Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor

The aim of this study was to characterize the pathological conditions of symptomatic ankles in patients with rheumatoid arthritis (RA) using power Doppler sonography (PDS). We analyzed 17 consecutive ultrasonography (US) records of RA patients with symptomatic ankles who underwent B-mode ultrasonography (BUS) combined with PDS of their ankles in our department because of clinical need. Correlations between US findings and clinical and serological data were assessed. The diagnostic capabilities of BUS and PDS were also compared. Common US findings were talocrural synovitis (76%), subtalar synovitis (71%), and talonavicular synovitis (59%). Tenosynovitis around the ankle was detected in ten patients (59%), including several cases of tenosynovitis of tibialis posterior (41%) and tenosynovitis of peroneus longus and brevis (35%). Achilles tendon enthesitis was detected in six patients, and retrocalcaneal bursitis was detected in five. Compared with BUS, PDS offers demonstrably superior diagnostic capability for the detection of rheumatoid ankle diseases, especially subtalar joint synovitis and peroneal tenosynovitis. Rheumatoid factor (RF) levels were significantly higher in patients with tenosynovitis than in patients without tenosynovitis. PDS is an excellent modality for diagnosing both intra- and extracapsular synovitis in rheumatoid ankles. Using PDS, we found positive association between ankle tenosynovitis and RF levels in RA patients.     

Ultrasound assessment of new onset bilateral painful shoulder in patients with polymyalgia rheumatica and rheumatoid arthritis

The aim of our study was to investigate by ultrasound (US) the anatomical structures affected during a new episode of bilateral painful shoulder in patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA) and to compare the findings between these two conditions. PMR and RA patients complaining of new onset bilateral painful shoulder were included. Subjects without any known rheumatic condition with a new onset unilateral painful shoulder were assessed as a control group. US evaluation includes the depiction subacromial–subdeltoid (SAD) bursitis, long head biceps (LHB) tenosynovitis and/or gleno-humeral (GH) synovitis. Thirty patients with PMR, 30 with RA, and 60 controls were included for a total of 60 shoulders per group. Unilateral SAD bursitis and LHB tenosynovitis were significantly more frequent in patients with PMR when compared to those with RA (p?<?0.0001 and p?<?0.01, respectively) and controls (p?<?0.001 and p?<?0.01, respectively). Unilateral GH synovitis was more common in RA than in PMR and controls (p?<?0.05 and p?<?0.01, respectively). Bilateral SAD bursitis was significantly more frequent in patients with PMR than in those with RA (p?<?0.01) as was bilateral LHB tenosynovitis (p?<?0.01). No significant differences were found in bilateral GH synovitis. US-detected periarticular inflammatory involvement more frequently in PMR both unilaterally and bilaterally and intra-articular inflammatory involvement was commonly in RA but only unilaterally.     

Evidence for synovitis in active polymyalgia rheumatica: sonographic study in a large series of patients

OBJECTIVE: To determine the frequency and localization of synovitis and enthesitis in patients with active, untreated polymyalgia rheumatica (PMR) by ultrasonography (US). METHODS: Polyarticular sonographic evaluation was carried out in 50 consecutive patients with PMR at disease onset. Results were compared with 50 consecutive patients with seronegative spondyloarthropathies (SpA) and 50 with seronegative and seropositive rheumatoid arthritis (RA) at disease onset. RESULTS: Synovitis and/or effusion was detected, in at least one joint, in 100% of patients with PMR. The most frequent alterations observed in patients with PMR were effusion in the subacromial-subdeltoid (SA-SD) bursa in 70% of patients, tenosynovitis of the long head of the biceps tendon (LHBT) in 68%, glenohumeral joint effusion in 66%, tenosynovitis of the flexor tendons in the carpal tunnel in 38%, radiocarpal effusion in 18%, wrist extensors tenosynovitis in 18%, coxofemoral joint effusion in 40%. knee effusion in 38%, and ankle effusion in 10%. Enthesitis and tendonitis of the anchoring tendons were relatively rare in all the articular sites. Comparison of the SpA and PMR patients showed that enthesitis (mostly in the elbow, knee, and heel) was significantly more frequent in SpA. There was a significant difference in glenohumeral and coxofemoral effusion between the PMR and SpA patients (66% vs 16% and 40% vs 14%, respectively). Comparison of PMR and RA patients showed no significant difference in the involvement of entheses, shoulder, hip, or wrist flexor tendons in the carpal tunnel. Synovitis of the elbow, knee, and wrist was significantly more frequent in the SpA and RA patients than in those with PMR. CONCLUSION: Synovitis was detected in at least one site in 100% of patients with PMR. SA-SD bursitis, LHBT tenosynovitis, carpal tunnel syndrome, and glenohumeral, knee and hip synovitis were the most frequent alterations in PMR. Enthesitis was relatively rare at any articular site.     

Assessment of both articular synovitis and tenosynovitis by ultrasound is useful for evaluations of hand dysfunction in early rheumatoid arthritis patients

Objectives: We investigated the association between hand dysfunction and ultrasound (US)-detected articular synovitis and tenosynovitis in patients with rheumatoid arthritis (RA).

Methods: Thirty RA patients were examined. In both hands of all subjects, articular synovitis and tenosynovitis were assessed by US at 22 joints and 12 tendons. Each joint and tendon was scored by gray-scale (GS) and power Doppler (PD) on a scale from 0 to 3. The sums of the GS or PD scores were used as the articular synovitis score and the tenosynovitis score. The sum of the articular synovitis and tenosynovitis scores was used as the combined US score. Hand dysfunction was evaluated by a grip-Health Assessment Questionnaire (HAQ) and visual analog scale of morning stiffness (MS-VAS). We used Spearman’s correlation coefficient to determine the relationships among the US scores, the two hand dysfunction indices, and the DAS28-ESR.

Results: The articular synovitis scores were significantly correlated with grip-HAQ (GS: r_s?=?0.47, p?=?0.009, PD: r_s?=?0.48, p?=?0.006), but not with MS-VAS. The tenosynovitis scores were correlated with MS-VAS (GS: r_s?=?0.38, p?=?0.039, PD: r_s?=?0.36, p?=?0.053), but not with grip-HAQ. Both grip-HAQ (GS: r_s?=?0.53, p?=?0.002, PD: r_s?=?0.55, p?=?0.001) and the MS-VAS (GS: r_s?=?0.39, p?=?0.031, PD: r_s?=?0.47, p?=?0.008) were correlated with the combined US scores.

Conclusions: The US scores combined with articular synovitis and tenosynovitis scores well reflect the severity of hand dysfunction in early-stage RA patients.     

Fat suppression magnetic resonance imaging in shoulders of patients with polymyalgia rheumatica

OBJECTIVE: To evaluate the sites of inflammatory process in the shoulders of patients with polymyalgia rheumatica (PMR) using fat suppressed magnetic resonance imaging (MRI). METHODS: Six consecutive, untreated new patients with PMR were investigated. Five patients with early rheumatoid arthritis (RA) and 4 patients with early psoriatic arthritis (PsA) with bilateral shoulder symptoms served as a control group. Bilateral shoulder fat-suppressed MRI sequences were performed in all patients and controls. We evaluated the presence of joint synovitis, bursitis, tenosynovitis, and bone and soft tissue edema. RESULTS: Bilateral subacromial/subdeltoid bursitis was found in all patients with PMR, in 1/5 (20%) patients with RA (p < 0.05), and in none with PsA (p < 0.02). Glenohumeral synovitis was present in all case and controls. Biceps tenosynovitis was observed in 4/6 (67%) patients with PMR, in 4/5 (80%) with RA (not significant, NS), and in all 4 patients with PsA (NS). No evidence of bone edema adjacent to the joint capsule and entheseal insertions or in the soft tissues was present in either cases or controls. CONCLUSION: The absence of extracapsular abnormalities in the early shoulder disease of PMR does not confirm the hypothesis of a capsular-based disorder.     

Anterior sonography of glenohumeral joint in patients with inflammatory joint disease

Ultrasonography (US) was shown as an effective imaging modality in evaluating the shoulder. The shoulder joint is probably the most accessible joint for sonography in adults. However, inflammatory changes of the shoulder have received too little attention in US studies. Anterior access for US assessment of glenohumeral joint (GHJ) has not been investigated. Another problem of patients with acute synovitis of glenohumeral joint is the difficulty to perform a 90° abduction for the axillary US because of severe pain and active and passive limitation. We offer the anterior access for assessment of glenohumeral joint synovitis (GHS). Sonographic evaluation (Sonosite-Titan) was carried out in 25 patients with acute GHS and 15 healthy controls. The diagnosis of GHS was made after the patients underwent physical examination and the laboratory evidence was obtained. We used the anterior position of transducer applied laterally to coracoid processus along the anterior joint cavity. The problem of anterior joint cavity investigation in neutral position is a poor presentation of the joint and the application of the biceps tendon. The problem is simply resolved after supination of the hand and external rotation of the shoulder. We measured and compared upper, middle, and lower width of the anterior GHJ cavity. Echogenicity of joint cavity was assessed by comparison with adjacent tissues. Homogeneity and regularity of GHJ cavity was designated in both groups as well. We measured labrum-infraspinatus distance on posterior view for assessment of GHJ synovitis. All cases of GHJ synovitis were confirmed by a US Doppler study. US investigation of healthy controls enabled to find normal values of the width of the anterior GHJ cavity that was less than 7.4 mm. The synovitis group showed GHJ cavity expansion: 8.3±2.4 (p=0.001) and 10.5±3.1 (p<0.001) for the middle and the lower anterior part of the GHJ respectively. The upper part width was not different in synovitis and control groups. Anterior joint cavity extension to 7.4 mm and upper in its lower part was high sensitive (96%) and specific (86%) US sign of synovitis with the test power above 0.9. The posterior labrum-infraspinatus extension had high specificity for synovitis (100%), but only seven of 25 patients (28%) had increased (>2 mm) the value of the labrum-infraspinatus dimension, which was previously proposed as the US sign of synovitis. Echogenicity of the anterior joint cavity in healthy controls was moderately high (far more echogenic than deltoid muscle). Echogenicity of synovitis declined, and mild effusions were found to be common. Those were not to be seen on US of GHJ in neutral position and were revealed only in supination and external rotation of the shoulder. Intra-articular tissue of healthy controls was relatively echo-homogenic compared with nonhomogenic one of the synovitis group. Bone irregularity was found in patients with long-standing GHJ synovitis reflecting erosive process. A certain position of the shoulder and good knowledge of the normal anterior joint cavity parameters enabled us to diagnose synovitis by anterior shoulder sonography, with the patients experiencing minimal pain during movements.     

Doppler sonographic findings in the long bicipital tendon sheath in patients with rheumatoid arthritis as compared with patients with degenerative diseases of the shoulder

OBJECTIVE: To compare power Doppler sonography (PDS) findings inside the bicipital tendon sheath in patients with rheumatoid arthritis (RA) and degenerative disorders of the shoulder, in order to evaluate the diagnostic value of PDS in distinguishing between inflammatory and noninflammatory shoulder pain. METHODS: The glenohumeral joints of 41 consecutive patients with shoulder pain were examined by ultrasound. Using ventral transverse and longitudinal scanning, the vascularity near and/or inside the bicipital tendon sheath was visualized by PDS. One fully trained and experienced examiner performed the sonography. Representative images were digitally stored and were read, under blinded conditions, by 2 independent investigators, who categorized the Doppler signals as being either inside or outside the tendon sheath. RESULTS: Biceps tendon sheath effusion, represented by the typical hypoechoic rim, was found in 95.8% of the RA patients (23 of 24) and in 58.8% of the patients with degenerative disorders (10 of 17). PDS signals were localized to inside the tendon sheath in 22 of the RA patients (91.7%) and in none of the patients with degenerative disorders. Although no PDS signal was found inside the tendon sheath in patients with degenerative disorders, in 9 of these patients (52.9%), signals could be localized to the environment of the tendon sheath. CONCLUSION: PDS demonstrates vascularity in the long bicipital tendon sheath of patients with RA, but not in those with degenerative shoulder disorders.     

Subclinical synovitis and tenosynovitis by ultrasonography (US) 7 score in patients with rheumatoid arthritis treated with synthetic drugs,in clinical remission by DAS28

ObjectiveTo identify synovitis and tenosynovitis active by using the Ultrasound 7 (US 7) scoring system in patients with rheumatoid arthritis (RA) in clinical remission induced by synthetic disease-modifying antirheumatic drugs (DMARDs).MethodsThis is a multicentric, cross-sectional, observational study including 94 RA patients >18 years old who were in remission as defined by the 28-joints disease activity score (DAS28) <2.6 induced by synthetic DMARD during at least 6 months. Patients with a previous or current history of biologic DMARD treatment were not included in the study. Demographic and clinical data were collected by the local rheumatologist; the US evaluation was performed by a calibrated rheumatologist, who intended to detect grayscale synovitis and power Doppler (PD) using the 7-joint scale. Intra and inter-reader exercises of images between 2 ultrasonographers were realized.ResultsPatients’ mean age was 49.1 ± 13.7 years; 83% were women. The mean disease duration was 8 ± 7 years and remission lasted for 27.5 ± 31.8 months. The mean DAS28 score was 1.9 ± 0.66. Grayscale synovitis was present in 94% of cases; it was mild in 87.5% and moderate in 12.5%. Only 12.8% of the patients had PD. The metatarsophalangeal, metacarpophalangeal, and carpal joints of the dominant hand were the joints more frequently affected by synovitis. Tenosynovitis by grayscale was observed in 9 patients (9.6%). The intra and inter-reading kappa value were 0.77, p < 0.003 (CI 95%, 0.34–0.81) and 0.81, p < 0.0001 (CI 95%, 0.27–0.83) respectively.ConclusionsLow percentage of synovitis and tenosynovitis active were founded according to PD US by 7 score in RA patients under synthetic DMARDs during long remission. This score has benefit because evaluate tenosynovitis, another element of subclinical disease activity.     

Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response

The aim of this study was to evaluate the ability of power Doppler sonography (PDS) with ultrasound contrast agent to assess the synovial perfusion changes induced by intra-articular steroid injection therapy in the knee joints of patients with rheumatoid arthritis (RA). Eighteen RA patients (16 women, 2 men) with a history and signs of active knee synovitis were studied. Tenderness was evaluated using Thompsons modified index of synovitis activity. All patients underwent joint aspiration followed by intra-articular injection of 40 mg of triamcinolone hexacetonide. Gray-scale ultrasonography and PDS with an intravenous ultrasound contrast agent (Levovist) examinations were carried out before and 3 weeks after the intra-articular steroid injection. The calculation of the time–intensity curves provided a quantitative estimation of the synovial perfusion. The median values of the index of synovitis activity decreased significantly from 7.0 (95% confidence interval (CI) 6.0–8.0) to 3.0 (95% CI 2.0–4.0) (p<0.01) 3 weeks after the intra-articular steroid injection. All patients showed a reduction of PDS signal after intra-articular steroid therapy and the baseline and follow up median values of the area underlying time–intensity curves were 7.48 (95% CI 5.79–8.73) and 2.45 (95% CI 1.92–3.61), respectively. The comparison between baseline and follow-up median values of the area under the curves showed a statistically significant reduction of PDS findings (p<0.01). At follow-up examinations the changes in the index score of the synovitis activity were significantly correlated to the changes in the values of the area underlying time–intensity curves (r=0.785; p<0.01). A significant correlation was also observed between baseline values of the area underlying time–intensity curves and C-reactive protein (CRP) (r=0.548; p=0.023). In conclusion, PDS with an intravenous ultrasound contrast agent has been shown to be able to detect changes in synovial perfusion after intra-articular steroid injection and may be an additional useful method in the evaluation of synovial inflammation and in the assessment of the therapeutic response.Abbreviations DMARD Disease-modifying anti-rheumatic drugs - NSAID Non-steroidal anti-inflammatory drugs - PDS Power Doppler sonography - RA Rheumatoid arthritis - RF Rheumatoid factor - US Ultrasonography     

MRI findings of the shoulder and hip joint in patients with polymyalgia rheumatica

Abstract

Objectives. The purpose of this study is to evaluate magnetic resonance imaging (MRI) findings of the shoulder and hip joint in patients with polymyalgia rheumatica (PMR).

Methods. MR images of a total of 25 PMR patients (23 shoulders and 6 hips), 43 rheumatoid arthritis (RA) patients (22 shoulders and 22 hips), and 50 control patients (25 shoulders and 25 hips) were examined. The following MRI findings were evaluated: In the shoulder, thickness and abnormalities of the supraspinatus tendon, effusion around the glenohumeral joint, subacromial-subdeltoid bursa, and the biceps tendon; In the hip, effusion around the acetabulofemoral joint, iliopsoas bursa, and trochanteric bursa. Periarticular soft-tissue edema and bone findings were also analyzed.

Results. The supraspinatus tendon was significantly thicker in PMR patients than in RA patients and control patients (p < 0.05). Severe rotator cuff tendinopathy was frequently observed in PMR patients (p = 0.002). The scores for the amount of effusions (joint, bursa, and tendon sheath in the shoulder and bursa in the hip) were much higher in PMR patients (p < 0.05). Periarticular soft tissue edema was detected more frequently in PMR patients than in RA patients and control patients (p < 0.05).

Conclusions. Thick supraspinatus tendon, severe rotator cuff tendinopathy, effusion around the joints, and periarticular soft tissue edema can be good indicators for the diagnosis of PMR.     

Ultrasound-detected tenosynovitis as a risk factor for flares in rheumatoid arthritis patients in clinical remission

Clinical Rheumatology - Our objective was to investigate the value of ultrasound (US) detected synovitis and tenosynovitis as risk factors for short term flare in rheumatoid arthritis (RA) patients...     

Is ankle involvement underestimated in rheumatoid arthritis? Results of a multicenter ultrasound study

The aim of this study is to investigate the prevalence of subclinical ankle involvement by ultrasound in patients with rheumatoid arthritis (RA). The study was conducted on 216 patients with RA and 200 healthy sex- and age-matched controls. Patients with no history or clinical evidence of ankle involvement underwent US examination. For each ankle, tibio-talar (TT) joint, tibialis anterior (TA) tendon, extensor halux (EH) and extensor common (EC) tendons, tibialis posterior (TP) tendon, flexor common (FC) tendon and flexor hallux (FH) tendon, peroneous brevis (PB) and longus (PL) tendons, Achilles tendon (AT) and plantar fascia (PF) were assessed. The following abnormalities were recorded: synovitis, tenosynovitis, bursitis, enthesopathy and rupture. BMI, DAS28, RF ESR and CRP were also obtained. A total of 432 ankles of patients with RA and 400 ankles of healthy controls were assessed. In 188 (87%) patients with RA, US showed ankle abnormalities whereas, in control group, US found abnormalities in 57 (28.5 %) subjects (p?=?0.01). The most frequent US abnormality in RA patients was TP tenosynovits (69/216) (31.9 %), followed by PL tenosynovitis (58/216) (26.9 %), TT synovitis (54/216) (25 %), PB tenosynovitis (51/216) (23.6 %), AT enthesopathy (41/216) (19 %) and AT bursitis (22/216) (10.2 %). In 118 RA patients out of 216 (54.6%), a positive PD was found. No statistically significant correlation was found between the US findings and age, disease duration, BMI, DAS28, RF, ESR and CRP. The present study provides evidence of the higher prevalence of subclinical ankle involvement in RA patients than in age- and gender-matched healthy controls identified by US.     

Abnormal sonographic findings in the asymptomatic arthritic shoulder

OBJECTIVE: To assess the diagnostic value of ultrasonography (US) in the evaluation of arthritic shoulder joints, especially in painless shoulders. METHODS: US examinations were performed in 57 consecutive patients with rheumatoid arthritis (114 shoulders) and in 32 controls (32 shoulders), using a 7.5 MHz linear probe and a standardized study protocol. US findings were compared with clinical, laboratory, and radiological data to find any relationship. RESULTS: Abnormal sonographic findings were found in 80 shoulders (70%); the most common were lesions in the supraspinatus tendon (38%), subacromial-subdeltoid bursitis (29%), bone erosions of the humeral head (20%), glenohumeral joint ellusion (19%), and biceps tendinitis (13%). Although US abnormalities were most frequent in patients with painful shoulders or abnormal findings on physical examination or radiography, a high rate of alterations was found in asymptomatic shoulders (51%), in normal shoulders on physical examination (44%) and in normal shoulders on radiographic assessment (61%). Differences of US findings in relation to time of evolution of rheumatoid arthritis, patient's age, and radiographic stage in hand and/or wrist joints were not found. CONCLUSION: US abnormalities in the shoulder joint are frequent in rheumatoid arthritis, both in patients with and without shoulder complaints as well as in patients with normal findings on physical examination.     

Ultrasonographic hand features in systemic sclerosis and correlates with clinical,biologic, and radiographic findings

Objective

To investigate ultrasonographic (US) hand features in systemic sclerosis (SSc) patients and their relationship with clinical, biologic, and radiographic data.

Methods

Fifty‐two consecutive SSc patients were included in a cross‐sectional observational study together with 24 rheumatoid arthritis (RA) patients enrolled as controls. All patients underwent clinical examination, including tender and swollen joint counts, measurement of disability indices, and hand/wrist radiographs. US was performed on the hand and wrist joints and was aimed at the detection of synovitis, tenosynovitis, and calcinosis.

Results

Synovitis and tenosynovitis were more frequently detected with US in SSc patients (46% and 27%, respectively) than with clinical examination (15% and 6%, respectively; P < 0.01 for both comparisons). Fifty‐seven percent of patients had inflammatory synovitis (mostly Doppler grade 1), and tenosynovitis was either inflammatory or fibrotic. Calcifications were observed using US and radiographs in 40% and 36% of SSc patients, respectively (P = 0.8). As compared to RA, US features specific to SSc were sclerosing tenosynovitis (P < 0.01) and soft tissue calcifications (P = 0.01).

Conclusion

Our study confirms that articular involvement in SSc is underestimated by a single clinical examination. It is characterized by mild inflammatory changes and the specific findings include sclerotic US aspects together with calcinosis. Further prospective studies are warranted to evaluate the predictive value of these findings and determine whether they should be considered for adapting a therapeutic strategy.     

Impact of hepatitis C virus infection on disease activity,functional status and ultrasonography findings in Egyptian rheumatoid arthritis patients

Background

Hepatitis C virus (HCV) infection is one of the most frequently encountered public health problems in Egypt. It is associated with many autoimmune diseases such as rheumatoid arthritis.

Effects of shoulder arthroplasty and exercise in patients with rheumatoid arthritis

The aim of this study was to examine pain and shoulder function in patients with rheumatoid arthritis (RA) before and after shoulder arthroplasty and postoperative exercise. Twenty-four patients (26 shoulders) were consecutively included in a multicentre study. Before surgery, at discharge from hospital and after 3 and 6 months, perceived shoulder function and shoulder pain were assessed by visual analogue scales, activities of daily living by the Modified Health Assessment Questionnaire (M-HAQ) and shoulder range of motion (ROM) by a goniometer. All patients showed considerable pain reduction at discharge from hospital (p<0.001). In those with intact rotator cuff and biceps tendon (n=13) improvements were found after 6 months in active and passive abduction and flexion ROMs (p<0.01) and in M-HAQ (p<0.001). Such improvements were not found in those with torn soft tissue (n=12). Preoperatively, abduction and flexion motor deficits (passive ROM >active ROM) were found for the total group (p=0.001). Less flexion motor deficit was found in the intact soft tissue than in the torn soft tissue group after 3 (p=0.002) and 6 months (p<0.001). No group difference was found with respect to abduction motor deficit. In conclusion, pain relief was obtained by all patients. Improvements in ROMs and activities of daily living were influenced by the state of the soft tissue.Sources of support: From EXTRA-funds from the Norwegian Foundation for Health and Rehabilitation     

Shoulder ultrasonography in the diagnosis of polymyalgia rheumatica: a case-control study

OBJECTIVE: Magnetic resonance imaging (MRI) showed that subacromial/subdeltoid bursitis is the most frequent shoulder lesion in polymyalgia rheumatica (PMR). We evaluated whether shoulder ultrasonography (US) was as effective as MRI in the detection of this lesion and assessed the sensitivity and specificity of bilateral subacromial/subdeltoid bursitis in the diagnosis of PMR. METHODS: A case-control study of 57 consecutive case patients with untreated PMR and 114 controls seen over a 6 month period in 3 secondary referral rheumatology centers. Control patients consisted of the next 2 consecutive patients with bilateral shoulder aching and stiffness observed after the case patient. In all case and control patients the glenohumeral joint space, bursae, and long head biceps tendon were assessed by bilateral shoulder US. The first 24 case patients were also examined by bilateral shoulder MRI. RESULTS: US showed subacromial/subdeltoid bursitis in 55/57 (96%) patients with PMR and in 25/114 (22%) controls (p < 0.001). The lesion was bilateral in 53/55 (96%) case patients and in 1/25 (4%) controls (p < 0.001). The frequency of glenohumeral joint synovitis and biceps tenosynovitis did not differ significantly between case patients and controls. In 100% of case patients MRI showed subacromial/subdeltoid bursitis confirming US findings. The sonographic evidence of bilateral bursitis had a sensitivity of 92.9%, specificity of 99. 1%, and positive predictive value of 98. 1% for the diagnosis of PMR. CONCLUSION: US and MRI were equally effective in confirming bilateral subacromial and subdeltoid bursitis in PMR. This finding, in view of its high sensitivity and specificity, could be used as a new diagnostic criterion for PMR.     

Ultrasonographic findings of painful shoulders and correlation between physical examination and ultrasonographic rotator cuff tear

The objectives of this study were to identify ultrasonographic (US) abnormalities and to compare physical examination with US findings, especially of rotator cuff abnormalities in patients with shoulder pain. A total of 120 patients with shoulder pain were prospectively studied. The physical examination of shoulders was performed as follows: (1) the area of tenderness; (2) the range of passive and active motion for abduction, forward flexion, external rotation, and internal rotation; (3) Neer and Hawkins's tests for shoulder impingement; and (4) maneuvers for determining the location of the tendon lesions. Transverse and longitudinal planes from the long head of the biceps, supraspinatus, infraspinatus, and subscapularis tendons, the subacromial-subdeltoid bursa, and the glenohumeral and acromioclavicular joints were included for US examination. The range of motion most affected by shoulder pain was abduction, followed by external rotation and forward flexion. The most frequent US finding was effusion in the long head of the biceps tendon. Among the rotator cuff tendons, supraspinatus was the most frequently involved. Physical examination had low sensitivity and specificity for the detection of tendon tear. US examination leads to an anatomical diagnosis of shoulder pain in many patients. Whether the US examination of the painful shoulder improves its treatment should be investigated.     

Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience

OBJECTIVE: To investigate the intra-articular vascularisation of the synovial pannus in the knee of patients with rheumatoid arthritis (RA) with power Doppler ultrasonography (PDS) and an echo contrast agent and correlate the area under the time-intensity curves with the clinical findings and laboratory measures of disease activity. METHOD: Forty two patients with RA (31 women, 11 men) with history and signs of knee arthritis, classified according to a modified index of synovitis activity (active, moderately active, and inactive), were studied. Clinical and functional assessment (number of swollen joints, intensity of pain, general health-visual analogue scale, disability index-Health Assessment Questionnaire, Ritchie articular index) and a laboratory evaluation were made on all patients. Disease activity was evaluated using the disease activity score (DAS) and the chronic arthritis systemic index (CASI) for each patient. All patients were examined with conventional ultrasonography and PDS before injection of intravenous ultrasound contrast agent (Levovist). The quantitative estimation of the vascularisation of the synovial membrane was performed with time-intensity curves and calculation of the area under the curves. RESULTS: The mean (SD) value of the area underlying time-intensity curves was 216.2 (33.4) in patients with active synovitis, 186.8 (25.8) in patients with moderately active synovitis, and 169.6 (20.6) in those with inactive synovitis. The mean value of the areas differed significantly between the patients with active and those with inactive synovitis (p<0.01). The mean value of the area under the curve of the entire group was weakly correlated with the number of swollen joints (p=0.038), but a strong correlation was found with composite indexes of disease activity such as the DAS (p=0.006) and CASI (p=0.01). No correlation was found with age, disease duration, and other laboratory and clinical variables. CONCLUSION: PDS may be a valuable tool to detect fractional vascular volume and to assist clinicians in distinguishing between inflammatory and non-inflammatory pannus. The transit of microbubbles of ultrasound contrast across a tissue can be used to estimate haemodynamic alterations and may have a role in assessing synovial activity and the therapeutic response to treatment of synovitis of the knee joint.     

Ultrasound7 versus ultrasound12 in monitoring the response to infliximab in patients with rheumatoid arthritis

This study aimed to assess the responsiveness of ultrasonography (US)-7 in patients with rheumatoid arthritis (RA). Eighty-two RA patients were recruited and followed up for 22 weeks. The clinical, laboratory, and X-ray assessments, along with grayscale US (GSUS) and power Doppler US (PDUS) examinations were performed at baseline, 6, 14, and 22 weeks after infliximab treatment. GSUS for synovitis and PDUS for synovitis and paratendinitis/tenosynovitis were assessed by a semi-quantitative (0 to 3) score, while GSUS for paratendinitis/tenosynovitis and bone erosion was qualitatively assessed as absent or present (0 or 1). US scores in both 7-joint (US7) and 12-joint (US12) systems were evaluated. After 6, 14, and 22 weeks of treatment with infliximab, indices such as US scores, 28-joint disease activity (DAS28) score, and tender and swelling joint count were all significantly improved compared to baseline. US7 scores were significantly correlated with that of US12. Strong correlations were identified between most US7 scores with DAS28, health assessment questionnaire (HAQ), and C-reactive protein (CRP) levels. When DAS28 was used as a reference, the US7 cutoff for disease remission was less than 35 for GS?+?PD and also less than 29 for GS and 1 for PD, respectively. Additionally, the positive percent agreement, negative percent agreement, and overall percent agreement for GS?+?PD were 77.78, 76.19, and 76.67 %, respectively, which were all higher than that of GS or PD. US7 may be a feasible tool to assess the therapeutic response in RA patients.