Ultrasonography In Clinical Practice Research Articles

Effective prediction of drug transport in a partially liquefied vitreous humor: Physics-informed neural network modeling for irregular liquefaction geometry

As the medium for intravitreal drug delivery, the vitreous body can significantly influence drug delivery because of various possible liquefaction geometries. This work innovatively proposes a varying-porosity approach that is capable of solving the pressure and velocity fields in the heterogeneous vitreous with randomly-shaped liquefaction geometry, validated with a finite difference model. Doing so enables patient-specific treatment for intravitreal drug delivery and can significantly improve treatment efficacy. A physics-informed neural network (PINN) model is also established for the simulation, and three cases are used for validation. Despite limited information, the PINN model, together with the varying-porosity approach, captured fluid and drug transport in the partially liquefied vitreous. This opens the possibility for optimizing intravitreal drug delivery based on ultrasonography in clinical practice.

Setting the Standards: Neonatal Lung Ultrasound in Clinical Practice.

The use of lung ultrasonography in neonates is increasing at a very fast rate. Evidence-based guidelines on the use of lung ultrasound (LU) in neonates and children have been published and well received across the world. However, there remains a lack of standardized curriculum for lung ultrasound training and standards for its application at the bedside. This article focuses on providing a standardized approach to the application of lung ultrasonography in neonates for the common neonatal conditions and how it can be integrated into bedside clinical decision-making.

Assessment of Thyroid Gland in Children with Point-of-Care Ultrasound (POCUS): Radiological Performance and Feasibility of Handheld Ultrasound in Clinical Practice

Point-of-Care Ultrasound (POCUS) refers to the use of portable ultrasound machines to perform quick and focused ultrasound examinations at a patient’s bedside or point-of-care. POCUS can be performed by all health workers with specific training to use POCUS. The aim of this study was to investigate the radiological performance and feasibility of POCUS using a handheld ultrasound device (HHUSD) in children for examining the thyroid gland. A pediatric endocrinologist performed thyroid imaging in children referred to our hospital with suspected thyroid disease using an HHUSD. The same children underwent ultrasonography (US) imaging using the same device by the first radiologist, and a second radiologist performed thyroid US using an advanced high-range ultrasound device (AHUSD) (defined as the gold-standard method) within two hours. The data obtained by the three researchers were compared with each other. This study included 105 patients [68.6% girls (n=72)] with a mean age 12.8±3.6 years. When the thyroid volume was evaluated, a strong correlation was found between the measurements of the three researchers (AA vs. MG: r=0.963, AA vs. GT: r=0.969, MG vs. GT: r=0.963, p<0.001). According to the Bland-Altman analysis for total thyroid volume, AA measured 0.43 cc [95% confidence interval (CI): -0.89-0.03] smaller than MG, and 0.11 cc (95% CI: -0.30-0.52) larger than GT, whereas MG measured 0.52 cc (95% CI: 0.09-0.94) larger than GT. When evaluated for the presence of goiter and nodules, a near-perfect agreement was found between the results of the three researchers (AA vs. GT; κ=0.863, MG vs. GT; κ=0.887, p<0.001, and AA vs. GT; κ=1.000, MG vs. GT; κ=0.972, p<0.001, respectively). When evaluated in terms of the longest axis of nodules, a high correlation was found between the measurements of the three researchers (AA vs. MG; r=0.993, AA vs. GT; r=0.996, MG vs. GT; r=0.996, p<0.001). When evaluated in terms of the final diagnosis, the evaluations of the three researchers showed excellent agreement with each other (AA vs. GT; κ=0.893, MG vs. GT; κ=0.863, p<0.001, accuracy rate AA vs. GT: 93.3%; MG vs. GT: 91.4%). A pediatric endocrinologist, equipped with sufficient training in thyroid US evaluation, incorporated HHUSD examination as a routine clinical tool in an outpatient setting. It was shown that, they could effectively assess normal thyroid tissue in pediatric patients. Moreover, the HHUSD proved to be useful in detecting thyroid pathologies. However, it is important to note that for a more comprehensive evaluation of thyroid nodules, including detailed assessment and Thyroid Imaging Reporting and Data System (TIRADS) classification, patients should be referred to radiology departments equipped with AHUSD systems. These specialized devices, along with the expertise of radiologists, are essential for in-depth evaluations and accurate classification of thyroid nodules.

Precision and Safety of Ultrasound-Guided versus Palpation-Guided Needle Placement on the Patellar Tendon: A Cadaveric Study.

For decades, needling interventions have been performed based on manual palpation and anatomic knowledge. The increasing use of real-time ultrasonography in clinical practice has improved the accuracy and safety of needling techniques. Although currently ultrasound-guided procedures are routinely used for patellar tendon pathology, e.g., during percutaneous electrolysis, the accuracy of these procedures is still unknown. This study used a cadaveric model to compare and evaluate both the accuracy and safety of ultrasound-guided and palpation-guided needling techniques for the patellar tendon. A total of five physical therapists performed a series of 20 needle insertion task each (n = 100), 10 insertions based on manual palpation (n = 50) and 10 insertions guided with ultrasound (n = 50) to place a needle along the interface between the patellar tendon and Hoffa's fat pad. All procedures were performed on cryopreserved knee specimens. Distance to the targeted tissue, time of the procedure, accurate rate of insertions, number of passes, and unintentional punctured structures between both applications (with and without ultrasound guiding) were compared. The results revealed higher accuracy (100% vs. 80%), a lower distance from needle to the targeted tissue (0.25 ± 0.65 vs. 2.5 ± 1.9 mm), longer surface of contact with the needle (15.5 ± 6.65 vs. 4.7 ± 7.5 mm), and a lower frequency of patellar tendon puncture (16% vs. 52%, p < 0.001) with the ultrasound-guided procedure as opposed to palpation-guided one. Nevertheless, the ultrasound-guided procedure took longer (54.8 ± 26.8 vs. 23.75 ± 15.4 s) and required more passes (2.55 ± 1.9 vs. 1.5 ± 0.95) to be conducted than the palpation-guided procedure (all, p < 0.001). According to these findings, the accuracy of invasive procedures applied on the patellar tendon is higher when conducted with ultrasound guidance than when conducted just on manual palpation or anatomical landmark. These results suggest that ultrasound could improve the clinical application of invasive procedures at the fat-patellar tendon interface. Due to the anatomical features of the targeted tissue, some procedures require this precision, so the use of ultrasound is recommended.

Physician Assistant Use of Ultrasound for Shoulder, Hip, and Knee Joint Injections

Background: Physician assistants (PAs) perform joint injections in the office setting. Although ultrasound (US) provides a safe option that increases accuracy of injections, this orthopedic specific training has not been routinely offered in PA education. The aim of this study was to examine the frequency with which orthopedic PAs performed shoulder, hip, and knee joint injections, with and without US, and how US training was obtained. Methods: In a quantitative descriptive cross-sectional study, PAs received a link to a self-designed survey by an email list provided by the physician assistants in orthopedic surgery. Results: Most PAs with access to US performed 10 or less shoulder, hip, and knee joint injections using US each month. The most common US training reported was on-the-job (n = 141; 35.30%), independent courses (n = 91; 22.80%), and self-taught (n = 70; 17.50%). Nearly one-half (n = 196; 49.00%) reported no US training, leading to 177 PAs (60.00%) perceiving they were not at all or only somewhat prepared to perform US in clinical practice. Conclusion: Overall, shoulder and knee joint injections were performed more often in the office than hip joint injections and were more commonly performed without US. Most PAs perceived they were not prepared to perform US in practice during their formal education, with many having sought further training.

The Dark Side of Ultrasound Imaging in Parathyroid Disease

The diagnosis of parathyroid diseases by imaging still has some intrinsic technical limitations due to the differential diagnosis of different structures of the neck that mimic the parathyroid glands. In this view, ultrasound (US) is an established, low-cost, and non-invasive imaging technique that still represents the first-line approach for evaluating patients with parathyroid disease. The objective of this article is to provide a comprehensive review of the applications of USs in clinical practice, discussing the histopathological and US characteristics of the parathyroid glands in normal and pathological conditions, the advantages of preoperative imaging, and novel updates on the most useful and currently available multiparameter US techniques.

Ultrasound intima media thickness cut-off values for cranial and extracranial arteries in patients with suspected giant cell arteritis.

ObjectiveTo determine the optimal ultrasound (US) cut-off values for cranial and extracranial arteries intima media thickness (IMT) to discriminate between patients with and without giant cell arteritis (GCA).MethodsRetrospective observational study including patients referred to an US fast-track clinic. All patients underwent bilateral US examination of the cranial and extracranial arteries including the IMT measurement. Clinical confirmation of GCA after 6 months was considered the gold standard for diagnosis. A receiver operating characteristic (ROC) analysis was performed to select the cut-off values on the basis of the best tradeoff values between sensitivity and specificity.ResultsA total of 157 patients were included, 47 (29.9%) with clinical confirmation of GCA after 6 months. 41 (87.2%) of patients with GCA had positive US findings (61.7% had cranial and 44.7% extracranial involvement). The best threshold IMT values were 0.44 mm for the common temporal artery; 0.34 mm for the frontal branch; 0.36 mm for the parietal branch; 1.1 mm for the carotid artery and 1 mm for the subclavian and axillary arteries. The areas under the ROC curves were greater for axillary arteries 0.996 (95% CI 0.991–1), for parietal branch 0.991 (95% CI 0.980–1), for subclavian 0.990 (95% CI 0.979–1), for frontal branch 0.989 (95% CI 0.976–1), for common temporal artery 0.984 (95% CI 0.959–1) and for common carotid arteries 0.977 (95% CI 0.961–0.993).ConclusionIMT cut-off values have been identified for each artery. These proposed IMT cut-off values may help to improve the diagnostic accuracy of US in clinical practice.

EXpert consensus On Diaphragm UltraSonography in the critically ill (EXODUS): a Delphi consensus statement on the measurement of diaphragm ultrasound-derived parameters in a critical care setting

BackgroundDiaphragm ultrasonography is rapidly evolving in both critical care and research. Nevertheless, methodologically robust guidelines on its methodology and acquiring expertise do not, or only partially, exist. Therefore, we set out to provide consensus-based statements towards a universal measurement protocol for diaphragm ultrasonography and establish key areas for research.MethodsTo formulate a robust expert consensus statement, between November 2020 and May 2021, a two-round, anonymous and online survey-based Delphi study among experts in the field was performed. Based on the literature review, the following domains were chosen: “Anatomy and physiology”, “Transducer Settings”, “Ventilator Impact”, “Learning and expertise”, “Daily practice” and “Future directions”. Agreement of ≥ 68% (≥ 10 panelists) was needed to reach consensus on a question.ResultsOf 18 panelists invited, 14 agreed to participate in the survey. After two rounds, the survey included 117 questions of which 42 questions were designed to collect arguments and opinions and 75 questions aimed at reaching consensus. Of these, 46 (61%) consensus was reached. In both rounds, the response rate was 100%. Among others, there was agreement on measuring thickness between the pleura and peritoneum, using > 10% decrease in thickness as cut-off for atrophy and using 40 examinations as minimum training to use diaphragm ultrasonography in clinical practice. In addition, key areas for research were established.ConclusionThis expert consensus statement presents the first set of consensus-based statements on diaphragm ultrasonography methodology. They serve to ensure high-quality and homogenous measurements in daily clinical practice and in research. In addition, important gaps in current knowledge and thereby key areas for research are established.Trial registration The study was pre-registered on the Open Science Framework with registration digital object identifier https://doi.org/10.17605/OSF.IO/HM8UG.

A New Era for the Early and Non-Invasive Diagnosis of Giant Cell Arteritis: The Use of Fast-Track Ultrasound in Clinical Practice

Background: The assessment of giant cell arteritis (GCA) in fast-track assessment clinics (FTA) including the use of ultrasound (US) is becoming the preferred practice in specialized centers. Methods: Patients with suspected GCA referred to the FTA of the Rheumatology Department, University of Pavia, Italy, between 2016 and 2021 were included to analyze the clinical and US findings. Results: A total of 553 US examinations were performed on 347 patients. A total of 246 were female (71%), and the mean age was 73 ± 12. Of these, 287 US on newly referred patients led to a confirmed diagnosis of GCA in 111 (39%). The sensitivity of US was 81.98% (95% CI 73.55–88.63%), and the specificity 99.43% (95% CI 96.88–99.99%). Only 4 patients required temporal artery biopsy. The most specific symptoms to inform the pre-test probability of GCA and differentiate from patients with other conditions were: jaw or tongue claudication, scalp tenderness, and bilateral visual loss. Headache was not reported in 33% of patients. Systemic symptoms were significantly more frequent in GCA (42.3%), together with combinations of cranial, systemic, and/or polymyalgia rheumatica symptoms. Out of 88 patients, there were 52% with a confirmed relapse. Of these, 67% had a positive US. Conclusion: The use of FTA in clinical practice ensures an early diagnosis, avoiding invasive procedures for the patient. Our data support the increasingly recognized adjunctive role of US in the monitoring of GCA.

Vascular ultrasound for the diagnosis of giant cell arteritis: a reliability and agreement study based on a standardised training programme

ObjectiveTo evaluate the impact of a standardised training programme including equipment adjustment for experienced musculoskeletal ultrasonographers without previous experience in vascular ultrasound (US) on the reliability of US in the...

SYNOVIAL HYPERTROPHY DETECTED USING ULTRASONOGRAM IN PRIMARY OSTEOARTHRITIC KNEES: PREVALENCE AND CORRELATIONWITH RADIOGRAPHIC STAGING

Background: Treatment of primary osteoarthritic (OA) knee has changed in recent decades with a greater focus on synovitis as one cause of cartilage destruction and degeneration. Ultrasonography (US), a noninvasive, low cost and convenient procedure may be used for early detection and monitoring synovitis in primary OA knee. Somehow, the lack of data on the prevalence of synovial hypertrophy (SH) and its correlation to disease progression has precluded the use of US in clinical practice. Objective: The study aimed to determine the prevalence of SH at each stage of the disease and its correlation to structural damage. Methods: In all, 214 knees among 127 cases diagnosed as having primary OA knee were examined using US. The midline scanning technique of US was performed and synovial thickness at the suprapatellar pouch was observed. All knees were categorized according to the Kellgren-Lawrence radiographic staging (KL). The prevalence of SH in each KL with 2, 2.5 and 3 mm cutoff level were calculated. The correlation between synovial thickness and KL was also analyzed. Results: The prevalence of SH with 2 mm cutoff level in KL I-IV was 38.8, 70.8, 66.6 and 91.1%, respectively. The prevalence of SH with 2.5 mm cutoff level in KL I-IV was 5.5, 37.5, 35.4 and 74.2%, respectively. The prevalence of SH with 3 mm cutoff level in KL I-IV was 0, 29.1, 20.8 and 56.4%, respectively. The overall prevalence with 2, 2.5 and 3 mm cut-off level was 72.2, 50.9 and 37.1%, respectively. Synovial thickness, measured in millimeters, correlated well with KL (p&lt;0.01). The correlation of synovial thickness between each KL was also statistically significant (p&lt;0.05) except those between KL II and KL III (p=0.98). Conclusion: Synovial thickness at the suprapatellar pouch detected with midline scanning US reflected the degree of synovitis which correlated well with structural damage and could be used to monitor disease progression in primary OA knee.

The Untapped Potential of Ultrasound in Reproductive Health: Interviews with Key Opinion Leaders

Ultrasound (US) has been a frequently-used tool in the field of reproductive health since the mid-1950s. It has been hugely successful, especially during pregnancy, in helping to detect issues such as fetal abnormalities. It is also a non-invasive procedure, working by bouncing ultrasonic soundwaves at body structures or tissues and detecting the echoes that bounce back. The quality of US scans has continually improved over the years, and with emergent technologies, such as Doppler and three dimensional (3D) imaging, the ability for physicians to use US to accurately visualise organs and structures within the female pelvis is extensive. However, across the broad spectrum of reproductive health physicians, there appears to be significantly more scope for US to be utilised in daily clinical practice, particularly in treating infertility and increasing the success rates of procedures such as in vitro fertilisation (IVF). To better understand the extent to which US can be utilised, the European Medical Journal recently interviewed two leading figures in reproductive health who are particularly strong proponents of a broad use of US in clinical practice. These were Dr Nicholas Raine-Fenning, Clinical Associate Professor &amp; Reader in Reproductive Medicine and Surgery, Faculty of Medicine &amp; Health Sciences, University of Nottingham, Nottingham, UK, and Prof Michaël Grynberg, Head of the Department of Reproductive Medicine and Fertility Preservation at the University Hospital Antoine-Béclère, Clamart, France. As well as providing a general overview of US across reproductive health, each provided an analysis from the perspective of their main area of clinical expertise: Dr Raine-Fenning focussed primarily on the use of US in IVF, while Prof Grynberg gave insights on its role in diagnosing infertility. In addition, Mr Stephen Hussey, General Manager, Women’s Health Ultrasound, Europe &amp; RCIS, GE Healthcare, Amersham Place, UK, was invited to share a commercial perspective on the use of US technology in reproductive medicine.

Curriculum for Fundamentals of Ultrasound in Clinical Practice.

Curriculum for Fundamentals of Ultrasound in Clinical Practice.

Clinical utility of carotid ultrasonography: Application for the management of patients with diabetes.

Carotid ultrasonography is a non‐invasive, simple and inexpensive modality to assess the severity of atherosclerosis. This article reviews related articles, summarizes the rationale for the application of carotid ultrasonography in clinical practice, and addresses the features and the limitations of carotid ultrasonography in cardiovascular risk prediction. Numerous large studies have confirmed that various carotid ultrasound measures, such as carotid intima‐media thickness, the presence or absence of carotid plaque, plaque number and plaque area, can be independent predictors of cardiovascular diseases in individuals with and without diabetes mellitus. Furthermore, many studies showed that the use of carotid intima‐media thickness (especially maximum intima‐media thickness, including plaque thickness) and/or carotid plaque in addition to traditional risk factors significantly improved the prediction of the occurrence of cardiovascular diseases, while controversy remains. Several studies showed that the progression of carotid intima‐media thickness also can be a surrogate end‐point of cardiovascular events. However, the accumulated evidence has not been sufficient. Further study with sufficient power should be carried out. As plaque disruption, which plays a crucial role in the pathogenesis of cardiovascular events, is dependent on the content of lipid in the atheroma and the thickness of the fibrous cap, tissue characterization of a plaque might be useful for determining its fragility. Interestingly, recent studies have shown that ultrasonic tissue characterization of carotid lesions could improve the prediction ability of future cardiovascular diseases. Thus, carotid ultrasonography is a useful modality for better clinical practice of atherosclerosis in patients with diabetes.

Rectal Endoscopic Ultrasound in Clinical Practice.

Endoscopic ultrasound (EUS) is routinely utilized for evaluation of disorders of the lower gastrointestinal tract. In this review, we summarize the current status of rectal EUS in clinical practice and describe recent developments in diagnostic and therapeutic rectal EUS. Recent guidelines recommend rectal EUS for rectal cancer staging as a second line modality in cases where MRI is contraindicated. Forward-viewing echoendoscopes and through the scope EUS miniprobes allow for EUS imaging of lesions through the entire colon and for evaluation beyond stenoses or luminal narrowings. EUS can be used to assess perianal disease and drain pelvic abscess associated with IBD, along with newer applications currently under investigation. For rectal varices, EUS can confirm the diagnosis, assess the optimal site for banding, guide therapy placement with sclerotherapy and/or coils, and assess response to treatment by confirming absence of flow. Therapeutic rectal EUS is emerging as a promising modality for drainage of pelvic fluid collection drainage and fiducial placement for rectal or prostatic cancer. Drug delivery mechanisms and substances that may increase the scope of therapy with rectal EUS are in varying stages of development. Rectal EUS continues to be an important modality for evaluation of benign and malignant disorders of the lower gastrointestinal tract, although its use as a cancer staging modality has declined due to improvements in MRI technology. Various technologies to enhance ultrasound imaging and for therapeutics have been developed that have or may contribute to expanded indications for rectal EUS.

Prediction of Acute Glomerular Filtration Rate Reductions Following Renin-angiotensin System Blockade in Chronic Kidney Disease: A Possible Application of Ultrasonography in Clinical Practice.

Objective Renal arteriolosclerosis is a risk factor for acute reductions in the glomerular filtration rate (GFR) when renin-angiotensin system (RAS) inhibitors are administered. Renal arteriolosclerosis can be detected by an increase in the resistive index (RI) on Doppler ultrasonography. The purpose of the present study is to determine whether or not the RI can predict acute GFR reductions following RAS blockade in chronic kidney disease (CKD). Methods We surveyed all CKD patients who were hospitalized in Otemae Hospital from January 2008 to December 2017. One hundred and eight patients who had been newly treated with RAS inhibitors were able to be followed for 14 weeks. The end point was an acute reduction in the GFR, defined as a decrease of ≥30%. Results Twenty-three of the 108 patients presented with acute GFR reductions. The cumulative probability of acute GFR reductions was 3.3% and 53% in patients with RI ≤0.70 and RI >0.70, respectively (p<0.001). A univariate Cox proportional-hazards analysis showed that the RI, age, GFR, systolic blood pressure, urinary protein excretion, diabetic kidney disease, coronary artery disease, and use of diuretics were significant variables. Multivariate hazard ratios were calculated from the RI and three established variables (age, GFR, diuretics), and the RI and use of diuretics were shown to be significant risk factors for acute GFR reductions. Conclusion These results suggest that an increase in the RI, as well as the use of diuretics, may be risk factors for acute GFR reductions following RAS blockade.

Romanian National Guidelines on Contrast Enhanced Ultrasound in clinical practice.

Contrast-enhanced ultrasound (CEUS) allows a real-time assessment of the vascular pattern of different types of lesions, asit has no renal or liver toxicity, it lacks radiation exposure and it is also cheaper than other imaging methods, having a diagnosticcapability that matches contrast-enhanced CT or MRI. In Romania CEUS is used more and more, especially by clinicians,and since some centres have extensive experience in this domain, we felt the need to disseminate our expertise in order toimplement this method in as many centres as possible. These Guidelines present the clinical applications of CEUS in the liver,spleen, pancreas, kidney, testis, bowel, intra-cavitary and endoscopic ultrasound, as well as other applications.

Contrast-enhanced ultrasonography in clinical practice in Crohn's disease: feasibility of destruction/replenishment method and software analysis.

The aim of this Pictorial Essay is to evaluate the feasibility in the clinical practice of CEUS destruction/replenishment method and time intensity curve (TIC) analysis using the available software in patients with Crohn's disease. The ultrasound (US) procedure using contrast agent is briefly described, elaboration and analysis of the US sequences are explained in detail, and some advantages and disadvantages of the method are highlighted. The Authors suggest that the destruction/replenishment method is useful and time-saving in Crohn's disease if multiple measurements are required on intestinal portions adjacent to each other or in different locations.

Hip ultrasonography in clinical practice.

The current practice of hip ultrasonography for developmental dysplasia of the hip (DDH) is based on more than three decades of experience. During this time, professional medical organizations in the United States have addressed both the clinical practice and imaging aspects of early detection of DDH. Current evidence-based clinical practice recommendations come from the American Academy of Pediatrics and the American Academy of Orthopaedic Surgeons. Consensus imaging recommendations come from the American Institute of Ultrasound in Medicine, the American College of Radiology, Society for Pediatric Radiology and the Society of Radiologists in Ultrasound. In this review the author compares and contrasts the current guidelines and offers additional practice tips for those providing comprehensive hip ultrasound services to infants.

Perceptions of Doppler ultrasound for rheumatoid arthritis disease activity assessment and education.

The aim of this qualitative study was to report the findings of the Defining rheumatoid arthritis progression using Doppler Ultrasound in Clinical practice (DEDUCE) Medical Practice Activity, which was developed to facilitate the utilization of Doppler ultrasound (DUS) by Australian rheumatologists in the treatment of patients with rheumatoid arthritis (RA). Twenty-one rheumatologists recruited a total of 80 patients with RA in Disease Activity Score of 28 joints (DAS28) remission for DUS assessment and completed a pre- and post-activity questionnaire assessing their experience with DUS, as well as a 6-month follow-up questionnaire. Rheumatologists discussed DUS results with patients using visual aids. Patients completed a pre- and post-DUS assessment questionnaire. Data were summarized using descriptive statistics. Following completion of the activity, 95% of rheumatologists (20/21) believed DUS was a useful assessment tool for patients with RA. The majority found the DUS results useful and more than half thought the DUS assessment fit well into their consultation. A majority of rheumatologists indicated they would use DUS imaging in patients with low disease activity and remission, and for disease activity assessment to inform in therapeutic decision-making. All patients who responded found the visual aids useful and most felt that discussing DUS results improved understanding of their disease and would help with medication adherence. Incorporation of DUS imaging into routine clinical practice is feasible, encourages rheumatologists to utilize and expand their clinical application of DUS imaging in patients with RA, and may improve patient understanding of their disease and adherence to medication.