An exploratory cross-sectional study of subclinical vascular damage in patients with polymyalgia rheumatica.

The aim of the study was to investigate the presence of subclinical vascular damage in polymyalgia rheumatica (PMR). We enrolled PMR patients having major cardiovascular risk factors (MCVRF) and, as controls, patients with MCVRF. All underwent: color Doppler ultrasound to evaluate the common carotid intima-media thickness (IMT), the anterior-posterior abdominal aortic diameter (APAD), and the prevalence of carotid artery stenosis; the cardio-ankle vascular index (CAVI) to measure arterial stiffness together with the ankle-brachial index (ABI) to investigate the presence of lower-extremity peripheral arterial disease. Finally, we measured the serum levels of adipocytokines implicated in vascular dysfunction. As a result, 48 PMR and 56 MCVRF patients were included. An increase of IMT (1.07/0.8-1.2 vs 0.8/0.8-1.05; p = 0.0001), CAVI (8.7/7.8-9.3 vs 7.6/6.9-7.8; p < 0.0001) and APAD values (21.15/18.1-25.6 vs 18/16-22; p = 0.0013) was found in PMR patients with respect to controls. No differences were reported in the prevalence of carotid artery stenosis or ABI values between the two groups. A significant correlation between IMT and CAVI in PMR and MCVRF subjects (r2 = 0.845 and r2 = 0.556, respectively; p < 0.01) was found. Leptin levels (pg/mL; median/25th-75th percentile) were higher in PMR than in MCVRF subjects (145.1/67-398.6 vs 59.5/39.3-194.3; p = 0.04). Serum levels of adiponectin (ng/mL) were higher in PMR patients (15.9/10.65-24.1 vs 6.1/2.8-22.7; p = 0.01), while no difference in serum levels of resistin (ng/mL) was found between PMR and MCVRF subjects (0.37/0.16-0.66 vs 0.26/0.14-1.24). Our study shows an increased subclinical vascular damage in PMR patients compared to those with MCVRF, paving the way for further studies aimed at planning primary cardiovascular prevention in this population.

Agreement between semiquantitative and quantitative Doppler scoring systems for the assessment of synovial pathological vascularisation in rheumatoid arthritis.

OBJECTIVES: To compare colour Doppler (CD) versus power Doppler (PD) semiquantitative and quantitative scoring of synovial vascularisation and to evaluate the relationship between semiquantitative and quantitative scores in patients with rheumatoid arthritis (RA). METHODS: One hundred RA patients underwent B-mode, PD, and CD assessments of 12 joints at two European centres. Each joint with synovial hypertrophy (SH) detected on B-mode was semiquantitatively scored (0-3) for PD (SPD score) and CD (SCD score) synovial signal. PD and CD synovial signal were also quantitatively scored (0-100%) (QPD and QCD scores, respectively) using a software integrated in the US equipment for counting the colour fraction. RESULTS: We found SH in 184 joints. SPD and SCD agreed in 92.3% (95%CI: 88.4; 96.2%) of paired scores, with Kendall rank correlation coefficient tau-b=0.95. QPD and QCD scores were highly correlated (Pearson's coefficient=0.70) but Blamd-Altman plot showed insufficient agreement, being the QCD scores systematically slightly higher than the QPD scores. The comparison of mean values of QPD and QCD between scores of SPD and SCD, respectively, showed significant differences between grade 0 and grade 1 (p<0.001), and grade 2 and grade 3 (p=0.042 and p=0.007, respectively) but not between grade 1 and 2 (p=0.154 and p=0.150, respectively). CONCLUSIONS: The SPD and SCD scores were concordant and the QPD and QCD scores highly correlated but were not concordant. There was an overlap between SPD and SCD mild and moderate scores regarding QPD and QCD scores.

Polymyalgia rheumatica and diverticular disease: just two distinct age-related disorders or more? Results from a case-control study.

In a previous report of two married cohabiting couples affected by polymyalgia rheumatica (PMR), we noticed that the wife of one couple and both members of the other couple suffered from symptomatic diverticular disease (DD), whose diagnosis was made before the onset of PMR. We investigated whether DD might be a risk factor for the development of PMR. We conducted a case-control study informed on a database containing the prospectively collected medical records of consecutive PMR patients. Among comorbidities, attention was focused on symptomatic DD, provided that the diagnosis had been made by colonoscopy and/or computed tomography scan. As controls, we identified one control per case at random among those matched by age and sex attending the ophthalmic and orthopedic outpatient clinics, as long as a PMR diagnosis had been excluded. A logistic regression model was used, following a multiplicative model, and results were presented as odds ratio (OR) and 95% confidence intervals (95% CI). The most frequent comorbidities in the two groups of patients (121 cases and 121 controls) were chronic coronary artery disease, atrial fibrillation, diabetes mellitus, hypertension, DD, hypercholesterolemia, osteoporosis, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and cholelithiasis. The association between PMR and DD (OR = 4.06; 95% CI: 1.76-9.35) was by far stronger than that found comparing PMR with the other comorbidities. The chronic bowel inflammation induced by dysbiosis in patients with symptomatic DD could be a critical immunopathological mechanism supporting the development or exacerbation of PMR in susceptible individuals.

"In sickness and in health": the peculiar occurrence of polymyalgia rheumatica in married cohabiting couples--a case series and review of the literature.

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic disorder in elderly people. It is frequently associated with giant-cell arteritis (GCA), although it is still debated if they are the same disease or two distinct pathologies. The etiology of PMR remains challenging, although current knowledge supports the role of both genetic and environmental factors. Among these, there is evidence that infectious agents could trigger the disease's onset in some cases. We describe the peculiar case where PMR occurred in two Italian married and cohabiting couples and provide a review of the literature for similar cases. This is the first reported occurrence of PMR in two conjugal pairs in Italy. Moreover, in the second case, the wife presented PMR associated with GCA. To date, seven cases of PMR and two of GCA in married couples are described in the literature. The occurrence of PMR in both a husband and a wife supports the pathogenetic role of an environmental factor.

Musculoskeletal ultrasonography in gout.

Gout is a frequent inflammatory disease induced by the deposition of monosodium urate crystals in joints and extra-articular tissues. The natural history of the disease includes four different phases: asymptomatic hyperuricemia, acute attacks, intercritical phase, and chronic tophaceous gout. Imaging techniques have several applications in the diagnosis, clinical monitoring and management of the disease but particularly, musculoskeletal ultrasound is able to detect a wide set of abnormalities in gout. This review reports the most relevant findings detectable by ultrasound and the current available data in the literature regarding the role of musculoskeletal ultrasound in gout..

Musculoskeletal ultrasound in the evaluation of Polymyalgia Rheumatica.

Polymyalgia rheumatica (PMR) is a relatively frequent disease affecting individuals older than 50 years and is characterized by inflammatory involvement of the shoulder and hip girdles and the neck. Clinical manifestations are represented by pain and morning stiffness in this regions. An extensive and comprehensive assessment of the inflammatory status is crucial in PMR patients, including imaging evaluation. This narrative review reports the current available data in the literature about the role of musculoskeletal ultrasound in PMR.

The use of musculoskeletal ultrasound in a rheumatology outpatient clinic.

INTRODUCTION: Musculoskeletal ultrasound (US) represents a valid, reliable and sensitive-to-change tool for the evaluation of patients suffering from rheumatic conditions. This method demonstrates a wide applicability and availability, finding place in the clinical practice in rheumatology outpatient clinic. AIM: To perform an epidemiological evaluation related to the use of US in a university rheumatology outpatient clinic. MATERIAL AND METHODS: During a 3-month period, data concerning consecutive patients attending to the US Unit of Department of Rheumatology, Sapienza University of Rome were registered. We collected the demographic data, the diagnosis, the reason for the US examination, the examined joints, as well as the requesting physicians' specialty. RESULTS: In the period October-December 2013, 572 patients (M/F 137/435; mean age+/-SD 55.2+/-15.8 years) were registered. The US examination was more frequently requested for the following diseases: rheumatoid arthritis (29.5%), osteoarthritis (10.6%), spondyloarthritis (9.1%), and connective tissue diseases (8.9%). In 239 of cases (41.8%), the US evaluation was requested for other indications. The US evaluation was requested slightly more frequently for monitoring (55.7%) compared to diagnosis (44.3%). The requesting physician was a rheumatologist in the majority of the cases (80.6%). The most frequent requested were the hand joints (28.9%) and wrists (23.3%). CONCLUSIONS: US examinations are most frequently used in the evaluation of patients with rheumatoid arthritis and mainly to monitor the disease. The exam is requested mostly by rheumatologists. The hand joints and wrists were the most frequently evaluated.

Subclinical synovitis detected by ultrasound in children affected by coeliac disease: a frequent manifestation improved by a gluten-free diet.

OBJECTIVES: Coeliac disease (CD) is a chronic autoimmune disease of the small intestine caused by the ingestion of gluten, in which musculoskeletal manifestations may occur. Aim of this study was to evaluate the prevalence and severity of joint involvement in paediatric patients with CD using musculoskeletal ultrasound (US). METHODS: Consecutive paediatric CD patients were enrolled and underwent US evaluations at level of knees, hips and ankles. The presence of joint effusion (JE), synovial hypertrophy, power Doppler signal and structural damage lesions (bone irregularities and erosions) was registered. Inflammatory abnormalities were scored on a semi-quantitative scale (0-3), and structural damage lesions on a dichotomous scale (0-1). RESULTS: Seventy-four CD children (mean age: 7.6 years; range: 1-14.2; M/F 24/50) were enrolled. Thirty-eight were on a gluten-containing diet (GCD) and 36 on a gluten-free diet (GFD). US showed the presence of abnormalities in 23 patients overall (31.1%); JE was the most frequently observed change (23/23). US abnormalities were observed in 19 patients (50.0%) of GCD group and in 4 of GFD group (11.1%, p=0.007). Interestingly, 12/23 (52.2%) patients with US-detected changes were asymptomatic. CONCLUSIONS: This is the first US study demonstrating joint involvement in children with CD. JE, the most frequent manifestation, was present also in asymptomatic patients and was reduced in those on GFD. These findings may indicate that, also at joint level, an inflammatory response represented by the appearance of JE may be induced by exposure to gluten.

Ultrasound in the assessment of musculoskeletal involvement in systemic sclerosis.

Systemic sclerosis (SSc) is a chronic connective disease in which the musculoskeletal involvement affects especially the hands and feet. Ultrasound (US) represents an important tool in the assessment of the joint and soft tissue involvement in this rheumatic disorder. Few authors have investigated the role of US in the evaluation of joints and peri-articular tissues in SSc patients. The current available literature regarding US applications in the assessment of musculoskeletal involvement in SSc has shown that US seems to be a useful tool in detecting the presence of inflammatory and structural abnormalities involving both joints and soft tissues. The aim of the present paper is to review the role of US in the assessment of musculoskeletal involvement in SSc.

Unilateral painful, swollen and erythematosus knee. Case report.

Musculoskeletal ultrasound (US) is gaining an increasing role in the assessment of a variegate set of joint and periarticular soft tissues abnormalities in rheumatology. In addition, US represents a useful technique in guiding local procedures such as aspiration of fluid collections and injections within the joints and periarticular musculoskeletal structures. We recently performed US in a patient with unilateral painful, swollen and erythematosus knee. Pre-patellar bursitis was demonstrated, without any signs of intra-articular abnormalities. US-guided aspiration of local effusion was performed; synovial fluid analysis demonstrated septic bursitis. Appropriate treatment determined the complete remission.

The interobserver reliability of ultrasound in knee osteoarthritis.

OBJECTIVE: To assess the interobserver reliability between sonographers with different levels of experience in detecting inflammatory and structural damage abnormalities in patients with knee OA. METHODS: After achieving consensus on definitions and scanning protocols, three ultrasonographers with different levels of experience in musculoskeletal US examined the knees of nine patients with OA. US examinations were conducted with independent blinded evaluations of inflammatory (joint effusion, synovial hypertrophy, power Doppler signal, Baker's cysts) and structural (osteophytes, cortical bone irregularities, femoral hyaline cartilage abnormalities, protrusion of the medial meniscus) lesions. All abnormalities were scored by applying a dichotomous scale (0-1). In addition, at each knee joint site global scores for joint inflammation, cortical bone abnormalities and cartilage damage were calculated by summing the single-lesion scores. Reliability was assessed using kappa (κ) coefficients. RESULTS: Seventeen knees were examined. Inflammatory abnormalities were observed with moderate to very good agreement (κ = 0.55-0.88) between the observers. From fair to very good agreement (κ = 0.31-0.82) was registered between sonographers for structural damage lesions. The overall κ was 0.716 for junior and 0.571 for beginner sonographers comparing their findings with those of senior sonographers. CONCLUSION: This represents the first ultrasonographic study focusing on the analysis of interobserver reliability between sonographers with different levels of experience in demonstrating inflammatory and structural abnormalities in knee OA. Globally, even considering some variable results that were mainly obtained by the evaluation of single components of bone involvement, US offered a reliable assessment of a wide set of abnormalities in knee OA.