Interventional ultrasound: a critical overview on ultrasound-guided injections and biopsies.

Over the last decades ultrasound-guided procedures have become increasingly diffused in rheumatology, mainly thanks to the technical advances achieved in the ultrasound (US) field, combined with the greater availability, good portability and reduced cost of US devices, compared to other imaging techniques already used in rheumatology units. The direct visualisation of the tissue under analysis and the real-time imaging performance enabled by US-guidance account for an improved accuracy and directness in needle placement in a number of rheumatology interventions such as tendon and intra-articular injections. Compared with blind procedures, US-guided injections are more accurate and safe and they result in better clinical outcome in terms of joints improvement in function and decreased risk of damages caused by needle misplacement. The accuracy in needle placement of US-guided injections has proven to be important not only in common intra-articular injections, but especially in case of complex anatomical areas like the hip, facet and atlanto-occipital joints, where blinded injections are deemed poorly accurate and thus highly risky. Moreover US guidance can be successfully employed in more complex procedures such as synovial biopsy, portal establishment or arthroscopy, where US can also be combined with other imaging techniques. Overall the employment of US-guided procedures is considered to be safe and well-tolerated, and increases the accuracy and therapeutic effectiveness of the interventions performed. This may pave the way for a more widespread employment of US-guidance in rheumatology units, and new studies could further explore the therapeutic advantages of these procedures.

High rate of disease remission in moderate rheumatoid arthritis on etanercept therapy: data from GISEA, the Italian biologics register.

The aim of this study was to evaluate the clinical outcomes of etanercept in rheumatoid arthritis (RA) patients with moderate or severe disease activity. We analyzed data from the Italian biologics register Gruppo Italiano Studio Early Arthritides (GISEA) to investigate the rate of disease remission and functional improvement, based on the 28-Joint Disease Activity Score (DAS28) and the (Health Assessment Questionnaire (HAQ) score in RA patients with moderate or severe disease activity beginning etanercept therapy. Disease was defined as severe (H-RA) with DAS28 ≥5.1 and moderate (M-RA) with DAS28 ≥3.2 to 5.1 at baseline. Patients were considered in remission if DAS28 was ≤2.6, and HAQ ≤0.5 defined normal function. We enrolled 953 RA patients, 320 with M-RA and 633 H-RA. Age and disease duration were similar in the two cohorts, but H-RA patients had significantly more comorbidities (p < 0.01) and took significantly more disease-modifying antirheumatic drugs (p < 0.001) than M-RA patients. After 1 year, the percentage of patients achieving disease remission and normal function (DAS28 ≤2.6 plus HAQ ≤0.5) was higher in M-RA (21.4 %) than in H-RA patients (14.8 %, p = 0.007), regardless of the disease duration. Additionally, female gender (p = 0.006) and H-RA class (p = 0.002) negatively predicted disease remission at 1 year. However, the drug survival rate did not differ between the two subsets. This study confirms that etanercept was effective in the treatment of active RA, but best response, in terms of disease remission and normal function ability, was greater and easier to attain in M-RA patients. These findings may aid clinicians to choose the best strategy to treat RA.

Use of ultrasound-assisted arthroscopy in rheumatology: an experience in 11 patients with different rheumatic diseases.

The 'real time' capability of ultrasound (US) allows dynamic assessment of joint and tendon movements, which can often aid in the detection of structural abnormalities. The simultaneous use of arthroscopy (AS) and US is therefore a logical progression. Here the results of a series of 11 patients with different rheumatic diseases in whom a combined use of US and AS was adopted are reported.

Improving diagnosis of early inflammatory arthritis : results of a novel triage system.

OBJECTIVES: Early treatment of inflammatory arthritis (IA) leads to reduced disease activity, reduced joint damage, decreased functional impairment and increased chance of remission. However, delay often occurs from referral to rheumatology appointment. This survey evaluated whether a preliminary triage carried out by healthcare workers without formal medical training could be effective in identifying patients with or without early IA. METHODS: Patients were recruited during their first call to our centre, before their first visit. A simple questionnaire, including three questions and aimed at investigating the presence of sign and symptoms of IA was developed. The same survey was administered twice: the first time, during patient's first call to our centre (telephone survey), and the second time, during their first visit with the rheumatologist (Ambulatory visit survey). We compared the outcomes of the survey with the actual diagnosis made by the rheumatologist following standard medical examination. RESULTS: In total 484 patients were included in the study, and 34/484 (7.02%) were confirmed to have early IA. The telephone survey was able to detect the non-early IA patients in 99.5% of cases; the same result was reported for the ambulatory visit survey. The median time required to complete the questionnaire was 1 minute in both surveys. CONCLUSIONS: The adoption of a simple survey, also administered by non-medical personnel, may effectively contribute to the early detection of IA.

Imaging in rheumatology: ultrasafe + ultrasure = ultrasound.

Technological advances in ultrasonography (US) in recent years has allowed for improvements to the imaging quality of gray-scale ultrasound and the development of more advanced forms of this imaging technique such as 3D and Doppler US. These improvements mean that US now has an accepted place in rheumatology not only in diagnosis, but also in the determination of disease progression and pathology and in facilitating guidance of interventional therapies. The increasing use of US-guided intervention by rheumatologists in the last 20 years is evidenced by the almost exponential increase in the number of publications in the relevant subjects.