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real time taken for image acquisition as well as profi ciency; both items require a
rather long learning curve. Therefore, specifi c curriculum and training programs
have been designed to ensure standardized joint scanning technique as well as rec-
ognition and usage for normal and pathologic sonographic defi nitions [ 3 – 6 ].
The Concept of Ultrasound-Detected Infl ammatory
and Structural Damage
Morphologic Infl ammatory Damage
In the “window of opportunity” era, MSUS has gained the prestige as an adjuvant
method for the diagnosis and monitoring of rheumatoid arthritis. Pathologically,
MSUS joint imaging has shown that “ morphologic infl ammation ” can be detected
before structural damage occurs and that it is reversible on management. Therefore,
it has been suggested as a predictor of poorer functional outcome in early chronic
infl ammatory arthritic conditions such as rheumatoid arthritis (RA) [ 7 ]. The three
principle European League Against Rheumatism ( EULAR ) MSUS joint recom-
mendations for the clinical management of RA stated that joint ultrasonography
should be considered for accurate evaluation of joint infl ammation, for monitoring
disease activity, as well as subclinical infl ammation assessment [ 8 ]. MSUS depicts
three articular morpho-functional features including joint, tendon sheath, and syno-
vitis: effusion defi ned on grayscale (GS) US as an anechogenic or hypoechogenic
compressible material that denotes the exudative aspect of the synovia; synovial
hypertrophy d e fi ned on grayscale US as hypoechogenic noncompressible material
that represents its proliferative characteristic; and abnormal synovial vasculariza-
tion assessed with power or color Doppler US and defi ned as the presence of
Doppler signal in the synovia that indicates the invasive nature of the synovia [ 5 ].
The presence of Doppler signal is considered an important marker of active infl am-
matory status at joint and patient level, given that it correlates with ongoing joint
destruction and disease activity [ 9 ].
To monitor treatment in rheumatoid arthritis, a precise measure of the disease
activity should be obtained by both clinical and para-clinical parameters. The dis-
ease activity of a joint is correlated with the synovial vascularization [ 9 ]. Therefore
quantitative assessment of synovial vascularization plays an important role in moni-
toring the disease activity status and response to therapy. There are several synovitis
grayscale and Doppler scoring systems for joint synovitis, yet the more widely used
is a semiquantitative system proposed by OMERACT (Outcome Measures in
Rheumatology), which was reported easy to learn, valid, as well as reliable [ 10 ].
The approach features the use of 0–3 scale, in which 0 entails no synovitis, 1 = mild,
2 = moderate, and 3 = severe synovitis [ 4 ]. Synovial Doppler signal is scored as
0 = no signal, 1 = single vessel signal, 2 = confl uent vessels less than 50 % of the joint
area, and 3 = more than 50 % of the joint area. OMERACT score called GLOSS is a
J. Uson and Y. El Miedany