Lucio Ventura-Ríos

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists.

Objective:To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas. Methods:A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level. Results:General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions. Conclusion:A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.

Molecular basis of oxidative stress in gouty arthropathy

Gout is a disorder of urate metabolism in which persistent high urate levels in the extracellular fluids result in the deposition of monosodium urate (MSU) crystal in joints and periarticular tissues. In recent years, this disease represents an increasingly common health problem, so the pace of investigation in the field has accelerated tremendously. New research advances in the pathogenesis of hyperuricemia and in the understanding of how MSU crystals induce an acute gouty attack have been focused in this review on the processes of inflammation and involvement of the innate immune response; in addition, we discuss new knowledge about the role of the reactive oxygen species in establishing oxidative stress in MSU crystal-induced arthritis.

Joint involvement in primary Sjögren's syndrome: an ultrasound "target area approach to arthritis".

Objective. To characterize the ultrasound (US) pattern of joint involvement in primary Sjögrens syndrome (pSS). Methods. Seventeen patients with pSS, 18 with secondary Sjögrens syndrome (sSS), and 17 healthy controls underwent US examinations of various articular regions. Synovitis (synovial hypertrophy/joint effusion), power Doppler (PD) signals, and erosions were assessed. Results. In patients with pSS, synovitis was found in the metacarpophalangeal joints (MCP, 76%), wrists (76%), and knees (76%), while the proximal interphalangeal joints, elbows, and ankles were mostly unscathed. Intra-articular PD signals were occasionally detected in wrists (12%), elbows (6%), and knees (6%). Erosions were evident in the wrists of three (18%) patients with pSS, one of these also having anti-cyclic citrullinated peptide (anti-CCP) antibodies. While US synovitis does not discriminate between sSS and pSS, demonstration of bone erosions in the 2nd MCP joints showed 28.8% sensitivity and 100% specificity for diagnosing sSS; in comparison, these figures were 72.2 and 94.1% for circulating anti-CCP antibodies. Conclusions. In pSS, the pattern of joint involvement by US is polyarticular, bilateral, and symmetrical. Synovitis is the US sign most commonly found in patients with pSS, especially in MCP joints, wrists, and knees, and bone erosions also may occur.

Ochronotic arthropathy as a paradigm of metabolically induced degenerative joint disease. A case-based review.

Alkaptonuria is a rare, hereditary metabolic disorder in which a deficiency in the homogentisate 1,2-dioxygenase enzyme results in an accumulation of homogentisic acid. Deposition of excess homogentisic acid in different intra- and extra-articular structures with high content of connective tissue causes brownish-black pigmentation and weakening, ultimately resulting in tissue degeneration and finally osteoarthritis. Ochronotic arthropathy is considered a rapidly progressive, disabling condition in which weight-bearing joints and the thoracolumbar spine are predominantly affected. Patients often require multiple joint replacements, such as in the case of the patient presented here. At present, there is no definitive cure for ochronosis, and management is predominantly symptomatic.

Ultrasonography in pediatric rheumatology in Latin America. Expanding the frontiers

For the past two decades, musculoskeletal ultrasonography (MSKUS) has developed exponentially and has become an essential tool in rheumatology practice. This development has been far more limited in pediatric rheumatology which is partially related to deficits in the evidence base. Many studies have shown that MSKUS is more sensitive than the clinical examination for detecting synovitis and enthesitis in adults. At the same time, there is a lack of studies demonstrating its validity, reliability, and reproducibility in pediatric rheumatology. In addition, clear definitions for the normal pediatric joint and enthesis as well as various findings in pathology associated with juvenile idiopathic arthritis (JIA) and juvenile spondyloarthritis (JSpA) have only started to emerge. Most of this work is being done through the Outcome Measurement in Rheumatology Clinical Trials (OMERACT) ultrasound pediatric task force but the Pan American League of Associations for Rheumatology (PANLAR) US Pediatric Task Force is also working on validating MSKUS in children. In addition, several MSKUS courses for pediatric rheumatologists have been offered in Latin American countries; these will not only complement the scientific work pediatric-specific ultrasonography training, but also represents an essential component for the successful implementation of this technique into daily practice as well.

New Ultrasound Modalities in Rheumatology.

AbstractOver the years, ultrasound (US) has accumulated important evidence supporting its relevant role for the assessment of inflammatory processes of different rheumatologic diseases, as well as in the follow-up in assessing the response to different therapeutic approaches. This has been possible because of the increase in training, competency, and knowledge, as well as the rapid progress in the US technologies.Currently, some US machines can be equipped by sophisticated software modalities (i.e., 3-dimensional US, elastosonography, automated cardiovascular software, and fusion imaging) that can augment US traditional role as a safe, fast, and easy-to-perform modality and giving it new life and increased relevance in rheumatology. In this article, we evaluated the US developments, from conventional B-mode to more sophisticated technologies, and their potential clinical impact in the field of rheumatology.Three-dimensional US can improve the accuracy of the assessment of bone erosions and the quantification of power Doppler because of its multiplanar view including coronal, axial and sagital view. Elastosonography is still looking for its role in rheumatology. Preliminary works induce us to consider it as a promise tool for the assessment of tendon pathology and skin of patients with connective tissue disorders. The automated method for the measurement of carotid intima-media thickness permits a rapid and accurate assessment. The preliminary published data showed that it is reliable, and valid compared to the traditional method; they also support the future of rheumatologists as the direct operators in evaluating the cardiovascular risk in daily practice. Fusion imaging increases the diagnostic power of US, displaying simultaneously in the monitor, the US image, and the corresponding computed tomography/magnetic resonance imaging image. However, there are no sufficient data supporting its application in daily rheumatologic practice.

Levels of cytokines and microRNAs in individuals with asymptomatic hyperuricemia and ultrasonographic findings of gout: a bench‐to‐bedside approach

To assess potential associations among serum cytokines and microRNA (miR) levels with ultrasound (US) findings suggestive of urate deposits in chronic asymptomatic hyperuricemia and gout.

Cristales de hidroxiapatita y pirofosfato de calcio imitando gota en una paciente con esclerosis sistémica

Mujer de 61 años de edad, que acudió a consulta por dolor moderado y limitación funcional de la rodilla izquierda de 4 meses de evolución. La paciente tiene historia de esclerosis sistémica de 2 años de evolución. Al examen físico la rodilla tenía aumento de volumen e hipertermia local. La velocidad de sedimentación globular fue de 47 mm/h. Las radiografías de las rodillas fueron normales. La ultrasonografía de las rodillas mostró sinovitis con Doppler de poder moderado, doble contorno del cartílago femoral (fig. 1A), y calcificación del menisco medial. El análisis de líquido sinovial por microscopia de luz polarizada mostró abundantes cristales de hidroxiapatita (HA) (fig. 1B) y escasos de pirofosfato de calcio (PC) (fig. 1C). Los cristales de HA han sido descritos en el cartílago hialino o en el líquido sinovial de pacientes con enfermedades

Reliability of ultrasound grading traditional score and new global OMERACT-EULAR score system (GLOESS): results from an inter- and intra-reading exercise by rheumatologists

This study aims to test the reliability of ultrasound to graduate synovitis in static and video images, evaluating separately grayscale and power Doppler (PD), and combined. Thirteen trained rheumatologist ultrasonographers participated in two separate rounds reading 42 images, 15 static and 27 videos, of the 7-joint count [wrist, 2nd and 3rd metacarpophalangeal (MCP), 2nd and 3rd interphalangeal (IPP), 2nd and 5th metatarsophalangeal (MTP) joints]. The images were from six patients with rheumatoid arthritis, performed by one ultrasonographer. Synovitis definition was according to OMERACT. Scoring system in grayscale, PD separately, and combined (GLOESS—Global OMERACT-EULAR Score System) were reviewed before exercise. Reliability intra- and inter-reading was calculated with Cohen’s kappa weighted, according to Landis and Koch. Kappa values for inter-reading were good to excellent. The minor kappa was for GLOESS in static images, and the highest was for the same scoring in videos (k 0.59 and 0.85, respectively). Excellent values were obtained for static PD in 5th MTP joint and for PD video in 2nd MTP joint. Results for GLOESS in general were good to moderate. Poor agreement was observed in 3rd MCP and 3rd IPP in all kinds of images. Intra-reading agreement were greater in grayscale and GLOESS in static images than in videos (k 0.86 vs. 0.77 and k 0.86 vs. 0.71, respectively), but PD was greater in videos than in static images (k 1.0 vs. 0.79). The reliability of the synovitis scoring through static images and videos is in general good to moderate when using grayscale and PD separately or combined.

AB1010 Ultrasound morphostructural pattern of the tibiofibular joint. preliminary results

Background The anatomy of the proximal tibiofibular (TF) joint is directly related to its ability to withstand stress applied in either a longitudinal or axial fashion. It is traditionally evaluated by CT scan, however, in certain conditions, it could be evaluated by ultrasound (US) conveniently; so far US has not been using to evaluate the TF joint. US is an innocuous, accessible and cheap image technique, that has demonstrated its utility for evaluating joints in several pathologic conditions, and might have an important role in the early diagnosis of inflammatory, degenerative or even tumoral lesions at the level of the TF joint; there are no studies that have evaluated the morpho- structural pattern of the TF joint. Objectives To describe the morphostructural pattern of the tibiofibular joint in healthy subjects. Methods Subjects older than 18 yrs old, with no history of past/present lesion of the knee, without any joint or neurovascular disease were included. A short questionnaire related to physical activity applied, and clinical evaluation to discard instability performed. US of both knees in extension done, using an Esaote ® MyLab 70 ultrasound equipment with a 7.5 - 12 MHz linear transducer. Descriptive statistics done Results Thirty-six patients (27 women, 75%) included, mean age 41.2±8.9 years, mean weight 71±12.46 kg, mean height 1.61±0.09 ms and BMI 71.07±12.40. 69% of the subjects practice mild exercise activities. By US mean distance between tibia and fibula were 3.2±1.17 cm; the mean thickness of the ligaments (superior and inferior) was 3.2±0.99 cm and 3.2±0.89 respectively, and in the superior e inferior fibular ligaments were 3.2±0.99 cm and 3.2±0.89 cm respectively. Ligaments were hyperechoic in 61.1%, a well-defined border was seen only in 48.6%. Inside of joints a hypoechoic tissue was observed Conclusions These preliminary results suggest that US can be a useful tool for evaluating the tibiofibular joint. Disclosure of Interest None declared