Sensitivity to Change of the Ultrasound synovitis SONAR Score in RA Patients: Results of the Scqm Cohort

Background/Purpose: Since the end of 2009, an ultrasound scoring call SONAR has been implemented for RA patients as a routine tool in the SCQM registry (Swiss Clinical Quality Management registry for rheumatic diseases). A cross-sectional evaluation of patients with active disease and clinical remission according to the DAS28ESR and the novel ACR/EULAR remission criteria from 2010 clearly indicated a good correlational external validity of synovial pathologies with clinical disease activity in RA (2012 EULAR meeting. Objective: of this study was to evaluate the sensitivity to change of B-mode and Power-Doppler scores in a longitudinal perspective along with the changes in DAS28ESR in two consecutive visits among the patients included in the SCQM registry Methods: All patients who had at least two SONAR scores and simultaneous DAS28ESR evaluations between December 2009 and June 2012 were included in this study. The data came from 20 different operators working mostly in hospitals but also in private practices, who had received a previous teaching over 3 days in a reference center. The SONAR score includes a semi-quantitative B mode and Power-Doppler evaluation of 22 joints from 0 to 3, maximum 66 points for each score. The selection of these 22 joints was done in analogy to a 28 joint count and further restricted to joint regions with published standard ultrasound images. Both elbows and wrist joints were dynamically scanned from the dorsal and the knee joints from a longitudinal suprapatellar view in flexion and in joint extension. The bilateral evaluation of the second to fifth metacarpophalangeal and proximal interphalangeal joints was done from a palmar view in full extension, and the Power-Doppler scoring from a dorsal view with hand and finger position in best relaxation. Results: From the 657 RA patients with at least one score performed, 128 RA patients with 2 or more consultations of DAS28ESR, and a complete SONAR data set could be included. The mean (SD) time between the two evaluations was 9.6 months (54). The mean (SD) DAS28ESR was: 3.5 (1.3) at the first visit and was significantly lower (mean 3.0, SD.2.0, p:_0.0001) at the second visit. The mean (SD) of the total B mode was 12 (9.5) at baseline and 9.6 (7.6) at follow-up (p_0.0004). The Power-Doppler score at entry was 2.9 (5.7) and 1.9 (3.6), at the second visit, p _0.0001. The Pearson r correlation between change in DAS28ESR and the B mode was 0.44 (95% CI: 0.29, 0.57, p_ 0.0001),and 0.35 (95% CI: 0.16, 0.50, p _ 0.0002) for the Power-Doppler score,. Clinical relevant change in DAS (_1.1) was associated with a change of total B mode score _3 in 23/32 patients and a change a Doppler score _0.5 in 19/26. Conclusion: This study confirms that the SONAR score is sensitive to change and provides a complementary method of assessing RA disease activity to the DAS that could be very useful in daily practice.

Routine use of intravascular ultrasound for endovascular aneurysm repair: angiography is not necessary.

INTRODUCTION: to assess the outcome of endovascular aortic aneurysm repair (EVAR) using intravascular ultrasound (IVUS) without angiography. MATERIALS/METHODS: eighty consecutive patients (median age 69 years (range 25-90): male 72 (90%), female 8 (10%)) underwent endovascular aneurysm repair (AAA 68 (85%), TAA 12 (15%)) using either angiography in 31/80 patients (39%) or IVUS in 49/80 patients (61%) in accordance to the surgeons preference. RESULTS: hospital mortality was 2/80 (3%), 1/68 for AAA (2%), 1/12 for TAA (8%), 2/31 for angiography (7%), and 0/49 for IVUS (0.0%: NS). Median quantity of contrast medium was 190 ml (range: 20-350) for angiography versus 0 ml for IVUS (p<0.01). Median X-ray exposure time 24 min (range 9-65 min) versus 8 min (range 0-60 min) for IVUS (p<0.05). No coverage of renal or suprarenal artery orifices occurred in either group. Conversion to open surgery was necessary in 4/80 patients (5%), 1/31 for angiography (3%) and 3/49 patients for IVUS (6%: NS). Early endoleaks were observed in 13/80 patients (16%): 8/31 patients for angiography (26%) versus 5/49 for IVUS (10%: p<0.05): 5/13 endoleaks resolved spontaneously (39%) whereas 8/13 (61%) required additional procedures. CONCLUSIONS: IVUS is a reliable tool for EVAR. In most cases, perprocedural angiography is not necessary.

Combining clinical factors and quantitative ultrasound improves the detection of women both at low and high risk for hip fracture.

We hypothesized that combining clinical risk factors (CRF) with the heel stiffness index (SI) measured via quantitative ultrasound (QUS) would improve the detection of women both at low and high risk for hip fracture. Categorizing women by risk score improved the specificity of detection to 42.4%, versus 33.8% using CRF alone and 38.4% using the SI alone. This combined CRF-SI score could be used wherever and whenever DXA is not readily accessible. INTRODUCTION AND HYPOTHESIS: Several strategies have been proposed to identify women at high risk for osteoporosis-related fractures; we wanted to investigate whether combining clinical risk factors (CRF) and heel QUS parameters could provide a more accurate tool to identify women at both low and high risk for hip fracture than either CRF or QUS alone. METHODS: We pooled two Caucasian cohorts, EPIDOS and SEMOF, into a large database named "EPISEM", in which 12,064 women, 70 to 100 years old, were analyzed. Amongst all the CRF available in EPISEM, we used only the ones which were statistically significant in a Cox multivariate model. Then, we constructed a risk score, by combining the QUS-derived heel stiffness index (SI) and the following seven CRF: patient age, body mass index (BMI), fracture history, fall history, diabetes history, chair-test results, and past estrogen treatment. RESULTS: Using the composite SI-CRF score, 42% of the women who did not report a hip fracture were found to be at low risk at baseline, and 57% of those who subsequently sustained a fracture were at high risk. Using the SI alone, corresponding percentages were 38% and 52%; using CRF alone, 34% and 53%. The number of subjects in the intermediate group was reduced from 5,400 (including 112 hip fractures) and 5,032 (including 111 hip fractures) to 4,549 (including 100 including fractures) for the CRF and QUS alone versus the combination score. CONCLUSIONS: Combining clinical risk factors to heel bone ultrasound appears to correctly identify more women at low risk for hip fracture than either the stiffness index or the CRF alone; it improves the detection of women both at low and high risk.

A multimodality vascular imaging phantom with fiducial markers visible in DSA, CTA, MRA, and ultrasound.

The objective was to design a vascular phantom compatible with digital subtraction angiography, computerized tomography angiography, ultrasound and magnetic resonance angiography (MRA). Fiducial markers were implanted at precise known locations in the phantom to facilitate identification and orientation of plane views from three-dimensional (3-D) reconstructed images. A vascular conduit connected to tubing at the extremities of the phantom ran through an agar-based gel filling it. A vessel wall in latex was included around the conduit to avoid diffusion of contrast agents. Using a lost-material casting technique based on a low melting point metal, geometries of pathological vessels were modeled. During the experimental testing, fiducial markers were detectable in all modalities without distortion. No leak of gadolinium through the vascular wall was observed on MRA after 5 hours. Moreover, no significant deformation of the vascular conduit was noted during the fabrication process (confirmed by microtome slicing along the vessel). The potential use of the phantom for calibration, rescaling, and fusion of 3-D images obtained from the different modalities as well as its use for the evaluation of intra- and inter-modality comparative studies of imaging systems are discussed. In conclusion, the vascular phantom can allow accurate calibration of radiological imaging devices based on x-ray, magnetic resonance and ultrasound and quantitative comparisons of the geometric accuracy of the vessel lumen obtained with each of these methods on a given well defined 3-D geometry.

Quantitative ultrasound in the management of osteoporosis: the 2007 ISCD Official Positions

Dual-energy X-ray absorptiometry (DXA) is commonly used in the care of patients for diagnostic classification of osteoporosis, low bone mass (osteopenia), or normal bone density; assessment of fracture risk; and monitoring changes in bone density over time. The development of other technologies for the evaluation of skeletal health has been associated with uncertainties regarding their applications in clinical practice. Quantitative ultrasound (QUS), a technology for measuring properties of bone at peripheral skeletal sites, is more portable and less expensive than DXA, without the use of ionizing radiation. The proliferation of QUS devices that are technologically diverse, measuring and reporting variable bone parameters in different ways, examining different skeletal sites, and having differing levels of validating data for association with DXA-measured bone density and fracture risk, has created many challenges in applying QUS for use in clinical practice. The International Society for Clinical Densitometry (ISCD) 2007 Position Development Conference (PDC) addressed clinical applications of QUS for fracture risk assessment, diagnosis of osteoporosis, treatment initiation, monitoring of treatment, and quality assurance/quality control. The ISCD Official Positions on QUS resulting from this PDC, the rationale for their establishment, and recommendations for further study are presented here.

The value of intraoperative ultrasound in oblique corpectomy for cervical spondylotic myelopathy and ossified posterior longitudinal ligament.

Intraoperative ultrasound (IOUS) has been described to be useful during central corpectomy for compressive cervical myelopathy. This study aimed at documenting the utility of IOUS in oblique cervical corpectomy (OCC). Prospective data from 24 patients undergoing OCC for cervical spondylotic myelopathy and ossified posterior longitudinal ligament (OPLL) were collected. Patients had a preoperative cervical spine magnetic resonance (MR) image, IOUS and a postoperative cervical CT scan. Retrospective data from 16 historical controls that underwent OCC without IOUS were analysed to compare the incidence of residual compression between the two groups. IOUS identified the vertebral artery in all cases, detected residual cord compression in six (27%) and missed compression in two cases (9%). In another two cases with OPLL, IOUS was sub-optimal due to shadowing. IOUS measurement of the corpectomy width correlated well with these measurements on the postoperative CT. The extent of cord expansion noted on IOUS after decompression showed no correlation with immediate or 6-month postoperative neurological recovery. No significant difference in residual compression was noted in the retrospective and prospective groups of the study. Craniocaudal spinal cord motion was noted after the completion of the corpectomy. IOUS is an inexpensive and simple real-time imaging modality that may be used during OCC for cervical spondylotic myelopathy. It is helpful in identifying the vertebral artery and determining the trajectory of approach, however, it has limited utility in patients with OPLL due to artifacts from residual ossification.

Ultrasound evaluation of synovitis in RA: Correlation with clinical disease activity and sensitivity to change in an observational cohort study.

OBJECTIVE: To evaluate the correlation between clinical measures of disease activity and a ultrasound (US) scoring system for synovitis applied by many different ultrasonographers in a daily routine care setting within the Swiss registry for RA (SCQM) and further to determine the sensitivity to change of this US Score. METHODS: One hundred and eight Swiss rheumatologists were trained in performing the Swiss Sonography in Arthritis and Rheumatism (SONAR) score. US B-mode and Power Doppler (PwD) scores were correlated with DAS28 and compared between the clinical categories in a cross-sectional cohort of patients. In patients with a second US (longitudinal cohort), we investigated if change in US score correlated with change in DAS and evaluated the responsiveness of both methods. RESULTS: In the cross-sectional cohort with 536 patients, correlation between the B-mode score and DAS28 was significant but modest (Pearson coefficient r=0.41, P<0.0001). The same was true for the PwD score (r=0.41, P<0.0001). In the longitudinal cohort with 183 patients we also found a significant correlation between change in B-mode and in PwD score with change in DAS28 (r=0.54, P<0.0001 and r=0.46, P<0.0001, respectively). Both methods of evaluation (DAS and US) showed similar responsiveness according to standardized response mean (SRM). CONCLUSIONS: The SONAR Score is practicable and was applied by many rheumatologists in daily routine care after initial training. It demonstrates significant correlations with the degree of as well as change in disease activity as measured by DAS. On the level of the individual, the US score shows many discrepancies and overlapping results exist.

Multislice CT for assessing in-stent dimensions after left main coronary artery stenting: a comparison with three dimensional intravascular ultrasound

Objective: To evaluate the agreement between multislice CT (MSCT) and intravascular ultrasound (IVUS) to assess the in-stent lumen diameters and lumen areas of left main coronary artery (LMCA) stents. Design: Prospective, observational single centre study. Setting: A single tertiary referral centre. Patients: Consecutive patients with LMCA stenting excluding patients with atrial fibrillation and chronic renal failure. Interventions: MSCT and IVUS imaging at 912 months follow-up were performed for all patients. Main outcome measures: Agreement between MSCT and IVUS minimum luminal area (MLA) and minimum luminal diameter (MLD). A receiver operating characteristic (ROC) curve was plotted to find the MSCT cut-off point to diagnose binary restenosis equivalent to 6 mm2 by IVUS. Results: 52 patients were analysed. PassingBablok regression analysis obtained a β coefficient of 0.786 (0.586 to 1.071) for MLA and 1.250 (0.936 to 1.667) for MLD, ruling out proportional bias. The α coefficient was −3.588 (−8.686 to −0.178) for MLA and −1.713 (−3.583 to −0.257) for MLD, indicating an underestimation trend of MSCT. The ROC curve identified an MLA ≤4.7 mm2 as the best threshold to assess in-stent restenosis by MSCT. Conclusions: Agreement between MSCT and IVUS to assess in-stent MLA and MLD for LMCA stenting is good. An MLA of 4.7 mm2 by MSCT is the best threshold to assess binary restenosis. MSCT imaging can be considered in selected patients to assess LMCA in-stent restenosis

Transcranial Doppler ultrasound in the acute phase of aneurysmal subarachnoid hemorrhage.

BACKGROUND: Angiographic studies suggest that acute vasospasm within 48 h of aneurysmal subarachnoid hemorrhage (SAH) predicts symptomatic vasospasm. However, the value of transcranial Doppler within 48 h of SAH is unknown. METHODS: We analyzed 199 patients who had at least 1 middle cerebral artery (MCA) transcranial Doppler examination within 48 h of SAH onset. Abnormal MCA mean blood flow velocity (mBFV) was defined as >90 cm/s. Delayed cerebral ischemia (DCI) was defined as clinical deterioration or radiological evidence of infarction due to vasospasm. RESULTS: Seventy-six patients (38%) had an elevation of MCA mBFV >90 cm/s within 48 h of SAH onset. The predictors of elevated mBFV included younger age (OR = 0.97 per year of age, p = 0.002), admission angiographic vasospasm (OR = 5.4, p = 0.009) and elevated white blood cell count (OR = 1.1 per 1,000 white blood cells, p = 0.003). Patients with elevated mBFV were more likely to experience a 10 cm/s fall in velocity at the first follow-up than those with normal baseline velocities (24 vs. 10%, p < 0.01), suggestive of resolving spasm. DCI developed in 19% of the patients. An elevated admission mBFV >90 cm/s during the first 48 h (adjusted OR = 2.7, p = 0.007) and a poor clinical grade (Hunt-Hess score 4 or 5, OR = 3.2, p = 0.002) were associated with a significant increase in the risk of DCI. CONCLUSION: Early elevations of mBFV correlate with acute angiographic vasospasm and are associated with a significantly increased risk of DCI. Transcranial Doppler ultrasound may be an early useful tool to identify patients at higher risk to develop DCI after SAH.

Ultrasound-assisted versus conventional catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis.

BACKGROUND: For patients with acute iliofemoral deep vein thrombosis, it remains unclear whether the addition of intravascular high-frequency, low-power ultrasound energy facilitates the resolution of thrombosis during catheter-directed thrombolysis. METHODS AND RESULTS: In a controlled clinical trial, 48 patients (mean age 50 ± 21 years, 52% women) with acute iliofemoral deep vein thrombosis were randomized to receive ultrasound-assisted catheter-directed thrombolysis (N = 24) or conventional catheter-directed thrombolysis (N = 24). Thrombolysis regimen (20 mg r-tPA over 15 hours) was identical in all patients. The primary efficacy end point was the percentage of thrombus load reduction from baseline to 15 hours according to the length-adjusted thrombus score, obtained from standardized venograms and evaluated by a core laboratory blinded to group assignment. The percentage of thrombus load reduction was 55% ± 27% in the ultrasound-assisted catheter-directed thrombolysis group and 54% ± 27% in the conventional catheter-directed thrombolysis group (P = 0.91). Adjunctive angioplasty and stenting was performed in 19 (80%) patients and in 20 (83%) patients, respectively (P > 0.99). Treatment-related complications occurred in 3 (12%) and 2 (8%) patients, respectively (P > 0.99). At 3-month follow-up, primary venous patency was 100% in the ultrasound-assisted catheter-directed thrombolysis group and 96% in the conventional catheter-directed thrombolysis group (P = 0.33), and there was no difference in the severity of the post-thrombotic syndrome (mean Villalta score: 3.0 ± 3.9 [range 0-15] versus 1.9 ± 1.9 [range 0-7]; P=0.21), respectively. CONCLUSIONS: In this randomized controlled clinical trial of patients with acute iliofemoral deep vein thrombosis treated with a fixed-dose catheter thrombolysis regimen, the addition of intravascular ultrasound did not facilitate thrombus resolution. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01482273.

Application of ultrasound in bone surgery: two case reports

The present study describes some of the applications of ultrasound in bone surgery, based on the presentation of two clinical cases. The Piezosurgery® ultrasound device was used (Tecnología Mectron Medical, Carasco, Italy). In one case the instrument was used to harvest a chin bone graft for placement in a bone defect at level 1.2, while in the other case a bony window osteotomy was made in the external wall of the maxillary sinus, in the context of a sinus membrane lift procedure. The Piezosurgery® device produces specific ultrasound frequency modulation (25-29 kHz), and has been designed to secure increased precision in application to bone surgery. This instrument produces selective sectioning of the mineralized bone structures, and causes less intra- and postoperative bleeding. One of the advantages of the Piezosurgery® device is that it can be used for maxillary sinus lift procedures in dental implant placement. In this context it considerably lessens the risk of sinus mucosa laceration by preparing the bony window in the external wall of the upper maxilla, and can be used to complete the lifting maneuver. The use of ultrasound in application to hard tissues can be regarded as a slow technique compared with the conventional rotary instruments, since it requires special surgical skill and involves a certain learning curve.