Ultrasonography in rheumatology: time to learn from patient views.

OBJECTIVE: The objective of this observational, descriptive, cross-sectional, multicentre study was to assess the perceived quality and grade of satisfaction expressed by patients with chronic arthropathies regarding the use of musculoskeletal (MSK) ultrasonography by rheumatologists as an integrated clinical care tool. METHODS: All Spanish rheumatology departments with MSK ultrasonography incorporated in their healthcare services were invited to participate in the study. A Spanish-language survey was offered to fill out anonymously to all consecutive patients with chronic arthropathies under follow-up in the rheumatology outpatient clinics who attended their centre for a period of 3 months. The survey consisted of three sections. The first section contained patients' demographics, disease data, frequency of performing rheumatological ultrasound and information about who performed their ultrasound assessments. The second section consisted of 14 questions about patient's experience and opinion on different aspects of the management, performance and perceived usefulness of performing ultrasound, to be answered on a Likert scale 1-5. The third section of the survey was addressed to the rheumatologist ultrasonographers. RESULTS: Nine hundred and four patients from 16 university hospital rheumatology departments completed the survey. All questions reached an overall favourable response ≥ 80%. Patients who reported usual ultrasound examinations in their rheumatology care and those in which it was their attending rheumatologist who performed the ultrasound assessments responded more favourably. CONCLUSION: Our encouraging patient-centred results may be useful in facilitating the implementation of rheumatological ultrasound in rheumatology care worldwide. Key Points • This is the largest multicentre survey carried out in patients with chronic joint diseases designed to assess their experience and perceived benefits with the use of ultrasonography performed by rheumatologists in daily practice. • Musculoskeletal ultrasound incorporated into rheumatology care was very well accepted and valued by most patients. • The patients perceived that ultrasonography helps not only their rheumatologist but also themselves to better understand their condition. • The patients believed that ultrasonography helps them accept and comply with the proposed treatment.

Long-term follow-up of certolizumab pegol in uveitis due to immune-mediated inflammatory diseases: multicentre study of 80 patients.

OBJECTIVES: To evaluate effectiveness and safety of certolizumab pegol (CZP) in uveitis due to immune-mediated inflammatory diseases (IMID). METHODS: Multicentre study of CZP-treated patients with IMID uveitis refractory to conventional immunosuppressant. Effectiveness was assessed through the following ocular parameters: best-corrected visual acuity, anterior chamber cells, vitritis, macular thickness and retinal vasculitis. These variables were compared between the baseline, and first week, first, third, sixth months, first and second year. RESULTS: We studied 80 (33 men/47 women) patients (111 affected eyes) with a mean age of 41.6±11.7 years. The IMID included were: spondyloarthritis (n=43), Behçet's disease (n=10), psoriatic arthritis (n=8), Crohn's disease (n=4), sarcoidosis (n=2), juvenile idiopathic arthritis (n=1), reactive arthritis (n=1), rheumatoid arthritis (n=1), relapsing polychondritis (n=1), CONCLUSIONS: CZP seems to be effective and safe in uveitis related to different IMID, even in patients refractory to previous biological drugs.

Ultrasound and Radiographic Abnormalities in a Patient With Chronic Severe Acromegaly / Los hallazgos ecográficos y radiográficos en una paciente con acromegalia crónica severa

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Artrosis interfalángica sintomática y asintomática: un estudio ecográfico / Symptomatic and asymptomatic interphalageal osteoarthritis: an ultrasonographic study

Objetivo. Pocos estudios han examinado si existen diferencias morfológicas detectables con ecografía entre las articulaciones sintomáticas y las que no lo son en pacientes con artrosis. Este estudio describe y compara los hallazgos clínicos, radiológicos y ecográficos de los pacientes con artrosis interfalángica proximal (IFP) y/o distal (IFD) que tienen articulaciones con y sin dolor. Métodos. Prospectivamente, se incluyó a pacientes con artrosis IFP y/o IFD según los criterios ACR. El reumatólogo clínico eligió hasta un máximo de 3 articulaciones dolorosas y 3 articulaciones no dolorosas de localización simétrica en cada paciente para formar 2 cohortes de artrosis: grupo con dolor (GD) y grupo sin dolor (GSD). La radiografía simple postero-anterior de las manos fue leída por un reumatólogo según las recomendaciones del atlas OARSI, ciego a toda información clínica y ecográfica. El estudio ecográfico fue realizado por un reumatólogo en las articulaciones previamente seleccionadas por el clínico ciego a los datos clínicos y radiológicos. Se registraron como ausente o presente: osteofitos, pinzamiento articular, sinovitis, señal Doppler intraarticular, erosiones y visualización del cartílago. Se realizó un estudio de fiabilidad intralector para la radiología y para la ecografía. Resultados. Se estudió un total de 50 articulaciones en cada cohorte de 20 mujeres diestras de 61,85 años de edad (46-73) con artrosis IFP y IFD diagnosticada hace 6,8 años (1-17 años). El 70% de las articulaciones del GD y GSD se localizaron en la mano derecha e izquierda, respectivamente. El GD tenía significativamente más osteofitos, sinovitis y ausencia de cartílago que el GSD. La fiabilidad interlector radiológico y ecográfico fue excelente. Conclusión. La ecografía detecta más daño estructural y sinovitis en las IFP y/o IFD artrósicas que presentan dolor (AU)

Objective: To date few studies have examined whether ultrasonography can depict morphologic differences in painful and painless osteoarthritis (OA). This study describes and compares the clinical, radiographic and ultrasonographic findings of patients with both painful and painless proximal interphalgeal (PIP) and/or distal interphalgeal (DIP) OA. Methods: Patients with PIP and/or DIP OA (ACR criteria) were prospectively recruited. The clinical rheumatologist chose up to 3 painful joints and up to 3 painless symmetric joints in each patient to define 2 cohorts of OA: symptomatic (SG) and asymptomatic (ASG). A conventional postero-anterior hand x ray was performed and read by one rheumatologist following the OARSI atlas, blinded to clinical and sonographic data. Ultrasound (US) was performed by an experienced rheumatologist, blinded to both clinical and radiographic data in joints previously selected by the clinical rheumatologist. US-pathology was assessed as present or absent as defined in previous reports: osteophytes, joint space narrowing, synovitis, intra-articular power doppler signal, intra-articular bony erosion, and visualization of cartilage. Radiographic and ultrasonographic intrareader reliability test was performed. Results: A total of 50 joints in the SG and ASG were included from 20 right handed women aged 61.85 (46-73) years with PIP and DIP OA diagnosed 6.8 (1-17) years ago. 70% SG joints and ASG were right and left sided respectively. The SG showed significantly more osteophytes, synovitis and non-visualization of joint cartilage. Intrareader radiographic and ultrasonographic agreement was excellent. Conclusion: This study demonstrates that painful PIP and/or DIP OA have more ultrasonographic structural changes and synovitis (AU)

Symptomatic and asymptomatic interphalageal osteoarthritis: An ultrasonographic study.

OBJECTIVE: To date few studies have examined whether ultrasonography can depict morphologic differences in painful and painless osteoarthritis (OA). This study describes and compares the clinical, radiographic and ultrasonographic findings of patients with both painful and painless proximal interphalgeal (PIP) and/or distal interphalgeal (DIP) OA. METHODS: Patients with PIP and/or DIP OA (ACR criteria) were prospectively recruited. The clinical rheumatologist chose up to 3 painful joints and up to 3 painless symmetric joints in each patient to define 2 cohorts of OA: symptomatic (SG) and asymptomatic (ASG). A conventional postero-anterior hand x ray was performed and read by one rheumatologist following the OARSI atlas, blinded to clinical and sonographic data. Ultrasound (US) was performed by an experienced rheumatologist, blinded to both clinical and radiographic data in joints previously selected by the clinical rheumatologist. US-pathology was assessed as present or absent as defined in previous reports: osteophytes, joint space narrowing, synovitis, intra-articular power doppler signal, intra-articular bony erosion, and visualization of cartilage. Radiographic and ultrasonographic intrareader reliability test was performed. RESULTS: A total of 50 joints in the SG and ASG were included from 20 right handed women aged 61.85 (46-73) years with PIP and DIP OA diagnosed 6.8 (1-17) years ago. 70% SG joints and ASG were right and left sided respectively. The SG showed significantly more osteophytes, synovitis and non-visualization of joint cartilage. Intrareader radiographic and ultrasonographic agreement was excellent. CONCLUSION: This study demonstrates that painful PIP and/or DIP OA have more ultrasonographic structural changes and synovitis.

Comparación de 2 estrategias de derivación en el diagnóstico de la espondiloartritis axial en España. Estudio RADAR / Comparison of 2 referral strategies for the diagnosis of axial spondyloarthritis in Spain. The RADAR study

Objetivos. Mejorar la derivación de pacientes con dolor lumbar a reumatología podría acelerar el diagnóstico de la espondiloartritis axial. El estudio RADAR comparó 2 estrategias de derivación de pacientes con dolor lumbar crónico (> 3 meses) de inicio antes de los 45 años desde atención primaria a reumatología con respecto al diagnóstico de espondiloartritis axial. Pacientes y métodos. Se asignó una estrategia a cada centro de salud para derivar a sus pacientes: (a) estrategia 1, si cumplían uno de los siguientes 3 criterios: dolor lumbar inflamatorio, HLA-B27 positivo o sacroilitis en prueba de imagen; (b) estrategia 2, si cumplían 2 de 6: dolor lumbar inflamatorio, HLA-B27 positivo, sacroilitis en prueba de imagen, historia familiar de espondiloartritis axial, manifestaciones extraarticulares y buena respuesta a antiinflamatorios no esteroideos. El reumatólogo estableció el diagnóstico final. Resultados. Ochenta y ocho pacientes (edad 36,8 años [DE 8,7]; 55,7% mujeres y 44,3% hombres) en España fueron derivados, 60 usando la estrategia 1 y 28 la estrategia 2. El diagnóstico de espondiloartritis axial definitiva se realizó en el 25,4% de los pacientes en la estrategia 1 y en el 28,6% en la estrategia 2 (p = NS). El dolor lumbar inflamatorio fue el criterio de derivación más utilizado y la concordancia entre médico de atención primaria y reumatólogo fue del 75%. Conclusiones. Una estrategia de derivación sencilla, basada en uno de 3 criterios, fue igual de eficaz que una estrategia basada en 2 de 6 criterios para el diagnóstico de espondiloartritis axial. El dolor lumbar inflamatorio fue el criterio más utilizado para la derivación (AU)

Objectives: Improving referral of patients with back pain to rheumatologists could accelerate the diagnosis of axial spondyloarthritis. The RADAR study compared two strategies in the referral of patients with chronic back pain (> 3 months) with an onset before the age of 45 years from primary care centers to rheumatology departments, in relation to the diagnosis of axial spondyloarthritis. Patients and methods: Each primary care center was assigned a referral strategy for its patients: (a) strategy 1, patients who had one of the 3 following criteria: inflammatory back pain, HLA-B27 positivity or sacroiliitis in imaging; or (b) strategy 2, patients who had 2 of the following 6: inflammatory back pain, HLA-B27 positivity, sacroiliitis in imaging, family history of axial spondyloarthritis, extra-articular manifestations or good response to nonsteroidal antiinflammatory drugs. The rheumatologist established the final diagnosis. Results: Eighty-eight Spanish patients (mean age 36.8 years [SD 8.7], 55.7% females and 44.3% males) were referred for evaluation, 60 patients under strategy 1 and 28 under strategy 2. A definitive diagnosis of axial spondyloarthritis was established in 25.4% with strategy 1 and in 28.6% with strategy 2 (p = NS). Inflammatory back pain was the criterion most commonly used for referral, and the agreement rate between the primary care physician and rheumatologist was 75%. Conclusions: A simple referral strategy based on one of three3 criteria proved as effective as a strategy based on two of 6 criteria in diagnosing axial spondyloarthritis. Inflammatory back pain was the criterion most commonly used for patient referral (AU)

Comparison of 2 referral strategies for the diagnosis of axial spondyloarthritis in Spain. The RADAR study.

OBJECTIVES: Improving referral of patients with back pain to rheumatologists could accelerate the diagnosis of axial spondyloarthritis. The RADAR study compared two strategies in the referral of patients with chronic back pain (>3 months) with an onset before the age of 45 years from primary care centers to rheumatology departments, in relation to the diagnosis of axial spondyloarthritis. PATIENTS AND METHODS: Each primary care center was assigned a referral strategy for its patients: (a) strategy 1, patients who had one of the 3 following criteria: inflammatory back pain, HLA-B27 positivity or sacroiliitis in imaging; or (b) strategy 2, patients who had 2 of the following 6: inflammatory back pain, HLA-B27 positivity, sacroiliitis in imaging, family history of axial spondyloarthritis, extra-articular manifestations or good response to nonsteroidal antiinflammatory drugs. The rheumatologist established the final diagnosis. RESULTS: Eighty-eight Spanish patients (mean age 36.8 years [SD 8.7], 55.7% females and 44.3% males) were referred for evaluation, 60 patients under strategy 1 and 28 under strategy 2. A definitive diagnosis of axial spondyloarthritis was established in 25.4% with strategy 1 and in 28.6% with strategy 2 (p=NS). Inflammatory back pain was the criterion most commonly used for referral, and the agreement rate between the primary care physician and rheumatologist was 75%. CONCLUSIONS: A simple referral strategy based on one of three3 criteria proved as effective as a strategy based on two of 6 criteria in diagnosing axial spondyloarthritis. Inflammatory back pain was the criterion most commonly used for patient referral.

Percepción subjetiva del dolor en cirugía local dermatologica / Subjective perception of pain in local dermatological surgery

Introducción. El dolor se mide difícilmente pues presenta un importante componente subjetivo. En Dermatología se ha estudiado poco este síntoma, en especial su componente psicoemocional (miedo previo a la intervención y sensación de liberación posterior a la misma). Se ha decidido evaluar cuantitativamente su percepción en intervenciones locales, en relación con diferentes momentos de la intervención y con la aplicación de una crema anestésica tópica como variable externa. Pacientes y métodos. Se documentó la percepción álgica con una escala de valoración verbal antes de y durante la infiltración anestésica y nada más finalizar la intervención quirúrgica, mediante tres preguntas: 1) ¿Cuánto cree que le va a doler?, 2) ¿cuánto le está doliendo? y 3) ¿cuánto le ha dolido?. Además se aleatorizó la aplicación de EMLA; (anestésico tópico en crema). Resultados. Se estudiaron 219 pacientes. Las puntuaciones en la pregunta 2 eran significativamente menores que las de la pregunta 1, y las de la pregunta 3 significativamente menores que las de las preguntas 1 y 2. Los pacientes tratados con EMLA puntuaron más bajo que los controles sólo en las preguntas 2 y 3. Discusión. Los pacientes piensan que les va a doler más la intervención que lo que en realidad les duele posteriormente y además borran “de inmediato” el recuerdo del dolor reciente. El uso de EMLA no modifica la idea del paciente de lo que le va a doler la intervención, pero sí percibe menos dolor que los que no lo utilizan. Es importante tranquilizar al paciente sobre la intervención para que éste no acumule ansiedad respecto al procedimiento y así se minimice su percepción álgica. Utilizar un anestésico local tópico en la zona de intervención podría ayudar a disminuir la sensación de dolor

Introduction. Pain is difficult to measure, as it has a significant subjective component. This symptom, and in particular its psycho-emotional component (fear prior to the operation and a feeling of release afterwards), has not been studied in extensively. We decided to quantitatively evaluate its perception in local surgery, in relation to different moments during the operation and using the application of a topical anesthetic cream as an external variable. Patients and methods. The perception of pain was documented with a verbal assessment scale before and during anesthesia infiltration and immediately at the end of the operation by means of three questions: 1) How much do you think it is going to hurt?, 2) How much does it hurt? and 3) How much did it hurt? In addition, the application of EMLA; (topical anesthetic cream) was randomized. Results. 219 patients were studied. The scores for question 2 were significantly lower than the ones for question 1, and the scores for question 3 were significantly lower than the ones for questions 1 and 2. The patients treated with EMLA only gave lower scores than the controls in questions 2 and 3. Discussion. Patients think that the surgery will hurt more than it really does, and they also immediately erase the memory of the recent pain. The use of EMLA does not modify the patient’s idea of how much the operation will hurt, but the patient does perceive less pain than those who do not use it. It is important to reassure patients about their operations so that they do not become overly anxious about the procedures, thus minimizing their perception of pain. The use of a topical local anesthetic in the area of the surgery could help decrease the sensation of pain

[Subjective perception of pain in local dermatological surgery]. / Percepción subjetiva del dolor en cirugía local dermatológica.

INTRODUCTION: Pain is difficult to measure, as it has a significant subjective component. This symptom, and in particular its psycho-emotional component (fear prior to the operation and a feeling of release afterwards), has not been studied extensively. We decided to quantitatively evaluate its perception in local surgery, in relation to different moments during the operation and using the application of a topical anesthetic cream as an external variable. PATIENTS AND METHODS: The perception of pain was documented with a verbal assessment scale before and during anesthesia infiltration and immediately at the end of the operation by means of three questions: 1) How much do you think it is going to hurt?, 2) How much does it hurt? and 3) How much did it hurt? In addition, the application of EMLA (topical anesthetic cream) was randomized. RESULTS: 219 patients were studied. The scores for question 2 were significantly lower than the ones for question 1, and the scores for question 3 were significantly lower than the ones for questions 1 and 2. The patients treated with EMLA only gave lower scores than the controls in questions 2 and 3. DISCUSSION: Patients think that the surgery will hurt more than it really does, and they also immediately erase the memory of the recent pain. The use of EMLA does not modify the patient's idea of how much the operation will hurt, but the patient does perceive less pain than those who do not use it. It is important to reassure patients about their operations so that they do not become overly anxious about the procedures, thus minimizing their perception of pain. The use of a topical local anesthetic in the area of the surgery could help decrease the sensation of pain.

Compliance and satisfaction with raloxifene versus alendronate for the treatment of postmenopausal osteoporosis in clinical practice: An open-label, prospective, nonrandomized, observational study.

BACKGROUND: The treatment of osteoporosis among postmenopausal women represents a major public health challenge because long-term therapy is needed to prevent fractures and chronic disability. Low patient compliance with prescribed osteoporosis treatments can severely distort the validity of controlled clinical trials. Raloxifene and alendronate have been shown to reduce the incidence of osteoporotic fracture in postmenopausal women in well-conducted randomized trials, but few data are available on the rate of adherence to these treatments in routine clinical practice. OBJECTIVE: The primary aim of this study was to assess the compliance of postmenopausal women at risk for osteoporotic fractures who were treated with raloxifene hydrochloride (RLX) versus alendronate sodium (ALN) during a 12-month observational period in a routine clinical setting. Secondary objectives were the assessment of factors that might contribute to noncompliance and patient satisfaction. METHODS: This open-label, prospective, multicenter, nonrandomized, observational, comparative study was conducted at 154 centers across Spain. Assignment to either RLX or ALN treatment was determined by the physician and was based on each patient's clinical profile. Compliance with RLX (60-mg tablet once daily) versus ALN (10-mg tablet once daily) was assessed using 3 different compliance assessment tools: the Morisky-Green test, the Autocompliance test, and the Compliance Questionnaire. A logistic regression model was used to assess different factors affecting compliance. Patient satisfaction was also assessed using a questionnaire. Adverse events (AEs) were collected as reasons for discontinuation in the Compliance Questionnaire and at the discontinuation visit. RESULTS: A total of 902 women (RLX group, n = 476; ALN group, n = 426) were included in the study (mean age, 64.4 [6.9] years). Overall, patients in the RLX group reported significantly better compliance than patients in the ALN group, as collected either by the Morisky-Green test (68.7% vs 54.0%; P < 0.001) or the Autocompliance test (94.7% vs 90.6%; P = 0.033). More patients discontinued treatment prematurely in the ALN group compared with the RLX group (25.8% vs 16.4%; P < 0.001). The age-adjusted relative risk for discontinuation was 1.4-fold higher for women treated with ALN than for those treated with RLX (95% CI, 1.21-1.61). The main reason for premature discontinuation was due to AEs (RLX 4.8% vs ALN 11.0%; P < 0.001). The proportion of patients with gastrointestinal AEs was 9.9% in the ALN group and 3.4% in the RLX group (P < 0.001). Only treatment and type of physician were independent covariates of treatment compliance. After 12 months of observation, significantly more patient in the RLX group were satisfied or very satisfied with their treatment than patients in the ALN group (P < 0.001). CONCLUSION: In this study of postmenopausal women at risk for osteoporotic fractures, compliance with 12-month treatment with daily RLX was higher than with daily ALN in clinical setting. RLX showed significant benefits compared with ALN in terms of compliance assessed by means of the Morisky-Green and Autocompliance tests and the patients' self-reported satisfaction.