Ultrasound guided injection with Collagen-based Medical Device: real-life evaluation of efficacy and safety in hip osteoarthritis.

AIMS: Data regarding the treatment of hip osteoarthritis (OA) with collagen-based extracellular bio-scaffolds are lacking. We evaluated the treatment of hip OA with ultrasound guided intraarticular injections of Collagen-based Medical Device (CMD). MATERIAL AND METHODS: Forty-four patients with Kellgren-Lawrence grade (KLG) I or II were selected, and 20/44 randomly selected patients (CMD group), were treated with 2 weekly consecutive ultrasound guided intraarticular injections of CMD (MD-HIP, Guna S.p.a. Milan, Italy). An additional 24/44 patients were treated with oral non-steroidal anti-inflammatory drugs (NSAIDs) daily (NSAIDs group). Clinical assessment, X-rays and ultrasound evaluation were performed at baseline, and after 1 month in both groups, and after 3 months in the CMD group. Outcome measures were general pain VAS (0-10), the whole WOMAC score, and the WOMAC specific subscores. RESULTS: CMD and NSAIDs group were homogenous for age, gender, VAS pain and WOMAC scores. The CMD group had significant improvement of the VAS pain (p<0.0001), global WOMAC score (p<0.0001) and WOMAC function (p<0.0001) from baseline to the 1st month, with further improvement from the 1st to the 3rd month (p<0,001; p<0.01; p<0.03, respectively). Significant improvement in WOMAC pain (p<0.0001) and WOMAC stiffness (p<0.0001) was detected at 1st month, with no significant change at 3rd month. In the NSAIDs group significant improvement in WOMAC function was detected after 1 month (p=0.021) only. No adverse events were recorded in the CMD and NSAIDs group. CONCLUSION: The ultrasound guided intraarticular hip injections of CMD resulted in significant improvement in VAS pain and WOMAC scores compared to treatment with oral NSAIDs.

The "starry night" (diffuse microcalcific myopathy) - thousands of muscle microcalcifications after 30 years of Trichinella infection detected by ultrasound.

Trichinellosis, a parasitosis transmitted through consumption of raw or undercooked meat from pigs and game animals, is responsible for a specific myositis. The calcifications of infected myocytes and larva can be detected during many years postin-fection. We present the case of a male patient with a history of severe trichinellosis with disease onset 30 years ago, presenting with generalized muscle microcalcifications detected during musculoskeletal ultrasound evaluation. The ultrasound aspect of the muscles was indeed spectacular; hence, the comparison with a "starry night".

Ultrasound-guided injection with hyaluronic acid in hip osteoarthritis: efficacy and safety in a real-life setting.

BACKGROUND: For knee OA, EULAR has included hyaluronic acid (HA) intra-articular injection in the 2003 recommendations, making the intra-articular injection a sound therapeutic option. The ultrasound-guided intra-articular injections (USGIAI) have been demonstrated to be more efficient and safe in comparison to the blind procedure. Our objectives were to evaluate the short- and medium-term efficacy and safety of USGIAI of HA in moderate hip OA and patients' additional NSAIDs/pain killer intake. PATIENTS AND METHODS: Patients with hip OA (KLG II/III), that failed standard of care therapy, received 3 consecutive HA-USGIAI (case group) while other patients (KLG II/III) treated according to current guidelines were chosen as a control group. Demographic data, comorbidities and medication intake were recorded. VAS pain scale and WOMAC score were performed at baseline and at 3 months. In the case group, they were additionally scored at 6 months. At baseline and at 6 months, hip X-ray assessment was also made. Ultrasound evaluation was made at each visit. RESULTS: In the case group, 15 patients were enrolled and 28 hip joints were injected. The control group consisted of 17 hip OA patients. In the case group, pain evaluated by VAS score and WOMAC score were significantly and progressively decreased (p < 0.0001) from baseline up to 3 and 6 months, respectively. Indeed, the case group showed a significantly lower NSAIDs/pain killer median intake at 3 months from baseline (p < 0.05). CONCLUSION: Our data suggest that HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits. Key Points • US hip evaluation before interventional maneuvers may identify capsular distension suggestive for concomitant septic involvement, microcrystal arthropathy or incipient hip osteonecrosis. • USGIAI may be fundamental to achieve an efficacious and safe injection. • HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits.

A questionnaire-based study on contraceptive practice in patients with rheumatic disease found no significant difference in age-matched healthy controls.

OBJECTIVE: Birth control is crucial in preventing unplanned pregnancy. The study analyzed contraceptive practice in women and men with rheumatic disease. METHODS: A questionnaire-based study investigated the actual contraceptive practices in patients of reproductive age from three European countries and compared them to age-matched healthy women and men. Associations between patient characteristics and contraception behavior were analyzed by association analysis. RESULTS: No significant difference in the frequency of contraception use was found in 133 rheumatic patients compared to 122 healthy controls. The main reason for not using contraception was lack of partner or the wish to become pregnant, whereas the current use of contraception was predominantly to limit family size in general or at this stage of life. Both patients and controls preferred barrier methods (48% and 45%, respectively) followed by hormonal contraceptives (31% and 38%, respectively). Characteristics associated with less use of contraception in patients were living single, having no children, and for being religious, whereas gender and education had no influence. Treatment with teratogenic drugs was no major patient concern, and 13 of 30 female patients using methotrexate, mycophenolate mofetil, or leflunomide did not practice birth control. CONCLUSION: Patients used contraception less frequently than healthy individuals, and the main reason for use was to limit family size. Contraception should be an integral part of counseling patients of fertile age, since the patient-preferred methods in case of active disease or therapy with teratogenic drugs were unreliable for the prevention of pregnancy.

Pregnancy Outcomes in Couples with Males Exposed to Longterm Anti-tumor Necrosis Factor-α Inhibitor Therapies: A Prospective Study.

OBJECTIVE: To examine the pregnancy achievement and outcomes in couples in which men with spondyloarthritis (SpA) were exposed to tumor necrosis factor inhibitors (TNFi). METHODS: Information about pregnancies involving fathers with SpA was prospectively collected by 6 Romanian rheumatology centers. RESULTS: Twenty-seven patients achieved 33 pregnancies and fathered 30 healthy children. Three elective abortions (personal reasons) and no spontaneous abortions, preeclampsia/eclampsia, stillbirths, congenital malformations, or pathologies in the children were recorded. Five patients showed normospermia before and after longterm TNFi treatment. CONCLUSION: Pregnancy and child outcomes in male patients with SpA exposed to longterm TNFi therapy were reassuring.

Ultrasound of Subtalar Joint Synovitis in Patients with Rheumatoid Arthritis: Results of an OMERACT Reliability Exercise Using Consensual Definitions.

OBJECTIVE: To evaluate the intraobserver and interobserver reliability of the ultrasonographic (US) assessment of subtalar joint (STJ) synovitis in patients with rheumatoid arthritis (RA). METHODS: Following a Delphi process, 12 sonographers conducted an US reliability exercise on 10 RA patients with hindfoot pain. The anteromedial, posteromedial, and posterolateral STJ was assessed using B-mode and power Doppler (PD) techniques according to an agreed US protocol and using a 4-grade semiquantitative grading score for synovitis [synovial hypertrophy (SH) and signal] and a dichotomous score for the presence of joint effusion (JE). Intraobserver and interobserver reliability were computed by Cohen's and Light's κ. Weighted κ coefficients with absolute weighting were computed for B-mode and PD signal. RESULTS: Mean weighted Cohen's κ for SH, PD, and JE were 0.80 (95% CI 0.62-0.98), 0.61 (95% CI 0.48-0.73), and 0.52 (95% CI 0.36-0.67), respectively. Weighted Cohen's κ for SH, PD, and JE in the anteromedial, posteromedial, and posterolateral STJ were -0.04 to 0.79, 0.42-0.95, and 0.28-0.77; 0.31-1, -0.05 to 0.65, and -0.2 to 0.69; 0.66-1, 0.52-1, and 0.42-0.88, respectively. Weighted Light's κ for SH was 0.67 (95% CI 0.58-0.74), 0.46 (95% CI 0.35-0.59) for PD, and 0.16 (95% CI 0.08-0.27) for JE. Weighted Light's κ for SH, PD, and JE were 0.63 (95% CI 0.45-0.82), 0.33 (95% CI 0.19-0.42), and 0.09 (95% CI -0.01 to 0.19), for the anteromedial; 0.49 (95% CI 0.27-0.64), 0.35 (95% CI 0.27-0.4), and 0.04 (95% CI -0.06 to 0.1) for posteromedial; and 0.82 (95% CI 0.75-0.89), 0.66 (95% CI 0.56-0.8), and 0.18 (95% CI 0.04-0.34) for posterolateral STJ, respectively. CONCLUSION: Using a multisite assessment, US appears to be a reliable tool for assessing synovitis of STJ in RA.

Schwannoma of the median nerve mimicking carpal tunnel syndrome in a pregnant patient. Case report.

In patients with symptoms of a peripheral neuropathy especially during pregnancy, use of imaging techniques such as Ultrasound (US) and Magnetic Resonance Imaging (MRI) may be essential for the diagnostic accomplishment. A 30-weekspregnant diabetic female attending US evaluation due to intermittent hand pain, numbness, and weakness bilaterally. Although, the US evaluation revealed the median nerve (MN) normal size, echogenicity and echo-texture within the right carpal tunnel; the US assessment applied proximally to the carpal tunnel, revealed a hypoechoic tumor-like mass and increased MN cross section area. In transverse view, the MN was detected as an eccentric, hypoechoic structure compressed by the aforementioned mass. A presence of MN schwannoma or neurofibroma was suspected. US has been proved to be extremely useful to determine location, extent as well as the type of nerve lesion.

Concepts in diagnosing, scoring, and monitoring tenosynovitis and other tendon abnormalities in patients with rheumatoid arthritis- the role of musculoskeletal ultrasound.

In the last years, important advancements have been made in implementing high resolution imaging related information inside the global management algorithm in RA patients. Musculoskeletal ultrasound has already proven its utility in visualizing directly the joint synovial tissue, the synovial vascularization and in monitoring the response to therapy. Recently, much attention has been given to the presence of tenosynovitis, as a constant, complementary but different facet of the inflammatory involvement in RA. Tenosynovitis identification in early RA stages may allow adequate treatment adjustment in early and established disease in order to prevent and/ or slow down the development of structural damage at tendon and joint level.

Musculoskeletal ultrasound guided manoeuvres - a security profile.

BACKGROUND: In daily rheumatology clinical practice, routine interventional musculoskeletal ultrasound (MSUS) guided maneuvers such as aspiration, intraarticular or periarticular drug injections require efficient cleaning and disinfection methods for both transducer and patient's skin. AIM: To study the efficacy of probe and skin disinfection measures after using simple protocols, to identify the prevalence of septic and other drug related side effects after MSUS guided interventions and to quantify the total procedure time. MATERIAL AND METHODS: Recruitment of consecutive patients with different joint/ periarticular MSUS guided interventions was made in 3 medical centers. Bacterial load was determined on the transducers footprint after dry cleaning with the removal of any gel trace and on patients' skin after rigorous skin disinfection with either Bethadine or alcohol 70° and Bethadine. Non-sterile gel was used as an ultrasound transmission medium. The time spent for some of the invasive procedures was quantified. RESULTS: Nine hundred and ninety eight MSUS guided interventional maneuvers were performed in 945 patients with inflammatory and degenerative musculoskeletal pathologies. Staphylococcus epidermidis was identified in 13.33% cases of the skin bacterial load analysis and in 37.50% cases of the footprint analysis. In two patients pathogenetic germs were detected on the skin. No septic post-procedural complications were reported. In 0.6% of the cohort other side effects occurred: aseptic osteonecrosis, skin depigmentation at injection site and iatrogenic microcristaline reactions. The median time frame dedicated to the intervention was 6 minutes. CONCLUSION: Rigorous transducer dry cleaning and Bethadine / Bethadine and alcohol 70° skin disinfection are efficacious methods. The risk for septic complications and other drug related side effects related to MSUS guided injections is very low in this context. A correct injection technique must accompany the previous requests. Rapid and safe interventional maneuvers reduce the risks and control the costs of the healthcare system.

TNF-α inhibitors do not impair sperm quality in males with ankylosing spondylitis after short-term or long-term treatment.

OBJECTIVE: The aim of this study was to study the influence of active disease status and TNF-α antagonists on sperm quality in a group of AS patients. METHODS: Twenty-three active AS patients and 42 controls were recruited. Patients' sperm samples were analysed at baseline (previous to) and at 3-6 months after TNF-α therapy (adalimumab, infliximab, etanercept) administration. Baseline assessment was made for only 20 patients, 2 of them proving to have normal fertility, 2 having a pregnant stable partner and the third having a 9-month-old child. Six patients were retested after 12 months of biologic therapy. Each patient acted as his own comparator. Results were further compared with sperm samples from age-matched controls. Sperm analysis was performed according to the World Health Organization (WHO) 1999 guidelines. RESULTS: Patients' baseline assessment showed normozoospermia in 91% and oligozoospermia in 9% of patients. No significant differences in sperm quality were noticed at follow-up visits compared with baseline. Comparison to controls showed no statistically significant differences in semen quality, with some exceptions: the control group presented a higher percentage of non-progressive and immobile sperm cells and higher numbers of head and tail atypias. CONCLUSION: Sperm quality in patients with active AS and after receiving short- and long-term TNF-α blocker therapy is comparable to sperm quality in healthy controls. Our study confirms that the disease process of AS does not have a major impact on sperm quality and that treatment with anti-TNF has no negative impact on sperm quality even under long-term treatment.

Impact of musculoskeletal ultrasound in an outpatient rheumatology clinic.

OBJECTIVE: To evaluate the impact of musculoskeletal ultrasound (MSUS) as a complementary method to clinical assessment on rapid diagnosis and therapeutic decisions in a busy outpatient rheumatology clinic. METHODS: Sixty patients with different musculoskeletal symptoms were included in the study. Three expert rheumatologists performed the clinical examination and filled out a standardized clinical report sheet with the following parameters: general and/or local diagnoses, planned systemic and/or local treatment, and their decision concerning the use of MSUS evaluation complementary to clinical examination. Another rheumatologist, blinded to clinical data, performed the MSUS assessment of the anatomic areas selected by the clinicians. The impact of the new information obtained by MSUS on the initial diagnosis and therapeutic strategy was estimated by the degree of change in the initial clinical diagnosis and therapy decisions. RESULTS: Of 60 patients (67 anatomic areas), MSUS was considered as necessary after clinical examination in 39 patients (65%), totaling 43 anatomic areas (64.17%). An overall change of the initial clinical diagnosis was present in 60% of the anatomic areas (P = 0.0175). In all of the anatomic areas (100%), the new diagnosis was more objective and detailed. An overall change of the initial systemic therapy was present in 25% of anatomic areas (P = 0.0014) and in 36% of anatomic areas (P = 0.095) for local therapy. A guided diagnostic aspiration was decided to be performed in 15% of anatomic areas and a guided therapeutic injection in 22% of anatomic areas. CONCLUSION: Enhanced information obtained by MSUS evaluation leads to changes, with a significant impact on the initial diagnosis and treatment strategy designed after clinical examination.

Ultrasonography of the hip.

A complete physical examination of the hip is often difficult due to its size and deep position. During the last two decades, ultrasonography (US) of the hip has been widely accepted as a useful diagnostic tool in patients with hip pain and /or limited range of motion. It is commonly used in both adults and children. This technique allows evaluation of different anatomical structures and their pathological changes, such as joint recess (joint effusion, synovial hypertrophy), changes within the bursae (bursitis), tendons and muscles (tendinopathy, ruptures, calcifications), as well as changes in the bony profile of the joint surfaces, ischial tuberosity, and greater trochanter (erosions, osteophytes, calcific deposits). US is very useful for guided procedures in hip joint and periarticular soft tissues under direct visualization. The needle aspiration of synovial fluid and steroid injections are commonly-applied activities in daily rheumatology practice. The relatively limited acoustic windows available to the US beam are the principal limitations to hip US. Therefore, conducting a detailed examination of some important structures together with the interpretation of Doppler signal (sometimes undetectable) is not easy, requiring good knowledge of the modality. The aim of this review is to analyze the current literature about US of the hip and to describe the most frequently-observed normal and pathological findings.

Ultrasound of the shoulder.

Ultrasonography (US) is a helpful imaging tool in the evaluation of the musculoskeletal system. It has some advantages over the other imaging techniques, such as plain radiography, computed tomography and magnetic resonance imaging, represented by the non-invasiveness and multiplanar imaging capability, repeatability, lack of radiation burden, good patient acceptance, and relatively limited costs. US offers an excellent resolution and a possibility for real-time dynamic examination of the joints and surrounding soft tissues, as well as enables monitoring of therapeutic response. The most common clinical indications for US examination of the shoulder are rotator cuff and biceps tendon pathology (tenosynovitis, tendinosis, complete and partial tears, and impingement) and disorders of other soft-tissue structures (joint recesses, bursae, muscles, suprascapular and axillary nerves) as well as bony cortex abnormalities. US is very useful for US-guided procedures (biopsy, joint and bursae aspirations and injections, aspiration and dissolution of calcific tendinosis). The aim of this article is to analyze the current literature about US of the shoulder and to describe both normal and pathological findings.

Ultrasound assessment of the elbow.

Ultrasonography of the elbow is a very helpful and reliable diagnostic procedure for a broad spectrum of rheumatic and orthopedic conditions, representing a possible substitute to magnetic resonance imaging for evaluation of soft tissues of the elbow. Musculoskeletal ultrasound (US) shows many advantages over other imaging modalities, probably the most important being its capability to perform a dynamic assessment of musculoskeletal elements with patient's partnership and observation during examination. In addition, ultrasonography is cost effective, easy available, and has excellent and multiplanar capability to visualize superficial soft tissue structures. Among all imaging procedures, US is highly accepted by patients. US assessment of the elbow requires good operator experience in the assessment of normal anatomy, and suitable high-quality equipment. US of the elbow provides detailed information including joint effusions, medial and lateral epicondylitis, tears of the distal biceps and triceps tendons, radial and ulnar collateral ligament tears, ulnar nerve entrapment, cubital or olecranon bursitis and intra-articular loose bodies. The aim of this paper is to review the screening technique and the basic normal and pathological findings in elbow US.

Ultrasound of the ankle and foot in rheumatology.

In the last years musculoskeletal ultrasound (US) has become a very useful imaging tool for the evaluation of rheumatic patients and a natural extension of the clinical examination of the ankle and foot. Musculoskeletal US allows the evaluation of the symptomatic and asymptomatic ankle and foot with a detailed analysis of a wide range of elementary lesions at the level of different anatomical structures and their distribution in early or long standing disease. In inflammatory pathology, it helps in the assessment of the disease activity and severity at the joint, tendon or entheseal level and in the detection of subclinical pathological features in early disease or residual activity after therapy. Moreover, US guided procedures allow accurate diagnostic and therapeutic interventions. It is a valuable imaging method that can be also used in the follow up of the treated patients (systemic and/ or local therapies or surgical procedures), being a patient friendly, non-invasive, and quick to perform method. The aim of this paper is to review the US technique of scanning and the indications of US in the analysis of the ankle and foot in rheumatic diseases.

The role of Doppler ultrasound in rheumatic diseases.

The use of Doppler techniques, including power, colour and spectral Doppler, has greatly increased in rheumatology in recent years. This is due to the ability of Doppler US (DUS) to detect pathological vascularization within joints and periarticular soft tissues, thereby demonstrating the presence of active inflammation, which has been reported to be correlated with the local neo-angiogenesis. In synovitis, DUS showed a high correlation with histological and MRI findings, thus it is considered a valid tool to detect pathological synovial vascularization. Moreover, it is more sensitive than clinical examination in detecting active joint inflammation and in the evaluation of response to treatment. In addition, DUS may be considered as a reference imaging modality in the assessment of enthesitis, MRI being not sensitive and histology not feasible. Moreover, it has been demonstrated to be able to detect changes in asymptomatic enthesis. In conclusion, DUS is a useful and sensitive tool in the evaluation and monitoring of active inflammation. Its widespread use in clinical rheumatological practice is recommended. The aim of this article is to review the current literature about the role of DUS in rheumatic diseases, analysing its validity, reliability and feasibility.

Luteinized unruptured follicle syndrome increased by inactive disease and selective cyclooxygenase 2 inhibitors in women with inflammatory arthropathies.

OBJECTIVE: Administration of nonsteroidal antiinflammatory drugs (NSAIDs) may impair fertility. The occurrence of the luteinized unruptured follicle (LUF) syndrome was assessed in women with inflammatory arthropathies exposed to NSAIDs and compared to that in nonexposed women. METHODS: Fourteen patients with inflammatory rheumatic disease, 29 women with noninflammatory musculoskeletal conditions, and 449 women not exposed to NSAIDs were studied by intravaginal ultrasound monitoring for follicular development and ovulation in 1 or more menstrual cycles. Disease activity was assessed in inflammatory rheumatic disease. RESULTS: In 59 monitored cycles of patients with continuous NSAID exposure, 35.6% of LUF syndromes occurred compared to 3.4% of LUF syndromes in untreated women (P < 0.001). Etoricoxib was responsible for 75% of LUF syndromes in patients exposed continuously, whereas diclofenac generated 15% of LUF syndromes. An ibuprofen dosage of 1,600 mg/day did not induce LUF syndrome either at continuous periovulatory or discontinuous exposure. Interestingly, the frequency of LUF syndrome was 46.2% in patients with inactive inflammatory disease compared to 15% in patients with active disease (P = 0.023). Etoricoxib generated LUF syndrome in 94.2% of the cases with inactive disease versus 28.6% in patients with active disease (P = 0.003). CONCLUSION: NSAIDs increased the risk of the LUF syndrome, particularly in patients with inactive disease. The selective cyclooxygenase 2 (COX-2) inhibitor etoricoxib was a more potent inductor of LUF syndrome than nonselective COX inhibitors. Continuous periovulatory exposure to NSAIDs should be avoided when planning a pregnancy in patients with rheumatic diseases.

Inter-observer reliability of ultrasound detection of tendon abnormalities at the wrist and ankle in patients with rheumatoid arthritis.

OBJECTIVE: To assess inter-observer reliability in US detection of tendon inflammatory and structural changes at wrists and ankles in RA patients. METHODS: Fourteen consecutive RA patients underwent bilateral US assessment of the extensor carpi ulnaris (ECUT) and tibialis posterior tendons (TPTs) by two blinded rheumatologists, with different level of experience in musculoskeletal (MS) US. Grey scale and power Doppler (PD) US assessment was focused on detection of tenosynovitis, tenosynovial and intra-tendon PD signal and structural lesions (i.e. tendinosis, tendon erosion, partial or total rupture). RESULTS: The frequency of US findings detected by Investigator 1 was 28.6% for inflammatory changes and 51.8% for structural damage changes while Investigator 2 detected 34 and 53.6% for the corresponding abnormalities. A high overall agreement (82.7%) was found for inflammatory pathology and 89.7% for structural lesions in all tendons. Mean kappa (κ) values for all tendons and pathology was moderate (κ = 0.42), with fair level of agreement for the wrist region (0.27-0.34) and moderate to good values for the ankle region (κ = 0.47-0.62). Subclinical abnormalities were detected in 37.5% of the tendons by Investigator 1 and 28.6% of the tendons by Investigator 2. CONCLUSIONS: MSUS showed high overall agreement and fair to moderate inter-observer κ-values between investigators with different levels of experience in detection of tendon pathology at the wrist and ankle in RA patients. Further standardization of scanning method and pathology definitions may improve MSUS reproducibility.