Is the intima-media thickness of temporal and axillary arteries influenced by cardiovascular risk?

OBJECTIVES: To measure with US the intima-media thickness (IMT) of temporal (superficial, parietal and frontal branches) and axillary arteries in subjects without a diagnosis of GCA and/or PMR with different cardiovascular (CV) risk; and to assess the performance of previously proposed cut-off values for normal IMT. METHODS: Subjects ≥ 50 years without a diagnosis of GCA or PMR were included. Bilateral US of the temporal arteries, including the frontal and parietal branches, and axillary arteries was performed by two sonographers using a 10-22 MHz and 6-18 MHz probe. The following previously proposed cut-offs were considered: superficial temporal artery: 0.42 mm; frontal branch: 0.34 mm; parietal branch: 0.29 mm; axillary artery: 1.0 mm. RESULTS: A total of 808 arteries in 101 subjects were evaluated; of these, 31 (30.7%) were classified as very high CV risk, seven (6.9%) as high, 34 (33.7%) as moderate and 29 (28.7%) as low risk. Subjects with very high or high risk showed higher IMT than those with moderate or low risk in the superficial temporal arteries [0.23 (s.d. 0.07) vs 0.20 (s.d. 0.04), P < 0.01] and in the axillary arteries [0.54 (s.d. 0.17) vs 0.48 (s.d. 0.10), P = 0.002] . The IMT was higher than the reference cut-off in 13/808 (1.6%) arteries, in ≥1 artery in 10/101 subjects (10.1%). Of these 10 subjects, 8 (80%) were classified as having very high or high risk. CONCLUSION: Our results suggest that CV risk might influence the US-determined IMT of the temporal and axillary arteries in subjects without GCA. Therefore, in patients with suspected GCA, particular attention should be paid when measuring the IMT in those patients with very high/high CV risk.

Inter- and intra-observer agreement of high-resolution ultrasonography and power Doppler in assessment of joint inflammation and bone erosions in patients with rheumatoid arthritis.

To assess the inter- and intra-observer reproducibility of musculoskeletal ultrasonography among rheumatologist in detecting inflammatory and morphostructural changes in small joints of the hands in patients with rheumatoid arthritis (RA). Five members of the "Escuela de Ecografía del Colegio Mexicano de Reumatología" tested their inter- and intra-observer reliabilities in the assessment of basic sonographic findings of joint inflammation and bone erosion. Their results were compared to those obtained by a group of international experts from European League Against Rheumatism. A clinical rheumatologist evaluated eight RA patients. Five Siemens Acuson Antares ultrasound machines (7-13 MHz linear probes) were used. The OMERACT preliminary definitions of joint effusion, synovial hypertrophy, bone erosions and tenosynovitis were adopted. Inter-observer and intra-observer agreement was calculated by overall agreement and kappa statistics. Mean kappa value for joint effusion was good, 0.654 (85%); synovial hypertrophy, 0.550 (77.2%); power Doppler signal, 0.550 (82.5%); bone erosions, 0.549 (81%); and tenosynovitis, 0.500 (91.5%). Mean and overall intra-observer agreement for semiquantitative score was good for joint effusion, 0.630 (77.2%) and bone erosions, 0.605 (56.25%); and moderate to synovial hypertrophy, 0.476 (65%) and power Doppler signal, 0.471 (80%). Mean kappa value for joint effusion was 0.381 (95%), synovial hypertrophy, 0.447 (72%); power Doppler signal, 0.496 (81%); bone erosions, 0.294 (81%); and tenosynovitis, 0.030 (66%). Mean and overall inter-observer agreement for semiquantitative score was poor for joint effusion, 0.325 (57%) and bone erosions, 0.360 (43%); and moderate to synovial hypertrophy, 0.431 (55%) and power Doppler signal, 0.496 (81%). Intra-observer variability reached the highest levels of agreement. Factors related to the experience of the rheumatologist, the time spent in each examination and knowledge of the software ultrasound equipment could influence the lower level of inter-observer agreement in this study.

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.

La ultrasonografía con sondas de alta frecuencia en el estudio de la piel y la uña psoriática / The use of high-frequency ultrasound in the study of skin and psoriatic nail

Durante los últimos años, el campo de la ultrasonografía ha tenido importantes avances tecnológicos, llegando a desarrollar equipos que producen imágenes de alta calidad con poder de resolución inferior a 0.1 mm y provistos de módulos power Doppler que permiten un detallado estudio morfológico de los tejidos blandos, inclusive la piel. El objetivo de esta viñeta pictórica es demostrar los principales hallazgos ecográficos que se verifican en pacientes con psoriasis utilizando sondas de última generación y técnica power Doppler. En este estudio se tomaron imágenes de 20 pacientes con psoriasis comparándolas con la piel de 10 sujetos sanos. Los resultados muestran una evidencia pictórica de que la ultrasonografía permite un estudio detallado, sea de la uña y de la piel, en pacientes con psoriasis.

Over the last few years, continuous advances have been made in the field of ultrasonography, developing equipments providing high-quality greyscale imaging with an axial resolution power less than 0.1 mm and very sensitive power Doppler technique. This fact has opened the way to detailed imaging of the superficial tissues, including the skin. This pictorial essay shows the main sonographic findings obtainable with "last generation" high-frequency transducers and power Doppler technique in patients with psoriatic disease. Sonographic images shown were selected from an image database collected in 20 patients with definite diagnosis of psoriasis and in 10 healthy subjects. The present report provides pictorial evidence that high resolution greyscale ultrasound and power Doppler technique allow for a detailed morphostructural assessment and a sensitive blood flow evaluation at both skin and nail level in patients with psoriatic disease.

La ultrasonografía y su rol actual en la artrosis / Ultrasonography and its current role in osteoarthritis

La artrosis es un proceso crónico caracterizado por alteraciones degenerativas propias del cartílago articular y modificaciones de tipo proliferativo del tejido óseo adyacente. La producción de equipos ultrasonográficos con transductores de alta frecuencia (>15 MHz) y elevada capacidad de resolución ha constituido un paso fundamental para la consolidación progresiva de este método de imágenes en el campo de estudio de la artrosis, permitiendo una detallada visualización de las distintas estructuras anatómicas (cartílago articular, membrana sinovial y tejido óseo) involucradas en las diferentes etapas del proceso artrósico, Este potencial ofrece relevantes aplicaciones prácticas en esta patología, considerando que generalmente las expresiones clínico-radiológicas de la artrosis tienden a manifestarse con notable retraso respecto a las expresiones iniciales de condropatía. La presente revisión tiene como objetivo principal demostrar la utilidad de la US en el estudio de pacientes con artrosis mediante la ilustración de los hallazgos ecográficos más representativos de dicha entidad.

Osteoarthritis is a chronic process characterized by degenerative alterations of articular cartilage and several changes of both bone profile and synovial membrane. Leading-edge ultrasound equipments with high frequency probes (>15 MHz) and high resolution allow for quick and accurate assessment of even minimal pathological changes in patients with osteoarthritis (articular cartilage, synovial membrane and bone tissue). This fact is fundamental for the early diagnostic of this condition considering that, in general, the clinico-radiological expression of osteoarthritis usually manifest some time prior to the initial expressions of chondropathy. The principal aim of this study is to demonstrate the utility of US in the study of patients with osteoarthritis by means of visualizing the most representative echographic findings.

Ultrasonografía musculoesquelética: su papel actual en el campo de la reumatología / Musculoeskeletal ultrasound: current role in the field of the rheumatology

En los últimos años, la ultrasonografía del aparato musculoesquelético ha ido generando cada vez mayor interés en el campo de la reumatología. Con la introducción de sondas de alta frecuencia (>13 MHz) se ha logrado obtener una detallada y clara visualización de las pequeñas articulaciones y de los tejidos blandos, lo que ha permitido, no sólo detectar de forma precoz los distintos procesos patológicos articulares y/o periarticulares (y consecuentemente la posibilidad de instaurar tratamientos en forma temprana y adecuada), sino quetambién ha convertido a la ultrasonografía en una herramienta de excelente ayuda para el monitoreo de la evolución y el grado de respuesta al tratamiento en distintas enfermedades de interés reumatológico. Es importante destacar que la consolidación de este método en el campo reumatológico es relativamente reciente y con un amplio camino por recorrer. La larga curva de aprendizaje, el carácter operador-dependiente, el alto costo del equipo y el difícil acceso a determinadas áreas anatómicas debido a la presencia de barreras acústicas, representan en este momento las principales limitaciones de la ultrasonografía.

Artropatías microcristalinas: rol actual de la ultrasonografía / Crystaline arthropaties: current role of the ultrasonography

En el transcurso de los últimos años, la ultrasonografía ha generado un interés cada vez mayor en el campo de la reumatología debido a su relevante potencialidad y sus numerosas posibilidades de aplicación. La mayor parte de los estudios científicos se han orientado principalmente hacia la evaluación del potencial de la ultrasonografía en la detección precoz del proceso inflamatorio y del daño articular en pacientes con artritis reumatoidea temprana, en la evaluación de los distintos síndromes regionales dolorosos, en el estudio y monitoreo terapéutico en pacientes con artritis inflamatorias crónicas y en su utilidad como guía para la terapéutica locoregional. Son pocos los estudios que se han avocado a determinar el rol y la potencialidad de este método de imágenes en pacientes con artropatías microcristalinas. El progreso continuo de la tecnología en el campo de la ultrasonografía musculoesquelética ha generado instrumentos con la capacidad de obtener imágenes de alta resolución que contribuyen a la detección de mínimos depósitos de cristales de urato monosódico y/o de cristales de pirofosfato de calcio, no detectables en muchas ocasiones mediante la radiografía convencional. La presente revisión tiene como objetivo principal demostrar la utilidad de la ultrasonografía en el estudio de pacientes con artropatías microcristalinas mediante la ilustración de los hallazgos ecográficos más representativos de dichas entidades.

La ultrasonografía de la mano y de la muñeca / Ultrasonography of the hand and the wrist

La mano y la muñeca son estructuras anatómicas frecuentemente comprometidas por una amplia variedad de enfermedades y síndromes de interés reumatológico. La mayor parte de dichas condiciones patológicas afectan a los tejidos blandos, y su precisa caracterización resulta particularmente compleja utilizando exclusivamente el examen físico y/o radiográfico. En los años 90 la introducción de transductores con alta frecuencia (>15 MHz) dio lugar a la adquisición de imágenes de gran calidad y resolución. Desde entonces ha sido cada vez mayor el número de estudios que tuvieron como finalidad demostrar el papel de la ultrasonografía (US) en el estudio de la mano y la muñeca. En la actualidad, los equipos ultrasonográficos permiten una visualización clara de estructuras anatómicas con una resolución espacial incluso inferior a 1 mm. La US es una técnica válida y fiable para el estudio de las estructuras articulares y periarticulares implicadas en las enfermedades reumatológicas. Es relativamente económica, inocua, reproducible, dinámica y bien aceptada por el paciente.

The hand and the wrist are anatomical regions frequently affected by a wide variety of diseases and syndromes that involve rheumatology. Most of these pathological conditions affect soft tissues, and precise characterization is particularly complex when using only physical and/or radiological examinations. During the nineties, the introduction of high-frequency transductors (>15 MHz) led to higher quality resolution images, which have been used more and more in studies of hand and wrist ultrasounds (US). This new generation ultrasound equipment, with high frequency probes allows comfort quick and accurate assessment of even minimal (< 1mm) pathological changes in patients with rheumatic conditions affecting small joints and soft tissues of the hand and wrist. Ultrasonography is a valid and reliable technique for the study of articular and periarticular structures involved in rheumatologic diseases, it is relatively inexpensive, non-invasive, quick, repeatable, and has high patient acceptability.

El rol actual de la ultrasonografía en reumatología / Actual role of ultrasonography in rheumatology

A lo largo de los últimos años diversos estudios han demostrado la utilidad de la ultrasonografía (US) del aparato musculoesquelético en la práctica reumatológica cotidiana. Sus ventajas, tales como la inocuidad, la ausencia de radiaciones, el bajo costo y la reproducibilidad, la posicionan como una técnica de imágenes que brinda una potencial ayuda en la orientación diagnóstica y en el manejo de las enfermedades o síndromes de interés reumatológico. Las principales indicaciones de la US en Reumatología incluyen: el estudio de los síndromes regionales dolorosos, la identificación de los cambios morfoestructurales que se verifican en la artritis temprana y crónica, el monitoreo a corto plazo de la terapia y su utilidad como guía para los procedimientos invasivos. El periodo de aprendizaje relativamente largo y la carencia de criterios estandarizados para la ejecución e interpretación de la imagen son los principales obstáculos para el empleo difuso de este método. Debe también recordarse que un adecuado y profundo conocimiento anatomoclínico de las enfermedades reumatológicas y de la semiología ultrasonográfica son requisitos fundamentales para una rápida y eficaz formación en el campo de la US musculoesquelética.

Over the last years, several studies have highlighted the value of ultrasonography (US) for both clinical and research purposes in rheumatology. Ultrasonography is a non-invasive, inexpensive and free-of-radiation-hazards imaging technique providing quick and useful information for the diagnosis and management of rheumatic diseases. The main indications of ultrasonography in rheumatology include the evaluation of patients with regional pain syndromes and chronic arthritis, short-term therapy monitoring and guidance for invasive procedures. Ultrasonography’s long learning curve is the main obstacle that hinders its widespread use in rheumatology. Many technical aspects may affect the scanning process, and a correct interpretation of sonographic images depends on several elements such as a deep knowledge of ultrasonography anatomy and pathology.