BACKGROUNDInfiltrations of the musculoskeletal system, in their various techniques, constitute a valuable therapeutic option, being a fundamental skill for the rheumatologist. The use of ultrasound in Rheumatology has been consolidating itself as an accessible complementary assessment method, with the possibility of use at the bedside in real time and to guide joint infiltrations, increasing its accuracy and safety. However, training and improvement for its use can be complex, with no recommendations or uniformity regarding its teaching, in addition to scarce and concentrated literature on vascular and anesthetic procedures. We present an ultrasound-guided infiltration training model aimed for teaching Rheumatology residents. METHODSThe schedule is carried out during the medical residency program in Rheumatology, initially with theoretical classes on infiltrations, physical principles and musculoskeletal assessment by ultrasonography (USG), and on guided procedures. Subsequently, practical training is carried out in models of refrigerated pieces of meat (chicken), for the improvement of psychomotor and visual skills. The training continues with the performance of procedures in patients with rheumatological pathologies under supervision. RESULTSThe training model started in 2020, with scheduled classes and training, with successful reproduction of the models and later implementation in outpatients. There are several common USG-guided techniques for arthrocentesis, of which are several in-plane and out-of-plane techniques. For convention, in-plane refers to a position with the needle directly below the USG transducer with the full length of the needle in constant view on the USG screen. Out-of-plane technique refers to a USG view in which a portion of the needle, ideally the tip, will be visualized on the USG screen. For the out-of-plane technique, the needle will be perpendicular to the USG probe and inserted at a steep angle with triangulation to introduce the needle tip at a depth of the effusion as seen on the USG screen. A general rule to adhere to with the out-of-plane technique is that the needle tip should never be advanced beyond the probe. The figures show different stages of the teaching model. CONCLUSIONHands-on bedside ultrasound instruction is a unique component of ultrasound education. It provides the opportunity for the learner to become facile with the ultrasound equipment, develop hand-eye coordination, gain exposure to different ultrasound exam core competencies, and practice obtaining the standard views with an instructor. We present the profile of the procedures performed at the infiltration outpatient clinic of a referral service in rheumatology in the interior of São Paulo, their main characteristics and outcomes.

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BACKGROUNDSystemic sclerosis is a connective tissue disease characterized by fibrosis and vascular and immunological abnormalities. The diffuse form is associated with high mortality. Progressive skin thickening, usually painful and pruritic, is the symptom that has the greatest effect on the patient's quality of life. The skin is a visible and accessible window to evaluate disease progression. In patients with the early form, skin involvement often begins distally, affecting the fingers, which become painful and swollen. This early edematous phase is sometimes misdiagnosed as inflammatory arthritis; however, after a few weeks, skin thickening appears. CASE REPORTFemale, 24 years old, white, previously healthy, had infection by the coronavirus, with mild symptoms, after receiving three doses of the vaccine. After eight weeks, she developed periorbital and lower limb edema, associated with dyspnea on minimal exertion, with complaints of paroxysmal nocturnal dyspnea and orthopnea. On admission physical examination, she was in a regular general condition, with tachypnea (24 incursions/min) and desaturation (87%), requiring the use of a nonrebreathing mask. On pulmonary auscultation, crackles. Laboratory tests with elevation of ALT (94 U/L), CRP (4.9 mg/dL) and ESR (51 mm/h). Blood count, renal, thyroid and liver function without changes. Urine exam without sediment. Requested ANA and anti-dsDNA, nonreactive. An echocardiogram was performed with the presence of a laminar pericardial effusion (2.5 mm), with no changes in function or the presence of areas of hypokinesia. Diuretic therapy was started with improvement of the complaints. Hospital discharged; however, symptoms recurred, initiating symmetrical and additive arthritis of elbows, knees, and ankles. She maintained a complaint of edema in the distal third of both legs and feet, with hypersensitivity to touch and mild skin thickening. Admitted to the care of Rheumatology and a new investigation was initiated. Echocardiogram, chest computed tomography (CT) and CT angiography scans of the abdomen and pelvis were performed, with no changes. A new autoimmune panel was requested, with ANA 1/160 being evidenced, with a nonspecific pattern, dense fine speckled nuclear, and reagent anticentromere. A hypothesis of edema was raised as a result of the edematous phase of systemic sclerosis, with initiation of corticosteroid therapy and methotrexate, with improvement of the complaints. CONCLUSIONThis report illustrates the onset of an atypical case of the edematous phase of systemic sclerosis, affecting the lower limbs, after a picture of COVID-19 infection. This early stage of the disease is often misdiagnosed, preventing early identification and treatment.