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Ultrasound is a non-invasive, innocuous, reproducible, cost-efficient imaging technique that provides immediate information, as it can be performed in our consultations. The good profile of ultrasound and the technological advances that have taken place in recent years, which have allowed a substantial improvement in the resolution of the image to make it almost anatomical, have promoted research on its application in the comprehensive study of systemic inflammatory diseases. At present, the threshold of using ultrasound to exclusively investigate musculoskeletal manifestations has been crossed, to also apply it to the study of extra-articular manifestations and comorbidities associated with rheumatic diseases. In this review we will revise its usefulness for the diagnosis of glandular involvement in Sjögren's syndrome, interstitial lung disease or giant cell arteritis and for stratification of cardiovascular risk in patients with chronic inflammatory rheumatic diseases.

espanolLa ecografia es una tecnica de imagen no invasiva, inocua, reproducible y coste-eficiente, que aporta informacion inmediata al poder realizarla en nuestras consultas. El buen perfil de la tecnica y los avances tecnologicos acontecidos en los ultimos anos, que han permitido una mejora sustancial en la resolucion de la imagen hasta hacerla casi anatomica, han impulsado la investigacion sobre su aplicacion al estudio integral de las enfermedades inflamatorias sistemicas. En la actualidad, se ha traspasado el umbral de utilizar la ecografia para investigar exclusivamente las manifestaciones musculo-esqueleticas, para aplicarla tambien al estudio de las manifestaciones extraarticulares y las comorbilidades asociadas a las enfermedades reumaticas. En la presente revision repasaremos su utilidad para el diagnostico de la afectacion glandular en el sindrome de Sjogren, la enfermedad pulmonar intersticial o la arteritis de celulas gigantes y para la estratificacion del riesgo cardiovascular en pacientes con enfermedades reumaticas inflamatorias cronicas. EnglishUltrasound is a non-invasive, innocuous, reproducible, cost-efficient imaging technique that provides immediate information, as it can be performed in our consultations. The good profile of ultrasound and the technological advances that have taken place in recent years, which have allowed a substantial improvement in the resolution of the image to make it almost anatomical, have promoted research on its application in the comprehensive study of systemic inflammatory diseases. At present, the threshold of using ultrasound to exclusively investigate musculoskeletal manifestations has been crossed, to also apply it to the study of extra-articular manifestations and comorbidities associated with rheumatic diseases. In this review we will revise its usefulness for the diagnosis of glandular involvement in Sjogren's syndrome, interstitial lung disease or giant cell arteritis and for stratification of cardiovascular risk in patients with chronic inflammatory rheumatic diseases.

Objective To evaluate the impact of the routine use of musculoskeletal ultrasound (MSUS) in rheumatology clinics by comparing one clinic with on-site MSUS (REU 1) and four clinics without this resource, which need to refer patients for the MSUS exams (REU 2–5). Methods The electronic medical records of all new patients at five rheumatology clinics during a 12-month period were reviewed. The impact of MSUS was analysed by comparing the percentage of direct discharges of patients from the different clinics, as an outcome of effectiveness, and the number and cost of radiology referrals for imaging exams (MSUS and MRI), as an outcome of cost-saving. Results The medical records of 4923 patients were included in the study, distributed as follows: REU 1, 1464 (29.7%); REU 2, 1042 (21.2%); REU 3, 1089 (22.1%); REU 4, 579 (11.8%); and REU 5, 749 (15.2%). There were more direct discharges from REU 1 (34.4%) than from REU 2–5 (15.6%) (P Conclusion The implementation of on-site MSUS in a new-patient rheumatology clinic is cost-effective, facilitating the direct discharge of patients and reducing the number and cost of radiological referrals for imaging exams.

Objective To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging in patients with spondyloarthritis, including psoriatic arthritis, and juvenile idiopathic arthritis. Methods Recommendations were generated following a nominal group technique. A panel of experts (15 rheumatologists and 3 radiologists) was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of participants voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence Based Medicine levels of evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. Results A total of 12 recommendations were proposed for each disease. They include, along with explanations of the validity of US and magnetic resonance imaging regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. Conclusions These recommendations will help clinicians use US and magnetic resonance imaging in patients with spondyloarthritis and juvenile idiopathic arthritis.

Resumen Objetivo Establecer recomendaciones, basadas en la evidencia, sobre el uso de la ecografia (US) y la resonancia magnetica en pacientes con espondiloartritis, incluyendo la artritis psoriasica, y en la artritis idiopatica juvenil. Metodos Las recomendaciones se consensuaron mediante metodologia basada en grupos nominales. Un grupo de expertos (15 reumatologos y 3 radiologos) definio el alcance, los usuarios, los apartados, las posibles recomendaciones y las revisiones sistematicas a realizar (se utilizaron y actualizaron las revisiones de documentos de consenso de EULAR), y se asignaron tareas. Los expertos delimitaron los apartados y redactaron las recomendaciones. El nivel de evidencia y el grado de recomendacion se establecieron utilizando el sistema del Centre for Evidence Based Medicine de Oxford, y el grado de acuerdo mediante Delphi a 2 rondas. Las recomendaciones se votaron segun una escala de 1 (total desacuerdo) a 10 (total acuerdo), definiendose el acuerdo como una puntuacion ≥ 7 por al menos el 70% de los participantes. El documento fue revisado por los expertos y el proyecto estuvo coordinado por un metodologo experto. Resultados Se emitieron 12 recomendaciones sobre la validez de la US y la resonancia magnetica para la deteccion de actividad y dano estructural, capacidad diagnostica, predictora (de progresion de dano estructural, brote de la enfermedad, respuesta al tratamiento, etc.), utilidad en la evaluacion y monitorizacion del tratamiento, y uso de la US como guia (para infiltraciones, biopsias, etc.) en pacientes con espondiloartritis y artritis idiopatica juvenil. Conclusiones Se presentan unas recomendaciones utiles para el manejo de la US y la resonancia magnetica por los clinicos en pacientes con espondiloartritis y artritis idiopatica juvenil.

There is no agreement among the rheumatology community in how to implement the musculoskeletal ultrasound (MSUS) technique in the Rheumatology Divisions. To test the perceived usefulness of the MSUS, under consensus indications, for referring colleagues for the clinical management of their patients with inflammatory arthritis (IA) and to score the satisfaction level of the patients with different aspects of the ultrasound (US) examination, after attend to the MSUS clinic. A written questionnaire-based survey regarding the usefulness and satisfaction with the implementation of a pilot MSUS clinic in a Rheumatology Unit. Over a 6-month period, 43 patients attended 10 MSUS clinics. Referral agreed indications were: US assisting in early/subclinical diagnosis (35 %), decision making with patient treatment (44 %), monitoring of disease activity/treatment response (39 %) and US-guided injection (11 %). Average scores of the referrers regarding usefulness of the information provided for the US for these indications were 8.0, 8.3, 8.7 and 8.6, respectively, with a high score of 9.0 regarding the valuable support of the US for the management of their patients with IA. Patient satisfaction scores in responders (44 %) were averaged 9.5 and higher for receiving an adequate explanation of the US procedure, indications, US findings and their significance, lack of discomfort and length of the appointment. The average score was slightly lower (8.5) for the waiting time frame for the appointment for the MSUS examination. The referrers expressed a perception of usefulness of our pilot US clinic, under previous consensus indications, for the clinical management of their patients with IA. In addition, this MSUS clinic seemed to show a good acceptability and a high satisfaction scores for the patients.

Objective.To assess the responsiveness and repeatability of volumetric power Doppler ultrasound (PDUS) evaluation of synovitis and bone erosions in rheumatoid arthritis (RA).Methods.Twenty-three patients with RA (19 women, mean age 52.7 ± 12.6 yrs, mean disease duration 10.1 ± 8.6 yrs) were prospectively enrolled. All patients were beginning therapy with rituximab because of disease activity despite therapy with synthetic disease-modifying antirheumatic drugs and tumor necrosis factor-blocking agents. Patients underwent clinical, laboratory, and volumetric PDUS examination at baseline, 6 months, and 12 months. Ten centers participated in the study. Four centers recruited the patients and performed the volumetric acquisitions of PDUS images, while the remaining 6 centers assessed the PDUS volumes, blinded to the identity of patients and date of the visits. The most symptomatic hand and foot were scored for B-mode synovitis, synovial PD signal, and bone erosions. The repeatability of the volumetric PDUS assessment was investigated.Results.An overall improvement in clinical and PDUS measurements was found at the followup assessments. The mean indexes for synovial PD signal and bone erosions and the number of sites with abnormalities decreased significantly throughout the followup (p < 0.05). The intraacquisition, intrareader reliability was excellent for all PDUS measurements (intraclass correlation coefficients > 0.9).Conclusion.The results of our pilot study suggest that volumetric PDUS can be responsive and repeatable in multicenter cohort studies of RA. This technique may minimize assessment biases and reduce acquisition variability in open-label and observational studies.

The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen's kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

Objective To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). Methods Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. Results A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. Conclusions These recommendations will help clinicians use US and MRI in RA patients.

Objective. To investigate the presence of synovitis, tenosynovitis and enthesitis with power Doppler (PD) ultrasonography (US) in patients with psoriasis without musculoskeletal diseases as compared with controls with other skin diseases without musculoskeletal disorders. Methods. A total of 162 patients with plaque psoriasis and 60 age-matched controls with other skin diseases, all without musculoskeletal diseases, were prospectively recruited at 14 centres. They underwent dermatological and rheumatological assessment and a blinded PDUS evaluation. Clinical assessment included demographics, comorbidities, severity of psoriasis, work and sport activities and musculoskeletal clinical examination. PDUS evaluation consisted of the detection of grey scale (GS) synovitis and synovial PD signal in 36 joints, GS tenosynovitis and tenosynovial PD signal at 22 sites, and GS enthesopathy and entheseal PD signal in 18 entheses. Results. US synovitis and enthesopathy were significantly more frequent in psoriatic patients than in controls (P = 0.024 and 0.005, respectively). The percentage of joints with US synovitis was 3.2% in the psoriasis group and 1.3% in the control group (P < 0.0005). US enthesopathy was present in 11.6% of entheses in the psoriasis group and 5.3% of entheses in the control group (P < 0.0005). Entheseal PD signal was found in 10 (7.4%) psoriatic patients, whereas no controls showed this finding (P = 0.05). Among demographic and clinical data, having psoriasis was the only significant predictive variable of the presence of US synovitis [odds ratio (OR) 2.1; P = 0.007] and enthesopathy (OR 2.6; P = 0.027). Conclusion. Psoriatic patients showed a significant prevalence of asymptomatic US synovitis and enthesopathy, which may indicate a subclinical musculoskeletal involvement.

Aims. To evaluate the agreement between a visual and an automatic counting system of lung B-lines by ultrasound (US) as well as to test the inter- and intra-observer reliability of both systems in patients with lung diseases.Material and methods. We included four patients with different lung conditions. Four ultrasonographers expert in lung US blindly, independently and consecutively performed, in two rounds, a US B-mode assessment of 8 lung intercostal spaces of each patient. Each US assessment consisted of a visual and an automatic counting of B-lines.Results. Agreement between visual and automatic counting of B-lines was good to excellent [intraclass correlation coefficient (ICC) 0.79-0.84, p

Objective: To evaluate synovial fluid levels of cartilage and bone biological markers after repetitive intra-articular injections of sodium hyaluronate (HA) in knee osteoarthritis (OA) patients. Methods: Twenty patients with knee OA were evaluated before and after 5 weekly injections of HA. To study cartilage and bone biological markers, synovial fluid and urine samples were collected simultaneously with the first (FI=week 0) and before the last injection (LI=week 4) of HA. Not commercially available markers (cartilage oligomeric matrix protein (COMP), proteoglycan monomers and cyanogen bromide peptide 11 of the type II collagen chains (α (II) CA11B)) were determined by an indirect inhibition ELISA developed and standardized in our laboratory. Results: We found a significant reduction in levels of proteoglycan monomers (30±16 vs. 22±10 μg/ml, p

Introduccion: En pacientes con artritis reumatoide (AR), el dolor en las rodillas puede ser inflamatorio, mecanico o extraarticular. La exploracion fisica (EF) no siempre detecta el derrame articular o el quiste de Baker (QB) en las rodillas de estos pacientes. Objetivo: Determinar la agudeza diagnostica de la EF en el diagnostico de derrame articular y QB en pacientes con AR evaluados con ultrasonografia osteomuscular (USME), la tecnica de imagen de referencia. Material y metodo: Se utilizaron 3 equipos de ultrasonido marca Toshiba Tosbee, Toshiba Capasee y Siemens Sonoline, con transductores lineares de 7,5 MHz para detectar derrame y QB en rodillas de pacientes con AR valorados previamente por clinica por un reumatologo, quien dictamino si los habia. Se registraron edad, sexo, duracion de la AR, factor reumatoide, tratamiento, clase funcional de AR (CFAR) y diagnostico clinico previo al USME. Resultados: Se evaluo a 40 pacientes (80 rodillas) con AR, el 80% eran mujeres, la edad promedio fue 61,3 ± 15 anos y la duracion de la enfermedad, 9,5 ± 11,3 anos; el factor reumatoide fue positivo en el 80% de los casos; CFAR I (3 pacientes), CFAR II (27), CFAR III (8), CFAR IV (2); el 55% de los pacientes recibian metotrexato. Hubo dolor referido por el paciente en 26 rodillas (32,5%). Se comunico derrame por USME en 49 rodillas (61,2%) y QB en 14 (17,5%); derrame por EF en 35 rodillas (43,7%) y corroborado por USME en 31 rodillas (38,75%), QB por clinica en 12 rodillas (15%) y corroborado por USME en 6 rodillas (7,5%). La sensibilidad de la EF para la deteccion de derrame fue 0,63 y la especificidad, 0,87; para la deteccion de QB fueron 0,43 y 0,91, respectivamente. Conclusiones: La EF mostro una agudeza diagnostica aceptable para el clinico. El uso complementario de la USME en la EF de los pacientes con AR puede ser un factor decisivo en la conducta terapeutica y diagnostica en pacientes con AR y afeccion de rodillas

Objective. Although clinical reports have described medial meniscal subluxation (MMS) in knee OA, few controlled studies have used dynamic US to examine the potential impact of MMS on OA. The aim of this study was to assess MMS in patients with knee OA and in asymptomatic controls by US in different weight-bearing positions. Methods. In a cross-sectional controlled study, MMS was evaluated by US in 33 symptomatic OA knees and in 13 control knees in supine neutral and unipodal weight-bearing positions. The reproducibility of US in this setting was assessed and the US measurements were compared between patients and controls. Results. MMS was observed more frequently in OA knees than in controls in the unipodal weight-bearing position both before (P = 0.014) and after (P = 0.035) walking 50 m. In both OA and control knees, an increase in MMS was observed in the unipodal weight-bearing positions compared with the supine neutral position, but this increase was greater in OA knees than in controls (P < 0.001). Conclusion. Our findings confirm clinical observations that the medial meniscus undergoes significant subluxation in knee OA. The degree of subluxation is greater in weight-bearing than in non-weight-bearing positions. Dynamic US is a reproducible method for the assessment of MMS.

Our objective was to describe the ultrasound features of patients with PsA in joints and skin and their changes after treatment with infliximab.Eight hospitals recruited PsA active patients. Clinical (joint count for pain, TJC, and swelling, SJC, pain VAS, ESR, C-reactive protein and PASI) and US variables (plaque thickness, PD signal of dermal lesions, synovitis, erosions, and PD signal, assessed by 4-category ordinal scales) were independently recorded at baseline and 4, 12 and 24-week after starting treatment with infliximab. The results were analysed with paired T, Wilcoxon test, ANOVA and marginal homogeneity test.Changes in 24 patients from baseline to last available data were significant for clinical variables, pain VAS, TJC and SJC as well as for ESR, CRP (all p0.0005). Dermatological PASI changed from 14.6±14.9 to 2.1±4.1 and plaque thickness from 3.34±1.75 mm to 1.74±0.96 mm (both p0.0005); synovitis and PD signal improved (both p0.0005). Psoriatic plaque PD improved across the study (p0.0005) with no signal increasing from 36.4% to 88.9% and positive PD signal decreasing from 63.6% to 11.1% of the plaques.Treatment with anti-TNF-α infliximab improves the symptoms of patients with PsA at joint and psoriatic skin levels from a clinical and ultrasonographic perspective.

To assess the multiexaminer reproducibility and the accuracy comparing with cadaver anatomic specimens of ultrasound (US) measurement of femoral articular cartilage (FAC) thickness.In 8 flexed cadaver knees, FAC thickness was blindly, independently and consecutively measured twice by 10 rheumatologists at the lateral condyle (LC), medial condyle (MC) and intercondylar notch (IN) with US. After the US measurements, the knees were dissected. Articular cartilage integrity was evaluated macroscopically in the femoral condyles. FAC thickness was blindly measured in the specimens using a stereoscopic magnifying loupe and a digitised image software. Interexaminer and intraexaminer reliability of US FAC thickness measurement and agreement between US and anatomic measurements were assessed by estimating the intraclass correlation coefficient (ICC).Interexaminer ICCs were higher than 0.90 for MC (p0.001) and IN (p0.001) and higher than 0.75 for LC (p0.01). Mean intraexaminer ICCs were 0.832 for MC (p0.001), 0.696 for LC (p0.001) and, 0.701 for IN (p0.001). Agreement between US and anatomic FAC thickness measurements was good for MC (ICC 0.719; p = 0.020) and poor for LC (p = 0.285) and IN (p = 0.332). Bland-Altman analysis showed that the difference between US and anatomic values was considerably high in the one knee with severely damaged FAC. After eliminating this knee from the analysis, ICCs were 0.883 (p0.001) for MC, 0.795 (p = 0.016) for LC and 0.732 for IN (p = 0.071).US demonstrated a good reproducibility in FAC thickness measurement by multiple examiners. In addition, US FAC thickness measurement was accurate in normal to moderately damaged cartilage.

Objective: To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses.Methods: We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels.Results: The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses.Conclusion: We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

Enthesitis is a remarkable feature of ankylosing spondylitis (AS) not specifically approached by the available measuring tools for the disease. Ultrasonography (US) has proved to be an excellent technique for the assessment of tendon pathology.To test a Sonographic Entheseal Index (SEI) of the lower limbs in a cohort of patients with AS, as a potential measuring tool.44 patients with AS and 10 healthy controls were enrolled. Bath Ankylosing Spondylitis Functional Index and Bath Ankylosing Spondylitis Disease Activity Index, pain at entheseal points, severity of symptoms, acute-phase reactants, Schober's test and stage of sacroiliitis were recorded. Patients underwent US examination of five entheseal regions from both lower limbs by two experts. Hypoechogenicity, increased tendon thickness, peritendinous oedema and bursitis were considered signs of active inflammation. Insertional bone erosions, intratendinous calcifications, decreased thickness and tears were considered signs of chronic injury. Each alteration independently scored one point. Data were analysed with Spearman's correlation method.A significant interobserver correlation in SEI scores (p0.001) and a fine discriminative power between controls and patients were observed. Acute entheseal lesions predominated (63% vs 37%), the most frequent alteration being tendon hypoechogenicity (43%). 72% of all lesions were located at the foot. The SEI correlated with reduction of Schober's test (p0.02), but not with other activity or severity parameters.A scoring method such as the SEI may be of help in characterising entheseal injury in AS, and for decision making in these patients.

Introduction In patients with rheumatoid arthritis (RA), knee pain can be inflammatory, mechanical, or extraarticular. The physical examination (PE) doesn’t always detect the presence of knee joint effusion or Baker's cyst (BC) in the knees of these patients. Objective To determine the diagnostic accuracy of PE in the diagnosis of effusion and BC in patients with RA evaluated with musculoskeletal ultrasound (MSUS), using this technique as the gold standard for comparison. Material and method Three different models of ultrasound machines with a 7.5 MHz linear probe were used (Toshiba Tosbee, Toshiba Capasee, and Siemens Sonoline). A rheumatologist evaluated the presence or absence of knee joint effusion or BC in patients. We registered age, gender, time of evolution of RA, rheumatoid factor, treatment, functional class of RA (FCRA), and previous clinical diagnosis to the MSUS study. Results Forty patients (80 knees) with RA were evaluated. Eighty percent were women, mean age 61.3 (15) years. Time since onset of RA was 9.5 (11.3) years, rheumatoid factor was positive in 80%, FCRA I (3 patients), FCRA II (27), FCRA III (8), FCRA IV (2). Fifty-five percent of the patients received methotrexate. Patients referred pain in 26 knees (32.5%). Joint effusion was reported by the clinician in 35 knees (43.7%) and corroborated by MSUS in 31 knees (38.75%), BC was reported by the clinician in 12 knees (15%) and corroborated by MSUS in 6 knees (7.5%). The sensitivity of the PE for detection of joint effusion was 0.63 and specificity of 0.87, for the detection of BC was 0.43 and 0.91, respectively. Conclusions The PE showed acceptable diagnostic accuracy for the clinician. The complementary use of the MSUS can change the therapeutic and diagnostic approach in patients with RA.

Purpose: To assess sonographic changes in Baker's cysts (BCs) of patients with knee osteoarthritis after a single intra-articular corticosteroid injection. Methods: Thirty patients with knee osteoarthritis complicated with a symptomatic BC received a single intra-articular injection of 40 mg triamcinolone acetonide. Knee pain, swelling, and range of motion were evaluated. BC area and thickness of the cyst wall were measured with sonography before and 4 weeks after local treatment. Results: A significant improvement in knee pain, swelling, and range of motion after corticosteroid injection was accompanied by a decrease in size of the BCs as well as in thickness of the cyst wall as measured by sonography. Moreover, the reduction of BC area on sagittal scans after treatment was significantly correlated with the improvement in range of motion. Conclusions: In this series of osteoarthritis patients, injection of corticosteroids inside the knee joint accounted for a reduction in BC dimensions as well as cyst wall thickness. Sonography can be used not only for the diagnosis of BCs but also to monitor response to therapy. © 2006 Wiley Periodicals, Inc. J Clin Ultrasound 34:113–117, 2006

Background: The treatment of osteoporosis among postmenopausal women represents a major public health challenge because long-term therapy is needed to prevent fractures and chronic disability. Low patient compliance with prescribed osteoporosis treatments can severely distort the validity of controlled clinical trials. Raloxifene and alendronate have been shown to reduce the incidence of osteoporotic fracture in postmenopausal women in well-conducted randomized trials, but few data are available on the rate of adherence to these treatments in routine clinical practice. Objective: The primary aim of this study was to assess the compliance of postmenopausal women at risk for osteoporotic fractures who were treated with raloxifene hydrochloride (RLX) versus alendronate sodium (ALN) during a 12-month observational period in a routine clinical setting. Secondary objectives were the assessment of factors that might contribute to noncompliance and patient satisfaction. Methods: This open-label, prospective, multicenter, nonrandomized, observational, comparative study was conducted at 154 centers across Spain. Assignment to either RLX or ALN treatment was determined by the physician and was based on each patient's clinical profile. Compliance with RLX (60-mg tablet once daily) versus ALN (10-mg tablet once daily) was assessed using 3 different compliance assessment tools: the Morisky-Green test, the Autocompliance test, and the Compliance Questionnaire. A logistic regression model was used to assess different factors affecting compliance. Patient satisfaction was also assessed using a questionnaire. Adverse events (AEs) were collected as reasons for discontinuation in the Compliance Questionnaire and at the discontinuation visit. Results: A total of 902 women (RLX group, n = 476; ALN group, n = 426) were included in the study (mean age, 64.4 [6.9] years). Overall, patients in the RLX group reported significantly better compliance than patients in the ALN group, as collected either by the Morisky-Green test (68.7% vs 54.0%; P < 0.001) or the Autocompliance test (94.7% vs 90.6%; P = 0.033). More patients discontinued treatment prematurely in the ALN group compared with the RLX group (25.8% vs 16.4%; P < 0.001). The age-adjusted relative risk for discontinuation was 1.4-fold higher for women treated with ALN than for those treated with RLX (95% CI, 1.21-1.61). The main reason for premature discontinuation was due to AEs (RLX 4.8% vs ALN 11.0%; P < 0.001). The proportion of patients with gastrointestinal AEs was 9.9% in the ALN group and 3.4% in the RLX group (P < 0.001). Only treatment and type of physician were independent covariates of treatment compliance. After 12 months of observation, significantly more patient in the RLX group were satisfied or very satisfied with their treatment than patients in the ALN group (P < 0.001). Conclusion: In this study of postmenopausal women at risk for osteoporotic fractures, compliance with 12-month treatment with daily RLX was higher than with daily ALN in clinical setting. RLX showed significant benefits compared with ALN in terms of compliance assessed by means of the Morisky-Green and Autocompliance tests and the patients' self-reported satisfaction.

A 32 year old white women was admitted to our hospital complaining of long term fever and fatigue. She reported recurrent episodes of fever lasting 7 to 10 days accompanied by joint pain and weakness during the past four months. Subsequently she developed a productive cough and pleuritic chest pain on the right side. She had not travelled recently or been exposed to contagious diseases. She had not noticed any skin lesions, but on specific questioning reported photosensitivity and Raynaud's phenomenon. She had a history of several lung infections and urolithiasis. She had had two normal deliveries and no miscarriages. There was a family history of interstitial lung disease.#### Key messages On admission she was febrile (37.8°C). Physical examination revealed a conjunctival injection and bilateral submandibular lymph nodes. Wheezes were audible in the right lung base. Cardiac auscultation and abdominal palpation were unremarkable. Joint examination showed tenderness of proximal interphalangeal joints. Laboratory data included the following: erythrocytes 4.75 × 1012/l, haemoglobin 128 g/l, platelets 200 × 199/l, leucocytes 6.8 x 109/l and erythrocyte sedimentation rate (ESR) 70 mm 1st h. Serum biochemistry: creatinine 110 μmol/l (normal range 60–110), calcium 2.42 mmol/l (2.1–2.5) and phosphorous 0.69 mmol/l.(0.97–1.45). Urine density was 1010, pH 7 and there were 12–20 erythrocytes/high magnification field and amorphous carbonates in the sediment. Immunoglobulins: IgG 22 g/l (8–16), IgA 2.23 g/l (1–3), IgM 1.24 g/l (0.8–2.5). Results were negative for HIV, Epstein-Barr serology, tuberculin test and direct examination of acid-alcohol resistant mycobacteria in sputum. A chest radiograph showed …

The aim of this work was to determine bone mineral density (BMD) in a group of patients with ankylosing spondylitis (AS) and to study alterations in bone remodeling in these patients. Eighteen patients (16 males and two females) with AS, mean age 44.7, range 21–75, and 18 age- and sex-matched healthy controls were studied. BMD was evaluated by dual energy X-ray absorptiometry. The following biochemical markers of bone remodeling were studied: formation – serum amino and carboxyterminal propeptides of procollagen I (PINP and PICP); resorption – urinary total and free deoxypyridinoline and pyridinoline (TDpyr, FDpyr, TPyr and FPyr), crosslinked aminoterminal telopeptides of collagen I (NTX), carboxyterminal telopeptide of collagen I (CTX) and serum bone sialoprotein (BSP). Receiver operating characteristic (ROC) curves of markers were also performed. We found a decrease of bone mass and an increase in TPyr, FPyr, TDpyr, FDpyr, NTX and BSP in AS, but no significant differences were found in PICP, PINP and CTX. FDpyr, FPyr and TPyr showed the highest discrimination between patients and controls according to the results of the ROC curves. TPyr/TDpyr was higher in AS than in controls. We found osteopenia, with a normal formation and a significant increase in bone resorption in AS. FDpyr, FPyr and TPyr seem to present the best sensitivity for the study of alterations of bone resorption in this pathology, although NTX, TDpyr and BSP also show significant differences. The elevation in the ratio TPyr/TDpyr in AS compared to controls indicates that in AS there is a type I-collagen degradation in tissues different from bone.

To the Editor: A patient with ankylosing spondylitis was treated with infliximab, a tumor necrosis factor (TNF) blocker that has been associated with reactivation of latent tuberculosis (TB). Because of reactivity in testing with purified protein derivative, isoniazid chemoprophylaxis was started 2 weeks before infliximab therapy. Four months later, a cavitary lung infection developed in the patient, caused by isoniazid-resistant Mycobacterium kansasii. To our knowledge, this is the first documented case of failure of isoniazid prophylaxis due to the emergence of isoniazid-resistant mycobacteria in patients receiving infliximab therapy. TNF blockers have contributed to the control of rheumatic diseases (1). Many of the damaging inflammatory mechanisms that they inhibit are important in maintaining TB in the latent phase. Consequently, drugs that target TNF functions have been associated with an increased risk of TB (2). For these reasons, prophylactic chemotherapy should be offered to patients with latent TB (3). We show the failure of isoniazid chemoprophylaxis in a patient receiving infliximab therapy in whom lung infection developed, caused by isoniazid-resistant M. kansasii. A 39-year-old man with ankylosing spondylitis was admitted to Jimenez Diaz Foundation hospital, Madrid, because of fever and lung infiltrates. He had been receiving anti-inflammatory drug therapy without amelioration of his symptoms. Therefore, treatment with infliximab was considered. Fifteen years before, the patient’s father had had pulmonary TB caused by M. tuberculosis that was susceptible to first-line antituberculous drugs, and the patient was given chemoprophylaxis with isoniazid, 300 mg/day, during a 9-month period. Before beginning infliximab therapy, the patient was again given chemoprophylaxis with isoniazid, 300 mg/day, because a tuberculin test with 5 units of purified protein derivative showed an induration of 18 mm at 72 hours. Results of chest radiographs were normal, and cultures for mycobacteria were negative. Results of HIV testing were also negative. After 4 months of infliximab therapy, fever, cough, and sputum production developed. New radiographs showed bilateral upper lung field infiltrates with cavitary lesions. Three acid-fast stains of sputum were positive, and treatment with rifampin, isoniazid, pyrazinamide, and ethambutol was started. A heavy growth of photochromogenic mycobacteria was detected in 3 sputum cultures. The isolate was identified as M. kansasii genotype 1 by using common biochemical tests and PCR–restriction fragment length polymorphism analysis of the hsp65 gene (4). Susceptibility tests showed resistance to isoniazid (>5 µg/mL), streptomycin, pyrazinamide, p-amino-salicylic acid, and kanamycin but susceptibility to rifampin, ethambutol, and fluoroquinolones. Treatment was continued with a combination of rifampin, levofloxacin, and ethambutol. Sputum cultures taken after 4, 6, and 9 months of antimicrobial drug therapy were negative. After 20 months of treatment, the patient was doing well with a partial resolution of lung infiltrates, and new cultures were negative. Isoniazid chemoprophylaxis can effectively lessen the likelihood of active TB in patients treated with TNF antagonists (5). However, at least 1 failure of TB chemoprophylaxis in a severely immunocompromised patient treated with infliximab and methotrexate has been published (6). Our patient is unique because the mycobacterial lung infection seemed to emerge as a result of the lack of activity of isoniazid chemoprophylaxis due to resistance of the infecting organism. Decreased susceptibility to isoniazid among M. kansasii isolates is common (7,8), and this microorganism is naturally resistant to pyrazinamide (9). This pattern of resistance is a serious obstacle for the use of these drugs in monotherapy or when combined with rifampin in the prevention of lung disease caused by M. kansasii (10). The source of the infection in this patient is unknown. In a large series of infectious diseases associated with infliximab therapy, nontuberculous mycobacteria were isolated in 9% of the patients who had mycobacterial diseases (2). As in our patient, these infections developed shortly after initiation of treatment with infliximab, which suggests that reactivation of a latent infection is the most probable origin of the disease. Although a mildly positive tuberculin skin test result can be observed in patients infected with atypical mycobacteria, the strong reaction seen in this patient suggests a latent infection with M. tuberculosis (10). We could speculate on the possibility of a double infection with M. tuberculosis (contracted through household contacts with his father) and M. kansasii through environmental exposure. In this scenario, isoniazid chemoprophylaxis could have prevented the former but not the latter. In summary, failure of isoniazid chemoprophylaxis can be anticipated in patients who initiate treatment with infliximab and who have latent infections due to M. kansasii. Despite routine antituberculous chemoprophylaxis, patients receiving infliximab therapy should be carefully evaluated for lung infection caused by atypical mycobacteria.