High-resolution musculoskeletal ultrasound (MSUS) has been increasingly employed in daily rheumatological practice and in clinical research. In rheumatoid arthritis (RA), MSUS can be now considered a complement to physical examination. This method evaluates synovitis through gray-scale and power Doppler and it is also able to identify bone erosions. The utilization of MSUS as a marker of RA activity has received attention in recent literature. Current data account for good correlation of MSUS with classical measures of clinical activity; in some instances, MSUS appears to perform even better. Diagnosis of subclinical synovitis by MSUS might help the physician in RA management. With some variation, interobserver MSUS agreement seems excellent for erosion and good for synovitis. However, lack of MSUS score standardization is still an unmet need. In this review, we describe several MSUS scores, as well as their correlation with clinical RA activity and response to therapy. Finally, we look at the relationship of MSUS with synovial tissue inflammation and discuss future perspectives for a better interpretation and integration of this imaging method into clinical practice.

ObjectivesOur goal is to study the correlations among gray-scale seven-joint ultrasound score (GS-US7), power Doppler seven-joint ultrasound score (PD-US7), disease activity score-28 joints (DAS28), simplified disease activity index (SDAI) and clinical disease activity index (CDAI) in patients with and without fibromyalgia (FM).MethodsA matched case-control study included all patients consecutively seen in the Rheumatoid Arthritis (RA) Clinic. Participants were allocated into one of two groups: RA with FM and RA without FM. Ultrasound (US) and clinical scoring were blinded for the presence of FM. Medians and proportions were compared by Mann-Whitney’s test and McNemar’s test, respectively. Spearman’s rank correlation coefficients (rs) were calculated among clinical and US scores and differences were tested by r-to-z transformation test.ResultsSeventy-two women were included, out of 247 RA patients, mostly white, with median (IQR) age of 57.5 (49.3–66.8) years, with RA symptoms for 13.0 (6.0–19.0) years and FM symptoms for 6.0 (2.0–15.0) years. Disease-modifying antirheumatic drugs, non-steroidal anti-inflammatory drugs and prednisone use was comparable between groups. Objective activity parameters were not different between groups. RA patients with FM had greater DAS28, SDAI and CDAI but similar GS-US7 and PD-US7. GS-US7 correlated with DAS28, SDAI and CDAI in patients with and without FM (rs = 0.36–0.57), while PD-US7 correlated with clinical scores only in patients without FM (rs = 0.35–0.38).ConclusionTo our knowledge, this is the first study to demonstrate that ultrasound synovitis scores are not affected by FM in RA patients. PD-US7 performed better than GS-US7 in long-standing RA patients with DAS28, SDAI or CDAI allegedly overestimated due to FM. Since sonographic synovitis predicts erosion better than swollen joint count, C-reactive protein and erythrocyte sedimentation rate, US should be considered a promising treatment target in RA patients with FM.

In practice, composite indices are used for rheumatoid arthritis (RA) disease activity evaluation. Despite valid and widely used, not rarely composite indices miss accuracy. Ultrasound (US) is more precise than clinical examination in synovitis appraisal. US-based disease activity estimation depends on the detection of synovitis. The most common synovitis abnormalities are proliferation, effusion, and neoangiogenesis. Gray scale ultrasound identifies synovial hypertrophy and effusion with its good soft tissue contrast. Additionally, power Doppler ultrasound depicts neoangiogenesis within synovia, remarking local inflammation. Several studies have combined local US findings to develop a patient level disease activity index. Most of them summed selected joint scores in an overall score of disease activity and evaluated its correlation with clinical composite indexes. To be incorporated into clinical practice, an overall US score must have some fundamental characteristics such as reproducibility, viability, and sensitivity to change over time. In global US score development, finding the joints that truly estimate individual disease activity is highly challenging. This article presents an up-to-date literature review on assessing RA disease activity with US and depicts the challenges in finding the perfect global US score.

Objectives: To compare the efficacy and safety of a new fixed dose combination of glucosamine sulfate and chondroitin sulfate capsules (GS/CS) versus the fixed dose combination of glucosamine hydrochloride and chondroitin sulfate (Cosamin DS®) in capsules in patients with osteoarthritis (OA) of the knee. Methods: Multicenter, randomized, double-blind study. Participants with knee OA Kellgren-Lawrence grades 1 to 3 and VAS of symptoms ≥4 cm were randomized to receive GS/CS or Cosamin DS® over 12 weeks. The primary efficacy endpoint was the evaluation of the analgesic efficacy by the investigator. Secondary efficacy endpoints included: joint pain and swelling, investigator efficacy of the medication, and the use of rescue medication. Adverse events and drug tolerability were analyzed. Results: One hundred patients were randomized, and 50 patients were allocated to each group. The analgesic efficacy evaluated by the investigator in the GS/CS group was 88.9, 95%CI: 75.2, 95.8% and in the Cosamin DS® group was 85.4%; 95%CI: 70.1, 93.4%. The mean reduction in the pain intensity was significant in both groups (p < 0.001), with no difference between them. The primary efficacy analysis demonstrated the non-inferiority of the GS/CS group compared with the Cosamin DS® group; the lower limit of the 90% confidence interval (CI) between the two groups (− 8.39%) was higher than the established margin of non-inferiority of − 10.00%. Improvement in other efficacy outcomes was observed, again without differences between groups. Adverse events were similar between groups and both presented good tolerability. Conclusions: The new fixed-dose formulation of GS/CS is effective in treating knee OA, presenting a good safety and tolerability profile. Trial Registration: (https://clinicaltrials.gov/ct2/show/NCT00955552?term=NCT00955552&rank=1; ClinicalTrials.gov; register number NCT00955552; First randomized patient: 08/17/2010).

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.

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Background Inflammatory activity may be quantified using Spectral Doppler (sD), which detects power Doppler (PD) signal through the internal resistance index (RI) in microcirculation1,2. Objectives Assess the RI in the nail bed in longitudinal (LRI) and transverse (TRI) planes; correlate with the presence of PD in the ungueal bed (NPD), change in standard trilaminar appearance of the nail (NGS), measure of the ungueal bed (mNGS) and clinical measurements. Methods In this cross-sectional study, 28 patients with psoriatic arthritis (PsA) diagnostic using the CASPAR classification criteria were included, as well as 7 patients control (71.42% healthy and 28.57% with osteoarthritis). They were submitted to an examination through an Esaote Ultrasound machine (Brazil, São Paulo), with 6–18 MHz broadband multifrequency linear transducer and Doppler frequency ranging from 7.1 to 14.3 MHz. The RI was considered changed when measuring ≤0.851. In the statistical study, the program SPSS Statistics 17.0. Spearman's correlation was used to analyze the non-parametric variables and the Pearson's correlation for the analysis of parametric variables. T-test was used for the comparison analysis between the PsA groups and the control. Results A total of 133 ungueal beds were assessed in patients and control individuals with the following variables: PsA (45.5% men and 54.5% women), race (96.42% Caucasian and 3.57% Asiatic) while controls variables were: 42.9% men, 57.1% women, race (85.71% Caucasians and 14.28% African); the procedure took place in the Instituto de Pesquisa Clínica of Campinas – IPECC and Pontifícia Universidade Catόlica of Campinas. The following average outcomes were observed in the controls: age 37.14±21.59 years; the general visual analog scale for pain (GVASp) 0.00±0.00 cm; LRI 0.86±0.41; TRI 0.70±0.16; NPD 1.0±0.00; mNGS 1.75±0.35 mm; NGS 0.00±0.00. Patients with PsA: 53.57% with no use of medication; 25% using methotrexate (15.71mg ±1.74), 14.28% using anti-TNF and 7.14% acitretin; average outcomes were: disease time 10.05±10.49 years; age 45.3±14.61 years; Psoriasis Area Severity Index (PASI) 6.03±12.27; medication time of use: 11.46±22.00 months; GVASp 1.78±3.42 cm; LRI 0.50±0.13; TRI 0.48±0.09, NPD 0.88±0.31; mNGS 1.73±0.68 mm; NGS 0.48±0.50. Significant correlations LRI with TRI r=0.333 (p=0.013); mNGS with NGS r=0.472 (p=0.023); LRI with drug time of use r=0.578 (p=0.002) and NGS with disease time r=0.551 (p=0.002). The LRI with NPD showed negative and very low correlation: -0.213 (p=0.038). The TRI with NPD, did not show any correlation (p=0.139). In the comparison between the groups in relation to the RIs: p<0.001 for the PsA group and p=0.002 for the TRI control (Test value = 0.85). Conclusions The sD may help confirm quantitatively ungueal inflammatory activity in PsA patients in future studies. References Terslev L, Torp-Pedersen S, Qvistgaard E, von der Recke P, Bliddal H. Doppler ultrasound findings in healthy wrists and finger joints. Ann Rheum Dis 2004; 63:644–648. Gutierrez M, Fi...

Background: Nail involvement has been described as a key clinical feature for both psoriasis (PsO) and psoriatic arthritis (PsA) and is an important risk factor in PsA. Thus, early diagnosis of nail involvement may be essential for better management of PsO and PsA. Ultrasonography is considered a highly promising method to visualize nail disease. The main aim of this review was to evaluate the use of ultrasonography for the diagnosis of nail disease in patients with PsO and PsA by reviewing ultrasound parameters with the best diagnostic accuracy. Main body of the abstract: A systematic search was performed in MEDLINE via the PubMed and LILACS databases. Conference proceedings of relevant rheumatology scientific meetings were also screened. Results: After applying eligibility criteria, only 13 articles and 5 abstracts were included in this review. The selected studies showed a huge variability in evaluation methods (and therefore in the results) and were mainly focused on the assessment of nails ultrasound parameters that may differ among patients and healthy controls, especially the morphological aspects in B-mode ultrasonography and vascularization of the nail bed by Doppler ultrasonography. Our research indicated that the evaluation of nail disease in PsO and PsA is still underrepresented in the literature, probably reflecting a restricted use in clinical practice, despite the widespread use of ultrasonography in the management of chronic arthritis. Short conclusions: Despite the potential relevance of ultrasonography for the diagnosis of nail disease, additional studies are needed to determine which features are more reliable and clinically pertinent to ensure accuracy in the evaluation of nail involvement in PsO and PsA.