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Ultrasound (US) is a recognized imaging modality for the assessment of gout. Recently it is being explored for its potential role in the evaluation of subjects with asymptomatic hyperuricemia (AH). Preliminary reports demonstrated the presence of monosodium urate (MSU)-crystal deposits including aggregates, double contour sign and/or tophi in both intra-articular and periarticular tissues of AH individuals. Although these results are exciting, the value and potential application of US in AH remain to be clearly delineated. In this systematic literature review, we aim to summarise the recent publications regarding the role of US in the assessment of AH. We analyzed possible application of US in the daily clinical practice and its future clinical and research potential in the evaluation of AH individuals.

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The aim of this study was to evaluate the reliability of the outcome measures in rheumatology (OMERACT) definitions for ultrasound (US) elementary lesions in gout through an image reading exercise. Images from patients with gout (static images and videos) were collected. As an initial step, we carried out a image reading exercise within the experts of the Pan-American League of Associations for Rheumatology (PANLAR) US Study Group (n = 16). The following step consisted in a web-based exercise with the participation of larger number of sonographers (n = 63) from different centers. Images were rated evaluating the presence/absence of any US elementary lesion. Inter- and intra-reader reliabilities were analyzed using kappa coefficients. Participants were stratified according to their level of experience. In the first exercise, inter-reader kappa values were 0.45 for aggregates, 0.57 for tophus, 0.69 for erosions, and 0.90 for double contour (DC). Intra-reader kappa values were 0.86, 0.76, 0.80, and 0.90, respectively. The web-based exercise showed inter-reader kappa values for aggregates, tophus, erosions, and DC of 0.42, 0.49, 0.69, and 0.79, respectively. The intra-reader kappa values were 0.62, 0.69, 0.77, and 0.85, respectively. Reliability was not influenced by the sonographer's level of experience. The reliability of the new OMERACT US definitions for elementary lesions in gout ranged from moderate to excellent, depending on the type of lesion.

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La paquimeningitis es un raro desorden caracterizado por engrosamiento focal o difuso de la duramadre, siendo una potencial manifestación de la enfermedad relacionada con IgG4. Presentamos 11 pacientes, seis hombres y cinco mujeres, entre 39-73 años, que consultaron por cefalea, alteraciones visuales, acúfenos, hipoacusia, pérdida de peso, agrandamiento de glándulas salivales, dorsalgia, cuadriplejía y compromiso de nervios craneales. Algunos de ellos presentaron elevación de la proteína C reactiva o del valor de sedimentación globular, mientras que la mayoría presentó niveles séricos normales de IgG4. Todos los pacientes mostraron engrosamiento de la duramadre en la resonancia magnética. La biopsia de duramadre, de vesícula biliar, hipófisis o glándula lagrimal, mostró un infiltrado linfoplasmocitario con o sin fibrosis estoriforme, con más de 10 plasmocitos IgG4 (+) y un rango IgG4: IgG que osciló del 20 al 60 por ciento. Los pacientes recibieron prednisona sola o con rituximab, metotrexate, ciclofosfamida o azatioprina, con respuesta favorable(AU)

Pachymeningitis is a rare disorder characterized by focal or diffuse thickening of the dura mater, being a potential manifestation of the disease related to IgG4. We present 11 patients, six men and five women, aged 39-73 years, who consulted for headache, visual disturbances, tinnitus, hearing loss, weight loss, salivary gland enlargement, dorsalgia, quadriplegia and cranial nerve involvement. Some of them presented elevation of the C-reactive protein or the erythrocyte sedimentation value, while the majority had normal serum levels of IgG4. All patients showed thickening of the dura in magnetic resonance imaging. The biopsy of dura mater, gallbladder, pituitary gland or lacrimal gland showed a lymphoplasmacytic infiltrate with or without storiform fibrosis, with more than 10 IgG4 (+) plasmocytes and an IgG4: IgG range that ranged from 20 to 60 percent. Patients received prednisone alone or with rituximab, methotrexate, cyclophosphamide or azathioprine, with favorable response(AU)

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BACKGROUND: Currently, two pathogenic pathways describe the role of obesity in osteoarthritis (OA); one through biomechanical stress, and the other by the contribution of systemic inflammation. The aim of this study was to evaluate the effect of free fatty acids (FFA) in human chondrocytes (HC) expression of proinflammatory factors and reactive oxygen species (ROS). METHODS: HC were exposed to two different concentrations of FFA in order to evaluate the secretion of adipokines through cytokines immunoassays panel, quantify the protein secretion of FFA-treated chondrocytes, and fluorescent cytometry assays were performed to evaluate the reactive oxygen species (ROS) production. RESULTS: HC injury was observed at 48 h of treatment with FFA. In the FFA-treated HC the production of reactive oxygen species such as superoxide radical, hydrogen peroxide, and the reactive nitrogen species increased significantly in a at the two-dose tested (250 and 500 µM). In addition, we found an increase in the cytokine secretion of IL-6 and chemokine IL-8 in FFA-treated HC in comparison to the untreated HC. CONCLUSION: In our in vitro model of HC, a hyperlipidemia microenvironment induces an oxidative stress state that enhances the inflammatory process mediated by adipokines secretion in HC.

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

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INTRODUCTION: Gout is an inflammatory condition induced by the deposition of monosodium urate (MSU) crystals in the joints and soft tissues that can produce acute or chronic arthritis. Several animal models of crystal-induced inflammation have been proposed that involve direct injection of MSU-crystals into different anatomical structures; however, only a few of these models reflect a true diarthrodial joint microenvironment in which an acute gouty attack takes place. The aim of this study was to assess the inflammatory and structural joint changes in a rabbit model of acute gout attack by ultrasound (US), synovial fluid (SF) and histopathological analyses. METHODS: Under US guidance, 42 rabbit knees were randomly injected with a suspension of 50 mg/ml of either MSU or allopurinol synthetic crystals. The control group received intra-articular vehicle of phosphate-buffered saline (PBS). US evaluation, SF and histopathological analyses were performed at days 1, 3, and 7. RESULTS: A total of 21 rabbit knees were assigned to the control group, 12 to the MSU-crystals group, and 9 to the allopurinol crystals group. By US, the MSU crystals group displayed the double contour sign and bright stippled aggregates in 67% and 75% of joints, respectively. Neither control knees nor allopurinol crystals group displayed these US signs. Power Doppler (PD) signal was moderate to intense in the MSU-crystals group and greater than both the allopurinol crystal and control groups at day 1 (P<0.001) and 3 (P<0.05), with its practical disappearance by day 7. SF leukocyte count was 40,312±6,369 cells/mm3 in the MSU-crystals group, higher than in controls (P=0.004) and allopurinol crystal group (P=0.006). At day 7, SF leukocyte count decreased in both MSU and allopurinol crystal groups reaching the non-inflammatory range. Histologically, at day 3 intense synovial polymorphonuclear cells infiltration and MSU aggregates were identified. CONCLUSION: The rabbit model of MSU crystal-induced acute arthritis efficiently reproduces the inflammatory, US, SF and histopathological changes of the human acute gouty attack.

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

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Ultrasonography (US) has been steadily and progressively gaining ground in the diagnostic approach to different areas of Rheumatology due to a combination of factors ranging from its low cost and portability, advantages related to the characteristics of the method, as the absence of ionizing radiation, the possibility of multiplanar imaging, high resolution real time and dynamic maneuvers to assess musculoskeletal structures with maximum functionality. Its specific role in osteoarthritis (OA) has allowed a detailed evaluation of the degenerative process, quantification of early or pre-radiological OA stages. The superb resolution of high power ultrasound probes can identify minimum alterations in the articular cartilage, bone tissue and other anatomical elements that contribute to OA. The aim of this review is to describe the major ultrasound findings in OA, and its usefulness as a diagnostic and monitoring disease progression in this rheumatic disease.

La ultrasonografía (US) viene ganando espacios, de manera continua y progresiva, en el abordaje diagnóstico de distintas áreas de la Medicina debido a una suma de factores que van desde su bajo costo y su portabilidad hasta ventajas relacionadas con las características propias del método, como la ausencia de radiación ionizante, la posibilidad de obtención de imágenes multiplanares de alta resolución en tiempo real, y de realizar maniobras dinámicas que permiten evaluar las estructuras en su máxima funcionalidad. Su específico rol en la evaluación de la osteoartritis se va afirmando a medida que se van generando métodos de evaluación que permiten una detallada cuantificación del proceso degenerativo, inclusive en las fases precoces o prerradiológicas. El magnífico poder de resolución de las sondas de última generación permite individualizar alteraciones mínimas de los elementos anatómicos frecuentemente comprometidos en la osteoartritis, como el cartílago articular y el tejido óseo. El objetivo de esta revisión es el de describir los hallazgos ultrasonográficos en osteoartritis, y su utilidad como herramienta diagnóstica y de seguimiento.

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

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