Smartphone usage behaviors and their association with De Quervain's Tenosynovitis (DQT)among college students: a cross-sectional study in Guangxi, China.

BACKGROUND: The growing prevalence of smartphone use among college students in China has led to health concerns, including De Quervain's Tenosynovitis (DQT). However, the specific smartphone usage behaviors contributing to DQT remain poorly understood. This study aimed to explore the relationship between smartphone usage behaviors and DQT in college students. METHODS: A cross-sectional study was conducted with 937 students from various majors in Guangxi between September 2021 and April 2022. Participants completed an online questionnaire assessing smartphone usage behaviors and their association with DQT. The Finkelstein test was employed to diagnose DQT. RESULTS: Over half of the college students (52%) tested positive for DQT via Finkelstein's test. Higher levels of smartphone usage time (6-8 h/day: OR = 4.454, 95%CI:1.662-12.229; ≥8 h/day: OR = 4.521, 95%CI:1.596-12.811), phone games (OR = 1.997, 95%CI:1.312-3.040), social media (OR = 2.263, 95%CI:1.795-3.833), and leisure activities (OR = 1.679, 95%CI:1.140-2.475) were significantly associated with an increased risk of DQT. Two specific gestures (Bilateral thumbs, BT: OR = 1.900, 95%CI:1.281-2.817; Bilateral thumbs-horizontal screen, BT-HS: OR = 1.872, 95%CI:1.244-2.818) and two screen sizes (5.0-5.5inch: OR = 2.064, 95%CI:1.108-3.846; 6.0-6.5inch: OR = 2.413, 95%CI:1.125-4.083) also exhibited a higher risk of DQT. Bilateral DQT was observed, with Gesture-BT identified as the primary risk factor. CONCLUSION: Our findings suggest that increased smartphone usage time, phone games, social media, and leisure activities elevate the risk of DQT among college students. Furthermore, two specific gestures and two screen sizes were also linked to a heightened DQT risk. To mitigate DQT development, college students should reduce smartphone usage time and adopt appropriate gestures.

Importance of tenosynovitis in preventing the progression through rheumatoid arthritis continuum.

Rheumatoid arthritis (RA) has long been characterized by synovitis and bone erosions typically developing symmetrically in small joints. However, recent advances in imaging modalities have indicated frequent association of tenosynovitis with RA, and some consider tenosynovitis to be not just a complication but a major trait of RA. Furthermore, as there are cases with tenosynovitis preceding the clinical detection of inflammatory arthritis in predisposed individuals, tenosynovitis may constitute an important biomarker in defining the pre-RA phase of disease development. Tenosynovitis itself must be treated as it causes functional impairment and physical as well as socioeconomic burden, and its treatment may result in effective prevention of RA development at a pre-arthritic stage. Thus, further efforts need to be taken in detecting and treating tenosynovitis in the pre-RA stage, which can be facilitated by ultrasonography and magnetic resonance imaging.

Defining imaging sub-phenotypes of psoriatic arthritis: integrative analysis of imaging data and gene expression in a PsA patient cohort.

OBJECTIVES: To define imaging sub-phenotypes in patients with PsA; determine their association with whole blood gene expression and identify biological pathways characterizing the sub-phenotypes. METHODS: Fifty-five patients with PsA ready to initiate treatment for active disease were prospectively recruited. We performed musculoskeletal ultrasound assessment of the extent of inflammation in the following domains: synovitis, peritenonitis, tenosynovitis and enthesitis. Peripheral whole blood was profiled with RNAseq, and gene expression data were obtained. First, unsupervised cluster analysis was performed to define imaging sub-phenotypes that reflected the predominant tissue involved. Subsequently, principal component analysis was used to determine the association between imaging-defined sub-phenotypes and peripheral blood gene expression profile. Pathway enrichment analysis was performed to identify underlying mechanisms that characterize individual sub-phenotypes. RESULTS: Cluster analysis revealed three imaging sub-phenotypes: (i) synovitis predominant [n = 31 (56%)]; (ii) enthesitis predominant [n = 13 (24%)]; (iii) peritenonitis predominant [n = 11 (20%)]. The peritenonitis-predominant sub-phenotype had the most severe clinical joint involvement, whereas the enthesitis-predominant sub-phenotype had the highest tender entheseal count. Unsupervised clustering of gene expression data identified three sub-phenotypes that partially overlapped with the imaging sub-phenotypes suggesting biological and clinical relevance of these sub-phenotypes. We therefore characterized enriched differential pathways, which included: immune system (innate system, B cells and neutrophil degranulation), complement system, platelet activation and coagulation function. CONCLUSIONS: We identified three sub-phenotypes based on the predominant tissue involved in patients with active PsA. Distinct biological pathways may underlie these imaging sub-phenotypes seen in PsA, suggesting their biological and clinical importance.

Which inflamed tissues explain a positive metatarsophalangeal squeeze test? A large imaging study to clarify a common diagnostic procedure.

OBJECTIVES: The squeeze test of MTP joints is frequently used because it is easy and cheap. It is traditionally perceived as a test for synovitis. Besides classic intra-articular synovitis, also tenosynovitis and intermetatarsal bursitis (IMB) represent synovial inflammation, albeit juxta-articularly located. Both are frequently present in RA and occasionally in other arthritides. Therefore we hypothesized that tenosynovitis and IMB contribute to a positive MTP squeeze test. METHODS: A cross-sectional study design was used. A total of 192 early arthritis patients and 693 clinically suspect arthralgia patients underwent the MTP squeeze test and forefoot MRI at first presentation. MRI measurements in age-matched healthy controls were used to define positivity for synovitis, tenosynovitis and IMB. Logistic regression was used. RESULTS: In early arthritis patients, synovitis [odds ratio (OR) 4.8 (95% CI 2.5, 9.5)], tenosynovitis [2.4 (1.2, 4.7)] and IMB [1.7 (1.2, 2.6)] associated with MTP squeeze test positivity. Synovitis [OR 3.2 (95% CI 1.4, 7.2)] and IMB [3.9 (1.7, 8.8)] remained associated in multivariable analyses. Of patients with a positive MTP squeeze test, 79% had synovitis or IMB: 12% synovitis, 15% IMB and 52% both synovitis and IMB. In clinically suspect arthralgia patients, subclinical synovitis [OR 3.0 (95% CI 2.0, 4.7)], tenosynovitis [2.7 (1.6, 4.6)] and IMB [1.7 (1.2, 2.6)] associated with MTP squeeze test positivity, with the strongest association for synovitis in multivariable analysis. Of positive MTP squeeze tests, 39% had synovitis or IMB (10% synovitis, 15% IMB and 13% both synovitis and IMB). CONCLUSION: Besides synovitis, IMB contributes to pain upon compression in early arthritis, presumably due to its location between MTP joints. This is the first evidence showing that MTP squeeze test positivity is not only explained by intra- but also juxta-articular inflammation.

Musculoskeletal ultrasound may narrow the gap between patients and physicians in the assessment of rheumatoid arthritis disease activity.

OBJECTIVES: To investigate the association between patient-physician discordance in the assessment of disease activity and residual US synovitis/tenosynovitis in a cohort of patients with RA in clinical remission. METHODS: A post hoc analysis of the STARTER study, promoted by the Musculoskeletal-US (MSUS) Study Group of the Italian Society for Rheumatology, was performed using data from 361 consecutive patients with RA in clinical remission. The global assessment of disease activity by each patient (PGA) and evaluator/physician (EGA) was recorded on a 100-mm visual analogue scale. The PGA-EGA discordance was classified as positive (PGA>EGA) or negative (PGA

ACPA-negative and ACPA-positive RA patients achieving disease resolution demonstrate distinct patterns of MRI-detected joint-inflammation.

OBJECTIVES: Although sustained DMARD-free remission (SDFR; sustained absence of clinical-synovitis after DMARD-discontinuation) is increasingly achievable in RA, prevalence differs between ACPA-negative (40%) and ACPA-positive RA (5-10%). Additionally, early DAS remission (DAS4months<1.6) is associated with achieving SDFR in ACPA-negative, but not in ACPA-positive RA. Based on these differences, we hypothesized that longitudinal patterns of local tissue inflammation (synovitis/tenosynovitis/osteitis) also differ between ACPA-negative and ACPA-positive RA patients achieving SDFR. With the ultimate aim being to increase understanding of disease resolution in RA, we studied MRI-detected joint inflammation over time in relation to SDFR development in ACPA-positive RA and ACPA-negative RA. METHODS: A total of 198 RA patients (94 ACPA-negative, 104 ACPA-positive) underwent repeated MRIs (0/4/12/24 months) and were followed on SDFR development. The course of MRI-detected total inflammation, and synovitis/tenosynovitis/osteitis individually were compared between RA patients who did and did not achieve SDFR, using Poisson mixed models. In total, 174 ACPA-positive RA patients from the AVERT-1 were studied as ACPA-positive validation population. RESULTS: In ACPA-negative RA, baseline MRI-detected inflammation levels of patients achieving SDFR were similar to patients without SDFR but declined 2.0 times stronger in the first year of DMARD treatment [IRR 0.50 (95% CI; 0.32, 0.77); P < 0.01]. This stronger decline was seen in tenosynovitis/synovitis/osteitis. In contrast, ACPA-positive RA-patients achieving SDFR, had already lower inflammation levels (especially synovitis/osteitis) at disease presentation [IRR 0.45 (95% CI; 0.24, 0.86); P = 0.02] compared with patients without SDFR, and remained lower during subsequent follow-up (P = 0.02). Similar results were found in the ACPA-positive validation population. CONCLUSION: Compared with RA patients without disease resolution, ACPA-positive RA patients achieving SDFR have less severe joint inflammation from diagnosis onwards, while ACPA-negative RA patients present with similar inflammation levels but demonstrate a stronger decline in the first year of DMARD therapy. These different trajectories suggest different mechanisms underlying resolution of RA chronicity in both RA subsets.

Comparison of the effect of ketorolac versus triamcinolone acetonide injections for the treatment of de Quervain's tenosynovitis: a double-blind randomized controlled trial.

BACKGROUND: De Quervain's disease is tenosynovitis of the first dorsal compartment causing severely painful radial-side wrist pain and impaired function. Steroids are effective in treating this condition due to their anti-inflammatory properties. However, this drug causes problems such as hypopigmentation, and is contradicted in diabetes mellitus patients. Non-steroidal anti-inflammatory drug (NSAID) which are efficacious in shoulder pathology and not contraindicated in diabetics and can be used to avoid the local effects of steroids could be beneficial for some patients. The present study was a randomized controlled trial to examine the differences in pain scores and functional response to local injections of a corticosteroid and the NSAID ketorolac. METHODS: Sixty-four patients with radial styloid tenosynovitis were randomized using a computer-generated random number table into two groups receiving either a ketorolac injection or a triamcinolone injection. We evaluated post-injection pain intensity using a verbal numerical rating scale (VNRS), functional outcomes using the Thai Disabilities of the Arm, Shoulder and Hand (DASH) scale, and evaluated grip and pinch strengths, recorded at baseline and 6 weeks after the injection. RESULTS: Thirty-one participants in the ketorolac group and 29 participants in the triamcinolone group completed the study and were included in the analysis. There were no significant differences in the assessments at baseline. At the 6-week conclusion of the study, patients in the triamcinolone group had a statistically lower average pain score than in the ketorolac group (0.7 ± 2.0 vs 5.3 ± 3.2, P < 0.001), higher DASH functional score (4.4 ± 6.5 vs 34.1 ± 20.2, P < 0.001), higher right grip strength (60.8 ± 16.8 vs 49.2 ± 18.6, P < 0.015), and higher left grip strength (59.8 ± 18.1 vs 50.3 ± 18.0, P < 0.04). However, there was no difference in pinch strength. CONCLUSIONS: Our study found that ketorolac injections resulted in inferior pain reduction, functional score and grip improvement than triamcinolone injection in patients with radial styloid tenosynovitis. Future studies are required to examine the effects of ketorolac in larger group and with longer follow-up periods to further elucidate the findings of this study. TRIAL REGISTRATION: The study was registered at Clinicaltrials.in.th (TCTR20200909006).

Psoriatic arthritis: Ultrasound peculiarities with particular emphasis on enthesitis.

The prevalence of psoriatic arthritis among patients with psoriasis has a marked variability with ethnic and geographic variations. Inflammatory changes associated with psoriatic arthritis include bone erosion, tenosynovitis, and synovial hypertrophy, but enthesitis is considered the hallmark. Both X-ray and magnetic resonance imaging (MRI) are usefull in the diagnosis of psoriatic arthritis, but ultrasonography is the best imaging modality to assess entheses. Ultrasound findings of enthesitis include a loss of the regular fibrillar architecture, hypoechoic thickening, hypervascularization of tendons, ligaments, and joint capsules at their bony attachment, bony changes (including irregularities and erosions). Ultrasound has also proved the ability to detect inflammatory subclinical findings and to be useful in the follow-up of therapies.

Tenosynovitis has a high sensitivity for early ACPA-positive and ACPA-negative RA: a large cross-sectional MRI study.

OBJECTIVES: Clinically evident tenosynovitis can be seen in established rheumatoid arthritis (RA). Imaging research has recently shown that tenosynovitis at small joints occurs in early RA, contributes to typical RA symptoms (including joint swelling) and is infrequent in healthy controls. Imaging-detectable tenosynovitis is often not recognisable at joint examination, hence its prevalence can therefore be underestimated. We hypothesised that if MRI-detectable tenosynovitis is a true RA feature, the sensitivity for RA is high, in both anti-citrullinated protein antibodies (ACPA)-positive and ACPA-negative RA, and lower in other diseases that are associated with enthesitis (such as spondyloarthritis (SpA) and psoriatic arthritis (PsA)). So far, no large MRI study addressed these questions. METHODS: Consecutive patients with early arthritis (n=1211) from one healthcare region underwent contrast-enhanced 1.5T MRI of hand and foot at diagnosis. MRIs were scored for synovitis and tenosynovitis by two readers blinded for clinical data. All included patients with ACPA-positive RA (n=250), ACPA-negative RA (n=282), PsA (n=88), peripheral SpA (n=24), reactive arthritis (n=30) and self-limiting undifferentiated arthritis (UA; n=76) were studied. Sensitivity was calculated. RESULTS: The sensitivity of tenosynovitis in RA was 85%; 88% for ACPA-positive RA and 82% for and ACPA-negative RA (p=0.19). The sensitivity for RA was significantly higher than for PsA (65%; p=0.001), SpA (53%; p<0.001), reactive arthritis (36%; p<0.001) and self-limiting UA (42%; p<0.001). The observed sensitivity of MRI synovitis was 91% in RA and ranged from 83% to 54% in other groups. CONCLUSIONS: MRI-detected tenosynovitis has a high sensitivity for early ACPA-positive and ACPA-negative RA. This supports that both juxta-articular (tenosynovitis) and intra-articular synovial involvement is characteristic of RA.

Idiopathic carpal tunnel syndrome and de Quervain's tenosynovitis: is there an association?

AIM: In this study, we aimed to investigate frequency of de Quervain's tenosynovitis (DQT) in patient with idiopathic carpal tunnel syndrome (ICTS). MATERIAL AND METHODS: We evaluated 356 hands of 310 patients who applied with the pre-diagnosis of ICTS. Patients who have pain over the radial styloid, pain on movement, tenderness over the first dorsal extensor compartment and also positive Finkelstein's test were accepted clinically DQT. Presence of DQT was confirmed by ultrasonography. Motor and sensory conductions of median and ulnar nerves were studied in every hand with the pre-diagnosis of ICTS. RESULTS: We determined ICTS in 302 (85%) hands. De Quarvain's tenosynovitis ratio was found to be 9.9% in hands with ICTS (n:302). In patients with ICTS and DQT in the same hand, the male-to-female ratio is 1/3. There were 29 cases (22 female, 7 male) with ICTS and DQT. Of the 30 hands with ICTS and DQT together; 18 had mild, nine had moderate, and 3 had severe ICTS. CONCLUSION: This is the first study that evaluates the DQT and ICTS together. We found that patients with ICTS have a prevalence higher than normal population to have DQT. We suppose that considering DQT in patients with the pre-diagnosis of ICTS during clinical evaluation has a positive impact on clinical follow-up and treatment of these patients.

CT scan assessment of the dimensions and morphological variations of the peroneal tubercle.

PURPOSE: The hypertrophied peroneal tubercle may result in lateral ankle pain with peroneal tendon tenosynovitis and rupture. The aim of this study was to evaluate different configurations and dimensions of the normal peroneal tubercle using two-dimensional CT scan. METHODS: Totally, 100 normal CT scans of cases older than 18 years of age were assessed to determine the shape of the peroneal tubercle. Moreover, height, length and width of different configurations of the normal peroneal tubercle were measured in axial and coronal sections of the ankle CT scans. RESULTS: Four different configurations based on the axial cut of the calcaneus were found; single-convex (59%), double-convex (24%), plateau (9%), and convex-concave (8%) without statistically significant difference between genders (p-value: 0.526). Totally, mean of height, length and width were 4.42 ± 1.38 mm, 28.88 ± 6.58 mm and 17.17 ± 3.85 mm, respectively. Although mean of the height in the single-convex and the double-convex types were 4.5 ± 1.4 mm and 5.0 ± 1.4 mm, respectively, the highest peroneal tubercle in the single-convex and the double-convex group were 10.2 mm and 8.5 mm, respectively. CONCLUSIONS: In cases with lateral ankle pain and suspicious to hypertrophied peroneal tubercle, two-dimensional CT scan can be an available practical modality to identify the pathological type of the peroneal tubercle based on the presented classification and normal values. As previously reported in the literature, considering cut-off point of 5 mm could result in overdiagnosis of the hypertrophied peroneal tubercle, especially in single-convex type; however, clinical correlation is always paramount. LEVEL OF EVIDENCE: Level IV.

Rheumatoid Arthritis and Tenosynovitis at the Metatarsophalangeal Joints: An Anatomic and MRI Study of the Forefoot Tendon Sheaths.

Background Although tenosynovitis in the hands is associated with rheumatoid arthritis (RA), it is unknown whether tenosynovitis of the forefoot is associated with RA. Purpose To determine the anatomy of tendon sheaths of the forefoot and the relationship between MRI-detected tenosynovitis at metatarsophalangeal (MTP) joints and RA. Materials and Methods Fourteen forefeet of donated bodies were examined at flexor tendons and extensor tendons for the presence and course of tendon sheaths. In the prospective study between June 2013 and March 2016, newly presenting patients with RA, patients with other early arthritides, and healthy control participants all underwent MRI of unilateral MTP joints 1-5. MRI studies were scored by two independent readers for tenosynovitis, synovitis, and bone marrow edema. The association between the presence of these features and RA was examined by using logistic regression. Results Macroscopically, all extensor and flexor tendons crossing MTP joints demonstrated sheaths surrounding tendons. Microscopically, a synovial sheath was present. MRI evaluation was performed in 634 participants: 157 newly presenting patients with RA (109 women; mean age, 59 years ± 11 [standard deviation]), 284 patients with other early arthritides (158 women; mean age, 56 years ± 17), and 193 healthy control participants (136 women; mean age, 50 years ± 16). MRI-detected tenosynovitis was associated with RA, both when compared with patients with other arthritides (odds ratio [OR], 2.5; 95% confidence interval [CI]: 1.7, 3.9; P < .001) and healthy control participants (OR, 46; 95% CI: 14, 151; P < .001). The association was OR of 2.4 (95% CI: 1.5, 3.8; P < .001) for flexor tendons and OR of 3.1 (95% CI: 1.9, 5.2; P < .001) for extensor tendons. The sensitivity of tenosynovitis in RA was 65 of 157 (41%; 95% CI: 35%, 50%). The specificity for RA was 63 of 284 (78%; 95% CI: 72%, 82%) compared with other arthritides, and three of 193 (98%; 95% CI: 96%, 99%) compared with healthy control participants. Conclusion Tendons at metatarsophalangeal joints are surrounded by tenosynovium. MRI-detected tenosynovitis at metatarsophalangeal joints was specific for rheumatoid arthritis when compared with findings in patients with other arthritides and findings in healthy control participants. © RSNA, 2020 Online supplemental material is available for this article.

Ultrasound Doppler and tenosynovial fluid analysis in tenosynovitis.

OBJECTIVE: To assess Doppler ultrasound (US) and tenosynovial fluid (TSF) characteristics in tenosynovitis within common rheumatic conditions, as well as their diagnostic utility. METHODS: Subjects with tenosynovitis underwent Doppler US and US-guided TSF aspiration for white cell count (WCC) and crystal analysis. Tenosynovial Doppler scores (DS) were semiquantitatively graded. TSF WCC and DS were compared using Kruskal-Wallis tests and logistic regression between non-inflammatory conditions (NIC), inflammatory conditions (IC) and crystal-related conditions (CRC). Receiver operating curves, sensitivity and specificity assessed the ability of WCC and DS to discriminate IC from NIC. RESULTS: We analysed 100 subjects from 14 sites. The mean age was 62 years, 65% were female, and the mean TSF volume was 1.2 mL. Doppler signal was present in 93.7% of the IC group and was more frequent in IC than in NIC group (OR 6.82, 95% CI 1.41 to 32.97). The TSF median WCC per 109/L was significantly higher in the IC (2.58, p<0.001) and CRC (1.07, p<0.01) groups versus the NIC group (0.38). A TSF cut-off of ≥0.67 WCC per 109/L optimally discriminated IC versus NIC with a sensitivity and specificity each of 81.3%. In the IC group, 20 of 48 (41.7%) subjects had a TSF WCC <2.00 per 109/L. CONCLUSIONS: A negative DS helps rule out IC in tenosynovitis, but a positive DS is non-specific and merits TSF testing. Unlike synovial fluid, a lower TSF WCC better discriminates IC from NIC. US guidance facilitates aspiration of minute TSF volume, which is critical for diagnosing tenosynovial CRC.

Posterior tibial tendon dysfunction: Imperfect specificity of magnetic resonance imaging.

MRI is frequently used in the evaluationand treatment of tibialis posterior tendon (PTT) dysfunction. MRI is reported to have sensitivity up to 95%, with 100% specificity, in the detection of rupture of the PTT. We present three cases where MRI demonstrated complete or partial rupture of the PTT, where subsequent surgery showed an intact PTT with tenosynovitis. In all cases, there was a source of inflammation external to the tendon. It is hypothesized that this exogenous origin of inflammation caused changes in the MRI signal in the PTT that resemble that seen in ruptures. These cases show that in the presence of inflammation near the tibialis posterior tendon, the MRI may falsely indicate a high-grade rupture of the tendon. Recommendations for treatment of suspected PTT rupture in the presence of significant other sources of inflammation are proposed.

Is joint pain in patients with arthralgia suspicious for progression to rheumatoid arthritis explained by subclinical inflammation? A cross-sectional MRI study.

Objectives: The development of RA includes a phase of arthralgia preceding clinical arthritis. The aetiology of symptoms of arthralgia is unclear. Since subclinical joint inflammation is expected to be causally related to pain, we aimed to study associations between subclinical MRI-detected inflammation and pain in patients with arthralgia suspicious for progression to RA. Methods: Unilateral MRIs of the wrist, MCP (2-5) and MTP (1-5) joints of 325 patients who fulfilled the EULAR definition of arthralgia suspicious for progression to RA were scored by two readers on subclinical inflammation (synovitis, bone marrow oedema and tenosynovitis). Associations between MRI-detected inflammation and overall pain severity at patient level (measured using the visual analogue scale), as well as with local joint tenderness, were studied. Analyses were stratified for ACPA. Results: At patient level, synovitis (ß = 0.10, P = 0.048) and tenosynovitis (ß = 0.11, P = 0.026) associated with the visual analogue scale pain. Of the 1620 imaged joints, 447 (28%) were tender. MRI-detected synovitis associated independently with joint tenderness in all patients (odds ratio 1.74, P < 0.001), and in the ACPA-negative stratum (odds ratio 1.96, P < 0.001). In the ACPA-positive stratum only bone marrow oedema (osteitis) was independently associated with tenderness (odds ratio 2.39, P = 0.005). Sensitivity analyses in patients who developed inflammatory arthritis during follow-up (n = 61) revealed similar associations. Subclinical inflammation was present in 51% of tender joints and 39% of non-tender joints. Conclusion: In patients with arthralgia suspicious for progression to RA, MRI-detected subclinical inflammation is associated with overall pain and local joint tenderness. However, the association is partial, indicating that subclinical inflammation is not the sole explanation of the arthralgia.

Tenosynovitis caused by Scedosporium apiospermum infection misdiagnosed as an Alternaria species: a case report.

BACKGROUND: Scedosporium apiospermum, which can usually be isolated from soil, polluted stream water and decaying vegetation, is increasingly recognized as an opportunistic dematiaceous fungus. The mortality rate of infection in immunocompromised hosts is over 50%. S. apiospermum is commonly responsible for dermal and epidermal infections (i.e., mycetoma) after traumatic penetration. CASE PRESENTATION: A 73-year-old woman was admitted to our hospital complaining of painful swelling and tenderness on the dorsum of the proximal left wrist and hand. The symptoms had persisted for approximately 2 months. A physical examination revealed a 4 x 3 cm, poorly defined, erythematous papule, which was fluctuant, with pustules and crusts on the dorsum of the left hand. CONCLUSIONS: We report a very rare case of tenosynovitis caused by S. apiospermum infection. We identified the infectious agent via molecular DNA sequencing. The infectious agent was initially misidentified as an Alternaria species by microscopic examination with lactophenol cotton blue (LPCB) staining. The infection was successfully treated with debridement and adjuvant fluconazole therapy.

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients.

The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen's kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

Ultrasound-detected tenosynovitis independently associates with patient-reported flare in patients with rheumatoid arthritis in clinical remission: results from the observational study STARTER of the Italian Society for Rheumatology.

OBJECTIVES: This study aimed to estimate the prevalence of US-detected tenosynovitis in RA patients in clinical remission and to explore its clinical correlates. METHODS: A total of 427 RA patients in clinical remission were consecutively enrolled from 25 Italian rheumatology centres. Tenosynovitis and synovitis were scored by US grey scale (GS) and power Doppler (PD) semi-quantitative scoring systems at wrist and hand joints. Complete clinical assessment was performed by rheumatologists blinded to the US results. A flare questionnaire was used to assess unstable remission (primary outcome), HAQ for functional disability and radiographic erosions for damage (secondary outcomes). Cross-sectional relationships between the presence of each US finding and outcome variables are presented as odds ratios (ORs) and 95% CIs, both crude and adjusted for pre-specified confounders. RESULTS: The prevalence of tenosynovitis in clinical remission was 52.5% (95% CI 0.48, 0.57) for GS and 22.7% (95% CI 0.19, 0.27) for PD, while the prevalence of synovitis was 71.6% (95% CI 0.67, 0.76) for GS and 42% (95% CI 0.37, 0.47) for PD. Among clinical correlates, PD tenosynovitis associated with lower remission duration and morning stiffness while PD synovitis did not. Only PD tenosynovitis showed a significant association with the flare questionnaire [OR 1.95 (95% CI 1.17, 3.26)]. No cross-sectional associations were found with the HAQ. The presence of radiographic erosions associated with GS and PD synovitis but not with tenosynovitis. CONCLUSIONS: US-detected tenosynovitis is a frequent finding in RA patients in clinical remission and associates with unstable remission.

Validity and sensitivity to change of the semi-quantitative OMERACT ultrasound scoring system for tenosynovitis in patients with rheumatoid arthritis.

OBJECTIVES: The aim was to evaluate the metric properties of the semi-quantitative OMERACT US scoring system vs a novel quantitative US scoring system for tenosynovitis, by testing its intra- and inter-reader reliability, sensitivity to change and comparison with clinical tenosynovitis scoring in a 6-month follow-up study. METHODS: US and clinical assessments of the tendon sheaths of the clinically most affected hand and foot were performed at baseline, 3 and 6 months in 51 patients with RA. Tenosynovitis was assessed using the semi-quantitative scoring system (0-3) proposed by the OMERACT US group and a new quantitative US evaluation (0-100). A sum for US grey scale (GS), colour Doppler (CD) and pixel index (PI), respectively, was calculated for each patient. In 20 patients, intra- and inter-observer agreement was established between two independent investigators. A binary clinical tenosynovitis score was performed, calculating a sum score per patient. RESULTS: The intra- and inter-observer agreements for US tenosynovitis assessments were very good at baseline and for change for GS and CD, but less good for PI. The smallest detectable change was 0.97 for GS, 0.93 for CD and 30.1 for PI. The sensitivity to change from month 0 to 6 was high for GS and CD, and slightly higher than for clinical tenosynovitis score and PI. CONCLUSION: This study demonstrated an excellent intra- and inter-reader agreement between two investigators for the OMERACT US scoring system for tenosynovitis and a high ability to detect changes over time. Quantitative assessment by PI did not add further information.