Spectral Doppler and resistive index. A promising tool in ultrasonographic evaluation of inflammation in rheumatoid arthritis

Ultrasonographic and resistance index evaluation of nails in psoriatic arthritis, psoriasis, and control groups: a cross-sectional study

BACKGROUND

Nail psoriasis occurs frequently in patients with psoriatic disease, it can lead to functional impairment, pain, discomfort, decreased quality of life and can also be a predictor for the development of arthritis. Early recognition of this condition can provide early and effective treatment and prevent structural impairment. This study aims to identify nail ultrasonographic characteristics in three groups: psoriasis (PsO), psoriatic arthritis (PsA) and controls patients, to determine if the ultrasonography (US) can identify early signs of nail psoriatic impairment or local inflammation. We conducted nail US to determine nail matrix resistance index (NMRI), nail bed resistance index (NBRI), and power Doppler (PD) and grayscale (GS) parameters in these 3 groups.

METHODS

Single-center, cross-sectional study. GS, PD, and spectral doppler images of bilateral 2nd and 3rd fingernails were acquired from 35 PsO, 31 PsA, and 35 controls patients. An US equipment with an 18 MHz linear transducer for GS and 8.0 MHz for PD was used. PD, NMRI, NBRI, nail plate thickness (NPT), nail bed thickness (NBT), nail matrix thickness (NMT), and morphostructural characteristics of the trilaminar structure (TS) were evaluated in saved images, blind.

RESULTS

Mean NMRI and NBRI did not differ between groups. Linear regression analysis detected no relationships between PsO or PsA and NMRI or NBRI. Nail PD grade did not differ between groups. Type I and IV TS changes were more frequent in PsO; types II and III changes were more frequent in PsA (p < 0.001). NPT was greater in PsA and PsO groups than controls: PsA 0.73 ± 0.14 mm, PsO 0.72 ± 0.15 mm, Controls 0.67 ± 0.10 mm (p = 0.001).

CONCLUSION

Echographic TS characteristics of the nail plate and NPT evaluated by GS are useful and can distinguish PsO and PsA nails from controls. NMRI, NBRI, and US nail microcirculation parameters could not distinguish psoriatic nails.

TRIAL REGISTRATION

72762317.4.0000.5327 (Certificate of Presentation of Ethical Appreciation - CAAE - Plataforma Brasil) Avaiable in  https://plataformabrasil.saude.gov.br/login.jsf .

Evaluation of enthesitis in patients with juvenile idiopathic arthritis by power color and spectral Doppler ultrasonography

OBJECTIVE

Ultrasonography in patients with juvenile idiopathic arthritis (JIA) could potentially be useful for evaluation of enthesitis. The aim of this study was to evaluate enthesitis in patients with JIA quantitatively by power color and spectral Doppler ultrasonography by determining color fraction (CF) and resistive index (RI).

METHODS

A cross-sectional single-center study was performed in 15 (61 entheseal sites) patients with JIA with clinical enthesitis. A total of 9 age and sex matched healthy controls (53 entheseal sites) were also examined and compared. Entheseal sites (quadriceps tendon, patellar tendon, tendo-Achilles, medial and lateral epicondyles of humerus) were examined on USG B mode for tendon thickening, hypo- and hyper-echogenicity, enthesophytes, and cortical erosions/irregularities by power Doppler ultrasound for the presence of Doppler signal and by power color Doppler and spectral Doppler ultrasonography to derive CF and RI respectively.

RESULTS

The mean thickness of entheseal site in patients and controls were 3.55±0.82 mm and 2.8±0.37 mm, respectively (p<0.001). The power Doppler signal was present in 93.4% of patients (p<0.001). The pooled data of all entheseal sites revealed a significantly higher CF in patients (0.08±0.03) than in controls (0.006±0.008) (p<0.001). The mean RI in patients (0.61±0.09) was significantly lower than that in controls (0.92±0.12) (p<0.001). The cut-off of RI (0.7) and CF (0.029) determined by receiver operating curve analysis revealed a diagnostic accuracy of 94.7% and 96.5%, respectively.

CONCLUSION

Evaluation of enthesitis by determining CF and RI via power color Doppler and spectral Doppler is possible in JIA patients.

Modeling the hepatic arterial flow in living liver donor after left hepatectomy and postoperative boundary condition exploration

Preoperative and postoperative hepatic perfusion is modeled with one-dimensional (1-D) Navier-Stokes equations. Flow rates obtained from ultrasound (US) data and impedance resulted from structured trees are the inflow and outflow boundary condition (BC), respectively. Structured trees terminate at the size of the arterioles, which can enlarge their size after hepatectomy. In clinical studies, the resistance to pulsatile arterial flow caused by the microvascular bed can be reflected by the resistive index (RI), a frequently used index in assessing arterial resistance. This study uses the RI in a novel manner to conveniently obtain the postoperative outflow impedance from the preoperative impedance. The major emphasis of this study is to devise a model to capture the postoperative hepatic hemodynamics after left hepatectomy. To study this, we build a hepatic network model and analyze its behavior under four different outflow impedance: (a) the same as preoperative impedance; (b) evaluated using the RI and preoperative impedance; (c) computed from structured tree BC with increased radius of terminal vessels; and (d) evaluated using structured tree with both increased radius of root vessel, ie, the outlets of the postoperative hepatic artery, and increased radius of terminal vessels. Our results show that both impedance from (b) and (d) give a physiologically reasonable postoperative hepatic pressure range, while the RI in (b) allows for a fast approximation of postoperative impedance. Since hemodynamics after hepatectomy are not fully understood, the methods used in this study to explore postoperative outflow BC are informative for future models exploring hemodynamic effects of partial hepatectomy.

Current status and recent advances on the use of ultrasonography in pediatric rheumatic diseases

BACKGROUND

Ultrasonography has become a useful tool in the clinical rheumatology settings in the last two decades, but its use has only recently been explored by pediatric rheumatologists. The aim of this article is to review the literature on the current status and recent advances on the use of ultrasound in pediatric rheumatic diseases.

DATA SOURCES

We have retrieved and reviewed the relevant articles from MEDLINE/PubMed databases published so far, on the applications of ultrasound in juvenile idiopathic arthritis (JIA), systemic lupus erythematosus, dermatomyositis, enthesitis, Sjogren's syndrome, and other rheumatic diseases. In addition, articles on novel ultrasound imaging technology of potential use in pediatric rheumatology are also reviewed.

RESULTS

In JIA, ultrasound can be used to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, to capture early articular damage, to monitor treatment response, and to guide intraarticular injections. Ultrasound is also considered useful in other rheumatic disorders for the evaluation of musculoskeletal symptoms, assessment of parotid gland pathology, and measurement of skin thickness and pathology. Novel ultrasound techniques developed to augment the functionality of ultrasonography may also be applicable in pediatric rheumatic disorders.

CONCLUSIONS

Ultrasound shows great promise in the assessment and management of children with rheumatologic disorders. However, standardization and validation of ultrasound in healthy children and in patients with rheumatic diseases are still needed.

Power Color Doppler and Spectral Doppler Ultrasonography to Evaluate Response to Intra-articular Steroid Injection in Knee Joints in Juvenile Idiopathic Arthritis

OBJECTIVE

To evaluate the role of ultrasonographic indices (Color Fraction and Resistive Index) in assessing the effect of intra-articular steroid (IAS) injection on synovial inflammation in knee joints of Juvenile Idiopathic Arthritis (JIA) patients and to determine the correlation between these ultrasonographic indices and clinical and laboratory parameters in JIA patients after IAS.

METHODS

Twenty seven patients of JIA and equal number of age and sex matched healthy controls were enrolled. Thirty six knee joints were injected with IAS. Duration of morning stiffness, swelling score, tenderness score, range of motion, visual analogue scale for pain, Physician global assessment of disease activity, Patient/Parent assessment of general well being, Juvenile Arthritis Disease Activity Score, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), synovial thickness, synovial effusion, Color fraction (CF) and Resistive index (RI) were measured at base line and at one and two months of follow-up.

RESULTS

At baseline, a significant difference was found in ESR, CRP, CF and RI values between cases and controls. A significant decrease in various clinical, core set variables and ultrasonographic parameters was observed at each follow-up. Synovial thickness, synovial effusion and CF decreased by 51.78%, 64.67% and 49.35% respectively and range of motion and RI increased by 166% and 31.94% respectively at second follow-up. Both CF and RI showed a significant correlation with active joint count. Both CF and RI had a high inter and intra-class correlation.

CONCLUSIONS

Power Color Doppler and Spectral Doppler ultrasonographic indices (CF and RI) may have a role in assessment of the response to IAS injection of inflamed knee joints.

Assessment of urethral vascularity using 2D colour Doppler high-frequency endovaginal ultrasonography in women treated for symptomatic stress urinary incontinence: 1-year prospective follow-up study

INTRODUCTION

Urethral vascularity is responsible for organ perfusion. It is also believed to contribute to maintaining the normal tension in the urethral mucosa and contributes to approximately one third of urethral closure pressure. We hypothesised that in women undergoing treatment for stress urinary incontinence (SUI), there is no change in blood flow intensity.

METHODS

In this pilot study we recruited women attending the urogynaecology clinics between July and October 2009. Exclusion criteria included symptoms of pelvic organ prolapse or urinary tract infection. Colour Doppler ultrasound was performed at the level of the mid-urethra using a high-frequency (9-12 MHz) endovaginal ultrasonography (EVUS) focusing on the following vascular parameters: flow velocity (V), area of the vessels (A), intensity of perfusion (I), Tissue Pulsatility Index (TPI) and Tissue Resistance Index (TRI). Vascular assessments were repeated at 1 year.

RESULTS

We examined 67 women with symptoms of SUI (17 women had surgery and 50 conservative management, i.e., pelvic floor muscle exercises). The mean (± SD) age in the conservative and surgical groups was 46 (±11) and 40 (±9) years respectively and median (range) parity was 2 (0-8) in both groups. Compared to baseline, no statistically significant differences were observed within each group (p > 0.05) or between the values of vascular parameters (V, A, I, TRI and TPI) at 1 year. There was also no difference in vascular parameters between the two groups.

CONCLUSION

At 12 months there is no change in vascularity parameters in women who opt for conservative or surgical treatment of SUI.

Gray-scale and color duplex Doppler ultrasound of hand joints in the evaluation of disease activity and treatment in rheumatoid arthritis

AIM

To evaluate the role of gray-scale and color duplex-Doppler ultrasound (CDUS) in diagnosis of changes of hand joints and assessment of treatment efficacy in patients with rheumatoid arthritis (RA) by comparing qualitative and quantitative US parameters with clinical and laboratory indicators of disease activity.

METHODS

Ulnocarpal (UC), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints in 30 patients with RA were examined by gray-scale and CDUS before and after six months of treatment. Morphologic and quantitative Doppler findings (synovial thickness, effusion quantity, vascularization degree, resistance index, velocities) were compared with clinical indicators of disease progression: disease activity score (DAS 28), Health Assessment Questionnaire (HAQ), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), and C reactive protein (CRP).

RESULTS

Clinical indicators changed significantly after treatment: ESR from 38.1±22.4 mm/h to 27.8±20.9 mm/h (P=0.013), DAS 28 from 5.47±1.56 to 3.87±1.65 (P<0.001), and HAQ from 1.26±0.66 to 0.92±0.74 (P=0.030), indicating therapeutic effectiveness. In all MCP and UC joints we observed a significant change in at least one US parameter, in 6 out of 12 joints we observed a significant change in ≥2 parameters, and in 2 UC joints we observed significant changes in ≥3 parameters. The new finding was that the cut-off values of resistance index of 0.40 at baseline and of 0.55 after the treatment indicated the presence of active disease and the efficacy of treatment, respectively; also it was noticed that PIP joints can be omitted from examination protocol.

CONCLUSION

Gray scale and CDUS are useful in diagnosis of changes in UC and MCP joints of patients with RA and in monitoring the treatment efficacy.

Vascularity of the urethra in continent women using colour doppler high-frequency endovaginal ultrasonography

Objectives

To assess the urethral vascularity in continent women using colour doppler high frequency endovaginal ultrasonography (EVUS).

Methods

We recruited 61 continent women attending gynaecology clinics between July and October 2009. Exclusion criteria included symptoms of urinary incontinence, voiding dysfunction, pelvic organ prolapse or urinary tract infection. The participants underwent EVUS using high frequency (9-12 MHz) biplane transducer (type 8848 BK Medical), according to a standardised protocol. Colour Doppler US was performed in sagittal plane and in transverse plane at the level of the mid-urethra. Ten seconds video files were recorded and following vascular parameters: flow velocity (V_mix), area of the vessels (A_mix), intensity of vascularity (I_mix), pulsatility index (PI_mix) and resistance index (RI_mix) was evaluated.

Results

There were 30 nulliparous (49.2%) women and 31 multiparous women (50.8%) with a mean (±SD) age of 32 (±4) and 46 (±6) years respectively. Significant impairment of vascularity was observed in multiparous patients as compared to nulliparous and was reflected by increased values of RI_mix (p < 0.001) and PI_mix (p < 0.001), and decreased values of V_mix (p < 0.001), A_mix (p < 0.001), I_mix (p < 0.001) in axial and midsagittal sections of the midurethra. A significant decrease of mean value ± SD of I_mix- from 0.02 ± 0.02 in nulliparous to 0.005 ± 0.01 in multiparous was observed.

Cronbach alpha, used to assess vascular correlations and parity demonstrated a reduction when expressed only for vascular parameters, indicating that number of deliveries is an important factor while assessing urethral vascularity.

Conclusions

Compared to continent nulliparous women, continent multiparous women demonstrated a significant reduction in the vascularity parameters in all measured variables when parity was accounted for.

Advances in knowledge

This study provides the basis for further research in assessing urethral vascularity in women.

The evolution of ultrasound in rheumatology

Musculoskeletal ultrasound is a powerful tool not only for evaluating joint and related structures but also for assessing disease activity. Ultrasound in rheumatology has rapidly evolved and been incorporated into routine clinical practice over the past decade. Moreover, technological development of equipment has made it more accessible for rheumatologists. We present a review of advances in ultrasound in rheumatology, focusing on major chronological developments.

Intra-articular corticosteroid therapy for juvenile idiopathic arthritis: report of an experiential cohort and literature review

The objective of the study to review an experiential cohort of patients receiving IACS and review the associated literature. Review of 121 IACS in 61 patients with JIA. At 3-month intervals, injected joints were evaluated for swelling and range of motion, and the patient and parent were questioned regarding associated pain and morning stiffness. Data were analyzed by log-rank analysis according to injected corticosteroid preparation and its dosage. Adverse events were also recorded. A thorough literature search was done for the literature review. Mean duration of response was 12.5 months (52% of joints in remission at 1 year, 20% after 2 years, and 7% after 3 years). Response was longer with at least 1 mg/kg of corticosteroid, with the longest responses seen with triamcinolone hexacetonide (THA)>triamcinolone acetonide>methylprednisolone. Adverse events were cutaneous atrophy at three injections sites (2.5%), and transient Cushingoid habitus and increased appetite in two patients (3%). Review of the literature generated similar responses to those included herein. Thus, there have been several recommendations for IACS to be a major JIA treatment, and surveys now demonstrate a high level of usage by pediatric rheumatologists. In conclusion the use of IACS in JIA substantiated. THA at a dose of 1-1.5 mg/kg is ideal.

Using ultrasonography to facilitate best practice in diagnosis and management of RA

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Advanced imaging in rheumatoid arthritis. Part 1: synovitis

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium. We now recognise that conventional radiographic images show changes of rheumatoid arthritis long after irreversible joint damage has occured. With the advent of powerful disease-modifying drugs, there is a need for early demonstration of rheumatoid arthritis and a need to monitor progress of the disease and response to therapy. Advanced imaging techniques such as ultrasound and MRI have focussed on the demonstration and quantification of synovitis and erosions and allow early diagnosis of RA. The technology to quantify synovitis and erosions is developing rapidly and now allows change in disease activity to be assessed. However, problems undoubtedly exist in quantification techniques, and this review serves to highlight them. Much of the literature on advanced imaging in RA appears in rheumatological journals and may not be familiar to radiologists. This review article aims to increase the awareness of radiologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses synovitis imaging. The second part will look at advanced imaging of erosions in RA.

Tendinopathy and Doppler activity: the vascular response of the achilles tendon to exercise

BACKGROUND

Intratendinous Doppler activity has been interpreted as an equivalent of neovessels in the Achilles tendon and as a sign of tendinosis (AT).

AIM

To evaluate the vascular response as indicated by color Doppler activity after repeated loading of both symptomatic and non-symptomatic Achilles tendons.

MATERIAL AND METHODS

Ten non-trained, healthy subjects ran 5 km. Ultrasound (US) Doppler activity was determined before and after the exercise. Eleven patients with chronic AT performed 3 x 15 heavy-load eccentric exercise. The Achilles tendons were scanned before and immediately after the exercise.

RESULTS

Non-symptomatic: six Achilles tendons in five subjects had intratendinous Doppler activity before the exercise. All but two subjects (80%) had intratendinous Doppler activity after running. Symptomatic: all patients had Doppler activity in the tendons, with a median color fraction before eccentric exercise of 0.05 (range 0.01-0.33). The Doppler activity did not disappear after exercise. Tendons with a color fraction below the median at baseline increased significantly after the exercise (P=0.02).

CONCLUSION

The mere presence of Doppler in the Achilles tendon does not per se indicate disease. Eccentric exercise does not extinguish the flow during or after one training session in patients with chronic AT.

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

BACKGROUND

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.

OBJECTIVE

To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.

METHODS

Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid-portion Achilles tendinosis. A unipolar coagulation device was used.

RESULTS

One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were "cured" after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0-10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.

CONCLUSIONS

Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid-tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.