Very low prevalence of ultrasound-detected tenosynovial abnormalities in healthy subjects throughout the age range: OMERACT ultrasound minimal disease study.

OBJECTIVES: This study aimed to determine the prevalence of ultrasound-detected tendon abnormalities in healthy subjects (HS) across the age range. METHODS: Adult HS (age 18-80 years) were recruited in 23 international Outcome Measures in Rheumatology ultrasound centres and were clinically assessed to exclude inflammatory diseases or overt osteoarthritis before undergoing a bilateral ultrasound examination of digit flexors (DFs) 1-5 and extensor carpi ulnaris (ECU) tendons to detect the presence of tenosynovial hypertrophy (TSH), tenosynovial power Doppler (TPD) and tenosynovial effusion (TEF), usually considered ultrasound signs of inflammatory diseases. A comparison cohort of patients with rheumatoid arthritis (RA) was taken from the Birmingham Early Arthritis early arthritis inception cohort. RESULTS: 939 HS and 144 patients with RA were included. The majority of HS (85%) had grade 0 for TSH, TPD and TEF in all DF and ECU tendons examined. There was a statistically significant difference in the proportion of TSH and TPD involvement between HS and subjects with RA (HS vs RA p<0.001). In HS, there was no difference in the presence of ultrasound abnormalities between age groups. CONCLUSIONS: Ultrasound-detected TSH and TPD abnormalities are rare in HS and can be regarded as markers of active inflammatory disease, especially in newly presenting RA.

Reliability assessment of the definition of ultrasound enthesitis in SpA: results of a large, multicentre, international, web-based study.

OBJECTIVES: To investigate the reliability of the OMERACT US Task Force definition of US enthesitis in SpA. METHODS: In this web exercise, based on the evaluation of 101 images and 39 clips of the main entheses of the lower limbs, the elementary components included in the OMERACT definition of US enthesitis in SpA (hypoechoic areas, entheseal thickening, power Doppler signal at the enthesis, enthesophytes/calcifications, bone erosions) were assessed by 47 rheumatologists from 37 rheumatology centres in 15 countries. Inter- and intra-observer reliability of the US components of enthesitis was calculated using Light's kappa, Cohen's kappa, Prevalence And Bias Adjusted Kappa (PABAK) and their 95% CIs. RESULTS: Bone erosions and power Doppler signal at the enthesis showed the highest overall inter-reliability [Light's kappa: 0.77 (0.76-0.78), 0.72 (0.71-0.73), respectively; PABAK: 0.86 (0.86-0.87), 0.73 (0.73-0.74), respectively], followed by enthesophytes/calcifications [Light's kappa: 0.65 (0.64-0.65), PABAK: 0.67 (0.67-0.68)]. This was moderate for entheseal thickening [Light's kappa: 0.41 (0.41-0.42), PABAK: 0.41 (0.40-0.42)], and fair for hypoechoic areas [Light's kappa: 0.37 (0.36-0.38); PABAK: 0.37 (0.37-0.38)]. A similar trend was observed in the intra-reliability exercise, although this was characterized by an overall higher degree of reliability for all US elementary components compared with the inter-observer evaluation. CONCLUSIONS: The results of this multicentre, international, web-based study show a good reliability of the OMERACT US definition of bone erosions, power Doppler signal at the enthesis and enthesophytes/calcifications. The low reliability of entheseal thickening and hypoechoic areas raises questions about the opportunity to revise the definition of these two major components for the US diagnosis of enthesitis.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies.

The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures.

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

The Diagnostic Value of MRI-Based Radiomic Analysis of Lacrimal Glands in Patients with Sjögren's Syndrome.

This study aimed to assess the effectiveness of MRI-based texture features of the lacrimal glands (LG) in augmenting the imaging differentiation between primary Sjögren's Syndrome (pSS) affected LG and healthy LG, as well as to emphasize the possible importance of radiomics in pSS early-imaging diagnosis. The MRI examinations of 23 patients diagnosed with pSS and 23 healthy controls were retrospectively included. Texture features of both LG were extracted from a coronal post-contrast T1-weighted sequence, using a dedicated software. The ability of texture features to discriminate between healthy and pSS lacrimal glands was performed through univariate, multivariate, and receiver operating characteristics analysis. Two quantitative textural analysis features, RunLengthNonUniformityNormalized (RLNonUN) and Maximum2DDiameterColumn (Max2DDC), were independent predictors of pSS-affected glands (p < 0.001). Their combined ability was able to identify pSS LG with 91.67% sensitivity and 83.33% specificity. MRI-based texture features have the potential to function as quantitative additional criteria that could increase the diagnostic accuracy of pSS-affected LG.

Shear wave elastography as a new method to identify parotid lymphoma in primary Sjögren Syndrome patients: an observational study.

Parotid non-Hodgkin lymphoma (NHL) in primary Sjögren syndrome (pSS) has no specific biomarker for diagnosis. Salivary glands ultrasound (US) is largely used, but its contribution in detecting parotid NHL has not been established. The aim of our study was to determine the added value of bidimensional shear wave elastography (2D-SWE) in pSS diagnosis and to determine its accuracy in identifying parotid NHL. Grey-scale US (GSUS) and 2D-SWE of salivary glands were performed in 35 patients with pSS and 35 healthy controls. The GSUS scores were calculated and the mean of three SWE consecutive measurements was used to appreciate the gland stiffness. SWE increase the diagnostic rate at a cut-off of 6.45 kPa (from 88.6 to 94.2%, p < 0.001) only if applied in patients with insufficient GSUS criteria for pSS diagnosis. The parotid glands with NHL (8 patients, all mucosa-associated lymphoid tissue type) had hyperechoic bands in more than half of the glandular parenchyma (in 68.75% of the glands), large hypoechoic area > 20 mm (all glands), traced gland area over 5 cm2 (all glands), parotid US score greater than 13 (in 68.75% of the glands), and high stiffness (elasticity modulus 13.9 ± 4.08 vs 6.32 ± 2.24) (all p < 0.001). These findings give high sensitivity (92.3%), specificity (100%), and positive (100%) and negative predictive values (98.3%) for NHL identification. The rest of GSUS findings did not correlate with the classic risk factors for lymphoma development (all p > 0.05). 2D-SWE had added value for pSS diagnosis in cases where GSUS aspect is normal or nonspecific. The higher stiffness of parotid NHL can be used for early diagnosis, biopsy guidance, and, possible, for treatment monitoring.

Q10 Coenzyme Supplementation can Improve Oxidative Stress Response to Exercise in Metabolic Syndrome in Rats.

Background: The metabolic syndrome leads to high morbidity and mortality. Almost all pathological states are associated with oxidative stress (OS) disorders. This study evaluates the effects of Coenzyme Q10 (CoQ10) supplementation on different lifestyles, in relation to serum and tissue OS parameters. Materials and methods: Twelve Wistar rat groups (10 rats/group) were equally divided in three types of diets: standard (St), high fat (HF), high sugar (HS); within each diet group there was one sedentary group with CoQ10 supplementation (100 mg/kg body weight), one sedentary without CoQ10, one trained group with CoQ10 and one trained group without CoQ10 supplementation. After 28 days blood samples were collected as follows: after 12 hours of fasting (T0), 1 hour postprandial (T1) and after 1 hour of exercise (T2) or sedentary postprandial time (T3). Thiol groups (SH) and malondialdehyde (MDA) were determined from serum and liver homogenate. Results: Significant changes were observed in fasting MDA for HF (p = 0.024 for training, 0.028 for CoQ10). Postprandial, OS status altered, with highest MDA in HF sedentary non-CoQ10 group (3.92 ± 0.37 vs 2.67 ± 0.41 nmol/ml in St trained CoQ10). At T2 the untrained and non-CoQ10 groups had the highest MDA levels (up to 22.3% vs T1, p < 0.001 in HF) as SH dropped (34.4% decrease vs T1, p < 0.001 in HF). At T3 high MDA levels were observed, correlated with low SH (Pearson r = -0.423 overall), irrespective of the CoQ10 supplementation. CoQ10 improved the liver OS status (MDA and SH decreased), but not the exercise, in all diets. Conclusions: CoQ10 supplementation accompanied by chronic exercise improved the OS serum profile, irrespective of the daily diet. CoQ10 lowered liver MDA and SH concentrations.

SERS-based liquid biopsy of saliva and serum from patients with Sjögren's syndrome.

In this preliminary study, we employed surface-enhanced Raman scattering (SERS) of saliva and serum samples for diagnosing Sjogren's syndrome (SjS), a systemic autoimmune disease characterized by dryness of the mouth and eyes. The saliva and serum samples from n = 29 patients with SjS and n = 21 controls were deproteinized with methanol and then the SERS spectra were acquired using silver nanoparticles synthesized by reduction with hydroxylamine hydrochloride. In the case of both saliva and serum, the SERS spectra were dominated by similar bands attributed to purine metabolites such as uric acid, xanthine, and hypoxanthine. Principal component analysis-linear discriminant analysis (PCA-LDA) models built from SERS spectra of saliva and serum yielded an overall classification accuracy of 94% and 98%, respectively. These results suggest that the SERS analysis of saliva and serum is able to capture the complex biochemical perturbations that accompany the onset of SjS, a strategy which could be translated in the future into a novel point-of-care diagnosis method. Graphical abstract.

Knee osteoarthritis grading by resonant Raman and surface-enhanced Raman scattering (SERS) analysis of synovial fluid.

In this preliminary study on synovial fluid (SF), knee osteoarthritis (OA) grading of n = 23 patients was accomplished by combining two methods: resonant Raman spectroscopy, and surface-enhanced Raman scattering (SERS) of native proteins acquired with iodide-modified silver nanoparticles and a laser emitting at 633 nm. Based on principal component analysis-linear discriminant analysis (PCA-LDA), the SERS spectra of proteins enabled the classification of low-grade and high-grade OA groups with an accuracy of 91%. Resonant Raman spectra of SF, recorded with laser excitation at 532 nm, exhibited carotenoid-associated bands that were less intense in the case of high-grade knee OA patients. Based on the resonant Raman spectra, the grading of OA patients was accomplished with an accuracy of 74%. Concatenating SERS and Raman spectral information increased the classification accuracy between the two groups to 100%. These results demonstrate the potential of Raman and SERS as a point-of-care method for aiding OA grading.

Raman spectroscopy applications in rheumatology.

Raman spectroscopy is a type of vibrational spectroscopy based on the inelastic scattering of photons, which has attracted much attention due to its potential clinical application in rheumatology. In this review, we discuss the typical spectral features of cartilage, bone, synovial fluid, and pathologic crystal deposits, as well as methods of amplifying the Raman signal of biofluids such as drop-coating deposition Raman spectroscopy. Further, applications of Raman and drop-coating deposition Raman spectroscopy in osteoarthritis are described, highlighting the clinical potential of these methods. We also discuss the role of Raman and related techniques in analyzing pathologic crystals such as monosodium urate, calcium pyrophosphate dihydrate, and hydroxyapatite. The results presented in this review demonstrate that Raman spectroscopy has grown past the stage of proof-of-concept, especially in the case of pathologies involving crystal depositions such as gout and calcium pyrophosphate deposition disease , for which the method has been validated on large number of samples. As the medical community becomes more and more aware of Raman spectroscopy, it is envisioned that it will become a standard technique in the near future.

The EFSUMB Guidelines and Recommendations for the Clinical Practice of Elastography in Non-Hepatic Applications: Update 2018.

This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.

EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis.

The increased information provided by modern imaging has led to its more extensive use. Our aim was to develop evidence-based recommendations for the use of imaging in the clinical management of the most common arthropathy, osteoarthritis (OA). A task force (including rheumatologists, radiologists, methodologists, primary care doctors and patients) from nine countries defined 10 questions on the role of imaging in OA to support a systematic literature review (SLR). Joints of interest were the knee, hip, hand and foot; imaging modalities included conventional radiography (CR), MRI, ultrasonography, CT and nuclear medicine. PubMed and EMBASE were searched. The evidence was presented to the task force who subsequently developed the recommendations. The strength of agreement for each recommendation was assessed. 17 011 references were identified from which 390 studies were included in the SLR. Seven recommendations were produced, covering the lack of need for diagnostic imaging in patients with typical symptoms; the role of imaging in differential diagnosis; the lack of benefit in monitoring when no therapeutic modification is related, though consideration is required when unexpected clinical deterioration occurs; CR as the first-choice imaging modality; consideration of how to correctly acquire images and the role of imaging in guiding local injections. Recommendations for future research were also developed based on gaps in evidence, such as the use of imaging in identifying therapeutic targets, and demonstrating the added value of imaging. These evidence-based recommendations and related research agenda provide the basis for sensible use of imaging in routine clinical assessment of people with OA.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology.

BACKGROUND: In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines. OBJECTIVES: To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology. METHODS: The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures). RESULTS: Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts. CONCLUSIONS: This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Bone mineral density, vertebral fractures and body mass index in postmenopausal women with abdominal aortic calcification.

BACKGROUND: Evidence suggest that there are connections between osteoporosis and cardiovascular diseases. OBJECTIVES: The aim of the study was to analyze the relationship between radiological measurements of abdominal aorta calcifications (AAC) and bone mineral density (BMD) in postmenopausal women. METHODS: In this cross-sectional study were included 125 postmenopausal women 50-84 years of age. BMD of the spine and hip was measured by dual energy X-ray absorptiometry (DXA). AAC were assessed by lateral radiographs of lumbar spine (L1-L4), using the antero-posterior severity score (0-24). Vertebral fractures were evaluated from T4 to L4 using Genant's semiquantitative method. RESULTS: Forty-one (32.8%) patients had osteoporosis and 61 (48.8%) had AAC with a mean score of 3.1. Postmenopausal women with AAC were older and had significantly lower femoral neck and trochanteric BMD than subjects without AAC (all p < 0.01). There were no significant differences in the frequency of fractures between subjects with AAC and those without AAC (p > 0.05). In univariate analysis, age, height, weight, femoral and trochanter BMD were significantly associated with the severity of AAC score. In multiple regression analysis, femoral neck BMD, but not lumbar spine, trochanter BMD or age, was an independent predictor of AAC. CONCLUSIONS: Reduced femoral neck BMD is negatively associated with the presence of AAC in postmenopausal women. The association between BMD and AAC seems to be age-independent, which suggests a common pathogenesis for bone loss and vascular calcifications.

Shear-Wave Elastography of the Achilles tendon: reliability analysis and impact of parameters modulating elasticity values.

PURPOSE: Shear wave elastography (SWE) has seen many advancements in Achilles tendon evaluation in recent years, yet standardization of this technique is still problematic due to the lack of knowledge regarding the optimal way to perform the examination. The purpose of this study was to evaluate the effects of ankle position, probe frequency and physical effort on the shear modulus of the Achilles tendon, but also to determine the intra and inter-observer reliability of the technique. METHODS: 37 healthy volunteers were included; SWE protocol was performed by two examiners. We analyzed the shear modulus of the tendon with the ankle in neutral, maximum dorsiflexion and maximum plantar flexion using two different high frequency probes. Afterwards, the subjects performed a brief physical exercise and SWE measurements were repeated. RESULTS: The L18-5 probe showed the highest ICC values (ICC = 0.798, 95% CI 0.660-0.880, p < 0.001) when positioned at 2 cm from the calcaneal insertion with the ankle in a neutral state. Conversely, utilizing the same L18-5 probe at 1 cm from the insertion during maximum plantar flexion of the ankle resulted in the lowest ICC (ICC = 0.422, 95% CI 0.032-0.655, p = 0.019). Significant variations in elasticity values were noted among different ankle positions and probe types, while no significant changes in elasticity were observed post-physical exercise. CONCLUSION: Ankle position and probe frequency are factors that influence elasticity values of the Achilles tendon. An ankle position between 10 and 20 degrees of plantar flexion is the most suitable for SWE evaluation. However, more research focusing on Achilles tendon SWE is essential due to the challenges encountered in standardizing this region.

Assessing forefoot bursitis in rheumatoid arthritis: a comprehensive approach with ultrasound, MRI, and baropodometry.

AIM: In rheumatoid arthritis (RA), forefoot bursitis is prevalent, with limited studies comparing ultrasonography (US) and Magnetic Resonance Imaging (MRI). This study aims to evaluate these bursae, providing a comparative analysis of US and MRI, and explore associations with demographic, disease-related factors, pain, clinical examination, and baropodometryin RA patients. MATERIAL AND METHODS: Participants with RA were recruited from the day-hospital clinic. The forefeet were assessed clinically, and the selected foot was examined by US and MRI to evaluate intermetatarsal (IMB) and submetatarsal bursitis (SMB). Baropodometry assessed plantar pressures and contact surfaces. RESULTS: Thirty-five RA patients were enrolled, 85.7% females, mean age 59.2 (11.3) years, mean body mass index (BMI) 26.5 (5.7) kg/m2, median disease duration of 36.0 (16.5-114.0) months, and 34.3% with painful forefoot. A total of 140 intermetatarsal and 175 submetatarsal spaces were evaluated. Agreement between US and MRI was high (PA=97.14%, k=0.801, p<0.001), and interobserver reliability for both modalities was excellent (US: PA=98.73%, k=0.888, p<0.001; MRI: PA=98.41%, k=0.900, p<0.001). IMB was negatively associated with disease duration (the only independent predictor) and linked to clinical signs like the opening toes sign and hammer toe deformity. SMB showed an association with BMI and erosions. Baropodometric analysis indicated no significant differences in plantar pressures for IMB, and larger contact surfaces in SMB regions. CONCLUSIONS: US and MRI are valuable tools for forefoot bursitis evaluation. IMB is associated with disease duration (negative association), the opening toes sign, and hammer toe deformity, while SMB correlates with BMI, erosions, and foot architectural deformity. Baropodometry revealed larger contact surfaces in regions with SMB.

Circulating matrix Gla protein: a potential tool to identify minor carotid stenosis with calcification in a risk population.

BACKGROUND: Carotid calcification is an independent marker for future ischemic events, which are more frequently encountered in postmenopausal women as the prevalence of type 2 diabetes mellitus (T2DM) and hypertension (HT) increases. Matrix Gla protein (MGP) is a major inhibitor of vascular calcification. Here, we report on the prospect of serum MGP to become an identifying tool for minor carotid stenosis (minCAS) with calcification in a risk population. METHODS: Based on carotid ultrasound examination, out of 72 enrolled postmenopausal women, 33 had minCAS with carotid calcification (minCAS group) and 39 were without minCAS and carotid calcification (non-minCAS group). Serum total MGP, high-sensitivity C-reactive protein (hs-CRP), bone mineral density (BMD) and carotid intima-media thickness (CIMT) were determined. RESULTS: We found significantly elevated serum MGP levels in the minCAS compared to the non-minCAS group (p < 0.05). MGP was independently associated with hs-CRP (unstandardized ß -regression coefficient = 2.6; 95 % CI 0.007 ­ 5.3; p = 0.049) and CIMT ( ß = ­ 611.3; 95 % CI ­ 1172.6 ­ ­ 49.9; p = 0.034) within the minCAS group, but not with BMD. Furthermore, significantly higher MGP levels were determined in two minCAS subgroups (one with HT or T2DM and second with both diseases) compared to a non-minCAS subgroup with HT or T2DM (p < 0.05 and p < 0.01, respectively). A threshold of 87.9 µ g/L serum MGP (area under the receiver operating characteristic = 0.72 } 0.06; 95 % CI 0.60 ­ 0.84; p = 0.001) may identify minCAS with calcification in postmenopausal women with 63 % precision. CONCLUSIONS: Higher circulating MGP levels could help identify minCAS with calcification in a relatively homogenous risk population (i.e., postmenopausal women), regardless of underlying cardiovascular risk factors.

Relationship between VKORC1 single nucleotide polymorphism 1173C>T, bone mineral density & carotid intima-media thickness.

BACKGROUND & OBJECTIVES: The effects of vitamin K-dependent proteins in bone mineralization and vascular calcification and the implication of vitamin K epoxide reductase gene (VKORC1) 1173C>T polymorphism in warfarin sensitivity are well known. The main objective of the study was to investigate the relationship between VKORC1 1173C>T polymorphism, bone mineral density (BMD), and atherosclerosis (evaluated by intima-media thickness of the carotid artery and the presence of calcified plaques) in patients suspected to have osteoporosis or osteopenia and referred for BMD determination. METHODS: VKORC1 1173C>T polymorphism was evaluated in 239 consecutive patients referred by their physicians for BMD measurement (dual energy X-ray absorptiometry at L2-L4 lumbar spine, femoral neck and total hip). Ultrasonography of the carotid arteries was performed, intima-media thickness (IMT) was measured and the presence of atherosclerotic calcified plaques was recorded. RESULTS: In the patients with osteoporosis and osteopenia there was a higher frequency of TT genotype of VKORC1 1173C>T (P=0.04). The TT genotype was significantly more frequent in the osteoporotic group compared to the osteopenic group (P=0.01). The mean age and body mass index were lower in the patients with normal BMD and TT genotype (P=0.02, P=0.03). There was no correlation between the IMT and VKORC1 1173C>T genotype but the TT genotype had a significant association with the presence of calcified atherosclerotic plaques (P=0.05). This finding was not correlated with normal or pathologic BMD. INTERPRETATION & CONCLUSIONS: VKORC1 1173C>T polymorphism (TT genotype) was associated with osteoporosis and calcified plaques in the carotid artery in patients referred for BMD measurement. Different mechanisms are probably involved in these associations. TT genotype may serve as a potential genetic marker for the risk of OP and ATS.

Factors influencing the Shear Wave Elastography evaluation of the patellar tendon.

AIM: There is no clear standardization for tendon Shear Wave Elastography (SWE), and data regarding the factors that influence the correctness of evaluation are scarce. We aimed to determine the intra- and interobserver agreement in patellar tendon SWE, and to establish the influence of various factors on elasticity values. MATERIALS AND METHODS: We recruited 37 healthy volunteers; SWE of the patellar tendon was performed by two examiners. The following factors were analyzed: probe frequency, degree of joint flexion, size of region of interest (ROI), distance of the color box from the probe footprint, utilization of coupling gel as standoff, and the effect of physical exercise on elastic modulus values. RESULTS: Highest overall interobserver [k=0.767, 95%CI (0.717-0.799), p<0.001] and intraobserver agreement [k=0.920 (0.909-0.929) for examiner 1, k=0.891 (0.875-0.905) for examiner 2] was obtained with the knee in the neutral position, using the L18-5 probe. With the knee flexed at 30º and 45º, the elasticity values were higher compared to the neutral position (p<0.001). With the probe immersed in 0.25 and 0.50 cm coupling gel, the median values were lower compared to the probe placed on the skin (p=0.001, p=0.018). The ROI dimensions and the placement of the SWE box at the level of the skin or at 0.5 cm below skin did not significantly influence the elastic modulus. After physical exercise, the elasticity values decreased in the proximal and middle portion of the tendon (p=0.002, p<0.001). CONCLUSION: The best results obtained in patellar tendon SWE were with the knee in neutral position, in the proximal or middle tendon, after 10 minutes of relaxation and with the probe placed directly on the skin with minimal pressure. The size and position of ROI do not significantly influence the examination.

The "starry night" (diffuse microcalcific myopathy) - thousands of muscle microcalcifications after 30 years of Trichinella infection detected by ultrasound.

Trichinellosis, a parasitosis transmitted through consumption of raw or undercooked meat from pigs and game animals, is responsible for a specific myositis. The calcifications of infected myocytes and larva can be detected during many years postin-fection. We present the case of a male patient with a history of severe trichinellosis with disease onset 30 years ago, presenting with generalized muscle microcalcifications detected during musculoskeletal ultrasound evaluation. The ultrasound aspect of the muscles was indeed spectacular; hence, the comparison with a "starry night".