Reliability of ultrasonography in detecting shoulder disease in patients with rheumatoid arthritis.

OBJECTIVE: To assess the intra and interobserver reproducibility of musculoskeletal ultrasonography (US) among rheumatologists in detecting destructive and inflammatory shoulder abnormalities in patients with rheumatoid arthritis (RA) and to determine the overall agreement between US and MRI. METHODS: A total of 14 observers examined 5 patients in 2 rounds independently and blindly of each other. US results were compared with MRI. Overall agreement of all findings, of positive findings on MRI, as well as intra and interobserver reliabilities, were calculated. RESULTS: Overall agreement between US and MRI was seen in 79% with regard to humeral head erosions (HHE), in 64% with regard to posterior recess synovitis (PRS), in 31% with regard to axillary recess synovitis (ARS), in 64% with regard to bursitis, in 50% with regard to biceps tenosynovitis (BT), and in 84% for complete cuff tear (CCT). Intraobserver and interobserver kappa was 0.69 and 0.43 for HHE, 0.29 and 0.49 for PRS, 0.57 and 1.00 for ARS, -0.17 and 0.51 for bursitis, 0.17 and 0.46 for BT and 0.52 and 0.6 for CCT, respectively. The intraobserver and interobserver kappa for power Doppler (PD) was 0.90 and 0.70 for glenohumeral signals and 0.60 and 0.51 for bursal signals, respectively. CONCLUSIONS: US is a reliable imaging technique for most shoulder pathology in RA especially with regard to PD. Standardisation of scanning technique and definitions of particular lesions may further enhance the reliability of US investigation of the shoulder.

[Reversible cognitive decline in a patient with relapsing polychondritis]. / Passagère cognitieve achteruitgang bij een patient met relapsing polychondritis.

Patient A, 58 years, is referred by the Rheumatologist to the Geriatrician concerning apathy. History reviews skipping arthritis, reddened and inflamed eyes, apathy and loss of interest. Physical examination revealed red tearing eyes, bradyphrenia and bradykinesia. Laboratory examination showed inflammation markers. The patient develops fever and bilateral reddened and inflamed ears. Diagnosis of relapsing polychondritis is made, the patient is treated with prednisone and the symptoms disappear. Relapsing polychondritis is a chronical disease associated with inflammation and destruction of cartilaginous structures and proteoglycan rich structures. We diagnosed Relapsing Polychondritis with a reversible dementia, probably due to cerebral vasculitis.

Can baseline ultrasound results help to predict failure to achieve DAS28 remission after 1 year of tight control treatment in early RA patients?

BACKGROUND: At present, there are no prognostic parameters unequivocally predicting treatment failure in early rheumatoid arthritis (RA) patients. We investigated whether baseline ultrasonography (US) findings of joints, when added to baseline clinical, laboratory, and radiographical data, could improve prediction of failure to achieve Disease Activity Score assessing 28 joints (DAS28) remission (<2.6) at 1 year in newly diagnosed RA patients. METHODS: A multicentre cohort of newly diagnosed RA patients was followed prospectively for 1 year. US of the hands, wrists, and feet was performed at baseline. Clinical, laboratory, and radiographical parameters were recorded. Primary analysis was the prediction by logistic regression of the absence of DAS28 remission 12 months after diagnosis and start of therapy. RESULTS: Of 194 patients included, 174 were used for the analysis, with complete data available for 159. In a multivariate model with baseline DAS28 (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.2-2.2), the presence of rheumatoid factor (OR 2.3, 95% CI 1.1-5.1), and type of monitoring strategy (OR 0.2, 95% CI 0.05-0.85), the addition of baseline US results for joints (OR 0.96, 95% CI 0.89-1.04) did not significantly improve the prediction of failure to achieve DAS28 remission (likelihood ratio test, 1.04; p = 0.31). CONCLUSION: In an early RA population, adding baseline ultrasonography of the hands, wrists, and feet to commonly available baseline characteristics did not improve prediction of failure to achieve DAS28 remission at 12 months. TRIAL REGISTRATION: Clinicaltrials.gov, NCT01752309 . Registered on 19 December 2012.

[Ultrasonography in rheumatological practice]. / Echografie in de reumatologische praktijk.

Musculoskeletal ultrasonography of the rheumatologist can be useful as a supplement to physical diagnostic assessment or as an aid to diagnostic puncture or therapeutic injection. The essence of musculoskeletal ultrasonography includes visualisation of joints and periarticular structures, muscles, tendons, tendon-sheets and insertions. With ultrasound, punctures, biopsies, and injections can be performed more precisely. A specific ultrasound technique is (color and power) doppler; three-dimensional ultrasonography is a promising new imaging modality. The learning curve of musculoskeletal ultrasonography differs according to indication. Data regarding the validity, reproducibility, sensivity and specificity of ultrasonographic findings are scarce. Further development of guidelines for the use and indications of musculoskeletal ultrasonography is warranted.

Clinical effect of radiation synovectomy of the upper extremity joints: a randomised, double-blind, placebo-controlled study.

PURPOSE: To compare the clinical efficacy of radiosynoviorthesis (RSO) with intra-articular radionuclide plus glucocorticoid (GC) injection (group A) with that of placebo plus GC injection (group B) for the treatment of persistent synovitis in joints of the upper extremity. METHODS: At baseline and at 6 and 12 months after intra-articular injection, six clinical parameters were scored. Changes in clinical values over time were summed to provide a change composite index (CCI), ranging from 0 (no effect) to 12 (maximal effect). A CCI > or =6 was considered to indicate successful treatment. Differences in response rate and CCI between groups A and B were examined. Regression analyses were performed to explore whether baseline variables could predict therapeutic effect. RESULTS: Sixty-eight joints in 44 patients were treated. Six months after intra-articular injection, response rates (CCI > or =6) were 69% (25/36) in group A and 29% (9/31) in group B (p=0.001). The mean CCIs +/- standard deviation at 6 months were 6.7+/-3.2 for group A and 3.3+/-3.8 for group B (p=0.001). At 12 months the response rates were 69% (25/36) in group A and 32% (8/25) in group B (p=0.004). The mean CCIs at 12 months were 6.8+/-3.3 for group A and 4.2+/-4.7 for group B (p= 0.046). None of the baseline variables predicted the therapeutic effect. CONCLUSION: RSO (radionuclide plus GC) of upper extremity joints with immobilisation for 72 h shows a significantly better response rate than placebo plus GC in patients with persistent synovitis after at least one failed outpatient intra-articular GC injection.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course.

OBJECTIVE: To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography. METHODS: The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results. RESULTS: Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae. CONCLUSIONS: Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.