2012 Provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

The objective of this study was to develop European League Against Rheumatism/American College of Rheumatology classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new-onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of rheumatoid factor and/or anti-citrullinated protein antibody (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness >45 minutes, elevated C-reactive protein and/or erythrocyte sedimentation rate, and new hip pain. These criteria are not meant for diagnostic purposes.

The US7 score is sensitive to change in a large cohort of patients with rheumatoid arthritis over 12 months of therapy

Purpose

To determine the sensitivity to change of the US7 score among RA patients under various therapies and to analyze the effect of each therapeutic option over 1 year. To estimate predictors for development of destructive bone changes.

Methods

Musculoskeletal ultrasound (US7 score), DAS28, CRP and ESR were performed in 432 RA patients at baseline and after 3, 6 and 12 months. The cohort was divided into four sub-groups: first-line DMARDs (Group 1; 27.3%), therapy switch: DMARDs to second DMARDs (Group 2; 25.0%), first-line biologic after DMARDs therapy (Group 3; 35.4%) and therapy change from biologic to second biologic (Group 4; 12.3%).

Results

The US7 synovitis and tenosynovitis sum scores in grey-scale (GSUS) and power Doppler ultrasound (PDUS) as well as ESR, CRP decreased significantly (p<0.05) after 12 months in group 1 to 3. Group 1+2 also illustrated a significant change of DAS28 after 1 year (p<0.001). Only in Group 4, the US7 erosion sum score decreased significantly from 4.3 to 3.6 (p=0.008) after 1 year. Predictors capable of forecasting US erosions after one year were: higher score of US7 synovitis (p<0.001), of US7 erosions in GSUS (p<0.001), as well as of DAS28 (p<0.001) at baseline.

Conclusions

The comparable developments of the US7 score with clinical and laboratory data illustrates its potential to reflect therapeutic response. Therefore, the novel US7 score is sensitive to change. Patients who switched from one biologic to another exhibited a significant decline in erosions after 12 months, while the erosions scores in the other groups were stable.

Head-to-head comparison of quantitative and semi-quantitative ultrasound scoring systems for rheumatoid arthritis: reliability, agreement and construct validity

OBJECTIVE

To evaluate the reliability and agreement of semi-quantitative scoring (SQS) and quantitative scoring (QS) systems. To compare the two types of scoring system and investigate the construct validity for both scoring systems.

METHODS

A total of 46 RA patients (median disease duration of 6.5 years) were enrolled in the study. They were investigated with colour Doppler ultrasound using the central position of the wrist. Disease activity score based on 28 joints (DAS-28) was determined for all patients using CRP. Two participants trained in the SQS system and two in the QS system evaluated the 46 anonymized images. All images were scored twice by each of the two assessors in order to assess both intra- and inter-reader reliability.

RESULTS

The reliability for the two systems were 0.964 for the QS, and 0.817 for the SQS, with a comparable inter-reader agreement for both scoring systems; 95% limits of agreement for the QS being between -7.7% and +6.7% on the colour fraction scale (0-100%), whereas SQS was between -0.8 and +0.8 on the ordinal scale from 0 to 3. There was a direct but non-linear relationship between the two modalities (Spearman's r = 0.73) and critical conceptual issues in the agreement between the scoring systems were revealed. The construct validity was poor for both systems with only a weak correlation to CRP.

CONCLUSION

High reliability and good agreement of both scoring systems were found when applied to the same patient cohort. Different scoring systems appear to be highly correlated.

Ultrasound evaluation of fluid in knee recesses at varying degrees of flexion

OBJECTIVE

Various methods are utilized in daily practice to obtain optimal information on effusion in the knee. Our aim is to investigate which scanning position provides the best information about synovial fluid in the knee by using ultrasound and to evaluate the magnitude of difference for measuring synovial fluid in 3 major recesses (suprapatellar, medial parapatellar, and lateral parapatellar) of the knee according to various degrees of flexion.

METHODS

Sonographers in 14 European centers documented bilateral knee joint ultrasound examinations on a total of 148 knee joints. The largest sagittal diameter of fluid was measured in scans corresponding to the 3 major recesses at different (0°, 15°, 30°, 45°, 60°, and 90°) degrees of flexion of the knee. The difference of measurement of effusion according to transducer position, knee position, and the interaction between them was investigated by analysis of variance followed by Tukey's test.

RESULTS

No correlation was noted between patient characteristics and ultrasound detection of effusion. The sagittal diameter of synovial fluid in all 3 recesses was greatest at 30° flexion. Analysis of variance and Tukey's test revealed that the suprapatellar scan and 30° flexion is the best combination for detecting effusion as confirmed by receiver operator characteristic curve analysis.

CONCLUSION

The suprapatellar scan of the knee in 30° flexion was the most sensitive position to detect fluid in knee joints. Sagittal diameter of fluid in all 3 recesses increased with the knee in the 30° flexed position as compared to the extended position.

2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.

Patient-reported outcomes in polymyalgia rheumatica

OBJECTIVE

To prospectively evaluate the disease course and the performance of clinical, patient-reported outcome (PRO) and musculoskeletal ultrasound measures in patients with polymyalgia rheumatica (PMR).

METHODS

The study population included 85 patients with new-onset PMR who were initially treated with prednisone equivalent dose of 15 mg daily tapered gradually, and followed for 26 weeks. Data collection included physical examination findings, laboratory measures of acute-phase reactants, and PRO measures. Ultrasound evaluation was performed at baseline and Week 26 to assess for features previously reported to be associated with PMR. Response to corticosteroid treatment was defined as 70% improvement in PMR on visual analog scale (VAS).

RESULTS

At baseline, 77% had hip pain in addition to shoulder pain and 100% had abnormal C-reactive protein or erythrocyte sedimentation rate. On ultrasound, 84% had shoulder findings and 32% had both shoulder and hip findings. Response to corticosteroid treatment occurred in 73% of patients by Week 4 and was highly correlated with percentage improvement in other VAS measures. Presence of ultrasound findings at baseline predicted response to corticosteroids at 4 weeks. Factor analysis revealed 6 domains that sufficiently represented all the outcome measures: PMR-related pain and physical function, an elevated inflammatory marker, hip pain, global pain, mental function, and morning stiffness.

CONCLUSION

PRO measures and inflammatory markers performed well in assessing disease activity in patients with PMR. A minimum set of outcome measures consisting of PRO measures of pain and function and an inflammatory marker should be used in practice and in clinical trials in PMR.

Self-directed learning of basic musculoskeletal ultrasound among rheumatologists in the United States

OBJECTIVE

Because musculoskeletal ultrasound (MSUS) is highly user dependent, we aimed to establish whether non-mentored learning of MSUS is sufficient to achieve the same level of diagnostic accuracy and scanning reliability as has been achieved by rheumatologists recognized as international experts in MSUS.

METHODS

A group of 8 rheumatologists with more experience in MSUS and 8 rheumatologists with less experience in MSUS participated in an MSUS exercise to assess patients with musculoskeletal abnormalities commonly seen in a rheumatology practice. Patients' established diagnoses were obtained from chart review (gout, osteoarthritis, rotator cuff syndrome, rheumatoid arthritis, and seronegative arthritis). Two examining groups were formed, each composed of 4 less experienced and 4 more experienced examiners. Each group scanned 1 predefined body region (hand, wrist, elbow, shoulder, knee, or ankle) in each of 8 patients, blinded to medical history and physical examination. Structural abnormalities were noted with dichotomous answers, and an open-ended answer was used for the final diagnosis.

RESULTS

Less experienced and more experienced examiners achieved the same diagnostic accuracy (US-established diagnosis versus chart review diagnosis). The interrater reliability for tissue pathology was slightly higher for more experienced versus less experienced examiners (kappa = 0.43 versus kappa = 0.34; P = 0.001).

CONCLUSION

Non-mentored training in MSUS can lead to the achievement of diagnostic accuracy in MSUS comparable to that achieved by highly experienced international experts. Reliability may increase slightly with additional experience. Further study is needed to determine the minimal training requirement to achieve proficiency in MSUS.

[Imaging techniques for giant cell arteritis. Ultrasound and MRI]

This article summarizes the examination technique, typical findings, interpretation and limitations of ultrasound diagnosis in patients with giant cell arteritis. Colour-coded sonography of the temporal artery has gained increasing attention. If experienced ultrasound examiners are available, diagnosis of giant cell arteritis in patients with a typical clinical constellation can be made based solely on sonographic findings, in particular by a hypoechogenic halo. The hitherto probably under-diagnosed large vessel variant of giant cell arteritis shows characteristic findings with a simple and quick ultrasound examination of the proximal arm arteries. High resolution MRI has been shown to be a promising technique for non-invasive imaging of giant cell arteritis. Mural inflammatory changes of the superficial temporal arteries can be depicted and the cranial involvement pattern can be readily assessed and in combination with MR angiography extracranial involvement can be determined within the same investigation. Aortitis is a feared complication of giant cell arteritis but can be detected and inflammatory stenoses of the aortic branch vessels can also be revealed. In the hands of an experienced operator ultrasonography can be regarded as the non-invasive imaging modality of first choice whereas MRI is more expensive and may not be as widely available. However, its imaging acquisition is standardized and is more observer-independent. Reading of the images is a routine task for a vascular radiologist and larger areas of the vasculature can be simultaneously assessed.

[Myalgia in polymyalgia rheumatica, temporal arteritis and other vasculitides]

Myalgias most commonly occur in polymyalgia rheumatica (PMR). About 45% of patients with giant cell arteritis present with symptoms of PMR. Other vasculitides may also lead to arthralgia and myalgia. While shoulder and pelvic pain is characteristic for PMR pain often also occurs in the back of the neck and in the region of the thoracic spine. In addition, patients often present with malaise, morning stiffness and weight loss. CRP and ESR are elevated. Ultrasound and MRI delineate minor synovitis, tenosynovitis and bursitis in the shoulder. Hip joint synovitis and trochanteric bursitis are also commonly seen. PMR should be distinguished from rheumatoid arthritis. The initial treatment comprises a prednisolone dose of 15-25 mg/day, followed by a weekly decrease of 1-2.5 mg. Once 10 mg/day has been reached the dose should be reduced more slowly.

[How effective is rituximab in rheumatoid arthritis?: lessons learned from clinical practice]

OBJECTIVES

Does experience with rituximab treatment of rheumatoid arthritis (RA) in daily clinical practice confirm the results of controlled randomized studies?

METHODS

This is a retrospective data-analysis of the first 50 patients from one center with rituximab treatment for RA. The patients received at least one cycle of 2 rituximab infusions (1000 mg, respectively) within 2 weeks. Clinical assessment was performed 3-5 months after the first infusion.

RESULTS

The patients were older (mean age, 59 years) as compared to previously published controlled studies. The DAS28 was lower (5.5). The mean prednisolone dose was high (13.4 mg/d). The rheumatoid factor was positive in 88% of patients. Only six patients would have fulfilled inclusion criteria for controlled studies such as prednisolone dose <or=10 mg/d, concomitant methotrexate treatment, previous TNF-inhibitor treatment, or absence of malignancy. Nevertheless, indications were compatible with recently published German Rheumatology Society recommendations on rituximab treatment. A total of 62% of patients achieved EULAR response, 20% good response and 10% remission. Response was greater in patients with concomitant methotrexate treatment (88% versus 53%). The results were independent of sex, presence of anti-CCP antibodies, ANA, and previous TNF-inhibitor treatment. Only three patients had pathologic infusion reactions at the first infusion and one patient at the second infusion.

CONCLUSIONS

Rituximab proved to be effective, particularly when combined with methotrexate. Most patients differed considerably from those who had entered randomized controlled studies. Recently published German Rheumatology Society recommendations proved to be feasible as they reflect daily clinical practice. Results of controlled studies could be confirmed.

What the practising rheumatologist needs to know about the technical fundamentals of ultrasonography

A transducer generates ultrasound waves and emits them into the body. Boundaries in or between tissues reflect the waves, and the transducer receives the reflected waves. A computer converts the information into images that are displayed on a monitor. Image resolution is greater with higher frequencies, and penetration is greater with lower frequencies. Linear probes with frequencies between 5 and 20 MHz are mainly used for musculoskeletal ultrasound. Image quality and resolution have improved significantly. Tissue harmonic imaging and cross-beam technology aid in differentiating between anatomical structures, although borders appear artificially thickened. Three-dimensional ultrasound provides additional coronary planes, and contrast agents increase the sensitivity for synovial blood flow in inflamed joints. This chapter provides further information regarding which ultrasound technology is the best for purchase by a rheumatology unit, how to organize ultrasound clinics, and how best to perform ultrasonography in daily practice, including the most important indications for ultrasound in rheumatology.

Pericardial effusion as primary manifestation of Takayasu arteritis

Takayasu arteritis (TA) is a chronic vasculitis, affecting young women in 80-90% of cases with greatest prevalence in Asians. As exudative pericarditis is an extremely rare, but a possible manifestation of TA, we report on a young women who presented with recurrent febrile pericardial effusion as primary manifestation of TA.

Do temporal artery duplex ultrasound findings correlate with ophthalmic complications in giant cell arteritis?

OBJECTIVE

Ophthalmic complications are common in acute GCA. Do temporal artery ultrasound and clinical parameters correlate with the occurrence and severity of ophthalmic complications?

METHODS

The results of temporal artery ultrasound examinations are compared with the occurrence of anterior ischaemic optic neuropathy (AION), central retinal artery occlusion (CRAO), branch retinal artery occlusion (BRAO), diplopia and amaurosis fugax in 222 consecutive patients with newly diagnosed, active GCA.

RESULTS

Temporal artery ultrasound displayed vasculitic wall swelling (halo), stenoses and/or acute occlusions in 84% (58% in 67 large-vessel GCA patients and 95% in 155 patients without proximal arm vasculitis). Ophthalmic complications occurred in 64 (29%), AION in 30 (14%), CRAO in 7 (3%), BRAO in 2 (1%), amaurosis fugax in 16 (7%) and diplopia in 9 patients (4%). Ophthalmic complications were insignificantly more common if temporal artery ultrasound was positive (31 vs 17%; P = 0.11) as a greater number of patients without arm vasculitis showed eye involvement (34 vs 18%; P = 0.02). The number of pathological temporal artery segments, presence of stenoses or bilateral findings did not correlate with ophthalmic complications. Age >or= 72 yrs at diagnosis correlated with a higher incidence of ophthalmic complications.

CONCLUSION

Ophthalmic complications occurred less frequently if proximal arm vasculitis was present. Findings of temporal artery ultrasound did not correlate with eye complications.

[Which ultrasound scan is the best to detect glenohumeral joint effusions?]

PURPOSE

It has not yet been systematically investigated which ultrasound scan is the best for detecting effusions of the glenohumeral joint. This question will be addressed by this study. Furthermore, this study determines reference values for distances to distinguish effusions from normal findings.

METHODS

Ultrasound was performed according to extended DEGUM and EULAR guidelines on 200 shoulders of 100 consecutive patients with shoulder complaints and on 40 shoulders of 20 healthy controls. Distances were measured between the surface of the humerus and the joint capsule in 3 positions: Axillary recess, dorsal transverse scan with 60 degrees internal rotation and with maximum external rotation. Normal values were calculated by ROC analysis.

RESULTS

The mean age of patients and controls was 58 and 55 years, and 67 % and 70 % were female, respectively. Ultrasound detected effusions in 81 shoulders of 56 patients. Effusions were seen in the dorsal scan with 60 degrees internal rotation in 30 %, in the axillary scan in 49 %, and in the dorsal scan in maximum external rotation in 94 % (p < 0.001, respectively). Five percent of the effusions were exclusively detected in the axillary scan. The upper normal limits for the distance between bone surface and joint capsule were 3.7 mm for the axillary recess, 2.7 mm for the dorsal region in 60 degrees internal rotation and 3.1 mm for the dorsal region in maximum external rotation .

CONCLUSIONS

Dynamic ultrasound examination including the dorsal scan with maximum external rotation is essential for detecting glenohumeral joint effusions. The axillary scan is superior to the dorsal transverse scan with 60 degrees internal rotation.

Color Doppler ultrasonography of hand and finger arteries to differentiate primary from secondary forms of Raynaud's phenomenon

OBJECTIVE

Modern ultrasound (US) equipment allows rheumatologists to directly visualize hand and finger arteries. How does US aid in diagnosis of Raynaud's phenomenon (RP)?

METHODS

Color Doppler US of the proper and common palmar digital, radial, and ulnar arteries and the superficial palmar arch of both hands was performed in 135 consecutive patients who presented with suspected RP.

RESULTS

US was pathologic in 63% of patients with secondary RP, in 6% with primary RP, and in none with pseudo-RP (p < 0.0001). We found 3 types of vascular pathology: Type 1 showed narrowing or chronic occlusion of some proper digital arteries; Type 2 was characterized by the same finding in all proper digital arteries; and Type 3 involved acute occlusions. Type 1 was found in 3 of 53 patients with primary RP and in 19 patients with secondary RP including 5 of 9 patients with anti-centromere positive systemic sclerosis (SSc); Type 2 occurred in 16 patients with SSc, MCTD, and dermatomyositis; and Type 3 was found in 8 patients with antiphospholipid antibody syndrome, thromboangiitis obliterans, vibration trauma, or vasculitis. The ulnar arteries were more commonly affected than the radial arteries. The 2nd radial, 3rd radial, 4th ulnar, and 5th ulnar proper palmar digital arteries were most commonly involved.

CONCLUSION

Aiding in differentiating primary versus secondary RP, severe versus less severe disease, and acute versus chronic vascular occlusion, digital artery US depicts the same anatomical structures as angiography, but it is cheaper, faster, and noninvasive.

Prognosis of large-vessel giant cell arteritis

OBJECTIVE

The prognosis of large-vessel GCA (LV-GCA) has not yet been investigated. How does it compare to GCA without arm vasculitis (GCA controls)?

METHODS

Charts of 53 LV-GCA patients and 53 GCA controls were reviewed following a predetermined protocol. Telephone interviews of patients or their primary care physicians were conducted. Forty LV-GCA patients underwent follow-up duplex ultrasound examinations of proximal arm arteries.

RESULTS

The mean observation time was 50 (s.d. +/- 31) months. None of the LV-GCA patients developed ischaemic arm complications. In 30%, proximal arm artery wall swelling disappeared completely. It decreased in 53%. In 8% it remained unchanged, in 5% it increased and in 5% arteries occluded with collateral flow. After the start of treatment, anterior ischaemic optic neuropathy developed neither in LV-GCA patients nor in GCA controls, amaurosis fugax occurred in 4 and 6%, arterial hypertension in 53 and 66%, strokes in 9 and 9%, myocardial infarction in 2 and 2%, diabetes mellitus in 30 and 25%, osteoporosis in 38 and 23%, and osteoporotic fractures in 15 and 4%, respectively. Mean corticosteroid dose was 3.7 mg/day. Mean duration of therapy was 42 months. All differences were insignificant. Four LV-GCA patients developed vasculitic popliteal artery stenoses.

CONCLUSIONS

The prognosis of LV-GCA is benign with regard to ischaemic complications. Proximal artery wall swelling decreases in most cases. Its course is similar to GCA without proximal arm arteritis.

Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis

Objective:

To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI.

Methods:

A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated.

Results:

Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver κ was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, −0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver κ for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively.

Conclusions:

US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

[Association between histopathologic type II synovitis and increased amounts of pyridinoline in synovial tissue samples in rheumatoid arthritis]

OBJECTIVE

To investigate the association between immunohistopathological and morphological features of synovitis in rheumatoid arthritis and the amounts of collagen degradation products pyridinoline and deoxypyridinoline in the synovial tissue and in body fluids in order to discover potential markers of erosive disease.

METHODS

Histopathological analysis of synovial tissue samples from 22 patients with RA was performed according to the histopathologic scoring system of RA synovitis by P. Stiehl. Accordingly, the samples were (a) classified into type I synovitis, type II synovitis, or undifferentiated synovitis and were (b) characterized for local features of disease activity, including basic activity and actual activity. The contents of pyridinoline and deoxypyridinoline were measured in the synovial tissue, the synovial fluid, serum and urine by HPLC analysis.

RESULTS

The amounts of pyridinoline in synovial tissue samples characterized by type II synovitis were 1.7-fold and 2.7-fold higher compared with those with type I synovitis and undifferentiated synovitis, respectively. In contrast, the content of deoxypyridinoline was not different between the histopathologic types of synovitis. At the same time, increased amounts of pyridinoline, but not deoxypyridinoline, were detected in synovial tissue samples with basic activity or actual activity grade II compared with synovial tissue samples with basic activity or actual activity grade I. The concentrations of both collagen degradation products in the synovial fluid, serum and urine did not differ between patients when they were analyzed either for histopathologic types of synovitis or local disease activity.

CONCLUSION

The amount of cartilage collagen degradation product pyridinoline in synovial tissue is positively correlated with the histopathological grading of local disease activity. Furthermore, the increased amounts of pyridinoline in synovial tissue samples with type II synovitis suggest a more erosive course of RA in patients with this type of synovitis.

Ultrasonography of salivary glands -- a highly specific imaging procedure for diagnosis of Sjögren's syndrome

OBJECTIVE

To verify ultrasonographic criteria for examination of the major salivary glands in diagnosis of primary and secondary Sjögren's syndrome (SS).

METHODS

Three hundred sixteen consecutive patients with rheumatic diseases were selected according to the European Consensus Study Group diagnostic criteria for SS. Fifty-seven had primary SS, 33 had secondary SS, 78 had Sicca symptoms, and 148 patients served as asymptomatic controls. This cohort was analyzed for size and parenchymal echogenicity of the major salivary glands by ultrasonography.

RESULTS

Evident parenchymal inhomogenicity in 2 or more major salivary glands was detected by ultrasonography in patients with primary and secondary SS with a sensitivity of 63.1% and 63.6%, respectively. The specificity of this imaging approach in our cohort was 98.7%. The volume of submandibular glands was reduced in patients with primary and secondary SS by about 30% compared to patients with sicca symptoms and asymptomatic controls. In receiver-operating characteristic (ROC) curve analysis, the detection of reduced volumes of both submandibular glands in patients with primary and secondary SS had a specificity of 93% and a sensitivity of 48% at the cutoff point of 3.0 ml. Of note, the volume of the parotid glands did not differ between the groups of patients. In patients with primary SS, parenchymal inhomogenicity of the salivary glands was strongly associated with positivity for anti-Ro and/or anti-La antibodies.

CONCLUSION

Ultrasonographic detection of parenchymal inhomogenicity of the major salivary glands and observation of reduced volume of the submandibular glands resulted in high specificities for diagnosis of primary and secondary SS. The data indicate that ultrasonography of major salivary glands is a noninvasive imaging procedure with high diagnostic value for the diagnosis of primary and secondary SS.

Recommendations for the content and conduct of European League Against Rheumatism (EULAR) musculoskeletal ultrasound courses

OBJECTIVE

To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses.

METHODS

We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels.

RESULTS

The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses.

CONCLUSION

We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

[Imaging procedures in rheumatology: imaging in vasculitis]

In small vessel vasculitides, imaging studies aid in determining disease extent and activity, localization for biopsy, and for disease monitoring. They do not directly delineate the vasculitic lesion. Imaging studies focus on the upper and lower respiratory tract. Cranial magnetic resonance imaging (MRI) shows upper respiratory and retrobulbar granuloma in Wegener's granulomatosis. Furthermore, MRI depicts both mastoiditis and mucosal inflammation of the ear, nose, and throat. It is sensitive but not specific for the detection of cerebral vasculitis. Computed tomography (CT) reliably detects osseous facial lesions. Chest radiography in two planes remains the standard method of investigation for the lower respiratory tract. High-resolution CT aids in detecting further interstitial pathologies. Medium-sized vasculitides frequently occur with aneurysms. The classification criteria for polyarteritis nodosa involve the angiographic detection of visceral aneurysms. Patients with Kawasaki disease may develop coronary aneurysms that may be described by echocardiography or angiography according to diagnostic criteria. In large-vessel vasculitides such as temporal arteritis (giant cell arteritis) and Takayasu arteritis, MRI, MR-angiography, CT, CT-angiography, and duplex sonography delineate characteristic homogenous wall thickening with or without stenoses in the aorta and other arteries. There is a high correlation with angiography and positron emission tomography. Duplex sonography of the temporal arteries has a high sensitivity and specificity for the diagnosis. Data on temporal artery MRI in giant cell arteritis have recently been published.

Summary findings of a systematic review of the ultrasound assessment of synovitis

This report presents the results of a recent systematic review performed by the OMERACT Ultrasound Group on the metric properties of ultrasound for the detection of synovitis in inflammatory arthritis. Reviews were conducted for the hand, wrist, elbow, shoulder, knee, ankle, and foot; most reports were related to the hand and knee, and the most common disease process was rheumatoid arthritis. The review highlights the current gaps in the literature, including a lack of reliability data with respect to intra-occasion and intra- and inter-reader reliability. Current work by our group is addressing these issues.

The OMERACT Ultrasound Group: status of current activities and research directions

Ultrasound (US) is a relatively new imaging modality in rheumatology that offers great potential as a diagnostic and management tool. In 2004, an OMERACT Ultrasound Special Interest Group was formed to address the metric qualities of US as a potential outcome measure. A preliminary systematic review highlighted the deficiencies in the literature, particularly with regard to the reliability of interpreting and acquiring images; as a consequence, a number of exercises were proposed to address these issues. This report describes a series of iterative studies that have resulted in improved intra- and inter-reader reliability for detecting and scoring synovitis from both static and real-time images of the hand joints of patients with rheumatoid arthritis. The reliability of acquiring images was also enhanced using standardized positions. Future studies will assess the value of US in clinical trials.

Technology Insight: the role of color and power Doppler ultrasonography in rheumatology

An increasing number of rheumatologists have access to ultrasound equipment that provide both color and power Doppler modes, which can be used to investigate musculoskeletal and vascular pathologies. Musculoskeletal Doppler ultrasonography can be used to estimate levels of inflammation, to document the anti-inflammatory effect of agents such as corticosteroids and tumor necrosis factor inhibitors, to differentiate between inflammatory and degenerative disease, and to distinguish between normal and inflamed joints in cases of minor synovial swelling. Vascular Doppler ultrasonography can be used to determine organ involvement in small-vessel vasculitides, to delineate aneurysms in vasculitides of medium-sized arteries, and to assess the characteristic findings in large-vessel vasculitis. Numerous studies, including a meta-analysis, have been published on the use of temporal-artery ultrasonography for the diagnosis of giant cell arteritis. Duplex ultrasonography is a sensitive approach for detecting characteristic edematous wall swellings in active temporal arteritis and for assessing vasculitis of the axillary arteries (large-vessel giant cell arteritis) in patients with suspected temporal arteritis, polymyalgia rheumatica, or fever of unknown origin. Duplex ultrasonography can also be used to assess vasculitis of subclavian and carotid arteries in younger patients with Takayasu's arteritis and acute finger artery occlusions in patients with small-vessel vasculitides.

Assessing the intra- and inter-reader reliability of dynamic ultrasound images in power Doppler ultrasonography

OBJECTIVE

To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips.

METHOD

99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system.

RESULTS

The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (kappa = 0.52-0.82).

CONCLUSIONS

Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.

Current diagnosis and treatment of temporal arteritis

Corticosteroid treatment should start directly after suspected diagnosis. The diagnosis should be confirmed within the next 5 days by histology or ultrasound. Clinical assessment includes auscultation of the axillary arteries in the search for large-vessel giant cell arteritis. Angiography, magnetic resonance angiography, positron emission tomography, or ultrasound can confirm the diagnosis of large-vessel giant cell arteritis. The initial prednisolone dose is 40 to 70 mg/d. It should be reduced in weekly steps of 5 to 10 mg until 20 mg/d, and by 2.5 mg until 10 mg/d. Dose reduction is 1 mg/mo below 10 mg/d, depending on symptoms and erythrocyte sedimentation rate or C-reactive protein. Patients with ophthalmologic complications receive three to four daily infusions of 250 mg of methylprednisolone for 3 days. Low-dose aspirin reduces the risk of ophthalmologic and cardiovascular complications. The benefit of methotrexate as a corticosteroid-sparing agent is controversial. Corticosteroid treatment requires monitoring of glucose, blood and eye pressure, and adequate prevention of osteoporosis.

Colour duplex sonography of finger arteries in vasculitis and in systemic sclerosis

CASE REPORTS

Three patients-two with Wegener's granulomatosis and one with an overlap syndrome of rheumatoid vasculitis, systemic lupus erythematosus, and antiphospholipid syndrome-are described. All patients experienced a sudden onset of Raynaud's phenomenon or acrocyanosis when they had a flare of their disease.

DISCUSSION

Ultrasonography (US) showed dark (hypoechoic) arteries without colour signals, resembling the US pattern of embolism. In contrast, US in patients with systemic sclerosis is entirely different, delineating a smaller artery lumen, reduced pulsation, and thickened, slightly hyperechoic artery walls.

Manifestation of rheumatoid arthritis in a patient with hereditary haemochromatosis

Articular symptoms are frequent manifestations of hereditary haemochromatosis. The clinical signs of the arthropathy of haemochromatosis are not specific and difficult to identify in case of co-incidence of haemochromatosis with Heberden's and Bouchard's osteoarthritis or rheumatoid arthritis (RA). Here the manifestation of RA in a patient is reported who was successfully treated for haemochromatosis. Six months after terminating phlebotomy, the patient presented again suffering from impressive swelling of all MCP joints, showing strong synovitis in ultrasound, and from morning stiffness longer than 1 h. ESR, CRP, IgM rheumatoid factor, and anti-cyclic citrullinated peptide antibodies were markedly elevated. Based on these findings the diagnosis of RA was made. Therefore, the high prevalence of RA and haemochromatosis in the general population underlines the usefulness of a screening for HFE gene mutations in RA patients with an atypical course of the disease as well as in patients with undifferentiated arthritis.

Takayasu and temporal arteritis

Takayasu and temporal arteritis are primary large-vessel vasculitides. Ultrasound directly depicts the inflamed vessel wall, which is homogenously and circumferentially thickened. Furthermore, stenoses and occlusions occur. Ultrasound almost completely depicts the whole length of the common superficial temporal arteries, including the frontal and parietal ramus. Inflammation is often segmental. This may lead to a false-negative histology. The wall swelling is hypoechoic in acute temporal arteritis. It disappears within 2-3 weeks with corticosteroid treatment. Sonographers should use 8-15 MHz linear probes. The pulse repetition frequency should be about 2.5 kHz. Color box steering and beam steering should be maximal. It is essential that the color covers the artery lumen exactly. Sensitivities and specificities with regard to clinical diagnosis and histology are high. Large-vessel giant cell arteritis is a subset of temporal arteritis, with involvement of the subclavian, axillary, and proximal brachial arteries. The wall swelling resolves much slower with treatment. In Takayasu arteritis ultrasound is a valuable diagnostic tool to investigate particularly the common carotid, subclavian, and vertebral arteries. The echogenicity of the arterial wall thickening is, in general, higher than in giant cell arteritis, as the nature of Takayasu arteritis is more chronic, with less wall edema.

Musculoskeletal ultrasound including definitions for ultrasonographic pathology

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

What is the best approach to diagnosing large-vessel vasculitis?

Temporal arteritis, including large-vessel giant cell arteritis, and Takayasu's arteritis are the two primary large-vessel vasculitides. Patients with temporal arteritis often present with headache, swollen temporal arteries, impairment of vision or symptoms of polymyalgia rheumatica. Clinical examination includes palpation of the temporal arteries and radial pulses, auscultation of the subclavian and axillary region, and fundoscopy. The presence of jaw claudication, diplopia and temporal artery abnormalities correlates with a high probability of positive histology. Duplex ultrasonography of the temporal arteries delineates a characteristic hypoechoic, oedematous wall swelling, stenoses and occlusions. It detects the same pathologies in the axillary arteries and other arteries in large-vessel giant cell arteritis. Angiography, magnetic resonance imaging, magnetic resonance angiography, electron beam computed tomography, computed tomography angiography and positron emission tomography show characteristic changes in the aorta and its primary branches in large-vessel giant cell arteritis and Takayasu's arteritis. Takayasu's arteritis often begins with diffuse symptoms such as low-grade fever, arthralgia, fatigue and weight loss. Clinical examination is important to detect bruits, pulse reduction and blood pressure differences. Profound experience exists with angiography. Other imaging methods are interesting alternatives as they are less invasive and may depict the inflammatory wall swelling.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course

OBJECTIVE

To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography.

METHODS

The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results.

RESULTS

Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae.

CONCLUSIONS

Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.

Fatal fetal hemorrhage and placental pathology. Report of three cases and a new setting

We report three cases of late third trimester fetal death in utero consequent to fetal exsanguination from the chorionic vasculature. In general, fetal hemorrhage is unusual, exsanguination is rare and the location and basis of the hemorrhage varies widely. Intragestational and intrapartum hemorrhage is far more often of maternal rather than fetal origin. Even when severe, the former is almost always manageable whilst the latter may be clinically obscure, intractable, catastrophic and fatal. In this presentation, we review and characterize fetal hemorrhage by anatomical location and on the basis of its underlying origins. In our first two cases, the chorionic vascular failure is understood on the basis of mechanical factors, such as tearing by the presenting part or an amniotomy hook. Our third case demonstrates the first reported instance in which a severe chorionic vasculopathy has damaged a placental surface vessel sufficiently to permit spontaneous rupture and fetal exsanguination.

Use of ultrasonography and positron emission tomography in the diagnosis and assessment of large-vessel vasculitis

PURPOSE OF REVIEW

Ultrasonography and positron emission tomography have been increasingly studied and, in part, introduced in clinical practice to diagnose large-vessel vasculitides, such as temporal arteritis, Takayasu arteritis, large-vessel giant cell arteritis, and isolated aortitis.

RECENT FINDINGS

Ultrasonography reveals characteristic homogenous, concentric wall thickening in vasculitis, often combined with stenoses and, less frequently, with acute occlusions. Thirteen studies describe sensitivities of 40 to 100% (median, 86%) for temporal artery vessel wall edema compared with histology, and of 35 to 86% (median, 70%) compared with clinical diagnosis. If wall edema, stenoses, and occlusions are included, sensitivities increase to 91 to 100% (median, 95%) compared with histology, and to 83 to 100% (median, 88%) compared with clinical diagnosis. Specificities for wall edema are 68 to 100% (median, 93%) compared with histology, and 78 to 100% (median, 97%) compared with clinical diagnosis. One should be aware of large-vessel giant cell arteritis in all patients with temporal arteritis and polymyalgia rheumatica. Ultrasonography reveals characteristic wall thickening, particularly of the distal subclavian, axillary, and proximal brachial arteries. Findings in Takayasu arteritis are similar, but the vessel wall swelling is usually brighter. Positron emission tomography reveals vasculitis in arteries with a diameter of more than 4 mm. Ultrasonography and positron emission tomography agreed completely in the anatomic distribution of changes in patients with large-vessel giant cell arteritis. It reveals asymptomatic large-vessel vasculitis in giant cell arteritis and Takayasu arteritis. Positron emission tomography is not suitable for the assessment of temporal arteries.

SUMMARY

Ultrasonography and positron emission tomography are new, promising techniques to assess large-vessel vasculitides.

Meta-analysis: test performance of ultrasonography for giant-cell arteritis

BACKGROUND

Giant-cell arteritis is a diagnostic challenge.

PURPOSE

To determine the diagnostic performance of ultrasonography for giant-cell arteritis.

DATA SOURCES

Studies published up to April 2004 in the MEDLINE, EMBASE, and Cochrane databases; reference lists; and direct contact with investigators.

STUDY SELECTION

Studies in any language that examined temporal artery ultrasonography for diagnosis of giant-cell arteritis, enrolled at least 5 patients, and used biopsy or the American College of Rheumatology (ACR) criteria as the reference standard.

DATA EXTRACTION

Two reviewers independently graded methodologic quality and abstracted data on sensitivity and specificity of ultrasonography for giant-cell arteritis. Diagnostic performance was determined for the halo sign, stenosis, or occlusion and for any of these ultrasonographic abnormalities.

DATA SYNTHESIS

Weighted sensitivity and specificity estimates and summary receiver-operating characteristic (ROC) curve analysis were used. Twenty-three studies, involving a total of 2036 patients, met the inclusion criteria. The weighted sensitivity and specificity of the halo sign were 69% (95% CI, 57% to 79%) and 82% (CI, 75% to 87%), respectively, compared with biopsy and 55% (CI, 36% to 73%) and 94% (CI, 82% to 98%), respectively, compared with ACR criteria. Stenosis or occlusion was an almost equally sensitive marker compared with either biopsy (sensitivity, 68% [CI, 49% to 82%]) or ACR criteria (sensitivity, 66% [CI, 32% to 89%]). Consideration of any vessel abnormality nonsignificantly improved diagnostic performance compared with ACR criteria. Between-study heterogeneity was significant, but summary ROC curves were consistent with weighted estimates. When the pretest probability of giant-cell arteritis is 10%, negative results on ultrasonography practically exclude the disease (post-test probability, 2% to 5% for various analyses).

LIMITATIONS

The primary studies were small and of modest quality and had considerable heterogeneity.

CONCLUSION

Ultrasonography may be helpful in diagnosing giant-cell arteritis, but cautious interpretation of the test results based on clinical presentation and pretest probability of the disease is imperative.

Doppler sonography in rheumatology

The importance of ultrasonography in rheumatology has increased dramatically within the last few years both with regard to clinical practice and to research. High-resolution colour Doppler ultrasound equipment is, to date, widely available. Colour and power Doppler studies of intra-articular and peritendinous blood flow allow an estimation of the inflammatory activity and aid in distinguishing anatomical structures. Contrast agent increases the ability of ultrasonography to detect even minor perfusion. These findings have a practical clinical impact on the management of inflammatory rheumatic diseases. The resolution of ultrasonography is superior to that of magnetic resonance imaging (MRI) and computed tomography (CT) with regard to superficial anatomical structures. Furthermore, ultrasonography can depict the artery wall in contrast to angiography. In temporal arteritis and Takayasu's arteritis, ultrasonography depicts characteristic, homogenous wall thickening, stenoses and acute occlusions. These pathologies resolve quickly with treatment in the temporal arteries and much more slowly in larger arteries.

Interobserver reliability of rheumatologists performing musculoskeletal ultrasonography: results from a EULAR "Train the trainers" course

OBJECTIVE

To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard".

METHODS

The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed.

RESULTS

Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%).

CONCLUSION

Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

Temporal arteritis with pauci-immune glomerulonephritis: a systemic disease

Temporal arteritis is easily diagnosed and responds gratifyingly to treatment. Renal complications are unusual, but nevertheless occur. Earlier, an association between pauci-immune glomerulonephritis and temporal arteritis was shown. We present a patient who clearly had temporal arteritis but also developed cerebral hemorrhage, pulmonary infiltrates related to granulomatous pulmonary vasculitis, and pauci-immune glomerulonephritis. We suggest that temporal arteritis is neither always localized nor temporal. Instead, the condition can be a lethal, systemic disease. Renal involvement in patients with temporal arteritis is not common and the presence of glomerulonephritis is rare [Jennette and Falk 1994]. Lenz et al. [1998] described a patient who developed vision loss, optic nerve atrophy, elevated erythrocyte sedimentation rate, a positive rheumatoid factor and terminal glomerulonephritis. The renal biopsy showed focal and segmental necrotizing glomerulonephritis, despite negative antineutrophil cytoplasmatic antibodies (ANCA), antinuclear antibodies and antiglomerular basement membrane antibodies. Giant cells were identified in the necrotic vessel walls within the kidney. Immunofluorescence was negative and a diagnosis of ANCA-negative pauci-immune glomerulonephritis was made. The patient did not respond to immunosuppression and developed end-stage renal disease. Although the clinical attributes were consistent with temporal arteritis, no temporal artery biopsy was done in that patient. We recently treated a patient with temporal arteritis and pauci-immune glomerulonephritis. Our patient's course was somewhat different in comparison to the patient described by Lenz et al. [1998].

Standard reference values for musculoskeletal ultrasonography

OBJECTIVES

To determine standard reference values for musculoskeletal ultrasonography in healthy adults.

METHODS

Ultrasonography was performed on 204 shoulders, elbows, hands, hips, knees, and feet of 102 healthy volunteers (mean age 38.4 years; range 20-60; 54 women) with a linear probe (10-5 MHz; Esaote Technos MP). Diameters of tendons, bursae, cartilage, erosions, hypoechoic rims around tendons and at joints were measured with regard to established standard scans. Mean, minimum, and maximum values, as well as two standard deviations (2 SD) were determined. Mean values +/-2 SD were defined as standard reference values.

RESULTS

Hypoechoic rims were normally present in joints and tendon sheaths owing to physiological synovial fluid and/or cartilage. Similarly, fluid was found in the subdeltoid bursa in 173/204 (85%), at the long biceps tendon in 56 (27%), in the suprapatellar recess in 158 (77%), in the popliteal bursae in 32 (16%), and in the retrocalcaneal bursa in 49 (24%). Erosions of >1 mm were seen at the humeral head in 47 (23%). Values for important intervals were determined. The correlation between two investigators was 0.96 (0.78-0.99). The reliability of follow up investigations was 0.83 (0.52-0.99).

CONCLUSIONS

Fluid in bursae as well as hypoechoic rims within joints and around tendons are common findings in healthy people. This study defines standard reference values for musculoskeletal ultrasonography to prevent misinterpretation of normal fluid as an anatomical abnormality.

Use of imaging studies in the diagnosis of vasculitis

Imaging studies are necessary to determine disease extension and disease activity in the small-vessel vasculitides. Computed tomography (CT) and magnetic resonance imaging (MRI) increase the number of pathologic findings compared with conventional radiography. MRI delineates mucosal inflammation and granulomas in the paranasal sinuses, whereas CT provides information about osseous lesions. CT is superior to MRI for the detection of pulmonary lesions. Radiograph angiography has been the gold standard for medium- and large-vessel vasculitides for decades. Echocardiography and MRI correspond well with conventional angiography to assess cardiac involvement in Kawasaki disease. MRI, CT, and CT angiography are alternative noninvasive techniques to delineate vasculitic lesions in polyarteritis nodosa, Takayasu's arteritis, and large-vessel giant cell arteritis. Duplex ultrasonography has the greatest resolution. It delineates typical artery wall swelling in temporal arteritis and Takayasu's arteritis. Positron emission tomography can assess inflammatory activity of large arteries.