Utilidad de la ecografía extraarticular aplicada a las enfermedades inflamatorias sistémicas en la práctica clínica / Usefulness of extra-articular ultrasound applied to systemic inflammatory diseases in clinical practice

La ecografía es una técnica de imagen no invasiva, inocua, reproducible y coste-eficiente, que aporta información inmediata al poder realizarla en nuestras consultas. El buen perfil de la técnica y los avances tecnológicos acontecidos en los últimos años, que han permitido una mejora sustancial en la resolución de la imagen hasta hacerla casi anatómica, han impulsado la investigación sobre su aplicación al estudio integral de las enfermedades inflamatorias sistémicas. En la actualidad, se ha traspasado el umbral de utilizar la ecografía para investigar exclusivamente las manifestaciones músculo-esqueléticas, para aplicarla también al estudio de las manifestaciones extraarticulares y las comorbilidades asociadas a las enfermedades reumáticas. En la presente revisión repasaremos su utilidad para el diagnóstico de la afectación glandular en el síndrome de Sjögren, la enfermedad pulmonar intersticial o la arteritis de células gigantes y para la estratificación del riesgo cardiovascular en pacientes con enfermedades reumáticas inflamatorias crónicas.(AU)

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.(AU)

Usefulness of extra-articular ultrasound applied to systemic inflammatory diseases in clinical practice. / Utilidad de la ecografía extraarticular aplicada a las enfermedades inflamatorias sistémicas en la práctica clínica.

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.

Cost-effectiveness of on-site musculoskeletal ultrasound in an outpatient rheumatology clinic.

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<0.001). REU 1 made radiological referrals for X-rays, MRIs or MSUS exams in 773 (52.8%) patients, compared with 2626 (75.9%) patients in REU 2-5 (P<0.001). An estimation of costs for the clinical assessment of 1000 new patients revealed a cost-saving in REU 1 of €21 413 in MSUS and of €877 in MRI exams. 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.

"There is something you must see": breaking down the remission concept in rheumatoid arthritis from a rheumatologist's perspective.

OBJECTIVES: To explore the remission concept in rheumatoid arthritis (RA) and the implications of the existing definitions when applied to clinical practice among rheumatologists with different profiles. METHODS: A qualitative study through focus groups was conducted. Three focus groups were organised from February to March 2016. Each group was composed of rheumatologists with extensive clinical experience with different profiles; experts in basic research (RBR), experts in imaging techniques research (RIR), and experts in clinical research (RCR). The data was collected with audio recording. Verbatim transcriptions of the audio files were made, and a subsequent reflexive thematic analysis assisted by ATLAS.ti (GmbH, Berlin, v. 7) software was performed. RESULTS: From the reflexive thematic analysis, three main themes were generated: (1) remission limitations, (2) instruments or measures to assess remission, and (3) a new definition of remission. Rheumatologists mentioned frequently that the following variables should be considered when developing a new remission definition: inflammatory activity, calprotectin, psychological variables, sex, disease stage, and sociocultural factors. Contrary to what could be expected, all groups acknowledged that their research field could contribute with domains for a gold standard remission instrument, but not in a hierarchical arrangement of importance. The dissonance existing in the entire remission evaluation process was outlined: remission in clinical practice versus remission in clinical trials, remission following the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean versus Musculoskeletal Ultrasound (US) remission, and remission from the rheumatologist's point of view versus the patient's point of view. CONCLUSIONS: Currently, rheumatologists would not accept a domain as more important than others in remission. Our suggestion is, not to generate a universal definition of remission - one that could cover all aspects - but rather to develop definitions of remission for the different settings that could be pondered by the patient's perspective.

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Visual versus automatic ultrasound scoring of lung B-lines: reliability and consistency between systems.

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<0.001]. Intra-observer reliability was good to excellent [ICC 0.62-0.99, p<0.001] except for one investigator in whom it was close to moderate for the automatic system [ICC 0.49, p<0.05]. Inter-observer reliability was excellent for both systems in both rounds [ICC 0.86-0.90, p<0.001]. CONCLUSIONS: US automatic counting was consistent with US visual counting of lung B-lines, as performed by experts in the field. Both systems showed a high intra- and interobserver reliability.

Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con artritis reumatoide / Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis

Objetivo. Establecer recomendaciones, basadas en la evidencia, sobre el uso de la ecografía (US) y la resonancia magnética (RM) en pacientes con artritis reumatoide (AR). Métodos. Las recomendaciones se consensuaron mediante metodología basada en grupos nominales. Un grupo de expertos (15 reumatólogos y 3 radiólogos) definió el alcance, usuarios, apartados del documento, posibles recomendaciones, revisiones sistemáticas a realizar (se utilizaron y actualizaron las revisiones de documentos de consenso previos de EULAR), y de la asignación de tareas. Los expertos delimitaron los apartados y redactaron las recomendaciones. El nivel de evidencia y grado de recomendación se realizó utilizando el sistema del Center for Evidence Based Medicine de Oxford. El grado de acuerdo se estableció mediante un Delphi a 2 rondas. Las recomendaciones se votaron según una escala de 1 (total desacuerdo) a 10 (total acuerdo), definiéndose el acuerdo como una puntuación ≥ 7 por al menos el 70% de los participantes. El documento completo fue revisado por los expertos y el proyecto coordinado por un metodólogo experto. Resultados. Se emitieron 20 recomendaciones que cubren: la validez de la US y RM para la detección de actividad y daño estructural, capacidad diagnóstica, predictora (de progresión de daño estructural, de brote de la enfermedad, respuesta al tratamiento, etc.), utilidad en la evaluación y monitorización de estos pacientes que están en tratamiento, y uso de la US como guía (para infiltraciones o biopsias). Conclusiones. Se presentan recomendaciones útiles para el manejo de la US y RM por los clínicos en pacientes con AR (AU)

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 (AU)

Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con espondiloartritis, incluyendo la artritis psoriásica, y en pacientes con artritis idiopática juvenil / Recommendations for the use of ultrasound and magnetic resonance in patients with spondyloarthritis, including psoriatic arthritis, and patients with juvenile idiopathic arthritis

Objetivo. Establecer recomendaciones, basadas en la evidencia, sobre el uso de la ecografía (US) y la resonancia magnética en pacientes con espondiloartritis, incluyendo la artritis psoriásica, y en la artritis idiopática juvenil. Métodos. Las recomendaciones se consensuaron mediante metodología basada en grupos nominales. Un grupo de expertos (15 reumatólogos y 3 radiólogos) definió el alcance, los usuarios, los apartados, las posibles recomendaciones y las revisiones sistemáticas 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 recomendación 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 según una escala de 1 (total desacuerdo) a 10 (total acuerdo), definiéndose el acuerdo como una puntuación≥7 por al menos el 70% de los participantes. El documento fue revisado por los expertos y el proyecto estuvo coordinado por un metodólogo experto. Resultados. Se emitieron 12 recomendaciones sobre la validez de la US y la resonancia magnética para la detección de actividad y daño estructural, capacidad diagnóstica, predictora (de progresión de daño estructural, brote de la enfermedad, respuesta al tratamiento, etc.), utilidad en la evaluación y monitorización del tratamiento, y uso de la US como guía (para infiltraciones, biopsias, etc.) en pacientes con espondiloartritis y artritis idiopática juvenil. Conclusiones. Se presentan unas recomendaciones útiles para el manejo de la US y la resonancia magnética por los clínicos en pacientes con espondiloartritis y artritis idiopática juvenil (AU)

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 (AU)

Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis. / Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con artritis reumatoide.

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.

Recommendations for the Use of Ultrasound and Magnetic Resonance in Patients With Spondyloarthritis, Including Psoriatic Arthritis, and Patients With Juvenile Idiopathic Arthritis. / Recomendaciones para el uso de la ecografía y la resonancia magnética en pacientes con espondiloartritis, incluyendo la artritis psoriásica, y en pacientes con artritis idiopática juvenil.

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.

Exploring the remission concept in rheumatoid arthritis with patients and rheumatologists: time for a new approach?

OBJECTIVES: To explore the remission concept in rheumatoid arthritis (RA) and to compare remission definitions and related concepts between rheumatologists and patients with the purpose of identifying similarities and disparities to comprehend the different perspectives of the disease. METHODS: This was a qualitative study of discourse and content analysis through focus groups, conducted from February to March 2016. Four focus groups were set up, each one with different interests: rheumatologists involved in basic research (BR), rheumatologists with high specialisation in imaging techniques (IR), clinical rheumatologists (CR), and patients (PA). RESULTS: There is no consensus in a remission definition in RA; differences exist between-groups, rheumatologists and patients value remission differently, and there are discrepancies within the group of rheumatologists. Rheumatologists highlight quantifiable objective parameters, in contrast, patients did not consider objective measures as the best instruments, and they prefer subjective measures of remission. The data confirmed the existence of two sources of knowledge of the disease, technical (physicians) and experiential (patients). These sources of knowledge should concur in order to establish new remission criteria well-adjusted to reality. CONCLUSIONS: The lack of consensus between key groups implicated in defining remission and remission criteria suggests a new strategy for its operational definition. Our group proposes that subjects with a balance between experiential and technical knowledge, should be the ones in charge of this assignment.

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients.

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.

Clinical usefulness and patient satisfaction with a musculoskeletal ultrasound clinic: results of a 6-month pilot service in a Rheumatology Unit.

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.

Dynamic ultrasound assessment of medial meniscal subluxation in knee osteoarthritis.

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.

Three-dimensional volumetric ultrasound: a valid method for blinded assessment of response to therapy in rheumatoid arthritis.

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.

A multicentre study on high-frequency ultrasound evaluation of the skin and joints in patients with psoriatic arthritis treated with infliximab.

OBJECTIVES: Our objective was to describe the ultrasound features of patients with PsA in joints and skin and their changes after treatment with infliximab. METHODS: 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. RESULTS: 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 p<0.0005). 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 p<0.0005); synovitis and PD signal improved (both p<0.0005). Psoriatic plaque PD improved across the study (p<0.0005) with no signal increasing from 36.4% to 88.9% and positive PD signal decreasing from 63.6% to 11.1% of the plaques. CONCLUSIONS: 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.

High prevalence of ultrasonographic synovitis and enthesopathy in patients with psoriasis without psoriatic arthritis: a prospective case-control study.

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.