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Background:Tocilizumab (TCZ) is the only biologic drug approved for the treatment of giant cell arteritis (GCA), having clinical trials and real-life studies proved its efficacy and safety. However, optimal duration of the treatment has yet to be determined, being its early interruption associated with an increased risk of relapse. Conversely, prolonged schemes of therapy may rise safety concerns.Objectives:The aim of the study was to evaluate the incidence of adverse events (AEs) and remission/relapse rate in a cohort of GCA patients treated with TCZ and an accelerated steroid tapering scheme, followed for 24 months.Methods:We retrospectively included patients referring to our clinic from January 2019 to November 2021 who were diagnosed with GCA and started subcutaneous TCZ treatment (162 mg/week). They also received up to 62,5 mg prednisone (PDN), tapered following an accelerated six-month scheme (Table 1). All patients underwent influenza and pneumococcal and, upon available in Italy, recombinant zoster vaccination.Results:We collected 38 patients, with a mean age of 76,4 years, treated for an average of 22,3 months. AEs occurred in 12 (32%) subjects, and only one episode of serious event was reported; 7 (18%) patients permanently discontinued TCZ. At the end of follow-up, all the patients continuing treatment showed clinical remission, and only 15% continued to require the administration of GCs (<5 mg PDN equivalent on average). We registered 3 (7,8%) minor relapses under TCZ, after an average of 15 months. No major relapses were reported.Conclusion:Our data, coming from one of the few studies covering an extended period of treatment of almost 2 years with TCZ in GCA, support the evidence of a safe and effective long-term use of anti-IL6R agents, especially when combined with low cumulative GCs doses. The occurrence of AEs after >1 year of treatment, instead of within the first six months of treatment as previously reported, possibly suggests a smaller effect of TCZ in their determination, compared to other contributing factors.REFERENCES:NIL.Table 1.Glucocorticoids tapering scheme for patients with a novel diagnosis of GCA.WeekGC dosing (mg/day, prednisone equivalent)1-4504-643,756-837,58-1031,2510-122512-1418,7514-1612,516-186,2518-20520-223,7522-242,524-261,2526-104-Acknowledgements:NIL.Disclosure of Interests:None declared.

BackgroundSubclinical giant cell arteritis (GCA) in polymyalgia rheumatica (PMR) is found in the 22.8% of patients on ultrasound examinations. The outcome and the optimal management of subclinical giant cell arteritis (GCA) in patients with polymyalgia rheumatica (PMR) have not been defined yet.ObjectivesThe aim of this study was to investigate the short-term outcome of PMR patients with concurrent subclinical GCA that were included in our multicenter project on the prevalence, characteristics and outcome of subclinical GCA (diagnosed by vascular ultrasound) in PMR [1].MethodsWe analyzed follow up data at 3, 6, 12 and 18 months of consecutive PMR patients from 7 European rheumatology centers. All patients fulfilled 2012 EULAR/ACR Provisional Classification Criteria for Polymyalgia Rheumatica and they had not symptom of clinical GCA. Patients were stratified into two groups: pure PMR and PMR with subclinical GCA, and the outcome between these two groups were compared. A relapse was defined as clinical and/or laboratory worsening of the disease after the initial remission and minor and major relapse EULAR definition was used [2].ResultsWe included 116 PMR patients (47 with concurrent subclinical GCA and 69 with pure PMR) followed for a median (IQR) of 21 (17; 23) months. We observed relapses in 35/116 patients (30.2%), 27/47 (57.4%) in PMR with subclinical GCA and 8/69 (11.6%) in pure PMR group (p<0.001). All relapses in the pure PMR group were minor relapses, whereas we observed 2 major relapses in the subclinical GCA group. The dose of corticosteroids used at the baseline visit was significantly higher in the GCA subclinical group, but tapering of steroids occurred faster than recommended by clinical guidelines [2]. Prednisone dose was significantly higher in patients with PMR and subclinical GCA than in patients with pure PMR both at baseline and at month 6 (Table 1). In patients with PMR with subclinical GCA mean starting dose of prednisone was 32.2±16.1 mg in those who relapsed and 36.2±12.8 in those who maintained remission (p=0.166); at 3 months, it was 13.2±7.1 and 18.2±7.9, respectively (p<0.05). Three patients in the PMR with subclinical GCA group received biological therapy at diagnosis; one of them had a minor relapse.Table 1.Patients characteristicsPure PMR(n=69)Subclinical GCA/PMR(n=47)pAge years (mean ± SD)71.2±8.074.8±7.60.079Sex (females %)59%52%0.526Relapses n (%)8/69 (11.6%)27/47 (57.4%)0.001Minor Relapses n (%)8/69 (11.6%)25/47 (53.2%)0.001Major Relapses n (%)02/47 (4.2%)Steroids basal (mean ± SD))18.3±9.134±14.80.001Steroids month 3 (mean ± SD)9.9±5.114.6±8.30.001Steroids month 6 (mean ± SD)5.6±2.18.8±6.80.037Steroids month 12 (mean ± SD)1.7±2.18.0±14.20.062Steroids month 18 (mean ± SD)1.1±1.83.6±5.60.09Steroids = mg prednisone; SD = standard deviation; n= number of patientsConclusionPMR patients with subclinical GCA had a significantly higher number of relapses during the follow-up than pure PMR group. These results suggest that subclinical GCA in PMR should be treated in the same manner as clinically overt GCA.References[1]De Miguel et al. Prevalence of subclinical giant cell arteritis in patients with polymyalgia rheumatica. Ann Rheum Dis 2022; volume 81, supplement 1, page 122.[2]Hellmich B et al. 2018 Update of the EULAR recommendations for the management of large vessel vasculitis. Ann Rheum Dis. 2020 Jan;79:19-30.AcknowledgementsWe would like to thank to the GCA/PMR study group for her contributions to the development of collaborative studies.Disclosure of InterestsNone Declared.

Upadacitinib (UPA), a JAK inhibitor engineered for a greater selectivity towards JAK1, has demonstrated a favourable benefit-to-risk profile in rheumatoid arthritis (RA) patients with an inadequate response to cDMARDs and biologic agents in randomized clinical trials. However, real-life data on its efficacy and safety are limited. We herein provide the first prospective multicentre experience on UPA efficacy and safety profile in RA in a real-life context, focusing on clinimetric and ultrasonographic (US) data. The primary aim of the study was to assess changes in clinimetric and US scores between different time point observations (baseline, 1 month, 3 months and 6 months). Secondary aims were to: (i) estimate the impact of biologic line of treatment and of concomitant therapies on response to therapy; (ii) explore changes in laboratory parameters; (iii) find potential predictive factors associated with response to therapy. Medical records of consecutive RA patients treated with UPA and referred to three Italian tertiary Centers were prospectively reviewed. Adult patients meeting ACR/EULAR classification criteria for RA were enrolled. Our real-life experience confirms the efficacy in terms of clinical and US improvement as well as displaying a good safety profile. The combination therapy with a conventional immunosuppressants predicts a significantly lower clinical and US improvement, likely reflecting a more severe and aggressive course worthy of ad-hoc and more in-depth investigation. An improvement in the SDAI and DAS28CRP was observed, already from the first month of therapy and has been maintained over time. In conclusion, these results demonstrated the short term efficacy of Upadacitinib 15 mg for up to 6 months and providing a prompt improvement of PROs. Even if further studies are needed to clarify those results, these novel findings may provide new insight for the management of UPA treatment in clinical practice. Our real-life experience confirms the efficacy in terms of clinical and US improvement as well as displaying a good safety profile. The combination therapy with a conventional immunosuppressants predicts a significantly lower clinical and US improvement, likely reflecting a more severe and aggressive course worthy of ad-hoc and more in-depth investigation. An improvement in the SDAI and DAS28CRP was observed, already from the first month of therapy and has been maintained over time. In conclusion, these results demonstrated the short term efficacy of Upadacitinib 15 mg for up to 6 months and providing a prompt improvement of PROs. Even if further studies are needed to clarify those results, these novel findings may provide new insight for the management of UPA treatment in clinical practice. NIL. NIL. None Declared. [Display omitted] Table 1Changes in clinimetric and ultrasonographic scores throughout the study period and significance levels (p values) for single comparisons between different observations in time.EndpointOverall significanceT0 vs T1T0 vs T3T0 vs T6T1 vs T3T1 vs T6T3 vs T6Synovitis grade< 0.0010.8040.090<0.001< 0.001< 0.001< 0.001PD signal grading0.0290.9140.3200.0260.0290.0090.066Tenosinovitis grading0.0120.9680.3700,0310,0180,0090,059DAS28-CRP0.0050.014< 0.001< 0.0010.2200.0150.035SDAI index< 0.0010.003< 0.001< 0.001< 0.001< 0.001< 0.001List of abbreviation: DAS28-CRP Disease Activity Score 28 – C-reactive protein, PD power Doppler, SDAI Simplified Clinical Activity Index, T0 baseline, T1 1 month evaluation, T3 3 month evaluation, T6 6 month evaluation

No definite clinical, laboratory or imaging finding has been identified to predict prognosis and different clinical course of PMR, nor the risk of further relapses. Primary endpoint was to assess the rate of PMR patients who, during the follow-up, undergo a diagnosis of GCA and arthritis, as well as to assess which clinical, laboratory and US findings are associated to a diagnostic shift and predict the long-term evolution of PMR. Secondary endpoint was to assess the optimal use of US in PMR. All patients who were diagnosed with PMR in our Rheumatology Unit from January 2017 to January 2022 and followed-up for at least 12 months were retrospectively included. If performed at the time of diagnosis, musculoskeletal and temporal (TA) and axillary arteries (AxA) US findings were recorded, too. A total of 201 patients (mean age 73.4 ± 7.63, M/F 89/112) were included. According to the US performed at baseline, patients were subdivided in 4 subgroups: in 32 of them, the diagnosis was only clinical (A); 35 underwent shoulders, hips, wrists and knees US (B); 48 underwent shoulders, hips, TA and AxA US (C), while 86 shoulders, hips, wrists, knees, TA and AxA US (D). At baseline, 14/132 (10.6%) of patients from groups C and D displayed findings consistent with GCA. During the follow-up, 47%, 52.8% and 60% of PMR patients who were re-evaluated at 12, 24 and 36 months, respectively, had a change in diagnosis (figure 1). The multivariate logistic regression showed that bilateral LHBT tenosynovitis at onset was the variable that better defined the persistence in PMR diagnosis (p=0.05, OR 8.425), whereas GH synovitis (p=0.022, OR 0.074) and RF positivity (p=0.028, OR 0.993) were the variables associated to a diagnostic shift on the follow-up. The model that better described (AUROC 0.854) a patient with a PMR-onset with subsequent diagnostic shift comprised higher frequency of bilateral GH synovitis, bilateral shoulder PD, higher values of CRP, WBC, PLT and Hb and longer time to obtain remission. On the other hand, the ones maintaining diagnosis of PMR had bilateral exudative LHBT tenosynovitis (OR 8.425) and SA-SD bursitis (OR 2.619), higher values of ESR (OR 1.015), lower values of Hb (OR 0.428) and shorter time to remission (OR 1.076). Continuous variables were included in a hierarchical clustering analysis identifying two groups. Cluster 2 identified older patients, with lower systemic inflammation, lower levels of WBC, PLT and Hb, who had a higher persistence in PMR diagnosis at 12 (42.7% vs 29.3%), 24 (37.2% vs 25.6%) and 36 months (36.4% vs 21.2%). Cluster 2 had lower frequency of PD positivity (PD 0 in 39.1% on shoulders and 47.1% on wrists) or peripheral synovitis (absence of synovitis on knee and MCF in 43.9% and 50% respectively), more frequent flares, and were taking PDN at 12 (until 45.8%) and 24 months (until 30.8%). An environmental trigger before onset were more commonly reported (in 5,8% vaccinations before onset, vs 1.4% in cluster 1) The comparisons among the B, C and D and A showed significant differences in diagnosis at 12 (p=0.0145) and 24 months (p=0.0432) and dosage of GC at 12 months (p=0.0009). At 12 months the complete withdrawal of PDN was achieved in a significant (p=0.002) lower number of patients belonging to group A (6.4%) when compared to group B (28.1%), C (37,5%) and D (12.9%). A direct correlation was obtained between GC dosage at 12 and 24 months (Spearman rho 0.284, p=0.002). Finally, a longer time to remission correlated positively with CRP and negatively with Hb, while fever at disease onset positively with ESR. More than half patients fulfilling criteria for PMR have their diagnosis changed during follow-up. The early use of US is associated with a more accurate diagnosis at baseline, as well as to a lower cumulative dosage of PDN. The early diagnosis of GCA is possible only in case of AxA and TA US at diagnosis. On the other hand, the lack of US is associated to a prolonged PDN treatment. Patient with a definite subset of clinical (fever, short time to remission), laboratory (lower Hb and CRP, higher ESR) and US findings (lower PD signal, LHBT tenosynovitis) are more prone to maintain the diagnosis of PMR during the follow-up. NIL. NIL. None Declared. [Display omitted]

Tocilizumab (TCZ) is the only biologic drug approved for the treatment of giant cell arteritis (GCA), having clinical trials and real-life studies proved its efficacy and safety. However, the optimal duration of the treatment has yet to be determined, being its early interruption associated with an increased risk of relapse. Conversely, prolonged schemes of therapy may rise safety concerns. The aim of the study was to evaluate the incidence of adverse events (AEs) and remission/relapse rate in a cohort of GCA patients treated with TCZ and an accelerated steroid tapering scheme, followed for 24 months. We retrospectively included patients referring to our clinic from January 2019 to November 2021 who were diagnosed with GCA and started subcutaneous TCZ treatment (162 mg/week). They also received up to 62,5 mg of prednisone (PDN), tapered following an accelerated six-month scheme. We collected 38 patients, with a mean age of 76,4 years, treated with TCZ for an average of 22,3 months. AEs occurred in 11 (29%) subjects, and only one serious AE was reported; 7 (18%) patients permanently discontinued TCZ. At the end of the follow-up, all the patients continuing treatment showed clinical remission, with a PDN dosage <5mg. We registered 3 (8%) minor relapses under TCZ, after an average of 15 months. Our data support the evidence of a safe and effective long-term use of TCZ in GCA patients, especially when combined with moderate GCs doses for the shortest possible duration.

No clear-cut guidelines exist about the use of diagnostic procedures for idiopathic inflammatory myopathies (IIM) and only scanty and conflicting data report the use of ultrasound (US). We aimed to assess if grey-scale (GS) and Power Doppler (PD) US, graded with a 0-3-points-scale, may be a reliable tool in a cohort of patients affected by IIM. We prospectively collected, since July to October 2020, all patients referred to Vasculitis and Myositis clinic, Rheumatology Unit, University of Siena, for suspected IIM, as well as patients with a previous, definite diagnosis of IIM and evaluated during follow-up or referred from other centers for a second opinion. All patients underwent US examination of both thighs in axial and longitudinal scans. Edema and atrophy, both assessed in GS, and PD, were graded with a 0-3-points-scale. Spearman test was used to identify the correlations between US and clinical and serological variables. A total of 18 patients was included. Four of them were evaluated twice, at baseline and within 3 months of therapy. Muscle edema was found to be directly correlated with physician global assessment (PhGA), serum myoglobin and PD and negatively with disease duration. PD score was positively correlated to PhGA and negatively to disease duration. Muscle atrophy directly correlated with Myositis Damage Index and patients' age. The single-thigh sub-analysis evidenced a direct correlation between PD score and Manual Muscle Test. In our cohort, we found that edema and PD are strictly related to early, active myositis, suggesting that an inflamed muscle should appear swollen, thickened and with Doppler signal. Conversely, muscle atrophy reflects the age of the patient and the overall severity of the disease. Such findings shed a new, promising, light in the role of US in diagnosis and monitoring of IIMs. None declared [Display omitted] Table 1Siena Myositis Ultrasound Grading Scale (SMUGS).Grey-scale edemaGrey-scale atrophyPower Doppler0Normal muscle echotexture with hyperechoic septa and hypoechoic muscle fibers, conserved thickness.Normal muscle echotexture, with hyperechoic septa and hypoechoic muscle fibers, conserved thickness.No PD signal.1Focal hypoechoic areas, where septa are less evident. Conserved thickness.Focal heterogeneously hyperechoic areas, where septa are thicker and more evident, and muscle fibers are thinner. Conserved muscle thickness.One or two PD signals in at least one muscle (PD vascular spots, small vessels of homogenous diameters, vessel diameters approximately not superior to fibrous intramuscular septa)2Diffuse and heterogeneous hypo echogenicity (rectus femoris as hypoechoic or more than vastus intermedius), septa diffusely less evident. Conserved thickness.Diffuse and heterogeneously hyperechoic muscle, with thicker septa and thinner muscle fibers. Conserved muscle thickness.More than 2 PD signals for each muscle (as vascular spots, small vessels of homogenous diameters, vessel diameters approximately not superior to fibrous intramuscular septa).3Diffuse and heterogeneous hypo echogenicity (rectus femoris as hypoechoic or more than vastus intermedius), septa diffusely less evident. Increased thickness (rectus femoris became thicker than vastus intermedius).Diffuse and heterogeneously hyperechoic muscle, with thicker septa and thinner muscle fibers. Reduced muscle thickness.More than 2 PD signals for each muscle with larger diameter of the vessel (at least superior to fibrous intramuscular septa), or vessels with different diameters or branched vessels.

BackgroundActive sacroiliitis represent the radiological hallmark of Ankylosing Spondylitis (Ax-SPA) and manifest as low back pain accompanied by morning stiffness (MS). The pain at rest as well as MS represent the main symptoms that impair patients’ quality of life. The treatment of Ax-SPA rely on non steroidal anti-inflammatory drugs (NSAIDs), monoclonal antibodies as Anti-TNF-α, anti interluekine-17/23 and, recently, on Janus Kinase Inhibitors; such compounds modify the disease natural history and reduce inflammation, thus restoring patient’s well being and quality of life. However, despite a full treatment regimen, sometimes it is not possible to reach a low disease activity or remission.ObjectivesIn rheumatological practice, corticosteroids (GCs) injections are successfully exploited in the every-day scenario to treat oligo-articular inflammatory disorders. In this context, we decided to evaluate the long-term efficacy of ultrasound-guided sacroiliac joint injections (US-SIJIs) of GCs in the treatment of active sacroiliitis and to understand whether local therapy has a role in the management of active sacroiliitis.MethodsWe enrolled patients affected by Ax-SPA with active sacroiliitis from our outpatient clinic. Some were treated with an US-SIJI when starting a biological disease modifying rheumatic drug (bDMARD) while others were treated with conventional therapy (bDMARD + NSAIDs) and used as controls. Variables such as age, gender, disease duration, type of bDmard, visuo-analogic pain scale (VAS) and MS were collected at baseline. VAS and MS were collected at each follow up visit that were scheduled at 24 and 48 hours, then after 7 days, 14 days, 1, 3, 6, 9 and 12 months. Each patient treated with SIJI received an explanation of the technique and informed written consent was obtained; subsequently, each patient was invited to lay pronated on a medical bed while a musculoskeletal sonographer individuated sacroiliac joints (SIJ) with a convex probe and demarcated the needle entry site with a dermographic pen. A sterile hood was put on the probe, the skin was accurately disinfected, then a 2,5 mL syringe was loaded with 40 mg of triamcinolone acetonide and a spinal needle of 22 gauge was used to reach SIJ. Each SIJI involved crossing the posterior sacroiliac ligament and each injection was carried out following real time the needle trajectory. All of the US-SIJI patients received a bilateral SIJI. The statistical analysis exploited descriptive statistics to define baseline anthropometric variables, ANOVA test and Test U of Mann were used to compare the means between groups. The p<0,05 was considered significant. The present study was conducted in accordance to the Declaration of Helsinki and was approved by the local ethical committee.ResultsWe enrolled 33 subjects: 12 received an US SIJI and 21 were treated with a standard therapy according the most up-to-date recommendations. Both groups were comparable for age and VAS pain at baseline. In US-SIJI group after 24 h was documented a significant reduction of VAS pain that lasted up to 1 year displaying always a persistent significant lower value compared to baseline; in SIJIs group the higher VAS pain reduction from baseline was documented after 7 days (- 71%); in the control group VAS pain reduction reached significance after 3 months from baseline and the higher VAS pain reduction was documented at end of study (-32 %). In the US-SIJI group MS dropped significantly after two weeks from SIJI while in the controls after 3 months from baseline. At the end of study the patients treated with US-SIJI displayed a higher VAS pain (-50 % in SIJIs vs. -32 %, p<0,05) as well as MS reduction compared to controls (- 71 % in SIJIs vs – 42%, p<0,05). Any serious adverse event was recorded.ConclusionThe US-SIJIs represent a safe and useful tool to control the symptoms of an active sacroiliitis and they should be performed concomitantly to the beginning of a bDMARD therapy to guarantee a rapid restoration of patients’ quality of life.Figure 1.REFERENCES:NIL.Acknowledgements:NIL.Disclosure of InterestsNone Declared.

Purpose Adhesive Capsulitis (AC) is a musculoskeletal disorder initially described by Codman in 1934. The disease is characterized by pain-limited restriction in active and passive glenohumeral range of motion (ROM) despite the lack of a structural deficit. In the last decades, arthroscopy and magnetic resonance imaging (MRI) has been the only diagnostic tools able to highlight the characteristic alterations of the glenohumeral capsular-ligament apparatus in AC; nevertheless, both arthroscopy and MRI are burdened by intrinsic limitations. The aim of this narrative review is to summarize the most significant evidence supporting the use of ultrasound (US) for the diagnosis of AC. Methods We extensively searched via PubMed library the terms “frozen-shoulder” and “adhesive capsulitis” each combined with “ultrasound”. Results We found 3723 papers on PubMed and selected those inherent to AC diagnosis, US imaging, correlation with arthroscopic and MRI findings. Forty papers which were strictly related to the topic of this narrative review were initially chosen, then 20 studies which described and exploited US for AC diagnosis were finally included. Coracohumeral ligament (2.65 ± 0.4 mm) and axillary pouch thickening (3.34 ± 0.8 mm), as well as an increase in vascularity at rotator interval (78/214, 36.44%), represented the commonest US signs useful for AC diagnosis and for which the most significant cut-off values were reported. Conclusions The evidence collected in this review testify that musculoskeletal US is as reliable as MRI for AC diagnosis, therefore we believe that in this context US should be considered a first-line imaging technique.

Background:Polymyalgia rheumatica (PMR) is the most common inflammatory disorder of elderly; an association with environmental triggers and deregulated immune response has been described.Objectives:The aim of this study was to investigate the presence of environmental triggers before the onset of PMR and its association to a particular subset of disease.Methods:The database of 58 consecutive PMR patients recruited from a single rheumatology secondary care setting was retrospectively analyzed to investigate the frequency of environmental triggers and correlations with clinical characteristics. Patients underwent multidistrict ultrasound examination of both proximal and distal sites. Laboratory tests were repeated after one month from first visit, when steroids were started, and about every three months during follow-up (for at least 24 months)Results:Fifteen PMR patients (26%) described a connection with environmental agents: six PMR patients reported a vaccination, 3 an upper respiratory tract infection and 1 pneumonia before the onset of disease. Five patients reported seasonal influenza as trigger of PMR. The model of multivariate linear regression which better predicted a shorter time to normalize inflammatory reactants (R squared 27,46%, p=0,0042) comprised the presence of an environmental trigger and a higher CRP. A linear regression analysis confirmed an inverse correlation between CRP at onset ant time to normalize inflammatory reactant (r= -0,3031, p=0,0208). A significant correlation was demonstrated between presence of environmental trigger and shorter time to normalize inflammation (r=-0,5215, p<0,0001), lesser frequency of gleno-humeral synovitis on US (r=-0,3774, p=0,0038).Conclusion:Our work describes a correlation between environmental triggers in PMR and higher CRP at diagnosis and faster response to therapy. We may suppose that these patients belong to a more specific subtype of PMR, in whom external stimuli, such as vaccinations or infections, may lead to a deregulated response within the context of an impaired immune and endocrine system. We recommend a systematic research of previous infections or vaccination in recent onset PMRDisclosure of Interests:None declared

Objective: To investigate by high frequency ultrasonography the appearance of calcium pyrophosphate dihydrate (CPPD) calcifications, in the most commonly affected sites in CPPD disease, and the relationship between ultrasonographic CPPD deposits and the presence of CPPD crystals in synovial fluid. Methods: Three ultrasonographic patterns of CPPD calcification were identified and 11 patients enrolled. A control group comprised 13 patients with no evidence of CPPD deposits. Synovial fluid was aspirated from all patients and controls and examined for identification of crystals. All patients underwent a standard radiography examination at the same sites investigated by ultrasound. Results: In all patients with ultrasonographically defined CPPD deposits, CPPD crystals were found in the synovial fluid. In two cases, standard radiographic examination did not show evidence of the calcific deposits that were identified by ultrasonography. CPPD crystals were not found in the synovial fluid of controls. In four control group patients, ultrasonography identified calcifications defined as deposits of another nature. Conclusions: The ultrasonographic pattern used in this study for the diagnosis of CPPD disease demonstrated a very high correlation with the presence of CPPD crystals in synovial fluid. Ultrasonography demonstrated a sensitivity and specificity at least equal to that of radiography in identifying CPPD crystal calcifications.