Glasgow Ultrasound Enthesitis Scoring System Research Articles

Ultrasound Can Be Usefully Integrated with the Clinical Assessment of Nail and Enthesis Involvement in Psoriasis and Psoriatic Arthritis.

Objectives: This study aimed to examine and compare the findings of nail and enthesis ultrasonography in patients with psoriasis and psoriatic arthritis. Methods: We identified 154 patients with psoriatic arthritis and 35 patients with psoriasis who were treated at Chang Gung Memorial Hospital, Taiwan, between September 2018 and January 2019. Results: There were significant differences in the Nail Psoriasis Severity Index scores and Glasgow Ultrasound Enthesitis Scoring System scores between patients with psoriasis and those with psoriatic arthritis. B-mode ultrasonography revealed that onychopathic changes were more common in the psoriasis group. The psoriatic arthritis group showed a higher proportion of lower-limb enthesopathy, with significant differences in distal patellar ligament thickness and Achilles tendon thickness. Conclusion: The findings of nail ultrasonography were more severe in psoriasis cases, and the ultrasonographic findings of enthesopathy of the lower limb were more severe in cases of psoriatic arthritis.

Sonographic evaluation of subclinical entheseal involvement in patients with hypoparathyroidism: a case control study.

Hypoparathyroidism is a disease characterized by low serum calcium, increased serum phosphorus and low PTH levels. Although patients are treated with active vitamin D and calcium, a proper serum calcium phosphorus balance cannot always be achieved. Ectopic calcifications that develop in organs during treatment are the most common complications. To date, there is not any published study on enthesopathy in patients with hypoparathyroidism. The aim of this study was to evaluate subclinical enthesopathy in patients with hypoparathyroidism with ultrasound and to compare the results with those of the control group. The study included patients aged 18-65years with postoperative hypoparathyroidism and hypothyroidism (group hypoP + hypoT), patients with postoperative hypothyroidism (group hypoT), and healthy age and sex-matched volunteers (group C). Ultrasonographic findings of enthesopathy in both extremities were documented according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS). GUESS scores in group hypoP + hypoT, were significantly higher when compared to the other groups. There was a statistically significant correlation between the total GUESS scores and total enthesophyte scores and the duration of hypoparathyroidism (p < 0.05, r = 0.43) (p < 0.05, r = 0.39) respectively. In the correlation analysis of all groups, a significant negative correlation was found between serum Ca and PTH levels and the total GUESS scores (p < 0.01, r = -0.37; p < 0.01, r = -0.54, respectively). This study showed that GUESS scores were significantly higher in patients with hypoparathyroidism compared to those with hypothyroidism and control subjects. GUESS scores were positively correlated with disease duration. Patients with hypoparathyroidism need to be evaluated for subclinical enthesopathy during follow-up.

P135 Usefulness of clinical and ultrasound indices to assess enthesis lesions in patients with inflammatory bowel diseases

Abstract Background The aim of the study was to assess existing clinical and ultrasound indices for the evaluation of enthesopathies in patients with inflammatory bowel diseases (IBD). Methods 95 pts with IBD were prospectively enrolled into the study: 55 of them with ulcerative colitis (UC) and 40 with Crohn’s disease (CD). Clinically we counted tender entheses in 46 points of the upper and lower extremities. LEI (Leeds Enthestis Index) (0–6 points), MASES (Maastricht Ankylosing Spondylitis Enthesitis Score) (0–13 points) and the SPARCC index (Spondylarthritis Research Consortium of Canada) (0–16 points) were calculated. Ultrasound examination was performed in B-mode and PD-mode. Entheseal hypoechogenicity, entheseal thickening, presence of vascularization were considered as acute lesions. Bone erosions and enthesophytes were considered as chronic lesions. GUESS (Glasgow Ultrasound Enthesitis Scoring System) (0–36 points), MASEI (Madrid Sonography Enthesitis Index) (0–136 points) and BUSES (Belgrade Ultrasound Enthesitis Score) (0–132 points) were calculated. Spearman coefficient used to calculate correlations. Results In pts with tender ≥ 1 enthesis, the LEI was positive in 26% of patients, the MASES index - in 7%, the SPARCC index - in 18%, the US indices were positive in a larger number of patients: GUESS - in 47%, MASEI - in 40% and BUSES - 54%.A total of 6460 entheses were examined using Doppler ultrasound. The number of enthesites was 293/6460 (4.5%), the number of enthesites with vascularization was 62/6460 (1.0%), the number of erosions was 313/6460 (4.8%), the number of enthesophytes was 91/6460 (1, 4%).A direct correlation is observed between the number of enthesites and LEI indices (SR = 0.54; p = 0.00), MASES (SR = 0.42; p = 0.00), SPARCC (SR = 0.54; p = 0, 00), GUESS (SR = 0.22; p = 0.02), BUSES (SR = 0.32; p = 0.001), as well as between the number of enthesitis with vascularization and LEI indices (SR = 0.24; p = 0.017), MASES (SR = 0.34; p = 0.00), GUESS (SR = 0.23; p = 0.022), MASEI (SR = 0.32; p = 0.001), BUSES (SR = 0, 29; p = 0.003). A statistically significant relationship was found between the number of erosion and the GUESS indices (SR = 0.48; p = 0.00), MASEI (SR = 0.49; p = 0.00), BUSES (SR = 0.5; p = 0, 00), as well as between the number of enthesophytes and the GUESS indices (SR = 0.75; p = 0.00), MASEI (SR = 0.28; p = 0.00), BUSES (SR = 0.57; p = 0.00). Conclusion Acute lesion of enthesis in patients with IBD can be assessed using both clinical (LEI, MASES, SPARCC) and ultrasound indices (GUESS, MASEI, BUSES). To assess chronic lesions (erosion, enthesophyte) changes in enthesis in patients with IBD, it is preferable to use ultrasound indices.

Clinical joints manifestations in patients with psoriatic arthritis on musculoskeletal ultrasound

To investigate the clinical joints manifestations under musculoskeletal ultrasound (MSUS) and hematological findings in patients with psoriatic arthritis (PsA), which may provide a basis for improving the early diagnosis of PsA. From September 2016 to February 2021, 328 patients with psoriasis visited the dermatological and rheumatic outpatient of the Beijing Friendship Hospital were enrolled in this retrospective study. Patients were enrolled according to a paired-design method. The PsA group included 164 patients diagnosed with PsA, and the control group included 164 patients diagnosed with psoriasis without PsA. Both groups of patients were evaluated by a rheumatoid immunologist, a dermatologist, and a sonographer. Demographic data, course of disease, severity of skin lesions, combined diseases, and previous treatment were all collected. All patients received MSUS and blood examinations. Lower extremity enthsis diseases were evaluated by Glasgow ultrasound enthesitis scoring system (GUESS). In the comparison of baseline clinical characteristics, the PsA group has longer course of psoriasis (P = 0.005), longer course of joints pain (P = 0.035), higher incidence of peripheral joints pain (P = 0.001), higher GUESS score (P < 0.001), and higher incidence of involved nails or toenails (P = 0.036) The most common joints involved were proximal interphalangeal joint (33.5%), knee (27.4%), and metacarpophalangeal joint (25.0%). Differences in clinical manifestations at different lower limb enthesitis on MSUS have also been proved. The positive incidences of rheumatoid factor (RF) (P = 0.002) and anti-cyclic citrullinated peptide (CCP) antibody (P < 0.001) in the PsA group were significantly higher than those in the control group. Binary Logistic regression showed that patients with anti-CCP antibody positive had a higher risk of active PsA compared to patients with negative antibodies in PsA group (OR: 0.626, 95%CI: 0.361-0.792, P < 0.05). In conclusion, the most common joints involved were proximal interphalangeal joint, knee, and metacarpophalangeal joint in patients with PsA, and the common types of diseased joints manifestations on MSUS were synovial thickening, fluid accumulation, bone destruction, increased blood flow signals, and attachment site inflammation. GUESS scoring systems can be used to identify PsA in patients with psoriasis. Psoriasis patients with RF and anti-CCP antibody positive were more likely to develop PsA, and anti-CCP antibody positive was a risk factor for active PsA. • GUESS scoring systems can be used to identify PsA in patients with psoriasis. • Psoriasis patients with RF and anti-CCP antibody positive were more likely to develop PsA, and anti-CCP antibody positive was a risk factor for active PsA.

Subclinical entheseal involvement in patients with rheumatoid arthritis

BackgroundEnthesopathy is a common feature of Spondyloarthritis (SpA) but can also be found in rheumatoid Arthritis (RA). Recognizing enthesopathy could be challenging because of low sensitivity and specific clinical testing. To detect enthesopathy, The European League Against Rheumatism (EULAR) recommends magnetic resonance imaging (MRI) or ultrasonography (US). Aim of the workTo investigate the frequency and distribution of entheseal involvement in RA patients and its relation to disease activity. Patients and methods100 RA patients with any symptom in foot and ankle were enrolled. Disease activity score (DAS28), Visual analogue scale (VAS), Health assessment questionnaire-Disability index (HAQ-DI) and Glasgow Ultrasound Enthesitis Scoring System (GUESS) were assessed. ResultsThe mean age of patients was 44.1 ± 12.2 years, disease duration was 7 ± 5.8 years and 86% were females. The mean DAS28 score was 4.3 ± 1.2 and GUESS score was 7.2 ± 4.2; all patients had variable degrees of enthesitis: 30% of patients had mild enthesitis, 42% had moderate enthesitis and 28% had marked enthesitis. GUESS was significantly higher in patients with moderate (7.8 ± 4.9) and high (7.2 ± 3.2) disease activity than in patients with low disease activity (5.2 ± 3.9) and those in remission (6.5 ± 1.9) (p = 0.015). HAQ, Age and ESR significantly correlated with GUESS score (r = 0.19, p = 0.049; r = 0.23, p = 0.023; r = 0.33, p = 0.001 respectively). ConclusionSubclinical enthesitis is remarkable in RA patients. Quadriceps tendon enthesis was mostly affected. Enthesitis is significantly related to age, ESR and HAQ. The presence of enthesitis in RA may represent a potential marker for disease activity.

Early detection of subclinical lower limb enthesopathy by ultrasonography in patients with psoriasis: Relation to disease severity

BackgroundEntheseal involvement is a frequent and distinctive feature of psoriatic arthritis (PsA). It is detected clinically but lacks sensitivity and reliability. Musculoskeletal ultrasound (MSUS) is an important tool for accurate detection of enthesitis. Aim of the workTo determine the frequency and distribution of subclinical entheseal abnormalities at lower limbs using MSUS in patients with psoriasis for early detection of PsA, and to evaluate its relation to disease severity. Patients and methods80 patients with psoriasis were studied. Psoriasis Area and Severity Index (PASI) was assessed. High-resolution MSUS assessment of quadriceps, patellar and Achilles tendons, and plantar fascia entheses was performed. Glasgow Ultrasound Enthesitis Scoring System (GUESS) was assessed. ResultsThe median (interquartile range; difference between 75th and 25th quartile) age of the patients was 46(26.3) years and were 42 males. The disease duration was 9(12) years, PASI was 10.9(18.9), and GUESS 6(4). Nail dystrophy was found in 48(60%). Clinical enthesitis was found in 15(18.8%) patients; MSUS revealed lower limb enthesopathy in at least one enthesis in 76(95%) patients, and abnormality in 421 of 800 entheses (52.6%). Distal insertion of the patellar tendon was the most frequently involved (68.8%). GUESS significantly correlated with the age, body mass index (BMI), and PASI. ConclusionPsoriasis is associated with a relevant frequency of asymptomatic entheseal abnormalities. MSUS is a valuable, simple, and noninvasive tool in early detection of enthesopathy in psoriatic patients, especially in the presence of older age, high BMI, and high PASI as potential parameters for detection of psoriatic enthesitis.

Lower limb entheseal involvement in systemic lupus erythematosus patients: Relation to disease activity

BackgroundMusculoskeletal involvement is extremely common in patients with systemic lupus erythematosus (SLE). Musculoskeletal ultrasound (MSUS) is an important tool for evaluation of patients with inflammatory arthritis as well as early detection of subclinical inflammation at the joint, tendon and entheseal level. Aim of the workTo investigate the frequency and distribution of lower limb entheseal abnormalities detected by MSUS in SLE patients and to evaluate its relation to disease activity. Patients and methods50 adult SLE patients were studied. SLE Disease Activity Index-2000 (SLEDAI-2K) was assessed. High-resolution MSUS assessment of quadriceps, patellar and Achilles tendons, and plantar fascia entheses was performed. Glasgow Ultrasound Enthesitis Scoring System (GUESS) was assessed. ResultsThe median age of the patients was 30 (interquartile range 23–36.3 years) and were 49 females. The median disease duration was 4 (2–8.3 years), SLEDAI-2K was 4 (2–8) and GUESS score 3 (1–5.3). Clinical enthesitis was found in 22 (44%) patients; 58% of the patients had evident MSUS features of enthesitis and 32% had minimal or isolated entheseal abnormalities. The age and SLEDAI-2K were significantly increased in those with clinical enthesitis compared to those without (p = 0.007 and p = 0.03 respectively). GUESS significantly correlated with the age (r = 0.39, p = 0.005) and SLEDAI-2K (r = 0.29, p = 0.04). ConclusionClinical and ultrasound-proved enthesitis are prevalent in SLE patients. Quadriceps tendon insertion is the most affected enthesis. Clinical enthesitis tends to occur in older SLE patients. Enthesitis has positive correlations with; age, and SLEDAI-2K score. The presence of enthesitis may represent a potential marker for SLE disease activity.

Clinical evaluation of foot disability in patients with axial spondyloarthritis

Objective: To evaluate foot disability both ultrasonographically and by using the Foot Function Index (FFI) in patients with axial spondyloarthritis (SpA) and to investigate its effects on patients' quality of life and functional capacity by determining the factors that may affect the level of disability.Patients and methods. A total of 100 patients were included in the study. Enthesis sites in the feet were assessed for tenderness and swelling. Ultrasonographic examination of the Achilles tendon and plantar fascia was made and the findings were scored according to Glasgow Ultrasound Enthesitis Scoring System (GUESS). The Foot Function Index (FFI) was used to investigate the effects of foot disorders on disability and activity limitation. The correlation between GUESS and FFI scores, and relationship of GUESS and FFI scores with age, disease duration, body mass index (BMI), smoking and disease activity parameters were investigated.Results and discussion. Physical examination revealed signs of enthesitis in 13 (13%) patients, while ultrasonographic (USG) evaluation – in 36 (36%) patients. A statistically significant correlation was found between all FFI and GUESS scores except between FFI for the right foot and GUESS for right Achilles tendon enthesitis. A positive correlation was found between age and BMI and FFI (p&lt;0.05). There was no correlation between disease duration and smoking and FFI scores. While there was a statistically significant correlation between all scores of GUESS and age, disease duration, and BMI, no correlation was found between smoking and GUESS scores. No significant difference was found in either FFI or GUESS scores between patients with or without / diabetes and patients who were smokers or non-smokers. All FFI and GUESS scores significantly correlated with BASDAI, ASDAS, BASFI, and ASQoL (p&lt;0.05).Conclusion. Enthesitis may lead to decreased functional capacity and loss of quality of life in ax-SpA patients. Subclinical enthesitis in the feet of patients with SpA is not rare and may be detected by USG.

Psoriatic arthritis: clinical and ultrasound parallels

Objective: to assess the relationship of the clinical characteristics and laboratory inflammatory markers to the ultrasound signs of synovitis and enthesitis in patients with psoriatic arthritis (PsA).Patients and methods. Examinations were made in 63 patients diagnosed with PsA according to the 2006 Classification Criteria for Psoriatic Arthritis (CASPAR) criteria. Among the patients, the majority were females (54.2%); the mean age was 42.9±10.3 years; the median (Me) PsA duration was 7 [3; 10] years; Me Disease Activity in Psoriatic Arthritis (DAPSA) was 16.5 [11.6; 25] years.All the patients underwent estimation of tender joint count, swollen joint count, tender entheseal count, inter alia using the Leeds Enthesitis Index (LEI), Maastricht Ankylosing Spondylitis Enthesis Score (MASES), and Spondyloarthritis Research Consortium of Canada (SPARCC). The investigators determined PsA activity by DAPSA and the prevalence and severity of psoriasis by the Psoriasis Area and Severity Index (PASI) and also estimated erythrocyte sedimentation rate (ESR) and high-sensitivity CRP (hs-CRP) levels. Ultrasonography was used to assess bilateral upper and lower limb joints, by calculating joint counts (JC) with synovitis signs (SJC), as well as tendon and ligament entheses (a total number of 54 in one patient), by determining the presence of vascularized enthesis count (VEC) and structurally changed enthesis count (SCEC) and using the ultrasound indices (Glasgow Ultrasound Enthesitis Scoring System (GUESS), Belgrade Ultrasound Enthesitis Score (BUSES), Madrid Sonography Enthesitis Index (MASEI), Sonographic Enthesitis Index (SEI)).Results and discussion. There were no significant differences in the frequency of damage to the upper (15.7%) and lower (19.3%) limb joints (p&gt;0.05), whereas inflammation in the entheses of the lower limbs (23.2%) was significantly more common than that in the upper limbs (15.3%) (p&lt;0.01). A weak relationship was established between SPARCC and SEI (r=0.276; p&lt;0.05). A positive correlation was found between VEC and hs-CRP levels (r=0.323, p=0.01), ESR (r=0.332, p&lt;0.01). Ultrasound imaging showed that SJC (p&lt;0.01), enthesitis count (p&lt;0.01), and SCEC (p&lt;0.05) increased with age. The relationship between SCEC and GUESS (r=0.724; p&lt;0.01) and that between the VEC and BUSES (r=0.562, p&lt;0.01) proved to be more pronounced.Conclusion. Ultrasound imaging indicates that the entheses of the lower limbs are more frequently affected in patients with PsA. There is no relationship between DAPSA and ultrasound inflammatory changes in the joints and extra-articular structures. A strong relationship is established between enthesiseal structural and inflammatory changes and GUESS and BUSES, respectively, which allows one to recommend the use of these indices for assessing enthesitis in PsA. Entheseal vascularization associated with inflammatory markers (hs-CRP, ESR) (p&lt;0.05) is a manifestation of PsA activity regardless of age and DAPSA.

Musculoskeletal Ultrasound Assessment of Enthesopathy in Fibromyalgia Patients

Background: Fibromyalgia (FM) is a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and unrefreshing sleep, and cognitive difficulties, often accompanied by multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living Objectives: To assess the frequency and pattern of enthesopathy in primary FM using musculoskeletal ultrasound with Glasgow Ultrasound Enthesitis Scoring System (GUESS) and Correlate these findings with clinical and laboratory parameters of FM. Patients and Methods: A cross-sectional study includes 100 persons divided into two groups as follows: Group (1): 50 patients with primary fibromyalgia syndrome (FM) were diagnosed. Group (2): 50 apparently healthy controls with comparable age and sex. Patients were selected from those attending the outpatient clinic of the Rheumatology & Rehabilitation Department of Al-Azhar University Hospital, Assiut. Results: There is no statistically significant difference between cases and control groups regarding age, gender, and BMI (P>0.05 for each), there were no statistically significant correlations between the GUESS scores and any of the clinical characteristics of FM patients. Although non-significant, these correlations were negative between the GUESS score and the tender point number, the Widespread Pain Index as well as the Fibromyalgia Impact Questionnaire. The total GUESS score of the FM group ranged between 0-12 with a mean ±SD of 5.3 ± 2.8. The total GUESS score of control group ranged between 0-6 with a mean ±SD of 0.97± 1.58, with a significant difference between the two groups (P<0.05) Conclusion: There were significant enthesopathic changes detected among FM patients especially affecting the Achilles, quadriceps, and proximal patellar tendons.

Musculoskeletal Ultrasound Assessment of Enthesopathy in Fibromyalgia Patients

Background: Fibromyalgia (FM) is a syndrome of persistent widespread pain, stiffness, fatigue, disrupted and unrefreshing sleep, and cognitive difficulties, often accompanied by multiple other unexplained symptoms, anxiety and/or depression, and functional impairment of activities of daily living Objectives: To assess the frequency and pattern of enthesopathy in primary FM using musculoskeletal ultrasound with Glasgow Ultrasound Enthesitis Scoring System (GUESS) and Correlate these findings with clinical and laboratory parameters of FM. Patients and Methods: A cross-sectional study includes 100 persons divided into two groups as follows: Group (1): 50 patients with primary fibromyalgia syndrome (FM) were diagnosed. Group (2): 50 apparently healthy controls with comparable age and sex. Patients were selected from those attending the outpatient clinic of the Rheumatology & Rehabilitation Department of Al-Azhar University Hospital, Assiut. Results: There is no statistically significant difference between cases and control groups regarding age, gender, and BMI (P>0.05 for each), there were no statistically significant correlations between the GUESS scores and any of the clinical characteristics of FM patients. Although non-significant, these correlations were negative between the GUESS score and the tender point number, the Widespread Pain Index as well as the Fibromyalgia Impact Questionnaire. The total GUESS score of the FM group ranged between 0-12 with a mean ±SD of 5.3 ± 2.8. The total GUESS score of control group ranged between 0-6 with a mean ±SD of 0.97± 1.58, with a significant difference between the two groups (P<0.05) Conclusion: There were significant enthesopathic changes detected among FM patients especially affecting the Achilles, quadriceps, and proximal patellar tendons.

Cutaneous immunohistochemical expression of interleukin-23 receptor (IL-23R) in psoriasis and psoriatic arthritis patients: Relation to musculoskeletal ultrasound findings

Aim of the workTo assess the immunohistochemical expression of cutaneous interleukin-23 receptor (IL-23R) in psoriasis and psoriatic arthritis (PsA) patients and study its relation to musculoskeletal ultrasound (MSUS) findings. Patients and methodsThe study was conducted on 40 patients: 20 with PsA and 20 with psoriasis only. The psoriasis area severity index (PASI) was estimated. Synovitis was assessed by Power Doppler ultrasound and enthesitis by Glasgow Ultrasound Enthesitis Scoring System (GUESS). ResultsThe mean age of PsA and psoriasis only patients (49.9 ± 11.6 and 44.9 ± 13 years) and gender (12 males and 8 females each) were comparable. IL-23R expression in the epidermal keratinocytes and dermal inflammatory cells of PsA patients scored 5 in 40% and 4 in 45% respectively while in psoriasis only the highest frequency of cases (40%) scored 2 in both. In psoriasis only, dermal and epidermal IL-23R were significantly associated to effusion (5 ± 0 vs 2.2 ± 0.7 and 4 ± 0 vs 1.5 ± 0.5, p < 0.001 respectively) and synovitis (5 ± 0 vs 2.4 ± 1 and 4 ± 0 vs 1.7 ± 0.8, p < 0.001 respectively) (p < 0.001) and both significantly correlated with erosions (r = 0.64, p = 0.002 and r = 0.64, p = 0.003) and GUESS (r = 0.68, p = 0.001 and r = 0.61, p = 0.005). Dermal IL-23R was significantly associated with the PASI score in PsA patients (r = 0.59, p = 0.01). On regression, IL-23R significantly predicted PsA (epidermal: p = 0.001 and dermal: p = 0.018). ConclusionIL-23R is highly expressed in psoriatic skin and strongly associated with psoriatic skin, joints and entheses findings. MSUS is valuable in the detection of subclinical arthritis. Cutaneous IL-23R expression may refer to early joint affection and with MSUS may allow early prediction and management.

Structural damage and motion rhythm of the spine and hip during trunk lateral bending in ankylosing spondylitis patients with mild to moderate radiographic signs

BackgroundAnkylosing spondylitis causes structural damage and motion restriction in spine. The study was designed to assess structural damage and incoordination pattern between the spine and hip during trunk lateral bending in ankylosing spondylitis. MethodsTwenty-three healthy adults and 39 adults with ankylosing spondylitis were recruited from a tertiary care medical centre. Patients with ankylosing spondylitis were divided into two subgroups: sacroiliitis or lumbar-level syndesmophytes (n = 27) and thoracic or cervical-level syndesmophytes (n = 12). An inertia motion system was used to record three-dimensional kinematic data during trunk lateral bending. FindingsSignificant differences were observed in lumbar spine syndesmophyte scores, sacroiliitis severity and Bath Ankylosing Spondylitis Metrology Index between the subgroups. The cervical supraspinous ligaments thickness revealed difference between the ankylosing spondylitis and control group, but the Glasgow Ultrasound Enthesitis Scoring System did not revealed difference. Motion analysis revealed that the ankylosing spondylitis group had a larger hip, cervical rotation and smaller lumbar-hip rhythm than the control group; however, the other motions of the spine and hip were smaller. The sacroiliitis or lumbar-level syndesmophytes group had the largest thoracic rotation among the three groups. InterpretationThe different lumbar-hip rhythm between ankylosing spondylitis patients depends on syndesmophyte formation levels. Cervical rotation, the Schober test, the chest expansion test, and lumbar–hip rhythm can indicate the levels of bone damage in ankylosing spondylitis. Clinical examination of ankylosing spondylitis should include kinematic measures of both the spine and hips in the early disease stage.

Is ultrasonographic enthesitis evaluation helpful for diagnosis of non-radiographic axial spondyloarthritis?

The aim of this study is to evaluate the diagnostic utility of ultrasonographic enthesitis assessment in patients with non-radiographic axial spondyloarthritis (nr-axSpA) and to compare different sonographic scoring methods. Patients with nr-axSpA (n = 30) and mechanical back pain (MBP) (n = 30) were enrolled in the study with standardized clinical criteria. For both of the groups, a total of 18 entheses were evaluated in each patient with B mode ultrasound and power Doppler by a sonographer who is blinded to initial clinical and radiological assessments. Glasgow Ultrasound Enthesitis Scoring System (GUESS), Madrid Sonographic Enthesitis Index (MASEI) and D'Agostino grading system were performed. Intra-rater and inter-rater reliability analyses were evaluated with the intraclass correlation coefficient (ICC). There was at least one enthesitis in 96.7% of patients with nr-axSpA. Median values of the number of enthesitis were 5 in nr-axSpA and 0 in MBP. Mean GUESS total scores were 0.9 in MBP and 4.5 in nr-axSpA. Mean MASEI total scores were 2.3 and 10.5, respectively. The sensitivities were 96.7% and 93.3% for GUESS and MASEI while the detected specificities were 80% for both methods. For Intra-rater reliability analysis, ICC was calculated as 0.981 for GUESS and 0.975 for MASEI, while it was calculated as 0.964 and 0.962 for inter-rater reliability analysis. Thus, evaluation of enthesitis with ultrasound is a reliable, helpful tool for the distinction of patients with nr-axSpA from patients with MBP. We favored the use of MASEI because of assessing upper extremity, using power Doppler and having a correlation with disease activity.

Enthesopathy in rheumatoid arthritis and spondyloarthritis: An ultrasound study

ObjectiveWe aimed to compare the prevalence of enthesopathy seen on ultrasonography (US) in spondyloarthritis (SpA) and rheumatoid arthritis (RA) and compared it to healthy controls. MethodsAll included patients with RA (2010 ACR/EULAR criteria) and SpA (ASAS criteria) and healthy controls underwent clinical and US evaluation of enthesis at seven sites (quadriceps, proximal and distal patellar, Achilles and triceps tendons, plantar aponeurosis and lateral epicondyle enthesis). The Glasgow Ultrasound Enthesitis Scoring System (GUESS) and the Madrid Sonographic Enthesitis Index (MASEI) scores were determined by two sonographers blinded to clinical data. ResultsWe included 30 patients with RA (mean age: 55.7±14.8 years, mean disease duration 10.5±7.9years); 41 with SpA (mean age: 45.3±15.4 years, mean disease duration 9.2±8.7years) and 26 healthy controls (HC) (mean age: 50.4±17.3years). Patients with SpA and RA had similar prevalence of painful enthesis of examined sites (17% vs. 14%, non-significant [ns]), but more than among in healthy controls (3%, P<0.05 for RA and SpA comparison). Comparison between SpA and RA patients revealed that at least one US enthesis abnormality was found with similar frequency (46% and 48% sites [ns]) but both rheumatic diseases had higher frequency of US enthesis abnormality than HC (31%, P<0.05 for RA and SpA comparison). The mean MASEI score was 8.5±7.3 for RA patients, 7.8±6.5 for SpA patients (ns) and 3.4±2.8 for healthy controls (P<0.05 for RA and SpA comparison). Overall, 6 RA (20%) and 4 SpA (10%) patients had a MASEI score≥18 (ns). None of the healthy controls had a MASEI score≥18 (P<0.05 for RA and SpA comparison). The mean GUESS score was 5.8±3.1 and 6.3±3.9 for RA and SpA patients (ns), and 4.0±3.1 for healthy controls (P<0.01 vs. SpA and <0.05 vs. RA). ConclusionsRA and SpA patients did not differ in entheseal abnormalities seen on US. Such US features may have low specificity in inflammatory conditions affecting joints and enthesis such as SpA and RA.

Ultrasonographic Evaluation of Lower Extremity Entheseal Sites in Diabetic Patients Using Glasgow Ultrasound Enthesitis Scoring System Score

ObjectiveThe prevalence of musculoskeletal complications in diabetes mellitus (DM) increases with the duration of disease and with poor glycemic control. Our aim was to evaluate lower extremity musculoskeletal complications in patients with DM using the Glasgow Ultrasound Enthesitis Scoring System, and to reveal the relationship between clinical and sonographic findings. Materials and methodsA total of 67 patients (25 men, 42 women) with DM were included in the study. All the diabetic patients were selected if they did not have any symptom of musculoskeletal system in the lower extremities. They were divided into four groups. Ultrasonographic assessment was performed according to the Glasgow Ultrasound Enthesitis Scoring System with an Esaote MyLab 5 device equipped with a 5–13 MHz linear transducer. Correlation between diabetes duration and lower extremity enthesopathy scores were evaluated. ResultsThere was a significant correlation between duration of DM and total Glasgow Ultrasound Enthesitis Scoring System scores (p < 0.001). In addition, duration of DM was significantly correlated with enthesophyte scores and erosion scores (both p < 0.001). There was a significant difference among Groups 1–4 for the mean enthesophyte score and mean erosion score (both, p < 0.001). ConclusionMusculoskeletal ultrasonography is an effective, inexpensive, and useful tool without radiation for evaluating diabetic patients for the early diagnosis of musculoskeletal complications.

Musculoskeletal ultrasonographic evaluation of lower limb enthesopathy in ankylosing spondylitis and Behçet’s disease: Relation to clinical status and disease activity

Using clinical and musculoskeletal ultrasonographic (MSUS) examination, we aimed to compare the frequency, pattern, and main sites of peripheral enthesopathies in the lower limbs of ankylosing spondylitis (AS) and Behcet’s disease (BD) patients, and to evaluate their relation with different clinical, laboratory, and functional parameters of both diseases. Fifteen AS patients (group I) and 22 BD patients (group II) were examined clinically and by carrying out MSUS for enthesopathy at five entheseal sites of the lower limbs. A control group of 20 apparently healthy male volunteers was also included. An enthesopathy score was calculated for each patient according to the Glasgow ultrasound enthesitis scoring system (GUESS). Disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index and the Behcet’s disease current activity form in both groups, respectively. The GUESS score was significantly higher (P 0.05), disease duration (P > 0.05), spinal pain scores (P > 0.05), local tenderness scores (P > 0.05), morning stiffness score (P > 0.05), total Bath Ankylosing Spondylitis Disease Activity Index (P > 0.05), Bath AS metrology indices (P > 0.05), AS quality of life scores (P > 0.05), radiographic scores (P > 0.05), erythrocyte sedimentation rate (P > 0.05), and C-reactive protein levels (P > 0.05). In group II, the mean GUESS score was significantly higher (P 0.05) with disease activity. Ultrasonographic changes at the entheseal sites of the lower limbs are prevalent in both AS and BD. These changes are more frequently related to functional and articular involvement. MSUS is more sensitive than clinical examination in detecting enthesopathies of the lower limbs in both AS and BD patients.

Musculoskeletal ultrasonographic evaluation of lower limb enthesopathy in ankylosing spondylitis and Behçet’s disease: Relation to clinical status and disease activity

Using clinical and musculoskeletal ultrasonographic (MSUS) examination, we aimed to compare the frequency, pattern, and main sites of peripheral enthesopathies in the lower limbs of ankylosing spondylitis (AS) and Behcet’s disease (BD) patients, and to evaluate their relation with different clinical, laboratory, and functional parameters of both diseases. Fifteen AS patients (group I) and 22 BD patients (group II) were examined clinically and by carrying out MSUS for enthesopathy at five entheseal sites of the lower limbs. A control group of 20 apparently healthy male volunteers was also included. An enthesopathy score was calculated for each patient according to the Glasgow ultrasound enthesitis scoring system (GUESS). Disease activity was assessed using the Bath Ankylosing Spondylitis Disease Activity Index and the Behcet’s disease current activity form in both groups, respectively. The GUESS score was significantly higher (P 0.05), disease duration (P > 0.05), spinal pain scores (P > 0.05), local tenderness scores (P > 0.05), morning stiffness score (P > 0.05), total Bath Ankylosing Spondylitis Disease Activity Index (P > 0.05), Bath AS metrology indices (P > 0.05), AS quality of life scores (P > 0.05), radiographic scores (P > 0.05), erythrocyte sedimentation rate (P > 0.05), and C-reactive protein levels (P > 0.05). In group II, the mean GUESS score was significantly higher (P 0.05) with disease activity. Ultrasonographic changes at the entheseal sites of the lower limbs are prevalent in both AS and BD. These changes are more frequently related to functional and articular involvement. MSUS is more sensitive than clinical examination in detecting enthesopathies of the lower limbs in both AS and BD patients.

Ultrasonography of peripheral entheses in the diagnosis and understanding of diffuse idiopathic skeletal hyperostosis (DISH).

The aim of this study was to investigate musculoskeletal ultrasound (MSUS) as a diagnostic modality in DISH and to explore whether it might help in elucidating its pathogenesis and events that precede the calcification/ossification process. Fifty patients with DISH and 34 patients with osteoarthritis of the lower limbs without DISH were investigated. Data regarding demographics and traditional cardiovascular risk factors were collected from all patients. An ultrasonography was performed according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS) by observers who were blinded to the diagnosis or the clinical findings in the patients. The total mean GUESS score for patients with DISH was 14.12 ± 5.2 and for patients without DISH 5.32 ± 4.99 (P < 0.0001). Univariate logistic regression analysis found a strong association between the GUESS and the probability of having DISH (P < 0.0001). The area under the ROC curve (AUC) revealed that the GUESS accuracy in diagnosing DISH was 88.53% with sensitivity and specificity of 92 and 70.6%, respectively, at a cutoff value of 6.36. A stepwise logistic regression analysis of the statistically significant items in the GUESS isolated four items, and the presence of either all of them or the first three items yielded the likelihood of having DISH to be 98.8 and 90.6%, respectively. The GUESS and the stepwise logistic regression analysis of the GUESS items demonstrated a high likelihood of having DISH. MSUS might help to identify entheseal changes in DISH. Further studies are needed to confirm these results.

Patients with Inflammatory Bowel Disease have Higher Sonographic Enthesitis Scores than Normal Individuals: Pilot Study in Taiwan

Background If a patient has inflammatory bowel disease (IBD) and enthesitis, he/she can be classified as having peripheral spondyloarthritis according to criteria set by the Assessment of Spondyloarthritis International Society. In Taiwan, IBD patients visiting outpatient clinics can present without joint symptoms, so the prevalence of these musculoskeletal manifestations may be underestimated. We conducted this study to evaluate enthesitis by ultrasonography (US) in IBD patients, and compared these data with healthy controls (HCs). Materials and methods Fourteen IBD patients and 14 HCs underwent independent clinical and ultrasonographic examination of both legs at five entheseal sites. The Glasgow Ultrasound Enthesitis Scoring System (GUESS) was used to assess the degree of enthesitis in the two groups. The total score of enthesitis was calculated on the basis of US findings. All US examinations were undertaken by an experienced rheumatologist blinded to clinical and laboratory findings. Results Two hundred and eighty entheses in 14 patients and 14 HCs were examined by US, which revealed 42/140 (30%) and 21/140 (15%) abnormal entheseal sites in patients and controls, respectively. The GUESS score was significantly higher in IBD patients than in HCs ( p Conclusion These data suggest that US is more sensitive than radiography and clinical assessment for the detection of entheseal abnormalities.