Pulmonale Manifestationen bei Erkrankungen des rheumatischen Formenkreises

Collagen based vascular diseases with pulmonary involvement comprise rheumatoid arthritis, systemic lupus erythematosus, progressive systemic sclerosis, dermatomyositis and polymyositis, ankylosing spondylitis, Sjögren's syndrome, and mixed connective tissue diseases. The different characteristics of pulmonary involvement are described. In such circumstances, early recognition of lung involvement is of considerable significance and the relationship to the corresponding disease has to be made. Frequently unrecognised pulmonary involvement ends up as fibrosis with irreversible deficits in respiratory function.

The role of ultrasound in the diagnosis and management of psoriatic arthritis

Psoriatic arthritis (PsA) presents many diagnostic, management and research challenges for rheumatologists who wish to obtain early diagnosis, differentiate synovitis and enthesitis, monitor disease activity accurately and objectively, prevent the development of structural damage, deliver local therapy accurately, and obtain PsA tissue for research purposes. Musculoskeletal ultrasound (MSUS) is widely used by European rheumatologists in their clinical practice to meet these challenges and has the potential to become the rheumatologist's stethoscope in Europe and North America. This paper examines the evidence that MSUS can improve clinical evaluation of patients with PsA for synovitis and enthesitis, that MSUS is more sensitive than plain radiography in detecting structural damage in joints, that MSUS can improve the success of joint aspiration and guide biopsy of PsA tissues. Recent exciting developments in the management of PsA are detailed including the role of power Doppler in the diagnosis of enthesitis in PsA, the role of MSUS in objective monitoring of disease activity, the evaluation of MSUS in the diagnosis of sacroiliitis, and the use of MSUS to guide therapeutic injection of the sacroiliac joints.

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.

Ultrasound in rheumatology

Over the last decade, several studies have highlighted the value of ultrasonography for both clinical and research purposes in rheumatology. Ultrasonography is a non-invasive, inexpensive and free-of-radiation-hazards imaging technique providing quick and useful information for the management of rheumatic diseases. Considerable evidence supporting the role of ultrasonography in rheumatological clinical practice has led many rheumatologists to want to become experienced with this imaging technique. The main indications of ultrasonography in rheumatology include the evaluation of patients with regional pain syndromes and chronic arthritis, short-term therapy monitoring and guidance for invasive procedures. Ultrasonography's long learning curve is the main obstacle that hinders its widespread use in rheumatology. Many technical aspects may affect the scanning process and a correct interpretation of sonographic images depends on several elements such as a deep knowledge of ultrasonography anatomy and pathology.

Radiologic investigation of rheumatic diseases

This article reviews the current use of the wide variety of imaging modalities now available, presenting the imaging features of common and important causes of acute and chronic rheumatic disorders including juvenile idiopathic arthritis, spondyloarthropathies/enthesitis-related arthritis, sepsis, autoimmune diseases, vasculitis, and osteoporosis.

Musculoskeletal ultrasound

Over the last few years a sonographic revolution has occurred in rheumatology. Ultrasonography has been shown to be capable of substantially changing the traditional approach to most clinical problems in daily rheumatological practice because of its ability to allow a quick, safe and inexpensive access to otherwise undetectable anatomical information on the early targets of most rheumatic diseases. Ultrasonography completes the physical examination in a rapid and accurate manner and allows the detection of a wide spectrum of pathological findings involving different anatomical structures in the musculoskeletal system. Guidance for intervention (joint aspiration, synovial or soft tissue biopsy, joint or tendon sheath injection) is a major application of ultrasonography. Sonographic guidance is particularly useful when fluid collections are very small or when the inflammatory process is adjacent to anatomical structures that could be seriously damaged by the injection.

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.

Recommendations for musculoskeletal ultrasonography by rheumatologists: Setting global standards for best practice by expert consensus

OBJECTIVE

To establish an expert consensus of best practice for rheumatologists performing musculoskeletal ultrasonography (MUS).

METHODS

A panel of worldwide experts in MUS was identified by literature review, membership of teaching faculty, and peer recommendation. They were invited to take part in a 4-stage Delphi process employing 2 iterative rounds to establish a consensus of specific indications, anatomic areas, and knowledge and skills required by rheumatologists performing MUS.

RESULTS

Experts in MUS were identified (n = 57; 37 radiologists, 20 rheumatologists). Successive rounds of this rigorous Delphi exercise enabled group consensus to be achieved in 30 of the proposed 37 categories comprising 8 of 13 indications (inflammatory arthritis, tendon pathology, effusion, bursitis, monitoring disease activity, monitoring disease progression, guided aspiration, and injection), 8 of 10 anatomic areas (hand, wrist, elbow, shoulder, hip, knee, ankle and heel, and forefoot), and 14 categories of knowledge and skills (physics, anatomy, pathology, equipment, clinical application and relevance, indications and limitations, artifact, machine function and operation, patient and probe position, planes and system of examination, image optimization, dynamic assessment, color Doppler, and power Doppler).

CONCLUSION

We have produced the first expert-derived, interdisciplinary consensus of recommendations for rheumatologists performing MUS. This represents a significant advance that will not only direct future rheumatology MUS practice, but will facilitate informed educational development. This is an important step towards the introduction of a specific training curriculum and assessment process to ensure competent rheumatologist ultrasonographers.

Scintigraphy in rheumatic diseases

The aim of this review is to summarise the clinical role of nuclear medicine in rheumatology taking into consideration the most specific diagnostic applications and other worthwhile therapeutic contributions. Traditional bone scintigraphy and recent inflammation-targeting radiopharmaceuticals, such as radiolabelled leucocytes and immunoscintigraphy, now allow us to obtain highly sensitive total-body and tomographical imaging information that can be used for the diagnosis of osteoarticular disease. The most common extra-articular manifestations of rheumatic diseases due to digestive, central nervous, respiratory and cardiovascular system involvement can be diagnosed by specific scintigraphic methods. Radiosynovectomy plays an important role in providing effective treatment for some joint diseases that are resistant to pharmacological therapy. Diagnostic and therapeutic applications of nuclear medicine show the highest efficacy in the early phase of rheumatic diseases. In more advanced stages, scintigraphical techniques play a complementary role to radiographical investigations in the assessment of prognosis and therapy efficacy.

Differential diagnosis of rheumatic diseases using conventional radiography

The approach to the differential diagnosis of rheumatic diseases using conventional radiography is systematic and module-oriented, which, with respect to future developments, forms the basis for computer-assisted diagnosis (CAD). The indications follow consensus-based referral criteria and attempts should be made to raise the evidence level of the recommendations. Investigation techniques have been improved in the last few years with the use of digital radiography. New imaging technologies may be available in the future that will achieve at least the same quality of images, while exposing patients to a significantly lower radiation dose. The interpretation of radiographical signs could be enhanced through a correlation with other imaging modalities. Computer-assisted techniques with image processing tools for automated measurements, lesion detection and in the form of expert systems are under development. With conventional radiography embedded in CAD systems, promising options will be available to enhance the differential diagnosis of rheumatic diseases.

Somatostatin and somatostatin analog scintigraphy: any benefits for rheumatology patients?

Somatostatin is a hormone that regulates several physiological cell processes via specific receptors expressed throughout the body, in particular by nerve cells, many neuroendocrine cells, and cells mediating inflammation and immune responses. Somatostatin receptor scintigraphy achieved by administration of somatostatin labeled with a gamma-emitting isotope has become an integral part of the work-up and treatment-monitoring program in patients with neuroendocrine tumors, most of which overexpress somatostatin receptors. Several studies have convincingly established that somatostatin receptor scintigraphy benefits patients with a number of chronic inflammatory diseases, including sarcoidosis and other granulomatous diseases. In the evaluation of hematological diseases and detection of mesenchymatous tumors manifesting as oncogenic osteomalacia, the preliminary results are sufficiently promising to warrant larger studies aimed at defining the role for this noninvasive whole-body imaging technique. In the treatment area, the development of somatostatin analogs with antisecretory and antiproliferative effects has radically changed the management of gastroenteropancreatic neuroendocrine and pituitary tumors. The antiinflammatory and analgesic effects of these drugs remain incompletely understood, but may prove useful in a number of autoimmune diseases.

The hand X-ray in rheumatology

X-ray of the hands is the most valuable imaging modality in rheumatology. Joint disease may be identified by individual features such as joint space narrowing, erosions, new bone formation, subluxation and deformity, which may be diagnostic. In diseases such as rheumatoid arthritis presence of erosions on hand X-ray give a valuable measure of disease progression and response to therapy.

[Practical approach to usual rheumatologic and traumatic diseases in elderly patients]

Rheumatologic and traumatic pathology is particularly important in elderly patients because it may compromise autonomy. The severity of the loss of autonomy is variable and it may be temporary or permanent. Therefore rapid and suitable care is necessary, old age in itself being an emergency factor. The purpose of this article is to develop an approach that based on presenting symptoms such as pain, mild or severe disability, or a modification of behavior in an elderly patient will enable:--to correctly evaluate the clinical findings which will guide the imaging--to not exclude a traumatic origin even if it doesn't seem obvious--to adapt the radiological examinations depending on the therapeutic possibilities--to demonstrate that plain radiographs are usually sufficient--to not deny access to CT or MRI systematically on the basis of old age. Knowledge of specific geriatric issues and correlation with imaging findings will usually improve the quality and quantity of life of elderly patients.

Salivary gland scintigraphy in Sjögren's syndrome: are quantitative indices the answer?

We evaluated the role of quantitative indices derived from dynamic 99mTc-pertechnetate salivary scintigraphy in the differentiation between a group of patients with Sjögren's syndrome (SS), a group of patients without xerostomia, but with underlying autoimmune disorders, and a group of controls. Seventeen patients with SS (group A), 18 patients with autoimmune disorders (group B) and 15 controls (group C) underwent dynamic salivary gland scintigraphy. Functional indices for the parotid and submandibular glands were calculated and comparisons were made between the groups. There were no significant differences between the three groups in terms of the maximum accumulation (MA), maximum secretion (MS) and pre-stimulatory oral index (PRI). The uptake ratios (URs) for both the right and left parotid glands and the left submandibular gland in group A were significantly lower than those in group C, but no different from those in group B. The URs for the parotid glands in group B were significantly less than those in group C. The percentage uptake by the right parotid gland at 4 min (U4) was significantly lower in group A than in groups B or C, and lower than the percentage uptake by the left parotid gland at 4 min in group A. The rest of the U4 values and all of the uptakes at 14 min (U14) were not significantly different between the three groups. The time taken for the right parotid gland to reach peak activity (Tmax) was significantly less in group A than in the other groups, but other glands showed no significant differences. It can be concluded that MA, MS and PRI cannot be used to differentiate between the three groups. The URs in groups A and B were no different, but were significantly lower than those in group C. However, the extensive overlap between xerostomic patients and normal controls for all the quantitative indices calculated imposes a severe limitation on their discriminatory power.

Clinical utility of the anti-CCP assay in patients with rheumatic diseases

OBJECTIVES

To determine the frequency of antibodies to cyclic citrullinated peptides (CCP) in a group of patients with a diversity of rheumatic diseases.

METHODS

249 consecutive sera from an arthritis clinic sent for rheumatology testing were selected for testing with the anti-CCP2 assays and for the presence of rheumatoid factor (RF). Patient charts were reviewed for demographic information, clinical diagnosis, radiographic information, and other laboratory data.

RESULTS

The sensitivity and specificity of anti-CCP reactivity for the diagnosis of rheumatoid arthritis (RA) were 66.0% and 90.4%, respectively. This compared with the sensitivity and specificity of RF for RA at 71.6% and 80.3%. Furthermore, 10/29 (34%) RF- patients with RA demonstrated reactivity to CCP. The presence of either anti-CCP or RF increased testing sensitivity for diagnosis of RA to 81.4%; the presence of both RF and anti-CCP demonstrated a testing specificity similar to that of anti-CCP reactivity alone for the diagnosis of RA (91.1%).

CONCLUSIONS

The detection of anti-CCP is useful for the diagnosis of RA, in fact even more so than RF, because of its higher specificity.

Sonographic training in rheumatology: a self teaching approach

OBJECTIVE

To evaluate a self teaching approach to be followed by a novice without previous practical experience in musculoskeletal ultrasonography.

METHODS

The novice was given short general training (two hours) by an experienced sonographer focusing on the approach to the ultrasound equipment, and asked to obtain the best sonographic images of different anatomical areas as similar as possible to the "gold standard" pictures in the online version of the guidelines for musculoskeletal ultrasonography in rheumatology (free access at http://www.sameint.it/eular/ultrasound). At the end of each scanning session, both novice and tutor scored "blindly" all the images from 0 (the lowest quality) to 10 (the highest quality), with a minimum quality score of 6 considered acceptable for standard clinical use. The tutor then explained how to improve the quality of the pictures. Fourteen consecutive inpatients (seven with rheumatoid arthritis, three with psoriatic arthritis, two with reactive arthritis, and two with osteoarthritis) and five healthy subjects were examined. Ultrasound examinations were performed with a Diasus (Dynamic Imaging Ltd, Livingston, Scotland, UK) using two broadband linear probes of 5-10 and 8-16 MHz frequency.

RESULTS

Sonographic training lasted one month and included 30 scanning sessions (24 hours of active scanning). 243 images were taken of the selected anatomical areas. The mean time required to produce each image was 6 minutes (SD 4.2; range 1-30). At the end of the training, the novice scored >/=6 for each standard scan.

CONCLUSION

A novice can obtain acceptable sonographic images in 24 non-consecutive hours of active scanning after an intensive self teaching programme.

[Radiologic diagnosis of rheumatic diseases]

Rheumatic disease have many common radiological characteristics. They all affect one or more joints. Radiological exams represent a part of the diagnostic procedure when there is a suspicion of rheumatic disease. This paper describes both the basics and characteristics radiological changes visible on a classic radiograph which, in addition to other results, allow the discrimination of different rheumatic diseases. Standard or classical radiographs are the cornerstones of radiological evaluation, and can be improved by other radiological methods such as US, CT or MR.

US assessment of hip joint synovitis in rheumatic diseases. A comparison with MR imaging

PURPOSE

To assess the significance of ultrasonography (US) in detecting hip joint synovitis in patients with rheumatic diseases.

MATERIAL AND METHODS

Forty patients with rheumatic disease and suspected hip joint synovitis underwent MRI and US of the hip joint. In addition to the throughout MRI evaluation, the anterior collum-capsule distance (CCD) was determined by both MRI and US. Thirteen healthy volunteers were examined with MRI to establish the criteria for normal findings in MRI when classifying hip joints to those with synovitis and those without. MRI was used as a gold standard.

RESULTS

Synovitis was found using MRI in 31 hips of 22 patients (9 patients had bilateral synovitis). The intraclass correlation was 0.61 between MRI and US in measuring CCD. In classifying hip joint synovitis with US, the sensitivity of the method was 87% and specificity 42%, when the CCD criterion for synovitis was determined to be > or = 7 mm. If the cut-off point was raised to 9 mm, the sensitivity decreased to 61% while specificity increased to 94%. A difference in CCD of > or = 1 mm between the hips as an additional criterion for synovitis increased the number of false-positive findings.

CONCLUSION

Measurement of CCD with US proved to be a rather inaccurate method to point out synovitis in rheumatic patients when using MRI as a reference. The main reason for this result was the thickened capsule, which US could not differentiate from a thickened synovium.