A Vascular Obstacle in Ultrasound-Guided Hip Joint Injection.

BACKGROUND: We evaluated the risk of lateral circumflex femoral artery (LCFA) injury during ultrasound-guided intra-articular hip injections. METHODS: This study was divided into three parts. (1) Four ultrasound-guided hip injections were performed on human cadavers. With needles in place, tissues were dissected to expose the LCFA. (2) Ultrasound-trained rheumatologists marked a planned needle trajectory from skin to hip joint on live human ultrasound images during an Observed Structured Clinical Examination (OSCE). Doppler was subsequently activated to locate the LCFA, and the distance between trajectory and arterial signal was recorded. (3) Rheumatologists certified in musculoskeletal ultrasound were surveyed about joint injection vascular complications. RESULTS: (1) In one of the four cadaveric dissections, the needle made direct contact with the LCFA. (2) Of 27 OSCE participants, only two activated Doppler before marking simulated hip injection trajectories. Trajectories passed through LCFA Doppler signal in six (22%) cases. Mean minimal distance from trajectory to arterial signal was 4 mm (range, 0-11 mm). (3) Of 62 survey respondents, 24% stated that they did not use Doppler routinely. While none reported bleeding injuries with their patients, 16% knew of a hip injection-related vascular complication performed by another provider. CONCLUSION: There is a risk of LCFA injury during ultrasound-guided hip joint injection. Routine use of Doppler should be considered in standard hip injection protocols.

Does starting allopurinol prolong acute treated gout? A randomized clinical trial.

BACKGROUND: Traditionally, allopurinol is not initiated during an acute gout attack to avoid prolonging the painful arthritis. The 2012 American College of Rheumatology Guidelines for the Management of Gout suggest that urate-lowering therapy can be started during an acute attack, based on "consensus opinion of experts, case studies, or standard of care." OBJECTIVE: The aim of this study was to determine whether initiating allopurinol will adversely affect the resolution of acute, treated gout. METHODS: We conducted a 28-day, placebo-controlled, double-blind study of allopurinol initiation in patients with acute gout. Patients with crystal-proven gout by arthrocentesis were enrolled if they presented to the rheumatology clinic with an acute gout attack within 72 hours from initial therapy. The patients were also required to meet at least 1 additional criterion for urate-lowering therapy including (1) the presence of gouty tophi, (2) more than 1 acute gout attack per year, (3) a history of nephrolithiasis, or (4) urate overproduction (>1000 mg in 24-hour urine collection). Patients were excluded from the study if they had a glomerular filtration rate of less than 50 or liver function test of greater than 1.25 times the upper limit of normal. The treating physician determined therapy for the acute gout attack. Standard prophylaxis, with colchicine or nonsteroidal anti-inflammatory drugs, was prescribed. Allopurinol or placebo was initiated at 100 mg daily for the first 14 days and then increased to 200 mg daily for the next 14 days. The primary end point was protocol defined days to resolution of acute gout, incorporating patient-rated joint pain and physician examination. Secondary measures included Physician Global Assessment, patient-rated pain, adverse effects of therapy, and serum uric acid. RESULTS: Thirty-one patients (17 on placebo, 14 on allopurinol) completed the study. Both intent-to-treat and completer analyses showed only a statistically insignificant difference in days to resolution (15.4 days in the allopurinol group completers vs 13.4 days in the placebo group; P = 0.5). The secondary measures revealed that the acute phase of pain rapidly improved in both groups. CONCLUSIONS: We initiated allopurinol at low doses during an acute gout attack in patients who met criteria for starting urate-lowering therapy and did not have abnormal kidney or liver function. In this cohort, allopurinol did not prolong the acute, treated attack.

Musculoskeletal ultrasound training and competency assessment program for rheumatology fellows.

OBJECTIVES: The purpose of this study was to establish standards for musculoskeletal ultrasound competency through knowledge and skills testing using criterion-referenced methods. METHODS: Two groups of rheumatology fellows trained in musculoskeletal ultrasound through a standardized curriculum, which required submission of ultrasound studies for review over 8 months. Both groups then completed written and practical examinations in musculoskeletal ultrasound. Instructors, advanced users, and intermediate users of musculoskeletal ultrasound served as comparison groups. A passing score (competency) was established for the written examination by the Angoff procedure and for the practical examination by the borderline method. RESULTS: Thirty-eight fellows (19 in each group) took the final examination. Five fellows failed the written examination, and 1 failed the practical examination, whereas none of the advanced users failed. Written examination scores did not differ between the two fellow groups (74% versus 70%; P > .05), were reliable, and were able to discriminate between the intermediate and advanced groups. Practical and written examination results correlated in both groups (first group, r = 0.70; P = .0008; second group, r = 0.59; P = .009). CONCLUSIONS: Criterion-referenced methods were used for the first time to determine fellow musculoskeletal ultrasound competency. The examination used to determine competency was reproducible, was reliable, and could differentiate musculoskeletal ultrasound users with different levels of experience. Most rheumatology fellows completing our program passed the written and practical examinations, suggesting achievement of basic musculoskeletal ultrasound competency.

Prevalence of Fibromyalgia Syndrome in Active-Duty Military Personnel.

OBJECTIVE: Previous research with civilian populations has found strong associations between fibromyalgia (FM) and posttraumatic stress disorder (PTSD). We undertook this study to investigate the prevalence of FM in military service members with and without PTSD. METHODS: Participants were active duty military personnel recruited into either an epidemiologic cohort study of service members before a military deployment or 1 of 3 PTSD treatment trials. Instruments used to document FM and PTSD included the PTSD Checklist-Stressor-Specific Version, the PTSD Symptom Scale-Interview, and the 2012 American College of Rheumatology FM questionnaire. RESULTS: Across the 4 studies, 4,376 subjects completed surveys. The prevalence of FM was 2.9% in the predeployment cohort, and the prevalence was significantly higher in individuals with PTSD (10.8%) compared with those without PTSD (0.8%). In the treatment trials, all of the participants met criteria for PTSD before starting treatment, and the prevalence of FM was 39.7%. CONCLUSION: The prevalence of FM in active duty service members preparing to deploy is similar to that reported for the general population of the US but is higher than expected for a predominantly male cohort. Furthermore, the prevalence of FM was significantly higher in service members with comorbid PTSD and was highest among those seeking treatment for PTSD. Further investigation is needed to determine the factors linking PTSD and FM.

STRONG STAR and the Consortium to Alleviate PTSD: Shaping the future of combat PTSD and related conditions in military and veteran populations.

The STRONG STAR Consortium (South Texas Research Organizational Network Guiding Studies on Trauma and Resilience) and the Consortium to Alleviate PTSD are interdisciplinary and multi-institutional research consortia focused on the detection, diagnosis, prevention, and treatment of combat-related posttraumatic stress disorder (PTSD) and comorbid conditions in military personnel and veterans. This manuscript outlines the consortia's state-of-the-science collaborative research model and how this can be used as a roadmap for future trauma-related research. STRONG STAR was initially funded for 5 years in 2008 by the U.S. Department of Defense's (DoD) Psychological Health and Traumatic Brain Injury Research Program. Since the initial funding of STRONG STAR, almost 50 additional peer-reviewed STRONG STAR-affiliated projects have been funded through the DoD, the U.S. Department of Veterans Affairs (VA), the National Institutes of Health, and private organizations. In 2013, STRONG STAR investigators partnered with the VA's National Center for PTSD and were selected for joint DoD/VA funding to establish the Consortium to Alleviate PTSD. STRONG STAR and the Consortium to Alleviate PTSD have assembled a critical mass of investigators and institutions with the synergy required to make major scientific and public health advances in the prevention and treatment of combat PTSD and related conditions. This manuscript provides an overview of the establishment of these two research consortia, including their history, vision, mission, goals, and accomplishments. Comprehensive tables provide descriptions of over 70 projects supported by the consortia. Examples are provided of collaborations among over 50 worldwide academic research institutions and over 150 investigators.

Musculoskeletal Ultrasound Instruction in Adult Rheumatology Fellowship Programs.

OBJECTIVE: Musculoskeletal ultrasound (MSUS) in rheumatology in the US has advanced by way of promotion of certifications and standards of use and inclusion of core fellowship curriculum. In order to inform endeavors for curricular integration, the objectives of the present study were to assess current program needs for curricular incorporation and the teaching methods that are being employed. METHODS: A needs-assessment survey (S1) was sent to 113 rheumatology fellowship program directors. For programs that taught MSUS, a curriculum survey (S2) was sent to lead faculty. Programs were stratified according to program size and use of a formal written curriculum. RESULTS: S1 (108 of 113 respondents; response rate 96%) revealed that 94% of programs taught MSUS, with 41% having a curriculum. Curricular implementation was unaffected by program size. Formal curricular adoption of MSUS was favored by 103 directors (95.3%), with 65.7% preferring such adoption to be optional. S2 (74 of 101 respondents; response rate 73%) showed that 41% of programs utilized a formal curriculum. Multiple teaching strategies were used, with content that was generally similar. Use of external courses, including the Ultrasound School of North American Rheumatologists course, was prevalent. Fewer barriers were noted compared to past surveys, but inadequate time, funding, and number of trained faculty still remained. Lack of divisional interest (P = 0.046) and interest of fellows (P = 0.012) were noted among programs without a formal curriculum. CONCLUSION: MSUS is taught by a significantly larger number of rheumatology fellowship programs today. Multiple teaching strategies are used with common content, and barriers still remain for some programs. Most program directors favor inclusion of a standardized MSUS curriculum, with many favoring inclusion to be optional.

Non-popliteal synovial rupture.

The ruptured popliteal synovial cyst is a common complication of chronic knee arthritis. In contrast, non-popliteal synovial rupture is less well recognized and may present a diagnostic dilemma. We report an 81-year-old woman who presented with chest wall pain and ecchymosis. Ultrasonography of the shoulder region readily diagnosed a dissecting parasynovial cyst. She developed the unusual complication of contralateral recurrence. Literature review revealed a small but important set of non-popliteal synovial ruptures in the regions of the shoulder, elbow, wrist, spine, hip, knee, and ankle. Local swelling, inflammation, ecchymosis, and nerve impingement may mimic other conditions. Awareness of the clinical presentations and a high index of suspicion are required to avoid diagnostic confusion. Management data are limited to case reports of arthrocentesis, injection, and very rarely, surgery.

Fibromyalgia in Primary Care.

Fibromyalgia is a common disorder and has substantial impact on quality of life. The cause remains unknown, but current evidence points to multifactorial involvement of pain processing. Clinical diagnosis is aided by evidence-based diagnostic criteria with subscores for widespread pain and symptom severity. Nonpharmacologic treatments, including cognitive behavioral therapy, sleep hygiene, and regular aerobic exercise, form the cornerstone of management. Pharmacologic intervention is an important adjunct, but benefit is variable. There is no cure for fibromyalgia at this time, but persistence and patience in management may lead to a satisfactory lifestyle.

Ultrasonographic Evidence of Persistent Synovitis in a Chikungunya-Infected Service Member.

Chikungunya virus (CHIKV) is an arthropod-borne alphavirus initially endemic to Central and East Africa but now spreading to Asia, Europe, and most recently the Western hemisphere. CHIKV infection initially presents as an acute, nonspecific febrile syndrome with rash and polyarthralgia, later leading to a chronic arthritis clinically similar to rheumatoid arthritis. We report a case of an active duty military member infected with CHIKV while deployed to Central America, who developed chronic arthritis. Active duty military members are at higher risk of contracting CHIKV because of deployment to countries with a high prevalence of this mosquito-borne illness. Severe chronic arthritis can result from CHIKV, resulting in serious impact on fitness for military duty.

Ultrasound Features of the Posterior Tibialis Tendon and Peroneus Brevis Tendon Entheses: Comparison Study Between Healthy Adults and Those With Inflammatory Arthritis.

OBJECTIVE: Limited literature exists on the sonographic appearance of the posterior tibialis tendon (PTT) and the peroneus brevis tendon (PBT) entheses. We determined the anatomic features and best imaging techniques of normal PTT and PBT using musculoskeletal ultrasound and compared these findings to subjects with inflammatory arthritis. METHODS: Adult subjects were enrolled as healthy controls (HCs), rheumatoid arthritis (RA) patients, or spondyloarthropathy (SpA) patients. Bilateral PTT and PBT entheses were imaged longitudinally, comparing 2 angles of insonation: perpendicular to the skin surface and 45° cephalad. Images were scored on semiquantitative scales assessing pathology. RESULTS: A total of 78 subjects were enrolled (37 HC, 21 RA, and 20 SpA). Complete enthesis visualization was achieved more frequently in the perpendicular than in the cephalad view for the PBT (76.3% versus 58.7%), but more frequently in the cephalad view for the PTT (58.0% versus 19.6%). RA and SpA subjects had higher rates of PTT fiber disruption (P < 0.001), PTT tenosynovial effusion (P < 0.001), and Doppler signal (P < 0.001) than HCs. No significant differences existed at the PBT enthesis. In multivariate analysis, RA and SpA subjects were found to be 5.1 times (P < 0.001) and 3.6 times (P < 0.001) more likely to exhibit ultrasound-detected pathology, respectively, than HCs. CONCLUSION: The perpendicular transducer aim is optimal for imaging the PBT, while the cephalad transducer orientation was more effective for evaluation of the PTT. Unlike distal PBT imaging, PTT imaging distinguished healthy and disease states, with both RA and SpA patients showing features of PTT enthesopathy. Distal PTT imaging is a useful technique for musculoskeletal ultrasound.

Anthrax Vaccine and the Risk of Rheumatoid Arthritis and Systemic Lupus Erythematosus in the U.S. Military: A Case-Control Study.

U.S. military personnel assigned to areas deemed to be at high risk for anthrax attack receive Anthrax Vaccine Adsorbed (AVA). Few cases of rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have been reported in persons who received AVA. Using a matched case-control study design, we assessed the relationship of RA and SLE with AVA vaccination using the Defense Medical Surveillance System. We identified potential cases using International Classification of Diseases, 9th Revision, Clinical Modification codes and confirmed cases with medical record review and rheumatologist adjudication. Using conditional logistic regression, we estimated odds ratios (OR) for AVA exposure during time intervals ranging from 90 to 1,095 days before disease onset. Among 77 RA cases, 13 (17%) had ever received AVA. RA cases were no more likely than controls to have received AVA when looking back 1,095 days (OR: 1.03; 95% confidence interval [CI]: 0.48-2.19) but had greater odds of exposure in the prior 90 days (OR: 3.93; 95% CI: 1.08-14.27). Among the 39 SLE cases, 5 (13%) had ever received AVA; no significant difference in receipt of AVA was found when compared with controls (OR: 0.91; 95% CI: 0.26-3.25). AVA was associated with recent onset RA, but did not increase the risk of developing RA in the long term.

Utility of musculoskeletal ultrasound in a Department of Defense rheumatology practice: a four-year retrospective experience.

OBJECTIVE: To analyze the utility of musculoskeletal ultrasound (MSUS) in a rheumatology department and characterize relevant clinical trends. METHODS: Electronic medical records of all patients (n = 503) requiring MSUS in our department from January 2007 to December 2011 were reviewed. Rheumatologists performed MSUS using MyLab 25 or MyLab 70 systems. Clinical data were collected, including age, sex, symptoms, joint(s) examined, MSUS findings, procedures, further radiologic studies, and additional specialty consults. Results were tabulated from 717 total MSUS encounters and each was categorized as a completed encounter or an incomplete encounter. All magnetic resonance imaging (MRI) reports that followed MSUS were examined for concurrence. Cumulative numbers of MSUS examinations and MRIs were totaled. The Medicare global national average cost for MRIs and potential savings were calculated. RESULTS: A total of 789 joint sites were examined by MSUS. There were 84 US-guided procedures. Overall, 158 specialty consults were generated. After MSUS, 55 additional radiologic studies were ordered. There were 613 (85.5%) primary completed MSUS encounters and 104 cases (14.5%) requiring further imaging studies or an orthopedic consultation. There was an increased use of MSUS and a concurrent decreased use of MRI in our department over 4 consecutive years. We calculated the total potential savings from our rheumatology service to the Department of Defense as approximately $27,937.80 to $38,047.20 over 4 years. CONCLUSION: MSUS has a positive impact in a rheumatology practice. MSUS augments the clinical examination, influences diagnosis and management, decreases reliance on other imaging modalities, and reduces health care costs.

Musculoskeletal ultrasound objective structured clinical examination: an assessment of the test.

OBJECTIVE: To determine the reliability and validity of an objective structured clinical examination (OSCE) for musculoskeletal ultrasound (MSUS). METHODS: A 9-station OSCE was administered to 35 rheumatology fellows trained in MSUS and to 3 expert faculty (controls). Participants were unaware of joint health (5 diseased/4 healthy). Faculty assessors (n = 9) graded image quality with predefined checklists and a 0-5 global rating, blinded to who performed the study. Interrater reliability, correlation between a written multiple choice question examination (MCQ) and OSCE performance, and comparison of fellow OSCE results with those of the faculty were measured to determine OSCE reliability, concurrent validity, and construct validity. RESULTS: Assessors' interrater reliability was good (intraclass correlation coefficient [ICC] 0.7). Score reliability was good in the normal wrist and ankle stations (ICC 0.7) and moderate in the abnormal wrist and ankle stations (ICC 0.4). MCQ grades significantly correlated with OSCE grades (r = 0.52, P < 0.01). The fellows in the bottom quartile of the MCQ scored 3.07 on the OSCE, significantly worse than the top quartile fellows (3.32) and the faculty (3.29; P < 0.01). Scores also significantly discriminated bottom quartile fellows from faculty in the normal wrist and ankle stations (3.38 versus 3.78; P < 0.01), but not in the abnormal stations (3.37 versus 3.49; P = 0.08). CONCLUSION: MSUS OSCE is a reliable and valid method for evaluation of MSUS skill. Normal joint assessment stations are more reliable than abnormal joint assessment stations and better discriminate poorly performing fellows from faculty. Therefore, MSUS OSCE with normal joints can be used for the assessment of MSUS skill competency.