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.

Transthoracic Ultrasound in the Detection of Interstitial Pulmonary Fibrosis in Patients with Rheumatic Connective Tissue Diseases

INTRODUCTION

Rheumatic connective tissue diseases are commonly complicated with interstitial lung disease that is responsive to anti-inflammatory therapy and generally carries a better prognosis if diagnosed early.

PURPOSE

The aim of our study was to determine the diagnostic value of lung ultrasound in the detection of interstitial pulmonary fibrosis in patients with rheumatic connective tissue diseases.

METHODS

Sixty two subjects with rheumatic connective tissue diseases diagnosed according to the American College of Rheumatology criteria for each disease were enrolled (4 males, 58 females; mean age: 47.5 ± 8.9 years; range: 21 to 76 years). All subjects underwent high resolution computed tomography followed by transthoracic ultrasound for comet tail sign detection in order to predict the degree of lung fibrosis. The modified transthoracic ultrasound assessment was performed at 10 intercostal spaces level. The Warrick score was calculated according standard high-resolution chest computed tomography images that were evaluated independently from each other by a radiologist and a pulmonary disease specialist.

RESULTS

A significantly positive correlation between transthoracic ultrasound and the severity of pulmonary involvement (Spearman's correlation coefficient = 0.68, p < 0.001), (LR = 70.4, p < 0.001) was found. When compared with standard high-resolution chest computed tomography as the gold standard method, the sensitivity, specificity, and positive and negative predictive value of transthoracic ultrasound was 69.9%, 84.8%, 93.5%, and 49.7%, respectively.

CONCLUSIONS

Our study showed that the modified transthoracic ultrasound comet tails scoring system could be useful in the assessment of the pulmonary involvement in patients with rheumatic connective tissue diseases.

Update on imaging in rheumatic diseases: cartilage

In recent years, the role of articular cartilage for understanding pathogenesis as well as for clinical research has become increasingly important. Whereas previously cartilage could only be assessed invasively, various imaging procedures are available for its evaluation now. Although still widely used, conventional radiography bears significant limitations since it assesses cartilage indirectly by joint space width. Today, the cartilage thickness and structure can be reliably evaluated using ultrasound, although the molecular structure cannot be determined, yet. Besides ultrasound, MRI offers the possibility to image morphological changes with a very high resolution. In addition, the quality and composition of joint cartilage can already be measured due to a constant technical improvement and new MRI sequences such as dGEMRIC even in small joints (e.g. MCP or MTP joints). Despite the advantages of contrast agents for the detection of inflammation, its use is reevaluated today. Regarding that contrast agent-free imaging techniques for the assessment of joint cartilage are developed with great effort to depict its quality and changes over time. These novel MRI methods such as T2/T2*- and T1ρ-mapping, gagCEST, and sodium imaging provide promising quantitative imaging biomarkers that can detect early cartilage changes before morphological alterations occur. Hence, US and MRI will likely be of paramount importance in future clinical trials and clinical assessment of inflammatory and degenerative joint diseases not only for understanding pathogenesis but also for using its possible value in daily practice.

MRI in imaging of rheumatic diseases: an overview for clinicians

Magnetic resonance imaging (MRI) is a technique that utililises powerful magnets and radiofrequency to produce 3-dimentional images. MRI does not involve ionising radiation and has superb tissue resolution, enabling excellent delineation of anatomy as well as pathology in joints. This article briefly reviews the technical principle of magnetic resonance and discusses advantages and disadvantages of the technique, with particular attention to rheumatologic imaging. New information is summarised concerning the use of contrast media, dynamic, contrast-enhanced MRI, diffusion-weighted imaging, cartilage imaging and whole-body MRI.

What's new in musculoskeletal ultrasound in pediatric rheumatology?

Musculoskeletal ultrasound (MSUS) has become almost indispensable in the rheumatology settings nowadays, allowing early diagnosis, careful guidance during procedures such as joint injections and therapy monitoring. Nonetheless, the applicability of MSUS in pediatric population is still limited. Recently, a standardized MSUS examination procedure in pediatric patients with rheumatic diseases, definitions for synovitis and the sonographic features of joints in healthy children has been developed. Also, important data on age-related  vascularization and ossification of joints in children have been published. Much work still needs to be done in the field. As juvenile idiopathic arthritis seems to be the most common use of MSUS in pediatric rheumatology, specific definitions and assessment techniques for enthesitis, tenosynovitis, bone and cartilage damage in children are very much expected. In this article, we will review briefly the current evidence-based knowledge regarding MSUS potential applications in the pediatric rheumatology clinical practice, along with an overview of the recent information about US appearance of musculoskeletal structures in healthy children.

Analysis of skin blood microflow oscillations in patients with rheumatic diseases

Laser Doppler flowmetry (LDF) has been applied for the assessment of variation in blood microflows in patients with rheumatic diseases and healthy volunteers. Oscillations of peripheral blood microcirculation observed by LDF have been analyzed utilizing a wavelet transform. A higher amplitude of blood microflow oscillations has been observed in a high frequency band (over 0.1 Hz) in patients with rheumatic diseases. Oscillations in the high frequency band decreased in healthy volunteers in response to the cold pressor test, whereas lower frequency pulsations prevailed in patients with rheumatic diseases. A higher perfusion rate at normal conditions was observed in patients, and a weaker response to cold stimulation was observed in healthy volunteers. Analysis of blood microflow oscillations has a high potential for evaluation of mechanisms of blood flow regulation and diagnosis of vascular abnormalities associated with rheumatic diseases.

Quantitative Doppler in musculoskeletal ultrasonography - suboptimal performance of both experienced and in-training sonographers in selection of the highest Doppler signal image from cine-loops

AIMS

Doppler ultrasonography assessment is mandatory nowadays for the complete description of rheumatic disease activity. Initially it was performed in semi quantitative way but recently the (fully) quantitative assessment is gaining more interest. In quantitative assessment, the ratio between total colorized and total pixels (CTR) is computed for the whole image or just for the region of interest (ROI). The frame with the highest amount of Doppler signal (also called worst case scenario image - WCSI) is usually the only one analyzed. The technique requires a very precise identification of WCSI from a certain number of consecutive frames, captured from the same position of the US probe, (and in most cases this is done manually). Our study examined the ability of both experienced and in-training sonographers to identify WCSI using a computerized analytical system as the gold standard.

MATERIALS AND METHODS

The study analyzed 480 frame selections done in two distinct exercises. The WCSI and other 3 images with a 5%, 10% and respectively 20% lower level of CTR compared with WCSI were packed in one selection. All frames emerging from the same video clip were randomly presented to six experienced and six in training sonographers; the request was to select the frame with the highest CTR (WCSI) from each package (twenty packages in total). A similar exercise was performed with CTRs decreasing in steps of 2%.

RESULTS

In the first exercise the WCSI was correctly identified in 79.1% cases and in 67% of cases in the 2nd exercise. The interobserver agreement between experienced and in-trainer evaluators for the 1st exercise was 0.78 and 0.4 in the 2nd exercise.

CONCLUSION

Using computerized analysis as the gold standard, we demonstrated a large heterogeneity across sonographers regarding their ability to identify the best Doppler image even from a small group of frames.

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Zusammenfassung. Die Qualitätssicherung zu Gunsten der Patienten ist im Alltag nicht mehr wegzudenken. Diese Arbeit beschreibt wichtige Aspekte bezüglich Sicherstellung von Standards zur Qualitätssicherung und Qualitätsverbesserung im diagnostischen und interventionellen rheumatologischen Ultraschall in der Schweiz durch die Arbeitsgruppe QIR («Quality in Rheumatology»). Qualitätsindikatoren in der Rheumatologie und Qualitätsstandards in der Arthrosonografie werden hervorgehoben und vorgestellt.

Impaired quality of life in adults with X-linked hypophosphatemia and skeletal symptoms

OBJECTIVE

Adults with X-linked hypophosphatemia (XLH) may suffer from skeletal symptoms leading to functional disability. No data on their quality of life (QoL) have been reported so far. Our objectives were to evaluate the QoL and its determinants in XLH adults.

PATIENTS AND METHODS

We conducted a prospective study in XLH adults, who consulted for musculoskeletal symptoms between 2013 and 2014. We assessed their QoL using HAQ, RAPID3 and SF36, and analysed the variables associated with low QoL. We compared their QoL to that of patients affected with axial spondyloarthritis (ax-SpA) (paired on age and gender), a rheumatologic disorder with a known low QoL.

RESULTS

Fifty-two XLH adults (37 women (71.1%); mean age 41.8±13.3 years) were included; 44 (84.6%) patients had an altered QoL. Increased age and presence of structural lesions were significantly associated with worse QoL (HAQ, RAPID3) (P<0.05). Presence of enthesopathies was significantly associated with worse RAPID3 (OR=4.45 (1.09-18.29), P=0.038). Treatment with phosphate supplements and vitamin D in XLH adults were significantly associated with a better SF36-mental component score (OR=0.14 (0.03-0.57), P=0.007 and OR=0.26 (0.07-0.98), P=0.047 respectively). QoL was significantly worse in XLH than in ax-SpA adults (VAS pain, SF36-PCS, RAPID3) (P<0.05).

CONCLUSION

Our study showed i) QoL of XLH adults is altered and significantly worse than that of ax-SpA patients (VAS pain, SF36-PCS and RAPID3), ii) structural lesions and especially enthesopathies are associated with a worse QoL and iii) treatment using phosphate supplements and/or vitamin D is associated with a better mental health score.

EFSUMB COMPASS for Rheumatologists dissemination and implementation--an international survey

AIM

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) competency assessment (COMPASS) for rheumatologists performing musculoskeletal ultrasound (MSUS) was developed and published 2 years ago. It consists of a 3 level competency system. The objective of this study was to evaluate how the EFSUMB COMPASS has been disseminated and implemented and to assess the potential obstacles encountered.

MATERIALS AND METHODS

A questionnaire was developed and distributed by e-mail to all rheumatologists certified as EFSUMB level 3.

RESULTS

Seventeen (85%) rheumatologists considered that the EFSUMB COMPASS is useful for training MSUS. The majority of them (17; 85%) had informed their colleagues or national rheumatology societies about the EFSUMB COMPASS. The most common obstacle encountered for the implementation of the COMPASS was the lack of time for supervision of the trainees (9; 45%). A total of 83 rheumatologists had been trained and assessed for competency in the three EFSUMB levels.

CONCLUSION

This survey highlights the current status of EFSUMB COMPASS implementation in European countries with an expected increased number of rheumatologists being able to train and assess new trainees. Still, more efforts should be done for a higher implementation of EFSUMB COMPASS across European countries.

Doppler imaging in inflammatory rheumatic diseases

Doppler imaging has increased in rheumatology during this millennium. The method can detect slow blood flow in inflamed synovium and soft tissues. Doppler imaging is more sensitive than clinical examination in the detection of joint inflammation. Ultrasound imaging combined with Doppler imaging is regarded as reference method in the evaluation of enthesitis,. Doppler imaging is an excellent tool in the diagnostics and follow up in the treatment of the inflammatory rheumatic diseases because it does not use radiation, can be performed bedside and repeated often. The adjustment of ultrasound and Doppler signal is machine specific.

Conventional Therapy in Adults With X-Linked Hypophosphatemia: Effects on Enthesopathy and Dental Disease

CONTEXT

Treatment of X-linked hypophosphatemia (XLH) with active vitamin D metabolites and phosphate can partially correct skeletal deformities. It is unclear whether therapy influences the occurrence of two major long-term morbidities in XLH: enthesopathy and dental disease.

OBJECTIVE

The objective of the study was to investigate the relationship between treatment and enthesopathy and dental disease in adult XLH patients.

DESIGN

The study was designed as observational and cross-sectional.

SETTING

The study was conducted at an academic medical center's hospital research unit.

PARTICIPANTS

Fifty-two XLH patients aged 18 years or older at the time of the study participated in the study.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

The number of enthesopathy sites identified by radiographic skeletal survey and dental disease severity (more than five or five or fewer dental abscesses), identified historically, were measured.

METHODS

Associations between proportion of adult life and total life with treatment and number of enthesopathy sites were assessed using multiple linear regression, whereas associations between these exposure variables and dental disease severity were assessed using multiple logistic regression. All models were adjusted for confounding factors.

RESULTS

Neither proportion of adult nor total life with treatment was a significant predictor of extent of enthesopathy. In contrast, both of these treatment variables were significant predictors of dental disease severity (multivariate-adjusted global P = .0080 and P = .0010, respectively). Participants treated 0% of adulthood were more likely to have severe dental disease than those treated 100% of adulthood (adjusted odds ratio 25 [95% confidence interval 1.2-520]). As the proportion of adult life with treatment increased, the odds of having severe dental disease decreased (multivariate-adjusted P for trend = .015).

CONCLUSIONS

Treatment in adulthood may not promote or prevent enthesopathy; however, it may be associated with a lower risk of experiencing severe dental disease.

Nailfold Capillaroscopy in Rheumatic Diseases: Which Parameters Should Be Evaluated?

Video nailfold capillaroscopy (NFC), considered as an extension of the widefield technique, allows a more accurate measuring and storing of capillary data and a better defining, analyzing, and quantifying of capillary abnormalities. Capillaroscopic study is often performed on the patients suspected of having microcirculation problems such as Raynaud's phenomenon as the main indication for nailfold capillaroscopy. Capillaroscopic findings based on microcirculation studies can provide useful information in the fields of pathophysiology, differential diagnosis, and monitoring therapy. Nailfold capillaroscopy provides a vital assessment in clinical practices and research; for example, its reputation in the early diagnosis of systemic sclerosis is well established and it is also used as a classification criterion in this regard. This review focuses on the manner of performing video nailfold capillaroscopy and on a common approach for measuring capillary dimensions in fingers and toes.

[Roles of Musculoskeletal Ultrasonography in the Management of Rheumatic Diseases]

Inflammation of soft tissues and the subsequent structural damage are the characteristic features of many rheumatic conditions. However, the conventional measures to evaluate these features are not accurate, potentially causing under- and over-diagnosis or treatment. Musculoskeletal ultrasonography, on the other hand, directly visualizes features which are characteristic to rheumatic conditions, such as synovitis, tenosynovitis, bursitis, enthesitis, crystal depositions, bone erosions, and osteophytes/enthesophytes. By visualizing these key features, ultrasound facilitates a more accurate evaluation of rheumatic diseases such as rheumatoid arthritis (RA), spondyloarthropathy, crystal-induced arthritis, and osteoarthritis. For RA, we investigated the impact of ultrasound on the 2010 ACR/EULAR RA classification criteria when joint involvement was determined. We assessed 109 patients with early arthritis using ultrasound. When the presence of joint swelling and number of involved joints were determined by ultrasound, the classification of RA was different from that without ultrasound in approximately 20% of the patients. Moreover, the accuracy of the classification to identify patients who required methotrexate treatment within a year improved by ultrasound. In addition, we and other investigators demonstrated the advantage of ultrasound over conventional measures in the assessment of disease activity of RA. Ultrasound also supports the education of both physicians and patients and communication between them. The utilization of musculoskeletal ultrasonography in more hospitals and clinics is expected to improve the quality of daily practice for rheumatic diseases.

Ultrasound in Rheumatology: two decades of rapid development and evolving implementation

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The use of musculoskeletal ultrasound in a rheumatology outpatient clinic

INTRODUCTION

Musculoskeletal ultrasound (US) represents a valid, reliable and sensitive-to-change tool for the evaluation of patients suffering from rheumatic conditions. This method demonstrates a wide applicability and availability, finding place in the clinical practice in rheumatology outpatient clinic.

AIM

To perform an epidemiological evaluation related to the use of US in a university rheumatology outpatient clinic.

MATERIAL AND METHODS

During a 3-month period, data concerning consecutive patients attending to the US Unit of Department of Rheumatology, Sapienza University of Rome were registered. We collected the demographic data, the diagnosis, the reason for the US examination, the examined joints, as well as the requesting physicians' specialty.

RESULTS

In the period October-December 2013, 572 patients (M/F 137/435; mean age+/-SD 55.2+/-15.8 years) were registered. The US examination was more frequently requested for the following diseases: rheumatoid arthritis (29.5%), osteoarthritis (10.6%), spondyloarthritis (9.1%), and connective tissue diseases (8.9%). In 239 of cases (41.8%), the US evaluation was requested for other indications. The US evaluation was requested slightly more frequently for monitoring (55.7%) compared to diagnosis (44.3%). The requesting physician was a rheumatologist in the majority of the cases (80.6%). The most frequent requested were the hand joints (28.9%) and wrists (23.3%).

CONCLUSIONS

US examinations are most frequently used in the evaluation of patients with rheumatoid arthritis and mainly to monitor the disease. The exam is requested mostly by rheumatologists. The hand joints and wrists were the most frequently evaluated.

Musculo-skeletal ultrasound in rheumatology practice

In rheumatology ultrasound is a relatively new but rapidly developing field, and now forms an important part of curriculum of rheumatology training programs in European countries. Ultrasound is now an accepted procedure to differentiate between arthralgia and arthritis, to look for erosions in early arthritis which is otherwise not visible on plain radiographs, to scan tendons in enthesopathies and to image blood vessels. It is particularly useful in early undifferentiated arthritis, where presence of synovitis by ultrasound can predict development of rheumatoid arthritis. It is also useful to aid in diagnosis of a wide variety of rheumatic conditions like gout, vasculitis and scleroderma. It facilitates correct placement of needle during intra-articular injections.The advantages of ultrasound are it is relatively inexpensive, noninvasive, lacks radiation and the images are acquired in real time. Following in the footsteps of the cardiologist who are using echocardiography are the rheumatologists who are increasingly using ultrasound in their clinics, such that some authors have likened the US probe to the rheumatologist's stethoscope.

Musculoskeletal ultrasound in Paediatric Rheumatology: a retrospective analysis

OBJECTIVES

Musculoskeletal Ultrasound (MSK-US) has become increasingly important in the diagnosis and follow-up of children with rheumatic diseases. We describe the experience of a large Portuguese centre and study the added value of MSK-US in the clinical assessment of paediatric rheumatic diseases.

MATERIAL AND METHODS

Patients were observed by assistant Rheumatologists, a clinical diagnosis was assigned and MSK-US requested. 330 MSK-US exams were performed to 222 children with rheumatic inflammatory diseases. The children's ages were between 1 and 18 years (mean=11.7±4.7 years) and 67.6% were female. Synovial membrane proliferation, intra-articular effusion, cartilage abnormalities, erosions and periarticular affections were searched in each joint. Clinical and ultrasonography data were compared.

RESULTS

MSK-US detected synovitis in 100 of 194 exams (51.5%) of patients with that clinical information and in 36 of 136 exams (26.5%) of patients who presented other clinical findings. In those in which MSK-US did not confirm the clinical information of synovitis (94; 48.5%), we detected tenosynovitis/tendinopathy in 13 cases (13.8%) and synovial cyst in four (4.3%). The remaining patients had no ultrasonography changes and MSK-US helped to exclude synovitis. The sensitivity for arthritis clinical assessment was good (73.5%), with modest specificity (51.5%), an accuracy of 60.6% and precision of 51.5%. Ultrasonography synovitis was mostly found in the knee (37.5%), followed by the ankle (22.8%) and hip (10.3%). Overall, 39 exams showed ultrasonographic tenosynovitis/tendinopathy, 15 of which had the same clinical diagnosis. Tenosynovitis/tendinopathy was mostly found in the ankle (59.0%) and knee (23.1%) areas.

CONCLUSIONS

MSK-US is an important aid to clinical evaluation, allowing both the detection and exclusion of joint pathology in children, contributing to a better assessment.

[Ultrasonography and rheumatology]

Muskuloskeletal ultrasound has been incorporated by rheumatologist to the clinical practice over the past decade. The technical improvements of the devices allowed the production of high quality images contributing to better identification of joint inflammation and structural damage. In this review, we highlight the applications of ultrasound in the study of different rheumatic conditions.

Optimising ultrasonography in rheumatology

Ultrasonography is an imaging modality that has been utilised in clinical medicine since the 1950s. However, application to joints and rheumatic disease was delayed until appropriate advances in technology made it feasible. Since the 1990s, rheumatologists have embraced ultrasonography as a useful clinical tool and it has increasingly been applied in routine practice. Initial criticism correctly focused on a lack of validity data, recognition that this modality is highly user-dependent and that reliability was not established. In response, the rheumatological community identified relevant pathologies to study, starting with synovitis in rheumatoid arthritis, and set about defining the ultrasound abnormalities, followed by demonstrating the validity, reproducibility and responsiveness of these measures. Much work is now ongoing in the areas of enthesitis, gout and osteoarthritis. Additionally, the evidence base for ultrasonography in clinical practice is being investigated, in order to understand its appropriate place. Given the sensitivity of ultrasonography over clinical examination for detection of inflammation, this work will focus on its role in optimising diagnosis, directing therapy through accurate assessment of disease activity and understanding the optimal selection of joints for feasible disease monitoring. This review summarises the work undertaken to date, ongoing work and future challenges of optimising the role of ultrasonography in rheumatology.

Enthesopathy of the lateral cord of the plantar fascia

The objective of this study was to raise awareness of the diagnosis of enthesopathy of the lateral cord of the plantar fascia (LCPF) and describe its sonographic findings. We conducted a retrospective case series of 13 sonographic examinations with the diagnosis of LCPF enthesopathy. Two cadaver dissections of the plantar foot were performed for anatomic correlation. Sonographic findings of LCPF enthesopathy included generalized or focal hypoechoic thickening, loss of the normal fibrillar echo texture, cortical irregularity of the fifth metatarsal tuberosity, and vascularity on color Doppler imaging. Anatomic dissections of the plantar foot detailed the course of the LCPF and served as a guide for optimal sonographic imaging. Enthesopathy of the LCPF is an important etiology of nontraumatic pain at the base of the fifth metatarsal. Sonographic evaluation can readily show the characteristic findings of LCPF enthesopathy.

A brief history of ultrasound in rheumatology: where are we going

Musculoskeletal ultrasound is an evolving technique widely used in rheumatology thanks to the numerous advances and the improved work on standardisation. This article deals with the new developments in terms of technology and validation.