G Meenagh

E-learning in ultrasonography: a web based approach

Objective: To propose e-learning methods that address the fundamental problems related to sonographic training in rheumatology. Methods: The project was designed for rheumatologists with strong motivation to learn ultrasound. A modular approach was constructed, consisting of a basic 3-day residential course, followed by a 6-month period of web-based tutoring, and culminating in a final 2-day residential course with a formal assessment of competency. Results: The website (http://www.e-sonography.com) was accessed by all 60 participants. A mean of 20 (range 10–80) log-on sessions were registered for each participant, and a mean of 250 min (range 60–600 min) of web access was recorded. A total of 163 sonographic images were submitted by 18 (30%) participants. The majority of the images focused on the following anatomical areas: shoulder 49 (30%), hand 34 (21%) and knee 20 (12%). A total time investment of approximately 14 h was made by the US tutors over the 6-month period for interaction with the participants. Conclusions: The e-learning methods described in this report represent the first attempt to adopt a novel technique to circumvent several of the inherent barriers to the many facets of teaching musculoskeletal ultrasound to a wide audience.

Antinucleosome antibodies in the diagnosis of systemic lupus erythematosus

Nucleosomes are fundamental units of chromatin released by internucleosomal cleavage during cell apoptosis, and nucleosomal material has been demonstrated in the surface blebs of apoptotic cells.1 Recent studies have shown the presence of antinucleosome antibodies in systemic lupus erythematosus (SLE).2,3 We measured the concentration of antinucleosome antibody present in the sera of patients with SLE and compared it with the concentration in healthy and disease control patients using a commercially available enzyme linked immunosorbent assay (ELISA) kit. Peripheral blood was sampled from 95 white patients with SLE (87 female, median age 47.0 years), 48 white patients with rheumatoid arthritis (RA) (41 female, median age 55.5 years), 28 white patients with fibromyalgia (23 female, median age 47.0 years), and 95 white normal healthy volunteers (64 female, median age 31.0 years). All patients with SLE fulfilled the American College of Rheumatology (ACR) diagnostic criteria. An indirect solid phase immunometric assay (ELISA) was used for the quantitative determination of IgG autoantibodies to nucleosomes (Organtec Diagnostika, Mainz, Germany; antinucleosome kit), according to the …

Ultrasonography and therapy monitoring

US permits accurate and reliable assessment of soft tissue involvement in rheumatic disease [3]–[3].Highresolution US with power Doppler equipment can detect even minimal morphostructural and perfusional changes within soft tissues [4]–[14], and may offer additional information for disease activity monitoring [15]–[24] (Figs. 6.1-6.6).

Sonographic and power Doppler semeiotics in musculoskeletal disorders

Sonography has great potential for the non-invasive study of hyaline cartilage, as it can depict microscopic lesions to be demonstrated with a high spatial resolution. The main limit to the sonographic study of articular cartilage is the relatively limited dimensions of acoustic windows available for the visualization of the cartilage surfaces. The most frequent errors in the study of cartilage, especially at knee level, are linked to incorrect examination. The most frequent artifacts come out in suprapatellar panoramic views, as the cartilage profile of the femoral trochlea is not perpendicular to the direction of the US beam. An apparent loss in sharpness of the chondro-synovial margin of the cartilage and an apparent reduction or increase of the cartilage thickness are the main artifacts caused by incorrect technique [2].

Ultrasound-guided procedures

Needle aspiration of synovial fluid and intralesional injection of various compounds are very common procedures in rheumatological practice. Local steroid injection, in particular, is relatively simple and cost-effective and may be alternative or adjunctive to systemic drug therapy in several rheumatological conditions [1]–[5]. Both efficacy and side effects of the injection depend on the correct placement of the tip of the needle inside or around the lesion. Particular attention must be taken to avoid direct needle contact with nerves, tendons, articular cartilage and blood vessels [6]. Intra-articular and intra-lesional therapy is usually performed using palpation and bony landmarks for guidance. Conventional blind interventional procedures may be particularly problematic when a small and/or deep target has to be reached, or when an injection has to be carried out into a dry joint

Sonographic and power Doppler normal anatomy

Cartilage is a greatly specialized type of connective tissue, mainly composed of water (70–80% by wet weight). It is avascular and aneural. The solid component of cartilage is formed of cells (chondrocytes) that are scattered in a firm gel-like substance (extracellular matrix) consisting of collagen and proteoglycans.Collagen forms a network of fibrils, which resists the swelling pressure generated by the proteoglycans. In the musculoskeletal system there are two types of cartilage: hyaline and fibrocartilage. Compared to hyaline, fibrocartilage contains more collagen and is more resistant at tensile strength.Fibrocartilage is found in intervertebral disks, symphyses, glenoid labra, menisci, the round ligament of the femur, and at sites connecting tendons or ligaments to bones.Hyaline cartilage is the most common variety of cartilage. It is found in costal cartilage, epiphyseal plates and covering bones in joints (articular cartilage). The free surfaces of most hyaline cartilage (but not articular cartilage) are covered by a layer of fibrous connective tissue (perichondrium). Hyaline cartilage structure is not uniform (Fig. 3.1). Instead, it is stratified and divided into four zones: superficial, middle, deep, and calcified. The superficial zone, also called tangential zone, is considered the articular surface and is characterized by flattened chondrocytes, relatively low quantities of proteoglycan, and numerous thicker fibrils arranged parallel to the articular surface in order to resist tension. In articular cartilage this layer acts as a barrier because there is no perichondrium.The middle zone, or transitional zone, in contrast, has round chondrocytes, the highest level of proteoglycan among the four zones, and a random arrangement of collagen.The deep (radiate zone) is the thickest zone, characterized by collagen fibrils that are perpendicular to the underlying bone, acting as an anchor to prohibit separation of zones and in order to resist at torsional and compressive mechanical strength

Quadri patologici nelle malattie reumatiche articolari

L’ecografia va riscuotendo crescenti consensi in ambito reumatologico per la dimostrata capacita di consentire una accurata valutazione dell’impegno dei tessuti molli in un’ampia gamma di malattie dell’apparato locomotore [1, 2, 3, 4, 5, 6, 7, 8, 9, 10]. I progressi tecnologici che si sono registrati nel corso degli ultimi anni hanno portato alla disponibilita di ecografi con un sempre piu elevato potere di risoluzione, tanto da consentire l’analisi di dettagli non valutabili con altre metodiche di imaging. Se alle notevoli potenzialita dell’ecografia non corrisponde una larga diffusione della stessa tra i reumatologi, cio si deve soprattutto al lungo training necessario per acquisire una piena autonomia operativa. L’impiego dell’ecografia in campo reumatologico e stato inizialmente confinato all’individuazione di ampie raccolte di liquido sinoviale (cisti poplitee, borsiti) [11].

Ecografia e monitoraggio della terapia

L’ecografia consente una valutazione rapida ed accurata dell’impegno dei tessuti molli nelle malattie reumatiche [1, 2, 3]. L’ecografia con tecnica power Doppler e sonde ad elevata risoluzione puo rivelare la presenza di minime alterazioni morfo-strutturali e di perfusione tessutale [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14] e presenta pertanto un potenziale di rilevante interesse nel monitoraggio dell’attivita di malattia [15, 16, 17, 18, 19, 20, 21, 22, 23, 24] (Figg. 6.1–6.6).

Procedure eco-guidate

L’artrocentesi e la terapia loco-regionale sono procedure di comune esecuzione nella pratica clinica reumatologica. Il trattamento loco-regionale con steroidi, in particolare, costituisce una efficace alternativa all’impiego di farmaci per via sistemica e trova indicazione in diverse malattie e sindromi di interesse reumatologico [1, 2, 3, 4, 5]. Sia l’efficacia che gli effetti collaterali dell’iniezione dipendono dal corretto posizionamento dell’ago all’interno o alla periferia del “bersaglio” prescelto.

Semeiotica ecografica delle malattie dell’apparato locomotore

Le potenzialita dell’ecografia nello studio non invasivo della cartilagine jalina sono di grande rilevanza sul piano clinico [1], in quanto consentono di dimostrare, con elevata risoluzione spaziale, la presenza di lesioni submillimetriche. Il principale limite nello studio ecografico della cartilagine articolare e rappresentato dalle dimensioni delle finestre acustiche, che talora non consentono una visualizzazione panoramica e completa delle superfici cartilaginee.