Current Rheumatology Reviews - Volume 7, Issue 3, 2011

Ultrasound has become an important tool in the practice of rheumatology over the last several years. Use of ultrasound at the bedside allows direct visualization of joints, ligaments and tendons as well as dynamic and functional assessments of these structures in real time at the bedside. MRI and CT may give us more detailed pictures with a broader view of the anatomy of a particular area, but with the newer high resolution scanners that are available the resolution of ultrasound is unsurpassed. Additionally, given that the operator has the clinical history at the time of performing the exam, important clinical decisions can be made almost instantaneously. Indeed, ultrasound may become not only what ECHO is to a cardiologist, but may provide the rheumatologist with a kind of stethoscope that we have sorely lacked. In this issue, we have an excellent collection of articles that touches on some of the facets of ultrasound in rheumatology. Validation of ultrasound measures is dealt with expertly by Dr. Iagnocco et al. and Terslev et al. and sonoantomy in general and that of the wrist, carpus and ankle are discussed in detail by Dr. Moller and Saenz and Bong et al. Lastly, the use of ultrasound in skin conditions in general and in scleroderma in particular is dealt with. It appears that the applications of ultrasound are limitless and growing by the day. Indeed, we view the advent of ultrasound as a major change in the practice of rheumatology and will incorporate additional articles and hot topics on ultrasound over the next year.

Over the last decade, musculoskeletal (MS) ultrasound (US) has played an increasingly important role in optimizing clinical assessment and monitoring of patients with rheumatologic diseases in clinical practice. We could also say that MSUS is now at the cutting edge of research in rheumatology. High-resolution MSUS with Doppler technique provides an accurate and sensitive assessment of joint inflammatory activity and structural damage in inflammatory arthritis and osteoarthritis. This technique allows a detailed diagnosis of soft tissue syndromes. There have been an increasing number of papers on the role and validity of US for evaluating the above abnormalities. However, some aspects such as the use of MSUS in clinical trials or how to measure US abnormalities are more challenging to address. Technical improvements in high-resolution US have facilitated the evolution of applications of this imaging modality that are worthy of attention. These include US assessment of the skin and dermatologic diseases, US diagnosis of hand and foot ligaments lesions, and US study of complex anatomic areas in the musculoskeletal system with potential utility for rheumatologists.

The use of ultrasound in inflammatory conditions has increased in recent years and is now a relatively accessible imaging modality in most clinical departments. It has no ionizing radiation and is able to visualize structures in real-time with high resolution. Though ultrasound is used widely in daily clinical practice, validation is of utmost importance if ultrasound is to be used as a research tool in clinical trials. The aim of the present review is to evaluate how well musculoskeletal ultrasound is validated in relation to technical performance, diagnostic and therapeutic impact and diagnostic performance and to determine which areas need further work.

The attempt to measure and quantify changes related to inflammation and structural damage lesions represents one of the most interesting topics in the field of musculoskeletal ultrasound in rheumatology. Different scoring systems have been used over the recent years to measure inflammation and structural damage lesions in patients affected by inflammatory and degenerative rheumatic diseases. In the last years quantitative and semiquantitative methods in several studies have been applied, with promising results. In the present review we reported the main studies about this topic. However, more studies are needed to address some technical issues and quantify ultrasonography-detected abnormalities.

Musculoskeletal ultrasound (US) is an important part of rheumatologic practice and requires a thorough understanding of the anatomic details of the involved structures. In this article, we present three clinically relevant examples whose diagnosis and treatment are greatly enhanced by US examination. The subsheath surrounding the extensor carpi ulnaris tendon is an important structure that stabilizes the tendon and can be confused with pathologic changes. The pulleys of the flexor tendons of the fingers that are commonly involved in patients with rheumatologic disorders and are readily visible on high-resolution US, should be part of the routine evaluation of these patients. Lateral hip pain is a frequent presentation and US enables us to recognize the actual etiology of this problem.

The ligaments of the wrist, ankle and foot play a critical role in the static and dynamic stabilization of the joints of these regions. The advent of high resolution ultrasound has markedly improved the evaluation of pathologic alterations of the structure by enabling direct visualization. In the wrist region, the focus is on the extrinsic ligaments, those ligaments that have their origin in the bones of the forearm and insert on the carpal bones, that include the radio-scaphoid, radioscaphocapitate, long radio-lunate (LRL), the short radio-lunate and radiotriquetral. The anatomy, sonoanatomy and sonopathology of the ankle ligaments (deltoid, anterior and posterior talofibular and calcaneofibular), anterior aspect of the ankle syndesmosis and the spring ligament complex are reviewed. Finally, the ligamentous anatomy of the forefoot is detailed as an understanding of this region is key to evaluation of its important sonopathologies.

In the latest years there has been an explosive growth in the use of ultrasound for exploring the soft tissues. Thus, the utility of sonography in the musculoskeletal field is now very well supported in literature. Moreover, this sonographic expansion has continued through the dermatologic field. The aim of this article is to review the recent advances in dermatologic ultrasound considering last-generation equipment, and assess the potential of ultrasound on rheumatic disorders that may present concomitant and challenging skin or nail lesions at some point during their clinical course.

Ultrasound (US) has an emergent and relevant role in the assessment of musculoskeletal disease and skin in Systemic Sclerosis (SSc), even if there are almost many fields and applications that were not still sufficiently explored until now. In this review, we will report an update of the available data regarding the employment of US in joints, tendons, peripheral nerves and skin involvement in SSc. The assessment of heart, kidney, lung or vascular involvement in SSc will not be the subjects of this paper. The routinary use of musculoskeletal US in SSc patient has not yet been adequately disseminated and, in the future, we hope that it will be included in the daily practice and clinical trials, to evaluate correctly some important aspects of the disease that might cause disability and worsening of quality of life.

Ubiquitin ligases are the substrate specific elements of the ubiquitination system, which comprises a posttranslational mechanism by which the immune response can be modulated, setting the tune for the TCR activation. Proteolysis dependent and independent mechanisms have been implicated. Ubiquitin ligases have been proven as key modulators of central and peripheral tolerance, involving the regulation of anergy and regulatory T cells. These enzymes involve a complex regulatory network designed to maintain an active surveillance system. Cbl-b, GRAIL and Itch are the main E3 ligases, considered as negative regulators of the immune response as part of the anergy induced genetic program. Recently, other ubiquitin ligases have been related to autoimmune pathologies such as Roquin and Ro52. Other key signalling pathways for the immune response, such as the NF-κB and TGF-β signalling are prone to be modulated by these ubiquitin ligases. Diverse processes have been implicated in the broad mechanisms of modulation of the immune response by these ubiquitin ligases, among them, the setting for TCR responsiveness, T cell differentiation, regulation of activation and costimulatory molecules as well as of inflammatory pathways are the best well characterized. The defective expression of some of these ubiquitin ligases has been related to the development of autoimmune disease, in experimental murine and human models. Most of the evidence points towards the physiopathogenic role of ubiquitin ligases, primarily Cbl-b in systemic (SLE) and organ-specific (type 1 Diabetes Mellitus and multiple sclerosis) autoimmune diseases.

Rheumatoid arthritis (RA) is an autoimmune disease that causes chronic inflammation of the joints. It is associated with increased mortality rates as compared to the healthy population. The actual cause of rheumatoid arthritis is unknown although several factors accelerating its progression are outlined. This review enlists various histopathological changes and encompasses a note on its applicability in target specific delivery with the aid of antibodies. There are various first-line, second-line and newer biological treatments available. This review gives brief detail of the novel approaches for the delivery of the targeted as well as non targeted systems like oral, topical, nasal and parenteral and the recent advancements that have been achieved. Moreover, it also gives an account of the amendment that can be made for future with the use of biotechnology, the application of gene profiling and gene array techniques.

Brucellosis continues to adversely affect human health throughout the world. Acute and chronic osteoarticular manifestations of brucellosis include sacroiliitis, spondylitis, peripheral arthritis, osteomyelitis, and bursitis. Substantial clinical experience with the presentation, clinical course, and treatment of brucellosis exists in countries of the former Soviet Union, including the Republic of Georgia. The present article reviews the unique Georgian and Russian medical literature in addition to the English-language medical literature on the topic of osteoarticular complications of brucellosis. Special emphasis is placed on current diagnostic approaches for osteoarticular brucellosis, including imaging techniques and laboratory tests (bacteriology, serology, PCR).