An MRI assessment of chronic synovial-based inflammation in gout and its correlation with serum urate levels.

It is unclear when the synovial-based inflammatory process of gout begins. The aim of this study was to determine the percentage of patients with inter-critical gout who have chronic synovial-based inflammation as evidenced by synovial pannus on a contrast-enhanced magnetic resonance imaging (MRI) of their most involved joint and determine if the presence and/or severity correlates with their serum urate levels. All patients received a 3 T MRI of their index joint, serum urate level, CRP, and creatinine. The primary endpoint was to determine the prevalence of synovial pannus and the correlation of serum urate levels with the presence and/or severity of the synovial pannus on that same joint. MRI erosions, tophi, swelling, effusion, and osteitis were also documented. Seventy-two of 74 subjects (90% men) completed the protocol. Fifty-three of 72 (74%) index joints were the first metatarsophalangeal joint. Thirty-nine (54.2%) of the patients were on urate-lowering therapy; 15 (20.8%) and 7 (9.7%) were taking colchicine or a NSAID daily, respectively. Of the 72 subjects, 63 (87.5%) had synovial pannus on their MRI with good inter-reader agreement between the two radiologists. The mean serum urate level was 7.93 mg/dL. There was no correlation with the presence (p = 0.33) or severity (p = 0.34) of synovial pannus and serum urate levels. There was also no correlation with the presence or severity of synovial pannus and the secondary endpoints. The majority of patients with inter-critical gout have evidence of chronic synovial-based inflammation. However, the presence and severity of this inflammation do not appear to correlate with serum urate levels.

Virtual rheumatology: using simulators and a formal workshop to teach medical students, internal medicine residents, and rheumatology subspecialty residents arthrocentesis.

BACKGROUND: Arthrocentesis is an important skill for medical practitioners at all levels of training. Previous studies have indicated a low comfort level and performance of arthrocentesis among primary care physicians that could be improved with hands-on training. OBJECTIVES: The objective of this study was to improve comfort with knee and shoulder arthrocentesis at all levels of medical training, including medical students, internal medicine residents, and rheumatology subspecialty residents, and in arthrocentesis of the elbow, wrist, and ankle for advanced subspecialty residents in rheumatology through the use of a formal workshop using simulators. METHODS: Fourth-year medical students and internal medicine residents were recruited from the University of South Florida. The rheumatology advanced subspecialty residents were participants from University of South Florida and from the American College of Rheumatology national meetings in 2008 and 2009. A 1-hour PowerPoint lecture followed by a hands-on practice session using Sawbones models (shoulder and knee for all groups, and elbow, wrist, and ankle additionally for the advanced subspecialty residents). A preworkshop self-assessment survey allowed the participant to rate his/her comfort level with arthrocentesis on a scale of 1 to 5. A survey with identical questions was completed immediately after the workshop. A follow-up survey was distributed by e-mail 3 to 6 months after the workshop. RESULTS: One hundred forty-one medical students, 75 internal medicine residents, and 39 rheumatology subspecialty residents participated from January 2008 until January 2010. Mean comfort level in knee and shoulder arthrocentesis improved from preworkshop comfort level for all joints and among all participants. In addition, rheumatology subspecialty resident mean comfort level improved for ankle from 2.37 to 3.65, elbow from 2.56 to 3.80, and wrist from 2.31 to 3.77 (P < 0.0001). CONCLUSIONS: Our study involved a very large number of participants encompassing different levels of training and is the largest number of advanced subspecialty rheumatology residents studied with regard to joint injection training. We have confirmed that a formal joint injection workshop using simulators is an effective method of improving comfort level in arthrocentesis among participants from all levels of medical training. Future studies should evaluate the effect of such training on actual clinical use and competence.

An analysis of MRI and ultrasound imaging in patients with gout who have normal plain radiographs.

OBJECTIVE: The aim of this study was to analyse the prevalence of occult destructive arthropathy in subjects with gout and normal plain radiographs by utilizing MRI and ultrasound (US). METHODS: The study consisted of two visits. At Visit 1, a plain radiograph of the 'index joint' was obtained. The 'index joint' was defined as a joint that has had the most acute attacks of gout historically. The index joint plain radiograph had to be free of erosive damage in order for the subject to qualify for Visit 2. At Visit 2, the subject had an MRI with contrast and an US of the index joint. Each subject also had an MRI and US of an 'asymptomatic joint'. The 'asymptomatic joint' was defined as a joint that had never experienced an acute attack of gout (determined by standard protocol). The primary endpoint was erosive changes on the MRI and/or US of the index joint. Secondary endpoints included erosive changes on the asymptomatic joint as well as bone marrow oedema (BME) (on MRI), synovial pannus (SP), soft tissue tophi (STT) or oedema (STE) on either the index or asymptomatic joint. RESULTS: Twenty-seven subjects (26 males; 1 female) completed both visits. Their average age and disease duration were 55.1 years (range 21-75 years) and 6.8 years (range 0.25-25 years), respectively. The subjects' average serum uric acid level over the past 5 years was 8.09 mg/dl (range 4.1-12.8 mg/dl); their average on the day of Visit 1 was 7.96 mg/dl (range 4.6-13.9 mg/dl). The first MTP was the most common index joint (17) followed by the ankle (5), mid-tarsal (2), knee (2) and wrist (1). The knee was the most common asymptomatic joint (21) followed by the wrist (3), MTP (2) and ankle (1). All subjects had both MRIs; one subject refused the US. Out of 27 subjects, 15 (56%) had erosions on MRI of their index joint (P < 0.0001); only 1 subject (4%) had erosions identified in the index joint by US (P = NS). Regarding the secondary endpoints on the index joint, the MRI detected SP (13), BME (4), STE (3) and STT (0); the US detected SP (1), STT (1) and STE (0). Regarding the MRI of the asymptomatic joint, positive findings included SP (3), BME (3), STE (2) and erosions (1). There were no positive findings by US in the asymptomatic joint. CONCLUSIONS: A large percentage of patients with gout and normal plain radiographs have occult destructive arthropathy that is only detected by advanced imaging such as MRI and/or US. However, MRI appears to be much more sensitive than US at detecting these findings.

Chlamydiae as etiologic agents in chronic undifferentiated spondylarthritis.

OBJECTIVE: The majority of patients with Chlamydia-induced reactive arthritis do not present with the classic triad of arthritis, conjunctivitis/iritis, and urethritis. Moreover, acute chlamydial infections are often asymptomatic. The aim of the present study was to assess the prevalence of synovial Chlamydia trachomatis and Chlamydia pneumoniae infections in patients with chronic undifferentiated spondylarthritis (uSpA). METHODS: Study patients met the European Spondylarthropathy Study Group criteria for SpA, without evidence of ankylosing spondylitis, psoriasis, inflammatory bowel disease, or preceding dysentery. Symptoms were present for >or=6 months. Each patient underwent a synovial biopsy; tissue and concomitantly obtained peripheral blood mononuclear cells (PBMCs) were analyzed by polymerase chain reaction (PCR) for C trachomatis and C pneumoniae DNA. Other data collected on the day of the biopsy included standard demographic information and medical history, including any known history of C trachomatis or C pneumoniae. Physical examination (including joint count, evaluation for dactylitis and/or enthesitis, and skin examination) and HLA-B27 typing were performed. Synovial tissue (ST) samples from 167 patients with osteoarthritis (OA) were used as controls. RESULTS: Twenty-six patients met the entry criteria and underwent synovial biopsy (25 knee, 1 wrist). Sixteen of them (62%) were positive for C trachomatis and/or C pneumoniae DNA (10 for C trachomatis, 4 for C pneumoniae, and 2 for both). PCR analysis of ST revealed the presence of Chlamydia significantly more frequently in patients with uSpA than in OA controls (P<0.0001). No specific clinical characteristics differentiated Chlamydia-positive from Chlamydia-negative patients. PBMCs from 4 of the 26 uSpA patients (15%) were positive for Chlamydia, and Chlamydia was found in ST from 2 of these 4 patients. No significant correlation between PCR positivity and HLA-B27 positivity was found. CONCLUSION: The frequency of Chlamydia-positive ST samples, as determined by PCR, was found to be significantly higher in patients with uSpA than in patients with OA. Our results suggest that in many patients with uSpA, chlamydial infection, which is often occult, may be the cause.

A safety assessment of tumor necrosis factor antagonists during pregnancy: a review of the Food and Drug Administration database.

OBJECTIVE: To present any congenital anomalies with respect to tumor necrosis factor (TNF) antagonists reported to the US Food and Drug Administration (FDA) to determine if there are common findings. METHODS: A review of the FDA database of reported adverse events with etanercept, infliximab, and adalimumab from 1999 through December of 2005 was performed. Key words for congenital anomalies were employed as search tools. Duplicate reports were eliminated. Any concomitant medicines were recorded. RESULTS: Our review of > 120,000 adverse events revealed a total of 61 congenital anomalies in 41 children born to mothers taking a TNF antagonist. Of these mothers, 22 took etanercept and 19 took infliximab. There were no reports in women taking adalimumab. The most common reported congenital anomaly was some form of heart defect. Twenty-four of the 41 (59%) children had one or more congenital anomalies that are part of vertebral abnormalities, anal atresia, cardiac defect, tracheoesophageal, renal, and limp abnormalities (VACTERL) association. There were 34 specific types of congenital anomalies in total, and 19 (56%) of those are part of the VACTERL spectrum. Nine of these 19 (47%) types of VACTERL anomalies were observed statistically significantly more than historical controls (p < 0.01); in 4 of these 9 the p value was < or = 0.0001. Thirteen (32%) of the children had more than one congenital anomaly; 7 of these 13 children had 2 defects that are part of the VACTERL spectrum. However, only 1 child was diagnosed with VACTERL. In 24/41 cases (59%) the mother was taking no other concomitant medications. CONCLUSION: A seemingly high number of congenital anomalies that are part of the VACTERL spectrum have been reported. These congenital anomalies are occurring at a rate higher than historical controls. This commonality raises concerns of a possible causative effect of the TNF antagonists.

Determining rheumatologists' accuracy at assessing functional disability in rheumatoid arthritis patients using the Health Assessment Questionnaire-Disability Index.

OBJECTIVE: To test rheumatologists' accuracy in determining functional disability of their patients with rheumatoid arthritis (RA). METHODS: We used the Health Assessment Questionnaire-Disability Index (HAQ-DI) as our guide at assessing functional disability in patients with RA. Included were male and female patients, 18 to 65 years of age, diagnosed with RA. Demographic data collected included the patients' age, disease duration, rheumatoid factor (RF) status, presence of rheumatoid nodules, absence or presence of erosive disease, and class and stage of their disease. The primary endpoint was the mean difference in the patients' HAQ-DI scores versus that of the physicians' (mHAQ-Diff). Secondary endpoints were the mean difference in pain assessment scale (mPAS-Diff) score; and assessing to see if the physicians' HAQ-DI was altered by the patients' age, disease duration, RF status, rheumatoid nodules, absence or presence of erosive disease, and class or stage of the patient's RA. RESULTS: A total of 223 patients (139 female, 84 male) were evaluated. The mHAQ-Diff score was statistically significant at -0.3 (p = 0.03) with the rheumatologists more often overestimating the degree of functional disability in their RA patients. The mPAS-Diff score was 0.16, but this was not significant (p = 0.53). There was no significant difference between the scores based on sex, presence or absence of RF, erosions, or rheumatoid nodules. However, the rheumatologists' estimated HAQ and PAS did seem to be more accurate in patients with lower class and stage of their RA. CONCLUSION: Our results indicate that there is a clear difference between patients' and rheumatologists' assessment of patients' functional disability in RA, with the rheumatologists significantly overestimating the degree of this disability. Although the rheumatologists' accuracy at determining the amount of their patients' functional disability was poor overall, they were somewhat more accurate in patients with RA having less severe disease.