Fibromyalgia Impact Questionnaire), FSQ (Fibromyalgia Survey Questionnaire), IBS-SSS (Severity Score System), EQ-5D (Euro-QOL quality of life instrument), and VAS (Visual Analogue Scale). Daily consumption of FODMAPs was quantified based on published food content analyses. Statistical analyses included ANOVA, non-parametric Friedman, t-student and Chi-square tests, using SPSS 22 software. RESULTS: The mean scores of the 38 participants at the beginning of the study were: FSQ (severity of FM, 0-31) - 22±4.4; RFIQ (0-100) - 65±17; IBS-SSS (0-500) - 275±101; and EQ-5D (0-100) - 48±19. Mean adherence to dietary regimens was 86%, confirmed by significant difference in FODMAP intakes (25g/day vs. 2.5g/day; p<0.01). Comparisons between the three moments of assessment showed significant (p<0.01) declines in scores in VAS, FSQ, and RFIQ scores, in all domains measured. An important improvement was observed with a reduction in the severity of GI symptoms, with 50% reduction in IBS scores to 138±117, following LFD therapy. A significant correlation (r=0.36; p<0.05) was found between improvements in FM impact (declined scores) and gastrointestinal scores. There was also a significant correlation (r=0.65; p<0.01) between "satisfaction with improvement" after introduction of LFDs and "diet adherence", with satisfaction of the diet achieving 77% among participants. A significant difference was observed between patients who improved as compared to those that did not improve (Chi-square χ2=6.16; p<.05), showing that the probability of improvement, depends on the severity of the RFIQ score. CONCLUSIONS: Implementation of diet therapy involving FODMAP restrictions, in this cohort of FM patients, resulted in a significant reduction in GI disorders and FM symptoms, including pain scores. These results need to be extended in future larger studies on dietary therapy for treatment of FM. IMPLICATIONS: According to current scientific knowledge, these are the first relevant results found in an intervention with LFD therapy in FM and must be reproduced looking for a future dietetic approach in FM.