Teledidactic Versus Hands-on Teaching of Abdominal, Thoracic, and Thyroid Ultrasound-The TELUS II Study.

BACKGROUND: The worldwide COVID-19 pandemic has initiated a change in medical education and the development of new teaching concepts has become inevitable to maintain adequate training. OBJECTIVE: This pilot study aims to compare teledidactic teaching with traditional face-to-face teaching for abdominal, thoracic, and thyroid ultrasound. DESIGN: Concurrently, a teledidactic and a face-to-face ultrasound course were held. The students completed seven 90-min modules using mobile ultrasound probes (Butterfly IQ). Each module consisted of a lecture, a demonstration of probe guidance, and independent training. PARTICIPANTS: A total of thirty medical students took part in the study and were randomly assigned to a teledidactic and a face-to-face group. MAIN MEASURES: An objective structured assessment of ultrasound skills (OSAUS) was performed as a pre-test and as the final exam and ultrasound images obtained during the exam were evaluated using the brightness mode quality ultrasound imaging examination (B-QUIET) scale. KEY RESULTS: No significant difference between the two cohorts on the OSAUS final exam was shown (p > 0.05 in all modules). There was a significant difference in the assessment of the images in the focused assessment with sonography for trauma (FAST) (p 0.015) and aorta (p 0.017) modules. Students in the teledidactic group performed better in both modules, scoring 33.59 (± 2.61) out of 44 in the module FAST (face-to-face group 30.95 (± 1.76)) and aortic images averaged 35.41 (± 2.61) points (face-to-face group 32.35 (± 3.08)). CONCLUSIONS: A teledidactic course for abdominal and thoracic ultrasound examinations is equally effective to traditional face-to-face teaching in this pilot study. Digital implementation with a portable ultrasound machine could be a great opportunity to promote ultrasound education worldwide and over great distances.

Prevalence of joint, entheseal, tendon, and bursal findings in young, healthy individuals by musculoskeletal ultrasound.

OBJECTIVE: The purpose of this study was to determine the prevalence of joint, enthesis, bursa, and tendon ultrasound findings in large and medium joints of young, healthy individuals. METHOD: Ultrasound assessment of large and medium joints, bursae, tendons, and entheses was performed in healthy individuals below the age of 30 years. Participants also underwent bioelectrical impedance analysis and conducted supervised weight training to determine maximum strength. The prevalence of ultrasound findings was calculated and a binary logistic regression model was applied to evaluate factors associated with the present findings. RESULTS: Fifty-one healthy individuals (52.9% female) with a mean age of 23.7 years were included in this study. Joint effusion in at least one joint was observed in 72.6% of the individuals (n = 37) and entheseal pathology in at least one enthesis was detected in 27.5% (n = 14). A binary logistic regression model indicated a significant association between reported hours of sports activity per week and the prevalence of effusion in the knee (p = 0.017). In addition, associations were observed between entheseal pathology in at least one entheseal site and body mass index (BMI) (p = 0.015) as well as fat mass index (p = 0.026). CONCLUSION: Joint effusion in large and medium joints, as well as entheseal hyperperfusion, bursal effusion, and tendon sheath effusion, are found in healthy individuals. Hours of sports activity per week, BMI and fat mass index showed significant associations with the findings in joints and entheses.

A study on echocardiographic findings in hospitalized patients with connective tissue diseases.

OBJECTIVE: To determine the prevalence of echocardiographic findings and their change over time in patients with connective tissue diseases (CTDs) and to analyse which findings were associated with escalation of immunosuppressive therapy. METHOD: We conducted a retrospective cohort study of consecutive hospitalized patients from a tertiary rheumatology referral centre who received transthoracic echocardiography between 1 January 2006 and 31 December 2015. We tested for associations between echocardiographic findings and treatment escalation via Fisher's exact test; p < 0.05 was considered significant. Escalation of therapy was defined by dosage of glucocorticoids and type of disease-modifying anti-rheumatic drug. The clinical relevance of echocardiographic findings concerning change in immunosuppressive therapy was recorded. RESULTS: In total, 1004 patients were included (865 females), with a total of 1660 echocardiographic examinations. The most frequent findings were mitral, tricuspid, and aortic valve regurgitation (found in 36.7%, 25.4%, and 17.7% of all patients), aortic valve sclerosis (20.1%), left ventricular dysfunction (21.5%), and left atrial dilatation (19.2%). Only pericardial effusions were more frequent in cases with treatment escalation (10.9% of cases with escalated therapy vs 6.9% of cases without, p = 0.007). In 314 patients who received follow-up examinations, echocardiographic findings were found to change between examinations. Only 73 of all 1660 examinations were discussed in depth considering the treatment strategy in the hospital discharge letter. CONCLUSION: Patients with CTDs exhibited a wide, dynamically changing spectrum of echocardiographic abnormalities. Most findings neither reflected disease activity nor appeared to influence the therapeutic regimen.

[Prevalence of hypophosphatasia in adult patients in rheumatology]. / Prävalenz der Hypophosphatasie bei adulten Patienten in der Rheumatologie.

BACKGROUND: Hypophosphatasia (HPP) is a genetic disorder caused by one or more mutations in the alkaline phosphatase (ALP) gene, responsible for encoding tissue-specific ALP and for the mineralization process. OBJECTIVE: Identification of the prevalence of HPP in rheumatology patients. MATERIAL AND METHODS: Medical records of all adult rheumatology patients with pathologically low total ALP levels (<35 U/L) treated in the Department of Rheumatology at the Clinic of Internal Medicine III, University Hospital Bonn between January 2017 and June 2019, were retrospectively examined for clinical signs as well as for results of genetic tests for HPP. RESULTS: In 60 out of 2289 patients (2.62%) pathologically low ALP levels were detected. Of these 30 (1.31%) were found to have persistently low ALP levels. Genetic testing for ALP gene mutations was performed in 19 of these 30 patients and 7 of the 19 patients (36.84%) had HPP signs (insufficiency fractures, or bad dental status since childhood), all with pathologic ALP mutations. Of these patients 3 (15.78%) each had a history of insufficiency fracture with normal bone densitometry. Overall, 13 out of the 19 patients (68.42%) had mutations in the ALP gene. Interestingly, no association with chondrocalcinosis was detected in any of the patients. CONCLUSION: The HPP seems to be an underdiagnosed disease with a higher proportion of affected rheumatology patients. Therefore, future studies should aim to develop a diagnostic protocol in the clinical practice.

[Coexistent septic arthritis and spondylodiscitis as important differential diagnosis in immunosuppressed patients]. / Koexistente septische Arthritis und Spondylodiszitis als wichtige Differenzialdiagnose bei immunsupprimierten Patienten.

Septic arthritis and spondylodiscitis, especially in immunocompromised patients, constitute a major differential diagnosis of joint or back pain. This results in the invasion of a joint or spinal disc and its adjacent vertebral body by a pathogen. In most cases this is manifested as unspecific symptoms, such as local joint or back pain, fever and malaise. If this is clinically suspected the bacterial infection of the joint can be confirmed by joint puncture and blood culture. For the diagnosis of spondylodiscitis magnetic resonance imaging should be used for visualization. In addition to adequate pain treatment and empirical antibiotic treatment, an arthroscopic removal of infected intra-articular tissue and debris is imperative. When complications caused by spondylodiscitis arise a surgical removal and stabilization should be performed. The following case report presents the findings of septic polyarthritis and spondylodiscitis in an immunocompromised patient with an HIV infection and provides insights into the occurrence of complications due to the delay of adequate treatment.

[Prevalence and treatment of rheumatological adverse events due to immune checkpoint inhibitor therapy]. / Prävalenz und Therapie von rheumatologischen Nebenwirkungen bei Immun-Checkpoint-Inhibitor-Therapie.

BACKGROUND: Immune checkpoint inhibitors (ICI) have essentially improved the treatment options for various malignant diseases. They lead to an activation of the immune system and subsequent attack of tumor cells by affecting the immune system and preventing tumor cells from avoiding detection. In addition to this desired effect, immune-related adverse events (irAE) can occur in nearly all organ systems and therefore also rheumatological irAE (rh-irAE). OBJECTIVE: The occurrence of rh-irAE has been described in various publications and is specifically investigated in this review. The aim is to provide an overview on the prevalence, severity, treatment options and altered tumor response in patients with rh-irAE. MATERIAL AND METHODS: We conducted a literature search for studies and case reports on rh-irAE under ICI therapy in PubMed up to January 2020 using the PICO model. RESULTS: A total of 18 publications were included, most of which were clinical studies (n = 13) and the rest case reports (n = 5). Several rh-irAE can occur with a wide variety of manifestations of which arthralgia, arthritis and myositis were the most common. Other rheumatic diseases, such as vasculitis, connective tissue diseases and sarcoidosis were less frequently described. The published prevalence of rh-irAE varied with a prevalence between 2.3% and 6.6%. Treatment of rh-irAE depends on the severity and most patients receive nonsteroidal anti-inflammatory drugs and glucocorticosteroids. In some cases, conventional DMARDs, such as methotrexate and biological DMARDs, were administered. Patients with rh-irAE in general had a higher tumor response rate compared to patients without side effects. CONCLUSION: A close observation of patients and early detection of rh-irAE are important in order to treat these side effects in time. Further prospective studies are necessary to systematically investigate rh-irAE.

Adrenal insufficiency is a contraindication for omalizumab therapy in mast cell activation disease: risk for serum sickness.

Omalizumab is an effective therapeutic humanized murine IgE antibody in many cases of primary systemic mast cell activation disease (MCAD). The present study should enable the clinician to recognize when treatment of MCAD with omalizumab is contraindicated because of the potential risk of severe serum sickness and to report our successful therapeutic strategy for such adverse event (AE). Our clinical observations, a review of the literature including the event reports in the FDA AE Reporting System, the European Medicines Agency Eudra-Vigilance databases (preferred search terms: omalizumab, Xolair®, and serum sickness) and information from the manufacturer's Novartis database were used. Omalizumab therapy may be more likely to cause serum sickness than previously thought. In patients with regular adrenal function, serum sickness can occur after 3 to 10 days which resolves after the antigen and circulating immune complexes are cleared. If the symptoms do not resolve within a week, injection of 20 to 40 mg of prednisolone on two consecutive days could be given. However, in MCAD patients whose adrenal cortical function is completely suppressed by exogenous glucocorticoid therapy, there is a high risk that serum sickness will be masked by the MCAD and evolve in a severe form with pronounced damage of organs and tissues, potentially leading to death. Therefore, before the application of the first omalizumab dose, it is important to ensure that the function of the adrenal cortex is not significantly limited so that any occurring type III allergy can be self-limiting.

[Ultrasound diagnostics in Sjögren's syndrome]. / Ultraschalldiagnostik beim Sjögren-Syndrom.

Ultrasound of the salivary glands is a specific examination for detecting pathology of salivary glands in the diagnosis of Sjögren's syndrome. It is easy to learn, rapidly performed, non-invasive and inexpensive. Other imaging techniques, such as sialography and scintigraphy, are currently only rarely performed. For the examination, linear ultrasound probes with frequencies between 7 and 12 MHz are recommended. Such probes are already widely available to the rheumatologist performing musculoskeletal ultrasound. The parotid and submandibular glands are bilaterally scanned both in longitudinal and transverse planes as a standard.Normal salivary glands have uniformly hyperechoic and homogeneous tissue. They can be clearly delineated from the surrounding muscles and soft tissue and appear similar to the thyroid gland. The salivary glands are typically hypoechoic and inhomogeneous in Sjögren's syndrome. Focal or diffuse hypoechoic or anechoic foci are found in the glands. The submandibular glands may become atrophic (sagittal diameter <8 mm). Particularly in disease flares, the parotid glands may become enlarged (sagittal diameter >20 mm). The sensitivity for the diagnosis is 60 to 90% and the specificity is over 90%.Doppler sonography does not further improve the diagnostic accuracy. Sonography has thus become an important tool in the diagnosis of Sjögren's syndrome.

Arthritis of the Knee Joint in Rheumatoid Arthritis - Evaluation of Treatment Response by Ultrasound in Daily Clinical Practice.

BACKGROUND: Rheumatoid arthritis (RA) commonly involves the knee joint in up to 30% of patients. Musculoskeletal ultrasound enables the skilled clinician to easily assess disease activity. OBJECTIVE: To evaluate the sensitivity to change of the sonography score of large joints in Rheumatology (SOLAR) for different treatments of knee arthritis in RA. METHOD: Joints were assessed by ultrasound at 4 visits. Laboratory, immunological and clinical parameters were recorded. RESULTS: 225 RA patients were analyzed. The DAS 28 in the subgroup receiving systemic steroids was significantly higher (p < 0.001) than in patients treated with intraarticular glucocorticosteroids (GCs) at T0, comparing the values from T0 to T3 the same appeared (p=0.003). Concerning the acute GC treatment regimens, the gray scale ultrasound (GSUS) sum score was found to be significantly higher in patients receiving intraarticular GCs versus no GCs (p=0,035), as well as in patients receiving systemic versus intraarticular GCs (p=0.001). Regarding the differences from T0 and T3, similar to the baseline analysis, a high GSUS sum score was significantly associated with intraarticular GCs, a low to no GC administration (p=0.035), while a high GSUS sum score was significantly linked to intraarticular GCs, rather than systemic GCs (p=0.008). CONCLUSION: SOLAR score is sensitive to change in knee arthritis. Intraarticular GC administration is performed in patients with high GSUS scores. Systemic administration of GC is linked to high disease activity (DAS28) rather than GSUS or power Doppler ultrasound (PDUS) results.

[Spinal epidural lipomatosis as a rare side effect in steroid-dependent Jo-1 antibody syndrome]. / Spinale epidurale Lipomatose als seltene Nebenwirkung bei steroidabhängigem Jo-1-Antikörper-Syndrom.

Spinal epidural lipomatosis (SEL) of the thoracic and lumbar spine is a rare entity, which leads to compression of the spinal canal. The exact pathogenesis is still unknown. It most commonly occurs in patients with long-term exogenous or endogenous glucocorticoid excess or morbid obesity but there are also idiopathic forms. The symptoms depend on the severity of the SEL and can manifest as clinically asymptomatic, non-specific back pain, radiculopathy up to spinal cord compression. The diagnosis is usually achieved by magnetic resonance imaging (MRI) of the affected spinal segments. The treatment varies between discontinuation of glucocorticoids, weight reduction up to multisegmental decompressive laminectomy. The following case report presents the findings of SEL in a patient with steroid-dependent Jo-1 antibody syndrome and provides a current literature review on this rare disease.