Ultrasound as a Useful Tool in the Diagnosis of Rheumatoid Arthritis in Patients With Undifferentiated Arthritis.

BACKGROUND: Nowadays, rheumatologists face challenges in finding an effective method to classify and treat patients with undifferentiated arthritis (UA). There is a need for new tools that could ensure accurate characterization of inflammatory processes in these patients. OBJECTIVE: The aim of this study was to investigate if a characterization of UA patients using ultrasound (US) may help to fulfill the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) classification criteria in a real-life cohort. METHODS: We conducted a cross-sectional study in 2 rheumatology care clinics. Patients not fulfilling the 2010 ACR/EULAR RA criteria were included. On the examination day, all patients underwent a physical examination, radiography, and US. The 7-joint US score was adopted to scan all patients. The US was performed according to EULAR criteria and interpreted by Outcome Measures in Rheumatology definitions. Gray-scale and power Doppler synovitis and tenosynovitis were scored. Bone erosions were also evaluated during the US examination. RESULTS: A total of 204 patients were included. The diagnosis was modified from UA to RA in 86 patients (42.1%). Also, the final score of the 2010 ACR/EULAR RA classification criteria changed from a mean of 4.6 to 6.5 after the US examination. In addition to synovitis, a wide range of tenosynovitis and bone erosions were detected by US. Synovitis was more frequently detected in second metacarpophalangeal joint followed by second metatarsophalangeal joint (MTPj) and fifth MTPj. The tendons of the wrist and second and third fingers were the most affected. In relation to bone erosions, second metacarpophalangeal joint and fifth MTPj were the joints with more proportion of anatomical damage. CONCLUSIONS: The US demonstrated to be useful to help accurately classify as RA patients previously diagnosed with UA.

Quantifying Potential Cost-Savings Through an Alternative Imaging-Based Diagnostic Process in Presumptive Seronegative Rheumatoid Arthritis.

BACKGROUND: Seronegative rheumatoid arthritis (SRA) is a condition that is not well understood and difficult to confirm by a conventional diagnostic process. We aimed to quantify the potential cost-savings of an alternative diagnostic process (ADP) imaging-based, for patients with presumptive SRA from everyday clinical practice. METHODS: We performed a retrospective analysis for patients with presumptive SRA who tested negative for both rheumatoid factor and anti-cyclic citrullinated peptide antibodies, through an ADP imaging-based, that is a standard clinical practice in our center. After we confirmed the diagnosis of SRA or reclassified patients in terms of another proper diagnosis, we estimate direct costs in two scenarios: a conventional and ADP. We compared the cost of RA treatment during the first year against the cost of the most misdiagnosed treatment (osteoarthritis) found after applying the ADP to determine potential cost-savings. RESULTS: We included 440 patients with a presumptive diagnosis of SRA. According to the imaging-based ADP, SRA was confirmed in 106/440 (24.1%), unspecified RA in 9/440 (2.0%), and osteoarthritis in 325/440 (73.9%) of those patients. Although the costs of conventional diagnosis per patient is lower than those of ADP ($59,20 USD vs $269,57 USD), we found a potential drug cost-savings of $1,570,775.20 US Dollars after 1 year of correct treatment. CONCLUSION: An alternative diagnosis process, including X-rays, US and MRI imaging, and clinical and blood-test assessment, not only increased diagnostic certainty in patients referred for evaluation of presumptive SRA but also suggested a potential cost-savings in pharmacological treatments avoided in misdiagnosed patients.

Clinical manifestations and diagnosis of gout.

Gout has been academically considered to be a step-up disease consisting of different stages: acute gout, intercritical gout, and chronic gout. This simple approach may lead to misinterpretation and misdiagnosis. In clinical practice, we should consider gout as a single disease with either or both acute (most commonly, episodes of acute inflammation) and persistent clinical manifestations, but not restricted to chronic synovitis. In this article, an innovative, practical, and rational approach to the clinical manifestations and diagnosis of gout is presented, which may be supportive for clinicians involved in everyday care and management of patients with gout.

Natriuresis y hemodinámica glomerular en un incomprendido sistema renina angiotensina aldosterona / Nutriuresis and Glomerular Hemodynamics in misunderstood Renin-angiotensin-aldosterone system

La respuesta natriur‚tica y la hemodin mica glomerular dependen de diversos sistemas de regulaci¢n intrarrenal; sin embargo, la mayor¡a de ellos posee alg£n grado de dependecia del sistema renina angiotensina. La distribuci¢n tisular y el efecto hemodin mico de este sistema son de vital importancia para el entendimiento de la regulaci¢n natriur‚tica y del filtrado glomerular en diversas enfermedades que se caracterizan por desregulaci¢n del equilibrio del sodio o del filtrado glomerular, tales como el s¡ndrome nefr¢tico, la falla renal aguda y cr¢nica e hipertensi¢n arterial.

Natriuretic response and glomerular hemodynamics depend on various intrarenal regulation systems; however, most of them possess some degree of dependence on the renin-angiotensin system. Tissue distribution and hemodynamic effects of this system are of vital importance for understandinf of the natriuretic and glomerular filtration regulation in the context of different diseases characterized by dysregulation of sodium balance or glomerular filtration rate, such as nephrotic syndrome, acute and chronic renal failure and hypertension.

Avaliaçäo do tratamento especifíco para Trypanosoma cruzi em crianças, na evoluçäo da fase indeterminada / Specific treatment evaluation for Trypanosoma cruzi in children, in the evolution of the indeterminate phase

Doze pacientes com idades entre 7 a 12 anos, na forma indeterminada da doença de Chagas, com sorologia e xenodiagnóstico positivos, receberam tratamento específico. Dois pacientes tomaram 7mg/kg de nifurtimox durante 60 e 90 dias e 10 usaram 5-7mg/kg de benznidazol durante 60 dias. A evoluçäo clínica foi verificada através de exame clínico, eletrocardiograma, exame radiológico contrastado do esôfago. Após o tratamento somente uma (8,3 por cento) paciente apresentou todos os exames negativos. Oito deles foram avaliados após oito anos do tratamento e 4 acompanhados durante 20 anos. Sete (58,4 por cento) permaneceram na forma indeterminada e 4 (33,3 por cento) chagásicos progrediram clinicamente para cardiopatia grau II e/ou esofagopatia, apesar do tratamento precoce. Säo necessários estudos com maior número de crianças na fase indeterminada e acompanhamento a longo prazo para se estabelecer a influência do tratamento específico na evoluçäo da doença de Chagas