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There have been a number of major scientific advances in our specialty in recent years and now we are beginning to see the impact of these developments on everyday clinical practice. Biologic therapies may have grabbed all the headlines but ultrasonography (US) has an even greater potential to influence the way we assess and treat our patients. In <10 yrs, it has evolved from a diagnostic tool used in a small minority of patients to a virtually indispensable clinical instrument which has been likened to the ‘rheumatologist's stethoscope’. Research in US has focused mainly on the assessment of regional pain syndromes, the early detection of structural damage in inflammatory arthritis, and US guidance of joint and soft tissue injections [ 1–3 ]. US has a number of properties which make it particularly attractive as an imaging tool. These include the lack of radiation exposure, the ability to assess the joints in a dynamic fashion and the power to measure tissue perfusion, and therefore inflammation. There are, however, several dilemmas that face the rheumatologist who wants to become a sonographer. ‘Do I need to buy my own US equipment and which is the best machine for my purposes?’ ‘How can I master the art of scanning and maintain my skills?’ ‘How do I interpret the images correctly and standardize my technique?’ Constant practice is the key to success when attempting to master the art of US, so unless you have unrestricted access to a machine, this can be very difficult. For most of us, this means that we will aspire to owning our own equipment. But which US machine should you buy? The most important point is to be patient and avoid a hasty purchase. Speak to colleagues who are experienced in the field and be clear in your mind how you intend to use the equipment. There is a wide array of different US machines on the market, so making a purchase can be a confusing business. Unfortunately, cost and quality are usually proportionate to one another ( Fig. 1 ) so in order to acquire a high quality machine, a large financial outlay is necessary [ 4 ]. Most US machines come with a variety of options that allow the purchaser to personalize the equipment. These can have a significant impact on the overall price of the machine. They include a choice of probes of different frequencies and sizes and optional software packages for more specialized imaging. Longitudinal view of the flexor pollicis longus tendon at the thenar eminence taken with two US systems of different price and subsequent quality. ( A) 100 000 Euro. ( B) 20 000 Euro. In general, it is wise to purchase the best machine that you can afford. Currently, the price range for US equipment is between 20 000 and 200 000 Euro. The key elements that should act as a guide for the selection of the machine are the spatial resolution of the probe(s) (directly related to the frequency) and the presence or absence of power Doppler. In recent years, the cost–quality ratio of the US equipment has improved dramatically and an investment of ∼40 000 Euro will buy you a machine that produces images of an acceptably high standard. US has been defined as a technical art form and as with any art, it can be difficult for the novice to acquire the necessary skills to reach an acceptable standard. The production of a high-quality US image requires several fundamental skills, but the most important is the precise placement of the probe over the anatomical target. There is a very fine balance between acquiring an image of high quality and one that is unacceptable. This underlines the importance of training and represents one of the main obstacles to the development of these skills by a significant number of rheumatologists. There is still much debate about the appropriate amount of training necessary to acquire the basic skills of sonography [ 5 , 6 ], but most experts agree that the best way to train is under the supervision of an expert [ 7 ]. The American College of Radiology recommends that US trainees should undertake 500 supervized scans in order to achieve an acceptable standard [ 8 ], but such a requirement would present major logistical difficulties for most rheumatologists, given the time constraints of a busy clinical practice and the limited number of rheumatologist sonographers. Innovative ways of addressing this challenge in US training in rheumatology are urgently needed. Radiologists and rheumatologists have developed elaborate scoring systems to permit the accurate assessment of joint disease progression from plain radiographs, usually of the hands and feet. A similar approach can be applied to US imaging but there are some fundamental limitations to this approach. US is the most operator-dependent of all the imaging modalities and as a consequence, images are difficult to interpret outside the process of real-time acquisition. Representative printed images, saved during the US examination, are only a small part of the complex scenery viewed by the operator. A sonographer's overall conclusions can be influenced by a variety of elements not all of which are visible to the naked eye. As a result, the efficacy of the technique depends largely upon the skill and experience of the sonographer. This limitation of conventional US has been largely overcome with the development of three-dimensional (3D) US technology. This is an exciting new modality which will allow independent readers to view imagery identical to that which is seen by the person performing the US examination. This minimizes the potential for discordance in image interpretation between the sonographer and the secondary assessor [ 1 , 9 ]. 3D-US is performed by navigating through a 3D-cube of images containing an endless number of single images. Modern software packages now permit an independent reader to modulate the image parameters thus improving the quality of the information acquired during the examination. The production of high-quality US images is intimately linked with rigorous standardization of US technique. In recent years, experts have published guidelines on the correct approach to imaging a variety of anatomical sites in an attempt to produce an agreed standard for clinical practice, training and research [ 7 ]. As a concept, standardization is well-known in the field of plain radiography. US presents specific difficulties in relation to standardization, by virtue of its dynamic nature and the operator dependency of the acquisition process. The advent of 3D-US should address many of these difficulties but since the majority of rheumatologists will continue to practice 2D-US, these issues will remain important in the foreseeable future. At present, two main methods of tutorship in the ‘laws of standardization’ exist for rheumatologist sonographers. These include ‘Teach the teachers’ courses and web-based consensus workshops. One of the useful spin-offs from the ‘Teach the teachers’ courses has been a formal assessment of inter-observer variability in image acquisition. The results of these studies have been impressive and have indicated that it is possible to achieve an acceptable level of standardization in 2D-US amongst a group of experienced sonographers [ 10 , 11 ]. This level of concordance between experts must be interpreted in light of the high quality of the US equipment used, the cumulative experience of those involved and the basic level of the sonographic pathology being examined. An attractive alternative to the residential ‘Teach the teachers’ course is a web-based forum such as that being currently used by the EULAR Working Group for Musculoskeletal Ultrasound for assessing and scoring synovitis. To date, there is no agreed pathway for the rheumatologist to follow in order to become a competent sonographer. Guidelines for basic training were drawn up by the EULAR Working Group for Musculoskeletal Ultrasound in rheumatology in 2001 [ 7 ]. These affirmed the importance of expert supervision during the training process and this principle has been demonstrated in a self-teaching project involving a novice who was able to produce 2D-US images of sufficient quality in a short period of time [ 12 ]. In a second study, another novice was taught to scan the hip joint and demonstrated an excellent level of concordance with the tutor [ 13 ]. Over the last five yrs, the EULAR Working Group for Musculoskeletal Ultrasound in rheumatology has been organizing basic and advanced US courses which have been successful in terms of the number of participants and the level of satisfaction amongst those who have attended. These courses are only the starting point of the training process and many issues regarding training in musculoskeletal US still remain unresolved [ 14 , 15 ]. These include the amount of time that should be devoted to training, the number of US examinations which need to be performed under supervision and the most effective way of assessing competency at the end of the training period. Recently, a group of rheumatologists from Belfast described a series of steps which they took, over a 5-yr period, to gain sufficient experience to achieve a basic level of competency in US. At the end of that period, they were assessed by an experienced rheumatologist sonographer in a formal test of their ability to perform basic US examinations on normal volunteers and patients [ 4 ]. This system has the attraction of being a ‘real-time’ assessment of a dynamic technique, but it requires a considerable commitment of time on the part of all the participants. Perhaps a more universal means of training and assessment can be devised with the help of the latest techniques of web-based learning. These are not a substitute for mentoring by an experienced sonographer but they could be a powerful adjunct to face-to-face learning. This approach has already been the subject of a pilot study in Italy where trainees have the benefit of a continuous interaction with tutors by submitting their US images to a web-based tutor for comment and feedback [ 16 ]. US has opened new avenues of research to rheumatology in recent years. These have principally focused on the detection of morphostructural abnormalities in target tissues in phases of the diseases where other imaging modalities may be of limited value [ 2 , 17 ]. In this context, US appears particularly promising as a tool to aid the rheumatologist in Early Arthritis Clinics. The detection of very early erosions (<1 mm), the identification of cartilage damage [ 18 ], the evaluation of synovial pannus [ 19 ] and the monitoring of disease activity [ 20 , 21 ] are only a few examples of many exciting research areas. Over the last 25 yrs there has been an explosion in the number of publications regarding US in rheumatology ( Fig. 2 A). Over 85% of these publications have originated from European countries particularly from the UK, Italy and Germany ( Fig. 2 B). A closer examination of the literature reveals that rheumatoid arthritis and shoulder problems are the most frequently investigated subjects ( Fig. 2 C and D). Number of US publications related to the year of publication ( A ), nationality of authorship ( B ), anatomical area investigated ( C ) and rheumatic disease evaluated ( D ). CPPD, Calcium pyrophosphate deposition disease. In conclusion, there are many exciting challenges ahead in the field of US in rheumatology. The common denominator in all of this is the union of sensitivity and specificity in the early detection of tissue changes induced by rheumatic diseases. At present, both the methodology and the technology exist to encourage a healthy interest in US, but a dramatic increase of active researchers is required to reach the critical mass necessary to embrace this challenge. The authors have declared no conflicts of interest.

Background<br/>The rationale behind this update of the 2016 BSR guidelines on prescribing anti-rheumatic drugs in pregnancy and breastfeeding (1, 2) was described in detail in the guideline scope (3). In brief, despite the existence of additional evidence-based guidelines on prescribing/managing rheumatic disease in pregnancy (4-7), the information contained within them requires continual review to include emerging information on the safety of new and existing drugs in pregnancy. <br/><br/>Chronic disease adversely affects pregnancy. Data from Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK (MBRRACE-UK), reports regularly from a national programme of work conducting surveillance and investigating the causes of maternal deaths, stillbirths and infant deaths (8). Data from 2017-19, found that 8.8 women per 100,000 died during pregnancy or up to six weeks after childbirth or the end of pregnancy, and most women who died had multiple health problems or other vulnerabilities (8). In all decisions regarding medication choices and changes, it is important to consider the potential for deterioration in the mother's wellbeing through side effects or reduced disease control (and its adverse impact on the baby). As such, the potential benefit to the fetus from any drug changes in the mother must be balanced against the possible risks to the fetus from loss of disease control in the mother (9).<br/><br/>Need for guideline<br/>There has been an appreciable increase in the number of published pregnancy exposures to biologic disease modifying anti-rheumatic drugs (bDMARDs), and two of these drugs are now licenced for use in pregnancy. In addition, therapeutic advances in management of various inflammatory rheumatic diseases (IRDs) have led to an expansion of bDMARDs and biosimilars with different modes of action, as well as a new class of targeted synthetic DMARDs (tsDMARDs).<br/><br/>The continuing expansion of existing and novel DMARDs means that uncertainty remains around use of many of these drugs in pregnancy. This uncertainty may still lead to withdrawal of treatment from pregnant women unnecessarily (10). Discontinuation of treatment in preparation for or during early pregnancy can increase the risk of disease activity and flares during pregnancy, and are reported following discontinuation of biologics in patients with IRDs (11). The compatibility of various immunosuppressive and disease-modifying medications relevant to rheumatic disease will be covered in this update. This updated information will provide advice for healthcare professionals and patients, to ensure more confident prescribing in these scenarios, and will highlight any medications that should be stopped and/or avoided in the reproductive age group unless highly effective contraception is used, in line with guidance issued by the Medicines and Healthcare Products Regulatory Agency (MHRA) and the Faculty of Sexual and Reproductive Healthcare (12, 13). <br/><br/>Objectives of guideline<br/>To update the previous BSR guidelines on prescribing in pregnancy in rheumatic disease of the following drug categories: antimalarials; corticosteroids; conventional synthetic (cs)DMARDs and immunosuppressive therapies; bDMARDs; and tsDMARDs. The full list of medications is shown in appendix 1. This revised guideline was produced by systematically reviewing all evidence published since the previous guideline, to answer specific questions in relation to each drug, as follows: Should it be stopped pre-conception? Is it compatible with pregnancy? Is it compatible with breastmilk exposure? Where possible, recommendations are made regarding compatibility with paternal exposure.<br/><br/>Target audience<br/>The primary audience consists of health professionals in the UK directly involved in managing patients with rheumatic disease who are (or are planning to become) pregnant and/or breastfeeding, men with rheumatic disease who are planning to conceive, and patients with rheumatic disease who have unintentionally conceived whilst taking these medications. This audience includes rheumatologists, rheumatology nurses/allied health professionals, rheumatology speciality trainees and pharmacists, as well as the patients themselves. The guideline will also be useful to obstetricians, obstetric physicians, midwives, renal physicians, dermatologists, gastroenterologists, respiratory physicians and general practitioners who prescribe these medications in pregnancy. <br/><br/>This guideline uses the terms “woman”, “maternal” or “mother” throughout. These should be taken to include people who do not identify as women but are pregnant or have given birth (14). Where the term “breastfeeding” is used in this guideline it also refers to infant breastmilk exposure via other methods (e.g. expressed breastmilk, administered via a bottle). <br/><br/>The areas the guideline does not cover<br/>This guideline does not cover the management of infertility or the indications for these drugs in specific rheumatic diseases in pregnancy. Other drug categories (pain management; non-steroidal anti-inflammatory drugs (NSAIDs) and low dose aspirin; anticoagulants; bisphosphonates; anti-hypertensives; and pulmonary vasodilators) are considered in the BSR guideline on prescribing drugs in pregnancy and breastfeeding: comorbidity medications used in rheumatology practice (reference to be inserted once published). All recommendations in this guideline were formulated by the working group on the basis of published evidence at the time of the systematic literature search, and do not necessarily refer to licencing information or Summary of Product Characteristics for individual medications.<br/><br/>Stakeholder involvement<br/>This guideline was commissioned by the BSR Standards, Guidelines and Audit Working Group. A Guideline Working group (GWG) was created, consisting of a chair (IG), alongside representatives from relevant stakeholders shown in appendix 2. In accordance with BSR policy, all members of the GWG made declarations of interest, available on the BSR website.<br/><br/>Involvement and affiliations of stakeholder groups involved in guideline development<br/>The GWG consisted of rheumatologists from a range of clinical backgrounds, various allied health professionals, other specialists in women’s health, lay members and representatives from the United Kingdom Tetralogy Information Service (UKTIS). All members of the working group contributed to the process for agreeing key questions, guideline content, recommendations and strength of agreement. <br/>

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Over the last few years, technological advances have resulted in dramatic improvements in quality and resolution of ultrasonography (US), allowing it to become a very powerful tool in rheumatological clinical practice. Despite the fact that the impact of US on final diagnosis or therapeutic options for rheumatic patients has not yet been defined, there is now growing evidence that US improves clinical diagnosis and intervention skills. This review discusses the most important issues connected with the practice of US in rheumatology including: basic requirements, scanning technique, clinical applications, training and future developments. Moreover, it provides a general overview of both US anatomy and pathology relevant for the rheumatologist.

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