The document outlines the agenda and objectives for a two-day Targeted Ultrasound Initiative (TUI) meeting in São Paulo, Brazil, which aims to introduce rheumatoid arthritis (RA) ultrasound algorithms for diagnosis, monitoring, and remission assessment, discuss implementing algorithms in clinical practice, and consider how ultrasound is used to assess psoriatic arthritis (PsA). The meeting will include sessions on using ultrasound in the RA patient pathway, challenging cases, developing tools for supporting ultrasound in PsA evaluation, and discussing next steps for national initiatives.
Comorbidities in spondyloarthritis 23.01.2014Boris Garro
This document discusses extra-articular manifestations that can occur in spondyloarthritis (SpA) patients. It separates manifestations into those that are SpA-specific (e.g. inflammatory bowel disease, psoriasis, uveitis) versus those that are non-specific. It notes that eye-skin-gut manifestations frequently involve clinical inflammation and may be related to axial or joint inflammation. It also discusses manifestations like lung and heart involvement that are very rare and usually not related to the locomotor disease.
This study tested whether substantia nigra hyperechogenicity measured by transcranial sonography can serve as a biomarker for disease progression in early onset Parkinson's disease patients. The study found that (1) substantia nigra hyperechogenicity increased progressively over time in both hemispheres of early onset Parkinson's patients initially presenting with signs in one hemisphere only, (2) this increase preceded the clinical detection of signs in the initially less affected hemisphere, and (3) transcranial sonography may be more sensitive than clinical exams alone in detecting progression from stage I to stage II of the disease.
AMIM Février 2017 New diagnostic tools for GCA luqmani marrakesh 020359
Ultrasound shows promise as a diagnostic tool for giant cell arteritis (GCA) that could reduce the need for temporal artery biopsies. A large study found ultrasound had higher sensitivity (54%) than biopsy (39%) for GCA diagnosis, though lower specificity. Using ultrasound first and only doing biopsies for high-risk cases could avoid 87-98% of biopsies while maintaining high sensitivity for GCA detection. Follow-up ultrasounds may help monitor disease activity and detect relapses in GCA patients treated with steroids.
Clinical Impact of New Viral Hepatitis Data From San Francisco 2018hivlifeinfo
2018 Annual Meeting of the American Association for the Study of Liver Diseases*
November 9-13, 2018; San Francisco, California
Expert faculty members summarize key viral hepatitis studies from this important annual conference. Use these slides to review data on newer HCV regimens, the HCV continuum of care, posttreatment HCV outcomes, HCV D+R- transplantation, NA cessation in chronic hepatitis B, and investigational HBV/HDV therapeutics.
Format: Microsoft PowerPoint (.ppt)
File Size: 362 KB
Released: November 28, 2018
Este poema expresa el amor de una persona hacia su pareja, describiéndolo como tímido pero también orgulloso. Aunque inicialmente la relación parece asfixiante debido al amor intenso, la persona se da cuenta que el amor verdadero requiere libertad. Al final, a pesar de la soledad, la persona encuentra su esencia y reafirma su amor.
Este documento discute como otimizar sites para atrair mais hóspedes. Aponta que 30 milhões de pessoas buscam hospedagem online mensalmente e que estar entre os primeiros resultados do Google é crucial já que 60% das viagens começam online. Recomenda contratar uma agência de SEO para melhorar o ranqueamento do site e direcionar mais hóspedes potenciais ao negócio de forma barata e eficaz.
Este documento describe diferentes tipos de organizaciones y estructuras dentro de una empresa. Explica conceptos como la organización, la estructura funcional, departamentalización por producto/servicio y proyecto, y las ventajas e inconvenientes de tramos amplios y estrechos. También presenta diagramas de organización como el organigrama.
Este álbum de fotografías contiene imágenes de varios eventos familiares y vacaciones a lo largo de los años. Las fotos capturan momentos felices como cumpleaños, reuniones y viajes a la playa. En conjunto, el álbum ofrece una mirada nostálgica a los recuerdos del pasado.
Comorbidities in spondyloarthritis 23.01.2014Boris Garro
This document discusses extra-articular manifestations that can occur in spondyloarthritis (SpA) patients. It separates manifestations into those that are SpA-specific (e.g. inflammatory bowel disease, psoriasis, uveitis) versus those that are non-specific. It notes that eye-skin-gut manifestations frequently involve clinical inflammation and may be related to axial or joint inflammation. It also discusses manifestations like lung and heart involvement that are very rare and usually not related to the locomotor disease.
This study tested whether substantia nigra hyperechogenicity measured by transcranial sonography can serve as a biomarker for disease progression in early onset Parkinson's disease patients. The study found that (1) substantia nigra hyperechogenicity increased progressively over time in both hemispheres of early onset Parkinson's patients initially presenting with signs in one hemisphere only, (2) this increase preceded the clinical detection of signs in the initially less affected hemisphere, and (3) transcranial sonography may be more sensitive than clinical exams alone in detecting progression from stage I to stage II of the disease.
AMIM Février 2017 New diagnostic tools for GCA luqmani marrakesh 020359
Ultrasound shows promise as a diagnostic tool for giant cell arteritis (GCA) that could reduce the need for temporal artery biopsies. A large study found ultrasound had higher sensitivity (54%) than biopsy (39%) for GCA diagnosis, though lower specificity. Using ultrasound first and only doing biopsies for high-risk cases could avoid 87-98% of biopsies while maintaining high sensitivity for GCA detection. Follow-up ultrasounds may help monitor disease activity and detect relapses in GCA patients treated with steroids.
Clinical Impact of New Viral Hepatitis Data From San Francisco 2018hivlifeinfo
2018 Annual Meeting of the American Association for the Study of Liver Diseases*
November 9-13, 2018; San Francisco, California
Expert faculty members summarize key viral hepatitis studies from this important annual conference. Use these slides to review data on newer HCV regimens, the HCV continuum of care, posttreatment HCV outcomes, HCV D+R- transplantation, NA cessation in chronic hepatitis B, and investigational HBV/HDV therapeutics.
Format: Microsoft PowerPoint (.ppt)
File Size: 362 KB
Released: November 28, 2018
Este poema expresa el amor de una persona hacia su pareja, describiéndolo como tímido pero también orgulloso. Aunque inicialmente la relación parece asfixiante debido al amor intenso, la persona se da cuenta que el amor verdadero requiere libertad. Al final, a pesar de la soledad, la persona encuentra su esencia y reafirma su amor.
Este documento discute como otimizar sites para atrair mais hóspedes. Aponta que 30 milhões de pessoas buscam hospedagem online mensalmente e que estar entre os primeiros resultados do Google é crucial já que 60% das viagens começam online. Recomenda contratar uma agência de SEO para melhorar o ranqueamento do site e direcionar mais hóspedes potenciais ao negócio de forma barata e eficaz.
Este documento describe diferentes tipos de organizaciones y estructuras dentro de una empresa. Explica conceptos como la organización, la estructura funcional, departamentalización por producto/servicio y proyecto, y las ventajas e inconvenientes de tramos amplios y estrechos. También presenta diagramas de organización como el organigrama.
Este álbum de fotografías contiene imágenes de varios eventos familiares y vacaciones a lo largo de los años. Las fotos capturan momentos felices como cumpleaños, reuniones y viajes a la playa. En conjunto, el álbum ofrece una mirada nostálgica a los recuerdos del pasado.
Análise dos locais de injeção pós-vacinal utilizando ultrassomAgriPoint
Análise das reações nos locais de injeção pós-vacinais em bovinos de corte utilizando ultrassom mostrou que animais vacinados com Vision 7 (2mL) tiveram menores reações nos dias 7 e 30 em comparação com vacina contra clotridioses com adjuvante alúmen (5mL), tanto na área superficial quanto na profundidade. A vacina Vision 7 proporcionou uma redução significativa no tamanho e profundidade das cicatrizes entre os dias 7 e 30.
El resumen es: Se anuncia una celebración de bodas de plata y promoción 88 el sábado 9 de noviembre a las 21:00 horas en el salón Siriono. La banda Poker amenizará el evento. Se proporcionan números de contacto y correo electrónico para obtener más información.
O documento resume as respostas de participantes do Fórum Social Mundial de 2010 à pergunta "O que os participantes do Fórum Social Mundial 2010 querem das empresas?". Os participantes pediram às empresas que adotem práticas de consumo sustentável, respeitem os direitos humanos e sejam socialmente responsáveis.
This document outlines the tentative program for a blended learning course taking place from August 29-30 and September 3-4, 2013. The two-day course will introduce participants to various digital tools for blended learning. On the first day, participants will learn about the i-Learn platform, data gathering tools like mind maps, and collaboration tools like Google Docs. The second day will cover communication tools like Skype and discussion forums, as well as a session on sharing blended learning methods. The goal is to equip participants with strategies for incorporating digital resources into their teaching practice.
O garoto tinha um temperamento explosivo e seu pai lhe deu uma tábua e pregos para martelar sempre que perdesse a paciência, diminuindo os pregos com o tempo. Quando não perdeu mais a paciência, retirou os pregos, mas a tábua ficou marcada, assim como palavras agressivas deixam marcas.
Slide di Andrea Piccoli, Direzione Tecnica – Cloud Evangelist – SOA Architect, Vecomp Software srl, in occasione del webinar "Gestione documentale e protocollo informatico: da adempimento a opportunità per migliorare trasparenza, efficienza e qualità organizzativa", organizzato da FPA in collaborazione con Microsoft. Il seminario si è svolto lunedì 20 giugno 2016.
O documento apresenta exemplos de substantivos divididos em diferentes categorias. Em três frases, descreve que substantivos nomeiam pessoas, lugares ou coisas e podem ser abstratos, concretos ou coletivos. Além disso, incentiva o leitor a aprender sobre os diferentes tipos de substantivos e dar exemplos de cada um.
Designing A.I. - Week 1 - Intro LectureDavid Young
The document provides an introduction to a course on designing artificial intelligence. It discusses the history and recent successes of AI, including deep learning techniques. It notes challenges like bias in data and the need for more diversity in AI development. The course will focus on current machine learning techniques and how AI could help underserved groups. Students will research AI technologies, propose solutions, and develop new ways for non-experts to understand AI through prototypes and reflection.
Este documento descreve uma dissertação de mestrado sobre o estudo do comportamento reológico de adesivos hot melt PSA e sua relação com a composição e propriedades adesivas. O trabalho analisou a influência de três parâmetros de formulação de HMPSA nas propriedades reológicas e mecânicas. Os resultados mostraram que os parâmetros afetam significativamente as propriedades mecânicas e estas podem ser correlacionadas às propriedades reológicas.
Rpp revisi 2016 sosiologi x rpp diva pendidikanDiva Pendidikan
Pemerintah Indonesia berencana meningkatkan anggaran belanja untuk sektor pendidikan dan kesehatan pada tahun depan. Anggaran pendidikan akan naik 10% menjadi Rp500 triliun, sedangkan kesehatan naik 15% menjadi Rp120 triliun. Kenaikan anggaran ini dimaksudkan untuk meningkatkan kualitas dan akses layanan dasar bagi masyarakat.
Evaluation of POSSUM scoring system in patients with perforation peritonitis ...Kundan Singh
Background: Continuous audit of clinical practice is an essential part of making improvements in medicine and
enhancing patient care. Recently, physiological and operative severity score for the enumeration of mortality and
morbidity (POSSUM) scores has been developed, which would help to identify those patients who are at increased
risk of developing complications and deaths. This scoring system is based on 12 physiological characteristics of
patient and 6 characteristics of the surgery performed.
Methods: This study was done in Department of surgery at Patna medical college, Patna, Bihar, India from April
2014 to October 2015 on 100 patients. Physiological variables were collected prior to induction of anesthesia and
operative variable collected during operation chi-square test was used for expected and actual mortality differences.
Results: In present study 100 patients of peritonitis due to different cause of intestinal perforation were studied.
Comparison of observed and POSSUM predicted mortality and morbidity rates were done. Observed to expect
mortality and morbidity ratio was 1.005 and 1.001 respectively and there was no statistically significant difference
between the predicted and observed values.
Conclusions: This study confirms and validates the findings of previous work that POSSUM is an accurate and
reliable tool for estimating in-hospital mortality.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
IMPROVING PERFORMANCE OF ALGORITHMS TO POWER UNMET NEED AND EFFECTIVENESS IN ...Schiffon Wong
The presentation discussed developing and validating algorithms to identify health outcomes using electronic health records and claims data. It provided an example of developing an algorithm to identify multiple sclerosis subtypes using both EHR clinical notes and claims data. Validation of the algorithms calculated positive predictive values by manually reviewing a sample of patient records classified as certain, likely, possible, or no matches. The presentation emphasized that algorithm validation is important to determine accuracy and support interpretation of results from algorithm-identified health outcomes. Audience participation was invited to discuss experiences with algorithm development, validation methods, and lessons learned.
This document summarizes a research project examining barriers to diagnosing and referring patients with suspected rheumatoid arthritis (RA) among primary care physicians (PCPs) in Port Said, Egypt. The study found that most PCPs prefer to order additional tests before referring patients to rule out RA, rather than referring based on clinical symptoms alone. This can delay proper diagnosis and treatment. The study also found limited access to rheumatology clinics for referrals. It concludes with recommendations to establish clear diagnostic guidelines, increase access to early arthritis clinics, and educate PCPs on the importance of clinical assessment over diagnostic tests for suspected RA cases.
This document summarizes three studies on imaging techniques for renal calculi:
1) A study on a new MRI contrast agent found it was successfully synthesized and showed potential as a contrast agent for bladder cancer detection with in vitro experiments.
2) A study found that contemporary CT radiation exposure for renal colic is only marginally higher than historic IVU techniques, with improved time to diagnosis.
3) A study found digital plain X-rays have good sensitivity for detecting calcium-based kidney stones larger than 5mm, especially in the upper urinary tract, but CT or ultrasound may still be needed for smaller or lower tract stones.
This document summarizes three studies related to imaging techniques for renal calculi:
1) A study comparing radiation exposure from CT scans used today to diagnose renal colic versus intravenous urograms (IVU) used in 1990, finding that radiation exposure is only marginally higher with current CT techniques.
2) A study evaluating the ability of digital plain X-rays to detect calcium-based urinary calculi compared to CT scans, finding that X-rays detected over 74% of stones on average and sensitivity was over 83% for stones larger than 5mm.
3) A preliminary study of 9 patients undergoing MRI/ultrasound fusion-guided prostate biopsies which detected prostate cancer in 67% of
Fisiol e anat ponv.PONV anatomy and physiology,risk of Claudio Melloni
This document discusses risk factors for postoperative nausea and vomiting (PONV) from several studies. It identifies non-anesthetic factors like female gender, history of motion sickness or PONV, and anesthetic factors like use of volatile anesthetics, nitrous oxide, and opioids as increasing PONV risk. Surgical factors like longer duration and types of surgery also impact risk. A key study developed a PONV prediction model using logistic regression to calculate individual patient risks based on their characteristics and procedure. Understanding risk factors can help optimize PONV prevention and management.
Ultrasound should be the first-line imaging modality for diagnosing acute appendicitis according to the authors. While ultrasound has excellent specificity, its sensitivity is limited. For cases where ultrasound is non-diagnostic due to non-visualization of the appendix, clinical reassessment and complementary MRI or CT imaging may be used if needed for diagnosis. Using ultrasound as the primary imaging tool can help decrease radiation exposure and healthcare costs while maintaining low rates of negative appendectomies and perforations.
This document discusses treatment options for STEMI patients during the COVID-19 pandemic. It recommends that PCI remains the standard of care for STEMI patients presenting to PCI-capable centers, with some precautions due to COVID-19. For patients initially presenting to non-PCI centers, fibrinolytic therapy may be considered if primary PCI cannot be performed within 120 minutes of diagnosis. However, PCI is preferred over fibrinolysis when possible due to superior outcomes. The document also notes that PCI was feasible and reasonable for treating STEMI patients during the COVID-19 pandemic at hospitals in Malang, Indonesia based on their experience.
Análise dos locais de injeção pós-vacinal utilizando ultrassomAgriPoint
Análise das reações nos locais de injeção pós-vacinais em bovinos de corte utilizando ultrassom mostrou que animais vacinados com Vision 7 (2mL) tiveram menores reações nos dias 7 e 30 em comparação com vacina contra clotridioses com adjuvante alúmen (5mL), tanto na área superficial quanto na profundidade. A vacina Vision 7 proporcionou uma redução significativa no tamanho e profundidade das cicatrizes entre os dias 7 e 30.
El resumen es: Se anuncia una celebración de bodas de plata y promoción 88 el sábado 9 de noviembre a las 21:00 horas en el salón Siriono. La banda Poker amenizará el evento. Se proporcionan números de contacto y correo electrónico para obtener más información.
O documento resume as respostas de participantes do Fórum Social Mundial de 2010 à pergunta "O que os participantes do Fórum Social Mundial 2010 querem das empresas?". Os participantes pediram às empresas que adotem práticas de consumo sustentável, respeitem os direitos humanos e sejam socialmente responsáveis.
This document outlines the tentative program for a blended learning course taking place from August 29-30 and September 3-4, 2013. The two-day course will introduce participants to various digital tools for blended learning. On the first day, participants will learn about the i-Learn platform, data gathering tools like mind maps, and collaboration tools like Google Docs. The second day will cover communication tools like Skype and discussion forums, as well as a session on sharing blended learning methods. The goal is to equip participants with strategies for incorporating digital resources into their teaching practice.
O garoto tinha um temperamento explosivo e seu pai lhe deu uma tábua e pregos para martelar sempre que perdesse a paciência, diminuindo os pregos com o tempo. Quando não perdeu mais a paciência, retirou os pregos, mas a tábua ficou marcada, assim como palavras agressivas deixam marcas.
Slide di Andrea Piccoli, Direzione Tecnica – Cloud Evangelist – SOA Architect, Vecomp Software srl, in occasione del webinar "Gestione documentale e protocollo informatico: da adempimento a opportunità per migliorare trasparenza, efficienza e qualità organizzativa", organizzato da FPA in collaborazione con Microsoft. Il seminario si è svolto lunedì 20 giugno 2016.
O documento apresenta exemplos de substantivos divididos em diferentes categorias. Em três frases, descreve que substantivos nomeiam pessoas, lugares ou coisas e podem ser abstratos, concretos ou coletivos. Além disso, incentiva o leitor a aprender sobre os diferentes tipos de substantivos e dar exemplos de cada um.
Designing A.I. - Week 1 - Intro LectureDavid Young
The document provides an introduction to a course on designing artificial intelligence. It discusses the history and recent successes of AI, including deep learning techniques. It notes challenges like bias in data and the need for more diversity in AI development. The course will focus on current machine learning techniques and how AI could help underserved groups. Students will research AI technologies, propose solutions, and develop new ways for non-experts to understand AI through prototypes and reflection.
Este documento descreve uma dissertação de mestrado sobre o estudo do comportamento reológico de adesivos hot melt PSA e sua relação com a composição e propriedades adesivas. O trabalho analisou a influência de três parâmetros de formulação de HMPSA nas propriedades reológicas e mecânicas. Os resultados mostraram que os parâmetros afetam significativamente as propriedades mecânicas e estas podem ser correlacionadas às propriedades reológicas.
Rpp revisi 2016 sosiologi x rpp diva pendidikanDiva Pendidikan
Pemerintah Indonesia berencana meningkatkan anggaran belanja untuk sektor pendidikan dan kesehatan pada tahun depan. Anggaran pendidikan akan naik 10% menjadi Rp500 triliun, sedangkan kesehatan naik 15% menjadi Rp120 triliun. Kenaikan anggaran ini dimaksudkan untuk meningkatkan kualitas dan akses layanan dasar bagi masyarakat.
Evaluation of POSSUM scoring system in patients with perforation peritonitis ...Kundan Singh
Background: Continuous audit of clinical practice is an essential part of making improvements in medicine and
enhancing patient care. Recently, physiological and operative severity score for the enumeration of mortality and
morbidity (POSSUM) scores has been developed, which would help to identify those patients who are at increased
risk of developing complications and deaths. This scoring system is based on 12 physiological characteristics of
patient and 6 characteristics of the surgery performed.
Methods: This study was done in Department of surgery at Patna medical college, Patna, Bihar, India from April
2014 to October 2015 on 100 patients. Physiological variables were collected prior to induction of anesthesia and
operative variable collected during operation chi-square test was used for expected and actual mortality differences.
Results: In present study 100 patients of peritonitis due to different cause of intestinal perforation were studied.
Comparison of observed and POSSUM predicted mortality and morbidity rates were done. Observed to expect
mortality and morbidity ratio was 1.005 and 1.001 respectively and there was no statistically significant difference
between the predicted and observed values.
Conclusions: This study confirms and validates the findings of previous work that POSSUM is an accurate and
reliable tool for estimating in-hospital mortality.
Can brain atrophy measurement help us in monitoring MS progression in routine...MS Trust
This presentation by Dana Horáková, Department of Neurology and Centre of Clinical Neuroscience at the Charles University in Prague, looks at why and how we should measure brain atrophy.
It was presented at the MS Trust Annual Conference in November 2014.
IMPROVING PERFORMANCE OF ALGORITHMS TO POWER UNMET NEED AND EFFECTIVENESS IN ...Schiffon Wong
The presentation discussed developing and validating algorithms to identify health outcomes using electronic health records and claims data. It provided an example of developing an algorithm to identify multiple sclerosis subtypes using both EHR clinical notes and claims data. Validation of the algorithms calculated positive predictive values by manually reviewing a sample of patient records classified as certain, likely, possible, or no matches. The presentation emphasized that algorithm validation is important to determine accuracy and support interpretation of results from algorithm-identified health outcomes. Audience participation was invited to discuss experiences with algorithm development, validation methods, and lessons learned.
This document summarizes a research project examining barriers to diagnosing and referring patients with suspected rheumatoid arthritis (RA) among primary care physicians (PCPs) in Port Said, Egypt. The study found that most PCPs prefer to order additional tests before referring patients to rule out RA, rather than referring based on clinical symptoms alone. This can delay proper diagnosis and treatment. The study also found limited access to rheumatology clinics for referrals. It concludes with recommendations to establish clear diagnostic guidelines, increase access to early arthritis clinics, and educate PCPs on the importance of clinical assessment over diagnostic tests for suspected RA cases.
This document summarizes three studies on imaging techniques for renal calculi:
1) A study on a new MRI contrast agent found it was successfully synthesized and showed potential as a contrast agent for bladder cancer detection with in vitro experiments.
2) A study found that contemporary CT radiation exposure for renal colic is only marginally higher than historic IVU techniques, with improved time to diagnosis.
3) A study found digital plain X-rays have good sensitivity for detecting calcium-based kidney stones larger than 5mm, especially in the upper urinary tract, but CT or ultrasound may still be needed for smaller or lower tract stones.
This document summarizes three studies related to imaging techniques for renal calculi:
1) A study comparing radiation exposure from CT scans used today to diagnose renal colic versus intravenous urograms (IVU) used in 1990, finding that radiation exposure is only marginally higher with current CT techniques.
2) A study evaluating the ability of digital plain X-rays to detect calcium-based urinary calculi compared to CT scans, finding that X-rays detected over 74% of stones on average and sensitivity was over 83% for stones larger than 5mm.
3) A preliminary study of 9 patients undergoing MRI/ultrasound fusion-guided prostate biopsies which detected prostate cancer in 67% of
Fisiol e anat ponv.PONV anatomy and physiology,risk of Claudio Melloni
This document discusses risk factors for postoperative nausea and vomiting (PONV) from several studies. It identifies non-anesthetic factors like female gender, history of motion sickness or PONV, and anesthetic factors like use of volatile anesthetics, nitrous oxide, and opioids as increasing PONV risk. Surgical factors like longer duration and types of surgery also impact risk. A key study developed a PONV prediction model using logistic regression to calculate individual patient risks based on their characteristics and procedure. Understanding risk factors can help optimize PONV prevention and management.
Ultrasound should be the first-line imaging modality for diagnosing acute appendicitis according to the authors. While ultrasound has excellent specificity, its sensitivity is limited. For cases where ultrasound is non-diagnostic due to non-visualization of the appendix, clinical reassessment and complementary MRI or CT imaging may be used if needed for diagnosis. Using ultrasound as the primary imaging tool can help decrease radiation exposure and healthcare costs while maintaining low rates of negative appendectomies and perforations.
This document discusses treatment options for STEMI patients during the COVID-19 pandemic. It recommends that PCI remains the standard of care for STEMI patients presenting to PCI-capable centers, with some precautions due to COVID-19. For patients initially presenting to non-PCI centers, fibrinolytic therapy may be considered if primary PCI cannot be performed within 120 minutes of diagnosis. However, PCI is preferred over fibrinolysis when possible due to superior outcomes. The document also notes that PCI was feasible and reasonable for treating STEMI patients during the COVID-19 pandemic at hospitals in Malang, Indonesia based on their experience.
This document discusses head and neck cancer and radiation therapy. It provides background information on head and neck cancers, noting they make up 6-9% of cancers and are more common in males. Risk factors include smoking, alcohol, HPV, and EBV. It then discusses the components of radiation therapy planning and delivery in detail, including patient preparation, positioning, volume definition, portal arrangement, dose and fractionation, plan acceptance, adding chemotherapy, and managing complications. The importance of a multidisciplinary team approach is also emphasized.
This study evaluated the impact of selective decontamination of the digestive tract (SDD) over one year in a mixed intensive care unit (ICU). They found that SDD was associated with:
1) A significant reduction in rates of nosocomial pneumonia, secondary bacteremia, and urinary tract infections.
2) A significant decrease in antibiotic-resistant bacteria infections with no cases of Clostridium difficile infection.
3) An important reduction in antibiotic consumption.
This document summarizes the work of Vasilios Papaioannou in critical care bioinformatics. It discusses challenges in treating critical illness such as early diagnosis and personalized treatment. It presents research using computational models and optical mapping to study the effects of endotoxin on heart function. Results are shown for longitudinal trends in inflammation markers and heart rate variability predicting weaning outcomes. Optical mapping and computational models are used to study mechanical ventilation and predict length of stay. The document promotes developing complex computational models and interdisciplinary teams for advancing critical care research.
This document discusses the role of ultrasound in evaluating diffuse changes in the liver. It provides an overview of how ultrasound can detect and quantify steatosis by identifying a "bright liver" appearance with posterior attenuation. Studies have shown ultrasound has good sensitivity and specificity for detecting moderate or severe steatosis compared to liver biopsy. Ultrasound can also detect advanced liver fibrosis by identifying features like an irregular liver surface, signs of portal hypertension, and splenomegaly. Liver stiffness measurements using elastography techniques like transient elastography or shear wave elastography provide a quantitative assessment of fibrosis. However, ultrasound cannot differentiate non-alcoholic steatohepatitis from non-progressive non-alcoholic fatty liver
Sophie Taieb : Breast MRI in neoadjuvant chemotherapy : A predictive respons...breastcancerupdatecongress
This document discusses the use of breast MRI in evaluating response to neoadjuvant chemotherapy. MRI can provide both morphological and functional information about tumors. Studies show DCE-MRI and DWI-MRI may help assess response after 1-2 cycles of chemotherapy, with changes in tumor size, kinetic parameters and ADC values predicting pathological complete or near-complete response. Larger prospective trials are still needed to standardize MRI methods and thresholds to determine if changes on MRI could guide modifications to chemotherapy regimens for non-responders. Overall, MRI shows potential as a predictive marker and non-invasive method for monitoring early response to neoadjuvant breast cancer treatment.
1) Neoadjuvant chemotherapy and preoperative chemoradiation can help increase the rate of R0 resection for gastric cancer by downstaging the tumor.
2) Multimodal preoperative treatment with delayed surgery between completion of therapy and surgery increases the probability of tumor downstaging but does not increase surgical morbidity or mortality when performed by experienced surgeons.
3) Preoperative chemoradiation has shown pathologic complete response rates of over 25% in clinical trials for gastric cancer.
These slides are from versions of a talk I gave at ESTRO in 2014 and again in Lille in 2015.
The talk aims to explain the importance of correctly defining the CTV with respect to nodes in curative radiotherapy planning.
The lecture makes some important points about the function of lymph glands and their potential to act as stem cell 'rests' for malignant cells: this fact might explain whilst lymph node failure rates don't necessarily equate to disease failure rates.
The lecture then goes on to emphasise the utility of the best imaging technologies may more accurately identify involved nodes.
Shrinking fields with confidence may be the best way to reduce radiation toxicity.
Evidence Based Approach to Pulmonary ThromboembolismKristopher Maday
This document summarizes key points regarding the evaluation and management of pulmonary thromboembolism (PTE). It discusses several clinical decision tools used to determine pre-test probability of PTE such as the Wells criteria and PERC rule. Diagnostic modalities like CT, VQ scan, and biomarkers are compared. The document reviews characteristics of low, intermediate, and high-risk PTE and treatments including anticoagulation, thrombolysis, and embolectomy. Recent studies on the use of thrombolysis for intermediate-risk PTE are also summarized.
1) The document discusses the principles and evidence for early management of spinal cord injuries, including early surgery within 24 hours, maintaining mean arterial blood pressure between 85-90 mmHg, and the use of methylprednisolone.
2) Ongoing clinical trials are exploring optimal perfusion pressure targets as well as neuroprotective agents like riluzole.
3) Specialized spinal cord injury units allow for up-to-date management and access to clinical trials exploring new treatments.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdfrightmanforbloodline
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
Test bank for karp s cell and molecular biology 9th edition by gerald karp.pdf
- Video recording of this lecture in English language: https://youtu.be/Pt1nA32sdHQ
- Video recording of this lecture in Arabic language: https://youtu.be/uFdc9F0rlP0
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Osteoporosis - Definition , Evaluation and Management .pdfJim Jacob Roy
Osteoporosis is an increasing cause of morbidity among the elderly.
In this document , a brief outline of osteoporosis is given , including the risk factors of osteoporosis fractures , the indications for testing bone mineral density and the management of osteoporosis
Summer is a time for fun in the sun, but the heat and humidity can also wreak havoc on your skin. From itchy rashes to unwanted pigmentation, several skin conditions become more prevalent during these warmer months.
The skin is the largest organ and its health plays a vital role among the other sense organs. The skin concerns like acne breakout, psoriasis, or anything similar along the lines, finding a qualified and experienced dermatologist becomes paramount.
Breast cancer: Post menopausal endocrine therapyDr. Sumit KUMAR
Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
1. TUI LATAM IV
TARGETED ULTRASOUND INITIATIVE (TUI)
A Targeted Ultrasound Approach in Practice
Date: Saturday 08th - Sunday 09th October, 2016
Time: 09.00 – 17.15 (Saturday); 08.30 – 13.30 (Sunday)
Where: Renaissance São Paulo Hotel, São Paulo, Brazil
3. Meeting objectives: Saturday
• To introduce final RA ultrasound algorithms for
using US in diagnosis, monitoring and remission
assessment
• To discuss implementing RA ultrasound algorithms
in clinical practice at national level
• To discuss and update on US training and
educational national initiatives during a TUI poster
session
• To discuss challenging cases in a `hands-on’ US
patient session
www.targetedultrasound.net
4. Meeting objectives: Sunday
• To discuss challenging cases in an interactive
session
• To review key clinical and ultrasonographic
challenges in PsA
• To introduce the TUI PsA programme
• To consider how US is used to assess PsA in clinical
practice
www.targetedultrasound.net
5. Anticipated meeting outcomes
• RA
• Support for using the RA ultrasound algorithms in clinical practice
• Support for assessing the impact of the RA ultrasound algorithms on clinical
decision-making
• PsA
• Suggestions for developing tools and resources to support using US evaluation in
PsA
www.targetedultrasound.net
6. Agenda: Saturday
www.targetedultrasound.net
09.30 – 10.15 When to use US in the RA patient pathway
Paul Emery
10.15 – 11.15 Ambassador feedback and RA ultrasound algorithms – discussion
Chaired by Maria Antonietta D’Agostino
11.15 – 11.45 COFFEE BREAK
11.45 – 13.00 Poster session
Introduced by Annamaria Iagnocco
13.00 – 14.00 LUNCH
14.00 – 16.00 Hands-on session
Introduced by Esperanza Naredo
16.00 – 17.15 Discussion feedback and next steps
Paul Emery
7. Agenda: Sunday
www.targetedultrasound.net
08.00 – 08.30 REGISTRATION
08.30 – 10.00 Challenging cases
Chaired by Peter Balint and Esperanza Naredo
10.00 – 10.15 COFFEE BREAK
10.15 – 10.30 Introduction to TUI PsA programme
Maria Antonietta D’Agostino
10.30 – 10.50 PsA: What are our greatest clinical challenges?
Paul Emery
10.50 – 11.10 PsA: What are our greatest ultrasonographic challenges?
Annamaria Iagnocco
11.10 – 12.00 PsA elementary lesions and interactive session
Chaired by Richard Wakefield and Maria Antonietta D’Agostino
12.00 – 12.30 TUI 2017 programme
Paul Emery
8. Acknowledgements
• Special thanks to Ieda Laurindo and Karina Bonfiglioli for
enabling the hands-on session with the participation of
their patients
• Thank you to AbbVie for continuing sponsorship
• Fabiola Spila, Maysa Arruda, Paulo Freitas (Abbvie Brasil)
• Abed Haddad, Nicolas Pokorny Anna Droggiti (Abbvie Global)
• Thank you to GE for supporting the hands-on session
• Paulo Pontes Araujo, Kallil Chebaro
• Thank you for completing the PsA survey
www.targetedultrasound.net
9. WHEN TO USE US IN THE RA PATIENT PATHWAY
Paul Emery
www.targetedultrasound.net
Paul Emery has received an honorarium from AbbVie to support his participation in the TUI LATAM meeting
10. 5.7
• Absence of specific guidance on how to
use ultrasound (US) to diagnose and
manage patients with inflammatory
arthritis hindered the optimal utilization
of US in clinical practice
• Produced five novel algorithms which
identify when US could be used to aid
diagnosis, inform assessment of
treatment response/disease and
evaluate stable disease state or
remission in patients with suspected or
established RA
• Pragmatic templates for using US at
certain time points of RA management
www.targetedultrasound.net
RA ultrasound algorithms
D'Agostino MA, Terslev L, Wakefield R, Østergaard M, Balint P, Naredo E,
Iagnocco A, Backhaus M, Grassi W, Emery P. Ann Rheum Dis. 2016 Aug 23. pii:
annrheumdis-2016-209646. doi: 10.1136/annrheumdis-2016-209646. [Epub
ahead of print] Review correspondence to PE
11. RA ultrasound algorithm 1 - diagnosis
Flow chart showing the ultrasound (US) evaluation in patients at risk of rheumatoid arthritis (RA). Purple rectangle denotes population of interest
(starting point); blue-green rectangles denote possible; Paths of the algorithm and red rectangle denotes final diagnosis. ACPA, anti-citrullinated
peptide antibody; ACR, American College of Rheumatology; EULAR European League against Rheumatism; RF, rheumatoid factor
12. Algorithm 1: a) clinical synovitis seronegative
5.7
• 45-year-old male
• 2/12 month history of progressive pain in wrists, MCPJ
and PIPJ
• EMS – 60 mins
• Partial response to NSAID
• O/E:
• Tenderness of wrists, MCPJ/ PIPJ 2 + 3 bilaterally
• Swelling of right 2nd MCPJ
• Normal inflammatory markers
• Anti-CCP and RF negative
14. Early IA: Predictors in CCP/RF -ve patients
• Aim: To determine best predictors of persistence of hand IA – 12 months
• Method: 50 patients, <12 weeks, suspected IA, (EMS >60 mins), no DMARD
or steroid
– US scan: bilateral MCPJ, wrists: 12 J
• Results:
– All RF and CCP Ab patients developed RA (i.e. no added value for US)
– In CCP/RF negative patients
• Best predictors: PD ≥2, GS 3, US detected erosions
• Conclusions:
– Pre-test probability in seronegative group – 6%
– Post-test with one swollen and 1 CR erosion – 30%
– Post-test with PD ≥2, GS 3 and US erosion – 94%
Freeston JE, et al. Ann Rheum Dis 2010;69:417–419
CCP, cyclic citrullinated peptide; CR, conventional radiography; DMARD, disease-modifying anti-rheumatic drug; EMS, early morning stiffness; IA, idiopathic arthritis;
MCPJ; metacarpophalangeal joint; RF, rheumatoid factor
15. Algorithm 1: a) clinical synovitis seronegative US findings
• MCP 2,3 PD2 +GS 3
• Erosion MCP 2
• = very high chance of persistence: start MTX
• If US negative: likely self-limiting, give IM steroid
5.7
17. RA ultrasound algorithm 1 - diagnosis
Flow chart showing the ultrasound (US) evaluation in patients at risk of rheumatoid arthritis (RA). Purple rectangle denotes population of interest
(starting point); blue-green rectangles denote possible; Paths of the algorithm and red rectangle denotes final diagnosis. ACPA, anti-citrullinated
peptide antibody; ACR, American College of Rheumatology; EULAR European Leave against Rheumatism; RF, rheumatoid factor
18. Algorithm 1: b) at risk: arthralgia Ab +ve, NO clinical synovitis
5.7
• 38-year-old female
• 6/12 month history of progressive pain in wrists
• EMS - 10 mins; pain > stiffness
O/E:
• Hypermobile
• Puffiness bilateral UCJ; non tender
• CRP < 5, ESR 10mm/hr
• CCP Ab – 3.6 U/ml (N < 2.99)
• X-rays of hands and feet - normal
19. ACPA+ve selection model for primary care
• Tenderness of small joints present
• EMS ≥ 30 minutes
• High level RF and/or anti-CCP
Clinical
Rakieh C, Nam J, Hunt L; Emery Predicting the development of clinical arthritis in anti-CCP positive individuals with non-specific musculoskeletal
symptoms: a prospective observational cohort study. ARD 2014
• 1
• 1
• 2
20. Model: secondary care
• Tenderness of small joints present
• EMS ≥ 30 minutes
• High level RF and/or anti-CCP
• Power Doppler present
• Shared epitope present
Clinical+Imaging+SE
•1
•1
•1
•1
•1
21. Aim:
To determine whether ultrasound can identify which anti-CCP antibody
positive patients with MSK symptoms and without clinical synovitis (CS)
progress to inflammatory arthritis (IA).
22. Predictive value of US in ACPA + patients with no clinical
synovitis
Nam J …….Emery P Ann Rheum Dis 2016
• 167 individuals >3000 joints scanned, 33% with PD signal
Progression to clinical synovitis
• PD = 0 5%
• PD = 1 16%
• PD = 2 55%
Risk of clinical swelling in a joint with PD signal >2
• 55% vs 4% Hazard Ratio= 31 (CI 16 to 63), p<0.001
Progression occurred earlier with PD ≥2
• median 7 vs 52 months
23. Algorithm 1: b) at risk: arthralgia Ab +ve, NO clinical synovitis
• Grade 2 Grey scale and Grade 2 PD in both ulnar carpal joints
• Mild erosive change of the ulna styloids bilaterally
Conclusion: grade 2 PD and erosions –changes risk from
low to moderate of progression to clinical arthritis
24. Algorithm 1: c) at risk: arthralgia Ab +ve, NO clinical synovitis
5.7
• 64-year-old female
• 4 months ago, left shoulder pain; impingement
symptoms → injected
• Now c/o aching of wrists and stiffness in fingers
• CCP Ab 300U/ml
• Clinical examination of hands tender
25. Model: secondary care
• Tenderness of small joints present
• EMS ≥ 30 minutes
• High level RF and/or anti-CCP
• Power Doppler present
• Shared epitope present
Clinical+Imaging+SE
•1
•1
•1
•1
•1
26. Algorithm 1: c) at risk: arthralgia Ab +ve, NO clinical synovitis
• PD >1 in 2 MCPs
• SE +ve
• Changed risk of progression to clinical synovitis
from moderate to high
27. Algorithm 1: d) at risk: Ab +ve, clinical synovitis
• 45-year-old female, c/o inflammatory hand pain for 8 weeks
• EMS – 45 mins
• 50% response to NSAIDs which she continues to take:
• Mild swelling in Right 2 MCPJ
• Investigations:
• Serology: RF+ and ACPA –ve, CRP 12 mg/dl
• X-rays hand and feet - normal
• Insufficient to make diagnosis of RA
• When clinical synovitis present can use imaging to define number of
affected joints
28. US findings
• Total synovitis scores
GS = 9
PD = 5
Combined = 9
• Ultrasound Report
• Synovitis scores
R 2 MCPJ GS 3, PD 3
R 2 PIPJ GS 1, PD 0
R 3 PIPJ GS 1, PD 0
L 2 MCPJ GS 2, PD 2
L 2 PIPJ GS 1, PD 0
L 3 PIPJ GS 1, PD 0
One erosion R 2 MCP
Mild OA – PIPJ
No evidence of crystal disease
6 joints
Score 6 = RA, Rx MTX)
29. RA ultrasound algorithm 2 - diagnosis
Flow chart showing the ultrasound (US) evaluation in patients who fulfil American College of Rheumatology (ACR)/European League
Against Rheumatism (EULAR) criteria. Purple rectangle denotes population of Interest (or starting point); blue-green rectangles denote
possible paths of the algorithm and red rectangle denotes final diagnosis.
30. • 54-year-old female
• 3-month history of pain in wrists, hands, knees and ankles
O/E
• EMS = 120 mins
• Swollen 4 MCPJ and 4 PIPJ, both knees and 2 MTPJ
• CRP – 40 mg/dl
• X-rays – no erosions
Algorithm 2: a) patients who fulfil EULAR/ACR criteria
31. Algorithm 2: patients who fulfil EULAR/ACR criteria
Grey scale 2-3 and PD≥ 2 synovitis in both wrists, 4 MCPJ and 3
PIPJ and 5 MTPJ
Mild erosive change on lateral aspect of one 5th MTPJ
Conclusion: Polyarticular inflammation with marked PD and
early erosive change = poor prognosis for aggressive therapy
32. • 47-year-old female
• 6-month history of pain in wrists, hands, knees and ankles
• O/E
• EMS = 20 mins
• Swollen 4 MCPJ and 4 PIPJ, CRP<5 mg/dl
• RF positive
• X-rays – no erosions
Algorithm 2: b) patients who fulfil EULAR/ACR criteria
33. • No significant synovitis GS<2 and small effusion of MCP2
• Changes diagnosis –not RA
Algorithm 2: b) patients who fulfil EULAR/ACR criteria
US findings
34. RA ultrasound algorithm 3 – therapeutic response
Flow chart showing the ultrasound (US) evaluation of therapeutic response in patients with rheumatoid Arthritis (RA) starting
csDMARDs or bDMARDs. Purple rectangle denotes population of interest (or) starting point); red text denotes csDMARDs; blue text
denotes bDMARDs; blue-green rectangles denote possible paths of the algorithm; red rectangle denotes proposed path for
csDMARDs population and blue rectangle denotes proposed path for bDMARDs.
35. Algorithm 3: initial assessment: csDMARD good response
US no PD
• Continue therapy
US significant PD
• What was baseline synovitis?
• If improved, continue therapy?
• If no change, escalate therapy
• With bDMARD continue therapy, as will not erode?
36. Algorithm 3: initial assessment : csDMARD poor response
US no significant PD
• What was baseline synovitis?
• If improved continue therapy
• If no change think of pain therapy
US significant PD
• Change/escalate therapy
37. RA ultrasound algorithm 4 – loss of response
Flow chart showing the ultrasound evaluation in patients with rheumatoid arthritis with loss of treatment Response (both
conventional synthetic or biological disease-modifying anti-rheumatic drugs). Purple Rectangle denotes population of
interest (or starting point) and blue-green rectangle denote possible paths of the algorithm.
38. Algorithm 4: loss of response
US significant PD
• Change/escalate therapy
US no significant PD
• What was baseline synovitis?
• If improved continue therapy but improve pain relief
• If no change think of pain therapy
39. RA ultrasound algorithm 5 – low disease
activity/remission
Flow chart showing the ultrasound evaluation in assessing remission or low disease activity in patients with
rheumatoid arthritis. Purple rectangle denotes population of interest (or starting point) and blue-green
rectangle denote possible paths of the algorithm.
40. Algorithm 5 – low disease activity/remission
• 56-year-old woman seropositive RA for 7 years
• In remission with MTX and TNF alpha blocker (DAS28< 2.1) for 12
months
• No tender joints but 1 swollen wrist with limited ROM
• No morning stiffness, CRP< 5 mg/l
• Tapering biological treatment
• Would you taper biological treatment?
• Would US aid decision?
41. Remission post TNFi discontinuation
Relapse-free period predicted only by US
Time after discontinuation of biologics (months)
DAS28 GS score PD score
Iwamoto T, Ikeda K, et al. Arthritis Care Res 2014
42. CHALLENGING CASES
Chaired by Esperanza Naredo and Peter Balint
www.targetedultrasound.net
Esperanza Naredo and Peter Balint have received honoraria from AbbVie to support their participation in the TUI LATAM meeting
43. CHALLENGING CASES – CASE 1
Presented by Oscar Sedano
ECOSERMEDIC, Lima, Peru
www.targetedultrasound.net
44. www.targetedultrasound.net
Case 1: clinical history
• 45-year-old male diagnosed with
psoriasis of 15 years evolution
• Referred for arthralgia in knees, ankles
and feet
• Clinical examination: no synovitis,
enthesis, painful knees and heels
- nail lesions in 3rd/4th finger of the hands
• ultrasound - 5 enthesis and nails
Images courtesy of Oscar Sedano
46. www.targetedultrasound.net
Case 1: ultrasound nails GS & PD
healthy control
EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice. Ann Rheum Dis 2015;74:1327
PsA
Images courtesy of Oscar Sedano
52. www.targetedultrasound.net
Case 1: conclusions
• Nail involvement is present and predicts PsA
• US is useful for diagnosis, monitoring, evaluating
microvasculare involvement, enthesitis and
differential diagnosis
• Ultrasound PsA should
include nail studio in
clinical practice
53. CHALLENGING CASES – CASE 2
www.targetedultrasound.net
Presented by Karina Bonfiglioli
University of São Paulo - FMUSP
54. www.targetedultrasound.net
Case 2: clinical picture and history
• MCN, 66 years, female, caucasian
• RA since 2006, RF- /anti-CCP-
• Multiple changes in therapy due to toxicity
• Good response to anti-TNF in monotherapy
• etanercept since 2014
• Co-morbidities: hypertension
55. www.targetedultrasound.net
Case 2: history
• Feb 2016: frequent flares
• arthritis in both knees, ankles and feet
• Using intramuscular bethmethasone (self-medication),
after feeling better for about 1 month, new flare
• US for evaluation of RA activity and probably drug switch
58. www.targetedultrasound.net
Case 2: follow up
• Seric uric acid: 9.7
• Treatment with alopurinol and colchicine (peptic ulcer,
contraindication for NSAIDs)
• Patient had no new episodes of arthritis and remains in
clinical remission (DAS 2.3)
59. www.targetedultrasound.net
Case 2: discussion points
• Long-standing RA, presenting flares during anti-TNF
monotherapy: first impression was secondary failure,
leading to a switch in biological therapy
• US presented an unexpected diagnosis, that entirely
changed the clinical approach
60. CHALLENGING CASES - CASE 3
www.targetedultrasound.net
Presented by José Alexandre Mendonça
Pontifical Catholic University of Campinas
61. www.targetedultrasound.net
Case 3: introduction
• The association of ocular disorders and psoriatic
arthritis was first reported in 1976 by Lambert and
Wright in a study of 112 patients
• Ocular inflammation was noted in 35 (31.2%) patients
Lambert JR, Wright V. Eye inflammation in psoriatic arthritis. Ann Rheum Dis. 1976; 35: 354–356; Paiva ES, Macaluso DC, Edwards A, Rosenbaum JT.
Characterisation of uveitis in patients with psoriatic arthritis. Ann Rheum Dis. 2000; 59 (1):67-70
62. www.targetedultrasound.net
Case 3: introduction - vitritis images
Mendonça J.A. Ultrasound Color histogram assessment allows better view of echotexture damage. Brazilian Journal Rheumatology 2014
http://dx.doi.org/10.1016/j.rbr.2014.12.016
• Ultrasound colour histogram
assessment allows better view of
echotexture damage
Images courtesy of J.A. Mendonça
63. www.targetedultrasound.net
Case 3: introduction - vitritis images
Image courtesy of J.A. Mendonça
Mendonça J.A. Ultrasound Color histogram assessment allows better view of echotexture damage.
Brazilian Journal Rheumatology 2014 http://dx.doi.org/10.1016/j.rbr.2014.12.016
65. www.targetedultrasound.net
Case 3: clinical history
• Patient, 28 years, male, soccer player
• Previously diagnosed with psoriasis
• Referred to the rheumatology service due to arthralgia
(inflammatory characteristics) in his right knee and ankle
• Diagnosis of psoriatic arthritis
• Ophthalmological examination without changes
• Referred to ultrasound for assessment of joint and eye
68. www.targetedultrasound.net
Case 3: right knee ultrasound examination detected
enthesitis with intense Doppler signal at the
proximal insertion of the patellar tendon
Image courtesy of J.A. Mendonça
71. CHALLENGING CASES – CASE 4
www.targetedultrasound.net
Presented by Karina Bonfiglioli
University of São Paulo - FMUSP
72. www.targetedultrasound.net
Case 4: introduction to Chikungunya fever
• Chikungunya fever (CF): arboviruses 1
• Polyartralgia is the main clinical feature
• Can become chronic (>3 months)
• 10 to 60% up to 3 - 5 years 2
• South America: Epidemic since 2013
• Brazil, 2016: 137,808 cases until June 3
1. Emilie Javelle, Anne Ribera, Isabelle Degasneet et al. Specific Management of Post-Chikungunya Rhematic Disorders: A
Retrospective Study of 159 Cases in Reunion Island from 2206-2012. PLOS Neglected Tropical Diseases; 2. Pineda C, Muñoz-Louis
R, Caballero-Uribe CV, Viasus D. Chikungunya in the Region of the Americas. A challenge for Rheumatologists and Health Care
Systems. Colin Rheumatol 2016 aura 24; 3. Boletim epidemiológico 2016;47(20)
73. www.targetedultrasound.net
Case 4: history
• MS, female, 45 years old, resident in north east of
Brazil (Bahia)
• No previous rheumatic conditions
• Presented with fever (38˚C) and acute, disabling
polyarthralgia in March 2016
• After acute illness, polyarthralgia persisted
• US evaluation in July/2016 (four months)
77. CHALLENGING CASES - CASES 5, 6, 7
www.targetedultrasound.net
Presented by Esperanza Naredo
Esperanza Naredo has received an honorarium from AbbVie to support her participation in the TUI LATAM meeting
78. www.targetedultrasound.net
Case 5: history
• 45-year-old, previously healthy male
• Pain and swelling at the medial
aspect of the left elbow
• Cut in finger 3 days ago
Image courtesy of Esperanza Naredo
79. www.targetedultrasound.net
Case 5: US findings
• US: medial aspect of the elbow, sonographic palpation +
US diagnosis?
Images courtesy of Esperanza Naredo
80. www.targetedultrasound.net
Case 5: US findings
• US: medial aspect of the elbow, sonographic palpation +
US diagnosis? reactive lymphadenopathy
Images courtesy of Esperanza Naredo
82. www.targetedultrasound.net
Case 6: US findings
• US left shoulder, SE tendon trans/long and
bicipital groove trans
US diagnosis? US-guided aspiration:
haemorrhagic fluid Images courtesy of Esperanza Naredo
83. www.targetedultrasound.net
Case 6: US findings
• US left shouder, SE tendon long and bicipital
groove trans
Diagnosis? Bronchogenic carcinoma with
bone metastasis
Images courtesy of Esperanza Naredo
84. www.targetedultrasound.net
Case 7: history
• 76-year-old female with hand OA
• Severe inflammatory pain in both shoulders with marked
functional limitation over the previous 2 weeks
• Increased ESR (50 mm/1st h) and CRP (2.0,normal 0-0.5
mg/dL)
• Normal blood count and biochemistry
• Negative RF and ACPA
88. www.targetedultrasound.net
Case 7: US-guided aspiration of SASD bursa
synovial fluid
• 40,000 white blood
cells/mm3
• Negative culture
• Microscopic
identification of CPPD
crystals
Images courtesy of Esperanza Naredo
90. INTRODUCTION TO THE TUI PSORIATIC ARTHRITIS PROGRAMME
Maria Antonietta D’Agostino
www.targetedultrasound.net
Maria Antonietta D’Agostino has received an honorarium from AbbVie to support her participation in the TUI LATAM meeting
91. TUI is a pragmatic educational programme
• TUI concept = US should be a standard outcome measure in RA
www.targetedultrasound.net
Wakefield et al. ARD 2012 71(6):799-803
D’Agostino et al. Ann Rheum Dis 2016
DRIVING CHANGE TARGETING
UNMET NEED
AUDIT TO SHOW
BENEFIT
92. TUI achievements so far
www.targetedultrasound.net
• Engagement in national activities
Global Network of National TUI Ambassadors
• Practical Support via website training resources and clinical
practice tools www.targetedultasound.net
Global Education and Resource Platform:
Tools for Clinical Practice, Training Materials
• TUI Concept Paper, TUI Statements, RA
Ultrasound Algorithms
Promoted Understanding of MSUS Role and
Application in Clinical Practice
93. Setting the scene
www.targetedultrasound.net
Considerable
logic and big
demand for
ultrasound
TUI
A pragmatic,
educational approach
to promote US as a
standard outcome in
RA
Several achievements so far:
- Educational programmes
- Statements
- Network of ambassadors
- Algorithms
Need for:
• Implementing this
approach to other
inflammatory
diseases:
• Psoriatic Arthritis
• SpA
94. Why TUI PsA?
www.targetedultrasound.net
Better classification of
the disease
Introduction of effective
therapies
Increase in demand for
efficient tools in PsA
Increased research
effort within imaging
Better dissemination
of US and better
applicability
PsA
95. PsA has a heterogeneous clinical appearance
• And, accordingly, imaging findings can vary
www.targetedultrasound.net
spinal
Manifestations
peripheral
articular
manifestations
peripheral
enthesitis
manifestations
dactylitis
cutaneous
manifestations
SKIN
NAILS
McInnes I.B. Clin Exp Rehumatol 2016;34(Suppl.98):S9-S11
96. PsA which lesions to target?
www.targetedultrasound.net
PsA: why US?
• Joint?
• Enthesis?
• Dactylitis?
• Extra-articular sites?
Images courtesy of Maria Antonietta D’Agostino
97. US spectrum in PsA
Are all adapted for the purpose?
What is the goal of TUI in PsA?
Images courtesy of Maria Antonietta D’Agostino
98. Current status of US in PsA
• US can detect inflammatory and structural lesions
• Skin, enthesis and peritenon seem specific features
• Potential for improvement of PsA management
www.targetedultrasound.net
Kaeley GS Curr Rheumatol Rep 2011 Aug;13(4):338-45, Gutierrez M, et al. Clin Rheumatol 2015 Aug 23 [Epub ahead of print], Coates L et al, Best Pract Res Clin
Rheumatol 2012 Dec;26(6):805-22, Grassi W and Gutierrez M J Rheumatol Suppl 2012 Jul;89:39-43
99. Proposed role of US in PsA management
www.targetedultrasound.net
Making/confirming
a diagnosis
evaluating
disease activity
VERIFYING
RESPONSE/ADJUSTING
THERAPY
CONFIRMING REMISSION
+
REMISSION
Predicting
successful medication
de-escalation
+
100. Initial promising data: US for making
a diagnosis/confirming PsA
www.targetedultrasound.net
• Patient with
psoriasis
• PsA?
2) symptomatic
patients
3) early arthritis
1) at risk patients (?)
• Patients with
arthralgia
101. Initial promising data: US for monitoring PsA
www.targetedultrasound.net
2) Verifying
response
3) Confirming
remission and successful
medication de-escalation
and progression
1) Evaluating
disease activity
102. Open questions
www.targetedultrasound.net
• Which lesions should we target by US?
• Should we use a composite scoring system ?
• Should we propose a standardized approach? mannequin?
• Time points of evaluation (minimal time point)
• Define minimal level of activity/normality
• Threshold in remission
• Threshold of sub-clinical activity
• Educational needs
103. TUI PsA Programme
• To extend the principles of the TUI RA programme to a
TUI PsA programme
• TUI PsA vision: to use US to improve the outcome of
patients with PsA through better defining treatment
response and disease state
www.targetedultrasound.net
104. TUI PsA programme objectives
• Share the ultrasonographic
challenges in PsA
• Discuss which lesions are targeted
with US in clinical practice
www.targetedultrasound.net
• Based on ambassador feedback from 2016 TUI
Programme and PsA survey, work on achieving
consensus for a standardized US approach:
• Which lesions to target?
• How to detect them?
• How many target lesions?
• PsA Patient Pathways for diagnosis, disease and
treatment monitoring, remission evaluation
• Stimulate and develop educational activities around PsA
Today’s focus 2017 onwards focus
105. TUI is a pragmatic educational programme
TUI Concept: promoting ultrasound as a standard outcome in inflammatory
arthritis
TUI PsA: developing tools and resources to aid ultrasound assessment
targeting
unmet need
target lesions patient
pathways
audit to show
benefit
TUI PsA: developing tools and resources to aid ultrasound assessment
106. TUI PsA: WHAT ARE OUR GREATEST CLINICAL CHALLENGES?
Paul Emery
www.targetedultrasound.net
Paul Emery has received an honorarium from AbbVie to support his participation in the TUI LATAM meeting
108. Clinical remission concept key questions
• How appropriate are the various remission definitions for the
different disease phenotypes (e.g. peripheral and axial disease,
enthesitis and dactylitis)?
• Pros/cons of the different definitions of clinical remission in
psoriatic arthritis (PsA) What is the most appropriate definition
of clinical remission from (a) the physician’s and (b) the
patient’s perspective?
• Responsiveness of remission criteria according to different
disease phenotypes and stages of disease
www.targetedultrasound.net
109. 1. Individualised to the patient
• Perfect for every patient
• Takes into account their:
• Disease manifestations
• Past disease history
• Past treatment
• Personal opinions
• Isn’t this normal care?
• What measure can you
use?
• Does disease get missed?
www.targetedultrasound.net
110. 2. DAPSA: PsA specific but only joints
• Quick
• Feasible
• Easy to calculate
• Accounts for most of
disease for most people
• Continuous score,
response measure and cut
offs for disease states
• Sensitive to change
• What about
• Skin and nail psoriasis
• Enthesitis
• Dactylitis
• Axial disease
• Skin excluded due to PsA
cohort
• Cut offs based only on
physician opinon
• Current measure needs
CRP (delay)
www.targetedultrasound.net
TJC + SJC + Pt pain VAS + Pt global VAS + CRP or ESR = DAPSA
Schoels et al, Ann Rheum Dis. 2015 Aug 12. [Epub ahead of print]
111. 3. MDA: PsA specific but global
• Pretty quick and feasible
• Easy to calculate
• Flexible on individual
measures
• Accounts for nearly all
disease for most people
• No bloods required
• Correlates well with Pt opinion
• Used in T2T study
• Modified versions (MDAjts,
MDA-6 and MDA-7)
• Only a measure of disease
state, not continuous
• Requires joints, skin and
enthesis exam
• Could allow active joint
disease
www.targetedultrasound.net
Coates LC, et al. Ann Rheum Dis 2010;69(1):48-53; Coates et al J Rheum 2016;43:371–5
112. 4. PASDAS/CPDAI: PsA specific but global
• Feasible (just)
• Accounts for nearly all disease
for most people
• Measure of disease activity,
response measures and
disease states
• PASDAS developed on real life
treatment decisions
• Disease states based on phys
and pt opinion
• Bit slower
• CPDAI not evidence based
• Requires joints, (skin) and
enthesis exam
• Need SF36 (PASDAS)
• Need online
calculator
(PASDAS)
• Need CRP
(PASDAS)
www.targetedultrasound.net
Phys global, Pt global, SF36-PCS, SJC, TJC, enthesitis, dactylitis, CRP = PASDAS
Peripheral joints, skin, enthesitis, dactylitis, axial disease all 0-3 = CPDAI
Helliwell et al ARD. 2013 Jun;72(6):986-91; Mumtaz et al ARD. 2011 Feb;70(2):272-7
PASDAS Improve >2 1-2 <1
Final score
<2.3
2.3-4.7
>4.7
113. 5. RAPID: Not PsA specific
• Very quick
• All done by patient
• Feasible
• Easy to calculate
• Highly sensitive to change
• No bloods required
• Questions not
specific to PsA and
all MSK not skin
• No specific physician
exam at all
(objectivity)
• Cut offs not validated
yet in PsA
www.targetedultrasound.net
Patient pain VAS + Patient global VAS + Function = RAPID3
Pincus et al Bull NYU Hosp Jt Dis. 2009;67(2):211-25
114. Hierarchy of potential measures
www.targetedultrasound.net
PASDAS
Pt global
Pt pain
Function
Joints and entheses
Dactylitis
Inflammatory marker
Phys global
MDA
Pt global
Pt pain
Function
Joints and entheses
Skin
RAPID3
Pt global
Pt pain
Function
115. PsA remission remaining questions
• Which target should we choose?
• Minimal level of activity/normality?
• Impact of disease duration on the likelihood of achieving
certain targets?
• Which dosing strategy should we apply?
• What is importance of sub-clinical synovitis/enthesitis?
www.targetedultrasound.net
116. 0.87
-0.51 -0.44
-2
-1
0
1
2
n=95 n=116 n=95
All patients
0.28
-1.29 -1.24
-2
-1
0
1
2
n=54 n=57 n=48
MTX at BL
(all patients) 1.64
0.25 0.38
-2
-1
0
1
2
n=41 n=59 n=47
Achieving MDA associated with reduced radiographic
progression at Week 256 in the GO-REVEAL study
116
MeanSHSscore
* *****
Without MTX at BL
(all patients)
***
never achieved MDA achieved MDA ≥3 consecutive visits achieved MDA ≥4 consecutive visits
*p<0.005 vs never achieved MDA; **p<0.01 vs never achieved MDA
***p<0.0001 vs without MTX at baseline
SHS, PsA-modified Sharp–van der Heijde Score Kavanaugh A, et al. ACR 2013;#341
118. Making a diagnosis in Psoriatic DISEASE
• Patient with psoriasis
www.targetedultrasound.net
1) At risk patients (?)
2) Symptomatic
patients
• Patients with pain/ arthralgia
3) Early arthritis • PsA?
119. PsO without MSK symptoms
www.targetedultrasound.net
Naredo et al. Rheumatology 2011 Oct;50(10):1838-48
120. PsO and pain: PsA vs fibromyalgia
www.targetedultrasound.net
Marchesoni A, et al Journal of Rheumatology 2012 Jul;89:29-31
121. PsO +MSK diagnosis: predictors of damage
www.targetedultrasound.net
Miedany Y, et al Clin Rheumatol 2015;34:307-313
122. PsO +MSK diagnosis: Early PsA vs RA
www.targetedultrasound.net
Iagnocco A, et al. Joint Bone Spine 2012;:323-334
• PDUS evaluation of enthesitis in psoriatic arthritis
123. PsO +MSK diagnosis: sub-clinical inflammation
www.targetedultrasound.net
Freeston J, et al. Arthritis Care Research 2014;66:432-9
• 75% of patients with early PsA have sub-clinical disease
• Median no. of joints involved: 3
• wrist, knee and MCPs
124. PsO +MSK monitoring: enthesitis
www.targetedultrasound.net
Naredo E, et al. J Rheumatol 2010 Oct;37(10):2110-7
Doppler ++++
125. PsO +MSK monitoring: PDUS Target
Baseline
www.targetedultrasound.net
Images courtesy of M. Gutierrez8 weeks
126. TUI PsA: WHAT ARE OUR GREATEST ULTRASONOGRAPHIC
CHALLENGES?
Annamaria Iagnocco
www.targetedultrasound.net
Annamaria Iagnocco has received an honorarium from AbbVie to support her participation in the TUI LATAM meeting
129. Enthesis
5.7
• The region where a tendon, ligament, or joint capsule is
attached to the skeleton
www.targetedultrasound.net
Image courtesy of EULAR
4 consecutive areas:
• dense fibrous connective tissue
• uncalcified fibrocartilage
• calcified fibrocartilage
• bone
fibrous enthesis
fibrocartilaginous enthesis
Enthesitis associated with SpA is typically
located at the fibrocartilaginous attachments
EULAR Online MSUS Course
131. Enthesitis is a landmark of SpA
www.targetedultrasound.net
structural changes
at entheses
• enthesophytes
• intratendinous calcification
• fissuring
• cell clustering
• fibrillation
• delamination of fibrocartilage
• necrosis
• cyst formation
• inflammatory cell infiltration
• lining cell hyperplasia
• formation of synovial villi
inflammatory changes
in the synovial
component of the SEC
Benjamin et al AR, 2007
132. Enthesitis is a landmark of SpA
• US may detect more enthesitis than clinical examination
• PD signal at bony attachment is typical of inflammatory enthesitis
tendinitis
enthesitis
bursitis
D’Agostino et al A&R 2002, D’Agostino et al A&R 2003, D’Agostino et al A&R 2009, D’Agostino et al ARD 2011, De Miguel et al A&R
2009, De Miguel et al ARD 2009, De Miguel et al ARD 2011
Image courtesy of Annamaria Iagnocco
www.targetedultrasound.net
133. How to define enthesitis by US? OMERACT US enthesitis
task force
www.targetedultrasound.net
• thickening of tendon insertion into the
bone (<2mm)
• hypoechogenicity of tendon insertion
• Doppler activity (i.e. hypervascularity) of
tendon insertion
• enthesophytes
• calcifications
• erosions
151. OMERACT US elementary lesions of active dactylitis
www.targetedultrasound.net
• superficial oedema – anechoic areas within subcutaneous tissues
• soft tissue thickening
• nail plate bilayer obliteration, nail bed thickening and nail bed
hypervascularity
• tenosynovitis
• profundus enthesitis – abnormalities insertion and vascularity
• collateral ligament thickening, hypervascularity
• synovitis
Bakewell CJ, et al. OMERACT Ultrasound Task Force. J Rheumatol 2013 Dec;40(12):1951-7
157. Nail changes
www.targetedultrasound.net
Loss of nail bilayer and
increased nail bed and extensor
tendon thickness
Normal tri-laminar
appearance
Fibers of extensor tendon
merge with proximal nail matrix
Images courtesy of M.A. D’Agostino and S. Aydin
158. PsA: What are our greatest US challenges?
www.targetedultrasound.net
• Detection and scoring of inflammatory abnormalities
• Assessment of structural damage
• role in early?
• US evaluation: which lesions for which purpose?
• diagnosis
• follow-up
• responsiveness
• disease activity/remission
Editor's Notes
Intraarticular and periarticular synovial inflammation and subsequent structural damage, bone erosions, articular cartilage damage and tendon and ligament damage are the principal pathologic markers of joint disease in inflammatory arthritis.
Delphi
e sublussazione (Figura 2). Caratteristica è la tumefazione a salsiciotto dell’intero dito (dattilite), dovuta all’edema infiammatorio delle parti molli del dito, soprattutto del tendine flessore. Lo