Higher rates of ultrasound synovial hypertrophy, bone erosion and power doppler signal in asymptomatic Brazilian elderly versus young adults: a cross-sectional study.

To evaluate the prevalence of musculoskeletal ultrasonography (MSUS) abnormalities in asymptomatic elderly individuals. A cross-sectional controlled study was conducted and MSUS of 23 joints (wrist, metacarpophalangeal-MCP, proximal interphalangeal-PIP, elbow, glenohumeral, hip, knee, ankle, and metatarsophalangeal-MTP joints) was performed in healthy individuals aged 18-29 (young, n = 32) and 60-80 years-old (elderly, n = 32). Quantitative synovial hypertrophy (SH) was measured in mm and a semiquantitative scoring system (0-3) was used to grade SH, power doppler (PD) and bone erosion (BE). Young and elderly participants were 26.2 ± 3.2 and 65.9 ± 4.4 years-old, respectively. As compared to the young participants, elderly individuals had higher SH values in 35% of the joint surfaces (P < 0.05), higher rates of scores 1-3 for SH at the dorsal surface of the 3rd MCP, palmar surface of the 2nd MCP, 2nd PIP, 3rd MCP and 3rd PIP and subtalar joints (17.2 vs. 1.6%, P = 0.002; 29.7 vs. 6.3%, P = 0.001; 12.5 vs. 1.6%, P = 0.016; 21.9 vs. 6.3%, P = 0.011; 21.9 vs. 7.8%, P = 0.025; and 24.2 vs. 6.3%, P = 0.005, respectively), BE at the radiocarpal, ulnocarpal, dorsal surface of the 2nd MCP and posterior area of the glenohumeral joints (10.9 vs. 1.6%, P = 0.028; 12.5 vs. 0%, P = 0.003; 9.4 vs. 0%, P = 0.012; and 29.7 vs. 10.9%, P = 0.008, respectively) and PD at the dorsal surface of the 2nd and 3rd MCP joints (9.4 vs. 0%; P = 0.012 and 7.8 vs. 0%; P = 0.023, respectively). BE scores ≥ 1 were more frequent in the elderly (P < 0.05) in 22 (88%) of the joint surfaces evaluated. MSUS abnormalities are more frequent in asymptomatic elderly individuals as compared to young subjects.

Intra-articular injection with platelet-rich plasma compared to triamcinolone hexacetonide or saline solution in knee osteoarthritis: A double blinded randomized controlled trial with one year follow-up.

OBJECTIVES: To compare the effectiveness of intra-articular injection (IAI) of Platelet-Rich Plasma (PRP) with Triamcinolone Hexacetonide (TH) and Saline Solution (SS), in patients with knee osteoarthritis (OA). DESIGN: A randomized controlled trial, with blinded patients and assessor. SETTING: Outpatient rheumatology service. SUBJECTS: Patients with knee osteoarthritis grades II and III. INTERVENTIONS: Patients received IAI with PRP, 40 mg TH, or SS. METHODS: Patients were assessed at baseline and after 4, 8, 12 e 52 weeks with: visual analogue scale (VAS) for pain at rest and movement, WOMAC questionnaire, Timed to Up and Go test, 6-min walk test, percentage of improvement, goniometry, quality of life SF-36 questionnaire, Likert scale and Kelgreen & Lawrence (KL) radiographic scale (only at baseline and 52 weeks). RESULTS: 100 patients were studied, with a mean age of 67.13(6.56) years. The TH group was superior for: percentage of improvement (versus SS group from 4 to 52 weeks); WOMAC total and pain (versus PRP group at 4 weeks); and WOMAC stiffness (versus SS group at 12 weeks). The SS group was inferior for WOMAC function (from 8 to 52 weeks). The PRP group showed lowest radiographic progression [TH 17 (51.51%) to 24 (72.72%); SS 17 (51.51%) to 30 (90.90%); PRP 20 (58.82%) to 21 (61.76%)]. CONCLUSION: The Triamcinolone Hexacetonide group was superior for percentage of improvement and WOMAC, pain and stiffness. For the WOMAC function, the Platelet-Rich Plasma group and Triamcinolone Hexacetonide group were superior to the Saline group. The Platelet-Rich Plasma group showed the lowest radiographic progression at 52 weeks of follow-up.

Is There a Difference Between the Joint Ultrasounds of Healthy Women and Men? A Study With Small, Medium, and Large Joints.

To compare joint ultrasound measurements between the sexes in healthy volunteers. A cross-sectional study compared the joint ultrasound measurements between the sexes in healthy volunteers. Quantitative (synovial hypertrophy and perpendicular measurement in the largest synovial recess) and semiquantitative (synovial hypertrophy, power Doppler, and bone erosion; score 0-3) ultrasound measurements were performed. Forty-six articular recesses were evaluated and compared between group 1 (100 females) and group 2 (60 males) who were matched by age and BMI. For the quantitative measurements, 7360 recesses were studied. For the semiquantitative measurements, 22,720 recesses were evaluated. Higher values (p < .05) were found in females for the quantitative measurements of synovial hypertrophy for the following: radiocarpal, distal radioulnar and ulnocarpal, second/third dorsal and second/third palmar interphalangeal, second palmar metacarpophalangeal, glenohumeral, hip, talocrural, talonavicular, and talocalcaneal recesses; the highest difference was found for the hip (6.21 ± 1.35 vs. 4.81 ± 2.40) and distal radioulnar (1.46 ± 0.40 vs. 1.07 ± 0.70) recesses. For the semiquantitative measurements, significant differences were found. For synovial hypertrophy, higher measurements for females in the second/third palmar metacarpophalangeal, second palmar proximal interphalangeal, hip, tibiotalar, talonavicular, talocalcaneal, and second metatarsophalangeal recesses (highest difference for second palmar metacarpophalangeal [44 (22.0%) vs. 5 (4.2%)]). For power Doppler, there were higher values for females in the talonavicular recesses and higher values for males in the first/second/fifth metatarsophalangeal recesses (highest difference for fifth [9 (7.5%) vs. 2 (1.0%)]). For bone erosion, there were higher measurements for females in the radiocarpal recesses (10 [5.0%] vs. 0 [0.0%]) and higher values for males in the talonavicular recesses (4 [3.3%] vs. 0 [0.0%]). Higher quantitative and semiquantitative ultrasound measurements of synovial hypertrophy were typically found in females.

Comparison between intra-articular Botulinum toxin type A, corticosteroid, and saline in knee osteoarthritis: a randomized controlled trial.

OBJECTIVE: To compare the effectiveness of intra-articular injection (IAI) with Botulinum toxin type A (BTA), triamcinolone hexacetonide (TH), and saline in primary knee osteoarthritis. DESIGN: A randomized controlled trial, with blinded patients and assessor. SETTING: Outpatient rheumatology service. SUBJECTS: Patients with knee osteoarthritis grades II and III. INTERVENTIONS: Patients received IAI with 100 IU BTA, 40 mg TH, or isotonic saline solution (SS) 0.9%. MAIN MEASURES: Patients were assessed at baseline and at 4, 8, and 12 weeks with the following instruments: visual analog scale for pain during movement (VASm; primary outcome) and visual analog scale for pain at rest (VASr), Western Ontario & McMaster Universities Osteoarthritis Index (WOMAC) questionnaire, 6-minute walk test, Timed Up and Go test, Short Form (SF)-36 questionnaire, range of motion of knee, and ultrasound (US) measurement of synovial hypertrophy. RESULTS: In total, 105 patients were randomized, with 35 in each group; 96 were female (91.4%) and 9 were male (8.6%), with a mean age of 64.2 years (±6.9). At 12 weeks, the TH group showed better results only for VASm. At four weeks, the TH group showed better results than the BTA and SS groups for VASm (-68.9% (37.8) vs. -35.3% (40.3) vs. -35.9% (51.4)), WOMAC pain (-56.0% (30.7) vs. -30.8% (34.3) vs. -30.0% (39.9)), WOMAC stiffness (-53.4% (38.4) vs. -17.2% (59.3) vs. -17.3% (78.1)), WOMAC function (-48.2% (34.6) vs. 30.8% (33.6) vs. -13.6% (64.9)), WOMAC total score (-51.2% (31.0) vs. -30.9% (30.0) vs. -18.8% (54.8)), and US measurement of synovial hypertrophy (-11.6% (44.9) vs. -1.5% (47.9) vs. +28.6% (81.3)). CONCLUSION: IAI with TH had a higher effectiveness than that with TBA or SS in the short-term assessment (four weeks) for pain in movement, WOMAC, and US measurement of synovial hypertrophy.

Effectiveness of an overall progressive resistance strength program for improving the functional capacity of patients with rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of overall progressive resistance training in patients with rheumatoid arthritis. DESIGN: Randomized controlled clinical trial with blinded assessor and intention-to-treat analysis. SETTING: Outpatient clinics. SUBJECTS: Sixty patients with rheumatoid arthritis according to the American College of Rheumatology criteria, aged between 18 and 65 years old, under stable medication and not performing regular physical activity were randomized into two groups: intervention group (IG) and control group (CG). INTERVENTIONS: IG performed the progressive resistance strength training, twice a week, during 12 weeks. The training consists of exercising various muscle groups using a load of 50% and 70% of one repetition maximum. The load was reassessed and adjusted after six weeks of baseline. Both groups remained in conventional drug treatment during the study. MAIN MEASURES: Patients were evaluated at baseline and after 6, 12, and 24 weeks, using HAQ and SF-36 questionnaires and strength. RESULTS: Thirty-three patients in the CG and 27 in the IG were evaluated. The groups were homogeneous at baseline. Statistical and clinical improvement were found with better results for the IG in the HAQ questionnaire ( P=0.030), functional capacity (0=0.022) and pain ( P=0.027) domains of SF-36; and muscle strength for flexors of right and left knee ( P=0.005 and p=0.14), abductors of shoulder ( P=0.041) and extensors of right and left wrists ( P=0.003 and P= 0.005). CONCLUSIONS: This progressive resistance strength training improves physical function as well as grip and muscular strength of knee flexors, shoulder abductors and wrist extensors in patients with RA, without adverse effects.

Hand ultrasound: comparative study between "no rhupus" lupus erythematosus and rheumatoid arthritis.

OBJECTIVE: To compare hand US between systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients. METHODS: Hands (1st-5th metacarpophalangeal [MCP] and 1st-5th proximal interphalangeal [PIP] joints) and wrists (radiocarpal and distal radioulnar joints) of 62 "no rhupus" SLE and 60 RA patients were compared through US (linear probe, 6-18 MHz). The findings were compared to clinical, functional, serological outcomes, and disease activity indices. RESULTS: 2108 and 2040 joint recesses were evaluated in SLE and AR patients, respectively. Synovitis was found in 46.8% and 75% of wrists, 83.9% and 86.7% of MCPs and 58.1% and 70% of PIPs in the SLE and RA groups, respectively. More significant US findings were found in RA group. Greater values of synovitis (mm) in RA group were only found in the joint recesses of wrist (p < 0.001-0.002). In SLE group, US findings were associated with "puffy hands," Health Assessment Questionnaire score and dynamometry. Twenty-two SLE patients (35.5%) had erosion in any of joints studied. SLE patient subgroup with US erosion was associated with hematological involvement and Jaccoud's arthropathy. CONCLUSIONS: US of "no rhupus" SLE and RA patients is different, especially in wrists. In SLE patients the clinical variable most associated with US findings was "puffy hands."

Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis ‒ A double-blinded randomized controlled trial with a one year follow-up.

OBJECTIVE: to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over 1-year. METHODS: A randomized, double-blind study. 60 patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for 1-year, at baseline and 1, 4, 8, 12, and 48 weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response. RESULTS: Sixty patients completed the follow-up. There were nine missed assessments. 97% were women; mean age of 61-years (SD = 8.2), and approximately 5-years of disease (SD = 3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades I and II, and the other half grades III and IV. The two groups evolved similarly at 48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p = 0.04 and p < 0.001, respectively) at 48-weeks. Radiographically there was no statistical difference between groups (KL, p = 0.564; erosive OA, p = 0.999; worsening, p = 0.573). CONCLUSION: The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint.

The SPIKES protocol does not influence the tolerance or effectiveness of intra-articular corticosteroid injection in the knees of osteoarthritis patients: A prospective, controlled, randomized single-blinded trial.

BACKGROUND: Patient user embracement involves behaviours of including and listening to the patient, appreciating their complaints, and identifying their needs, whether individual or collective. The aim of this study was to evaluate the influence of a user embracement protocol (SPIKES protocol) for patients with knee osteoarthritis (OA) immediately before intra-articular injection (IAI) relative to procedure tolerance and its effectiveness in the immediate, short and medium terms. METHODS: This was a randomized controlled trial. Patients received IAIs with triamcinolone hexacetonide (40 mg) preceded or not by the SPIKES protocol. The outcomes measured were: visual analogue scale for pain at rest, pain on movement and joint swelling; morning stiffness; Western Ontario McMaster Universities Index Functional Questionnaire (WOMAC); pain catastrophizing scale; McGill pain questionnaire; SF-36 questionnaire on quality of life; Trace State Anxiety Inventory (IDATE); and a Timed Up and Go functional test. RESULTS: One hundred patients were randomized in the user embracement group (n = 50) or the control group (n = 50); 89% were women and 60% white, mean age was 67.1 (±7.3) years, and mean disease time was 6.3 (±6.2) years. No statistically significant differences were found between the groups for any variables at pre-procedure time, nor did the groups differ in their tolerance to the procedure or during the 12 weeks of follow up for any evaluated variables. CONCLUSIONS: No benefit was identified by applying a user embracement protocol to patients with knee OA prior to IAI with corticosteroid, neither to tolerance at the time of the procedure nor to its effectiveness in the immediate, short, and medium terms.

Time Effect of Intra-articular Injection With Triamcinolone Hexacetonide and Its Correlations: A Case-Control Prospective 12-Month Study.

OBJECTIVE: The aim of the study was to assess the time effect of intra-articular injection with triamcinolone hexacetonide in rheumatic patients. DESIGN: A prospective case-control study with patients submitted to one intra-articular injection with triamcinolone hexacetonide. Patients were followed monthly (12 mos) for pain and swelling. RESULTS: Two hundred sixty-two joints were assessed in 158 patients with mean ± SD age of 60 ± 13.7 yrs. Remission was observed at 3, 6, and 12 mos in 142 (54.19%), 111 (42.36%), and 105 (40.07%) joints, respectively. The mean ± SD time effect were 8 ± 4.0 mos; 8.4 ± 3.9 for rheumatoid arthritis patients and 6.9 ± 4.0 for osteoarthritis patients (P = 0.012) and 10.4 ± 2.7 mos for small, 7.7 ± 4.1 for medium, and 6.8 ± 4.0 for large joints. The joints were divided into two groups: long-term group (time effect of intra-articular injection longer than 6 mos) and short-term group. The following are the variables associated (P < 0.05) with long-term group: rheumatoid arthritis, small and medium-sized joints, female sex, lower pain and swelling visual analog scale scores, and use of leflunomide. The following are the variables associated with short-term group: receiving only one intra-articular injection, hypertension, diabetes mellitus, and biological therapy. CONCLUSIONS: The mean ± SD time effect of intra-articular injection with triamcinolone hexacetonide was 8.0 ± 4.0 mos. The associated predictors were rheumatoid arthritis, small and medium joints, lower pain/swelling visual analog scale scores, and use of leflunomide.

Ultrasound of entheses in ankylosing spondylitis patients: The importance of the calcaneal and quadriceps entheses for differentiating patients from healthy individuals.

OBJECTIVES: To compare the ultrasonographic findings of entheses in ankylosing spondylitis (AS) patients with those of healthy control individuals and to assess the ability of ultrasound (US) to identify aspects related to the disease. METHODS: A cross-sectional study involving 50 patients with AS and 30 healthy controls was performed. Clinical assessment included the use of a visual analog scale for pain, assessment of swelling of the enthesis, global assessments for patients and physician, use of a disease activity index, mobility and dysfunctional indices, erythrocyte sedimentation rate and clinical enthesitis index. US was performed for the following entheses by two experienced musculoskeletal radiologists: brachial triceps, distal quadriceps, proximal and distal patellar tendons, calcaneal tendon, and plantar fascia; the total and subitems of the Madrid Sonographic Enthesitis Index were used for evaluations. RESULTS: Comparison between groups showed a statistically significant difference with worse scores in AS patients, with bone erosion of the calcaneal enthesis and bone erosion and thickening of the plantar fascia. The odds ratio for thickening of the plantar fascia in the AS group was 3.47, according to logistic regression analysis. The AS group also had worse scores regarding the presence of calcification in the quadriceps enthesis, with a fivefold increased risk. CONCLUSION: US analysis showed that only entheses of the foot and quadriceps were able to differentiate AS patients from healthy individuals.

Measurement of upper limb ulcers in patients with systemic sclerosis: reproducibility and correlation with pain, function, and quality of life.

BACKGROUND: There are a large number of studies addressing the treatment and assessment of chronic ulcers. Despite the fact that ischemic ulcers are frequent and difficult to manage in cases of systemic sclerosis, there is minimal literature on assessment measures regarding these wounds or on their reproducibility. OBJECTIVES: The aim of this study was to investigate intraobserver and interobserver reproducibility regarding ulcer dimension measurements in patients with systemic sclerosis. Correlations between pain, upper limb function, pinch strength, and quality of life were also determined. METHODS: A prospective 11-week follow-up study was carried out to assess active upper limb ulcers. Ulcer diameter, ulcer area, and interobserver reproducibility were performed weekly. Quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey), upper limb function (disabilities of the arm, shoulder, and hand), pinch strength, pain, visual analog scale, and intraobserver reproducibility were assessed at baseline, 3, 7, and 11 weeks. RESULTS: Fifty-one active ulcers were recorded. Larger ulcer diameter, smaller ulcer diameter, and ulcer area demonstrated excellent intraobserver (r > .81, p < .001) and interobserver reproducibility (r > .76, p < .001). There was significant correlation between ulcer dimension and visual analog scale scores for pain (r = .42; p < .001) and some Medical Outcomes Study 36-Item Short-Form Health Survey; pinch strength; and disabilities of the arm, shoulder, and hand domains (r >or= .40; p < .01). DISCUSSION: Simple measurement instruments for the assessment of ischemic ulcers were reproducible in patients with SSc and correlated to other variables of interest for these wounds.

Interventional rheumatology: the competence of Brazilian rheumatologists.

OBJECTIVES: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. METHODS: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. RESULTS: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p<0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p<0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p<0.001), synovial biopsy (OR: 5.75, p=0.043), image-guided IAI (OR: 4.16, p<0.001), viscosupplementation (OR=3.41, p<0.001), joint lavage (OR=3.22, p=0.019), salivary gland biopsy (OR=2.16, p=0.034) and over 6-month training (OR: 2.16, p=0.008). CONCLUSIONS: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.

Patients with juvenile idiopathic arthritis in clinical remission with positive power Doppler signal in joint ultrasonography have an increased rate of clinical flare: a prospective study.

BACKGROUND: Ultrasonography (US) studies carried out on joints of juvenile idiopathic arthritis (JIA) patients in clinical remission demonstrate the presence of subclinical synovitis. The significance of subclinical synovitis and the positive power Doppler (PD) signal on US in JIA in clinical remission is not well understood. The objectives of this study were to assess whether the changes detected by US in patients with JIA in clinical remission can predict disease flare and to evaluate factors associated with flare and joint damage over 30 months of follow-up. METHODS: A prospective study was performed with clinical and ultrasound evaluation in 34 joints of JIA patients in clinical remission. Clinical evaluation including physical exam, functional capacity and inflammatory markers was performed at baseline and every six months thereafter, for a total period of 30 months. US evaluation included presence of synovitis, PD signal and erosion at baseline and every 12 months thereafter. Subclinical synovitis was defined when there was synovitis with or without positive PD signal in US joints of patients in clinical remission. Flare was defined as any joint presenting clinical arthritis requiring therapy modification. RESULTS: We evaluated a total of 35 patients, 28 (80%) girls, 14 (40%) persistent oligoarticular subtype, 12 (34.3%) oligoarticular extended and 9 (25.7%) polyarticular and 26 (74.3%) in remission on medication. Twenty (57.1%) patients flared. The risk of flare was five times higher in patients with positive PD signal and 14 times higher in patients in remission on medication. Regarding the assessment of joints after 6 months and 12 months of US evaluation, 70/3162 (2.2%) joints and 80/2108 (3.8%) joints flared, respectively. Joints with subclinical synovitis with positive PD signal flared more after 6 and 12 months. Twenty five of 2108 (1.2%) joints showed erosion over time. Joints with subclinical synovitis with or without positive PD signal showed more erosion. CONCLUSIONS: Patients in remission on medication with subclinical synovitis with positive PD signal on US have a higher risk of flare, therefore they should be monitored closely during treatment. In the same way, joints with subclinical synovitis with or without positive PD signal should be monitored due to the risk of flare and joint damage.

Intra-articular injection with triamcinolone hexacetonide in patients with rheumatoid arthritis: prospective assessment of goniometry and joint inflammation parameters.

OBJECTIVES: To evaluate local joint variables after intra-articular injection with triamcinolone hexacetonide in rheumatoid arthritis patients. METHODS: We blindly and prospectively (baseline, 1, 4, 12 and 24 weeks) evaluated metacarpophalangeal, wrist, elbow, shoulder, knee and ankle joints after triamcinolone hexacetonide intra-articular injection by the following outcome measures: visual analogue scale 0-10cm (VAS) for rest pain (VASR); VAS for movement pain (VASM); VAS for joint swelling (VASSw); flexion (FlexG) and extension (ExtG). RESULTS: 289 patients (635 joints) were studied. VASSw (p<0.001) and VASR (0.001

Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis - A double-blinded randomized controlled trial with a one year follow-up

Abstract Objective: to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over 1-year. Methods: A randomized, double-blind study. 60 patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for 1-year, at baseline and 1, 4, 8, 12, and 48 weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response. Results: Sixty patients completed the follow-up. There were nine missed assessments. 97% were women; mean age of 61-years (SD = 8.2), and approximately 5-years of disease (SD = 3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades I and II, and the other half grades III and IV. The two groups evolved similarly at 48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p = 0.04 and p < 0.001, respectively) at 48-weeks. Radiographically there was no statistical difference between groups (KL, p = 0.564; erosive OA, p = 0.999; worsening, p = 0.573). Conclusion: The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint.

Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response. / Infiltração intra-articular em pacientes com artrite idiopática juvenil: fatores associados à boa resposta.

INTRODUCTION: Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. OBJECTIVES: To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. METHODS: Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. RESULTS: Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p=0.037) and the occurrence of uveitis in the course of the disease (p=0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p=0.001), lesser values stated in the overall visual analogue scale by the physician (p=0.015) and by parents/patient (p=0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. CONCLUSION: In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response.

INTRODUCTION: Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. OBJECTIVES: To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. METHODS: Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. RESULTS: Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p=0.037) and the occurrence of uveitis in the course of the disease (p=0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p=0.001), lesser values stated in the overall visual analog scale by the physician (p=0.015) and by parents/patient (p=0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. CONCLUSION: In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

Effectiveness of intra-articular injection in wrist joints according to triamcinolone hexacetonide dose in rheumatoid arthritis: a randomized controlled double-blind study.

OBJECTIVE: The aim of this study was to compare the effectiveness in the medium term between low and high doses of triamcinolone hexacetonide used in intra-articular injection in medium-sized joints of rheumatoid arthritis (RA) patients. METHODS: A randomized double-blind study was carried out in rheumatoid arthritis patients with wrist painful refractory synovitis. Sixty wrists were included and randomized to receive low dose (20 mg) or high dose (40 mg). The outcomes assessed in T0, T1, T4, T8, and T12 weeks were visual analog scale for pain and for swelling, chronic disease activity index, goniometry, simplified Stanford Health Assessment Questionnaire, and side effects. RESULTS: Baseline mean (standard deviation) values were pain visual analog scale of 6.1 (1.6) and 6.3 (1.7), P = 0.562; swelling visual analog scale of 5.9 and 6.4, P = 0.466; chronic disease activity index of 17.8 and 16.8, P = 0.366; and Health Assessment Questionnaire of 0.8 and 0.7, P = 0.238, in the high- and low-dose groups, respectively. Both groups improved pain and swelling assessed by the visual analog scale, P < 0.001, in the intragroup analysis. Chronic disease activity index, goniometry, and Health Assessment Questionnaire also improved equally over time in both groups in the intragroup analysis (P < 0.001, 0.001, and 0.002, respectively). No serious side effects were detected. CONCLUSIONS: High and low triamcinolone hexacetonide doses had good effectiveness in wrist-blinded intra-articular injection of rheumatoid arthritis patients, without statistical difference between them.

Effectiveness of Triamcinolone Hexacetonide Intraarticular Injection in Interphalangeal Joints: A 12-week Randomized Controlled Trial in Patients with Hand Osteoarthritis.

OBJECTIVE: To evaluate the effectiveness and tolerance of intraarticular injection (IAI) of triamcinolone hexacetonide (TH) for the treatment of osteoarthritis (OA) of hand interphalangeal (IP) joints. METHODS: Sixty patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH/lidocaine (LD; n = 30) with TH 20 mg/ml and LD 2%, or just LD (n = 30). The injected joint was immobilized with a splint for 48 h in both groups. Patients were assessed at baseline and at 1, 4, 8, and 12 weeks by a blinded observer. The following variables were assessed: pain at rest [visual analog scale (VAS)r], pain at movement (VASm), swelling (physician VASs), goniometry, grip and pinch strength, hand function, treatment improvement, daily requirement of paracetamol, and local adverse effects. The proposed treatment (IAI with TH/LD) was successful if statistical improvement (p < 0.05) was achieved in at least 2 of 3 VAS. Repeated-measures ANOVA test was used to analyze intervention response. RESULTS: Fifty-eight patients (96.67%) were women, and the mean age was 60.7 years (± 8.2). The TH/LD group showed greater improvement than the LD group for VASm (p = 0.014) and physician VASs (p = 0.022) from the first week until the end of the study. In other variables, there was no statistical difference between groups. No significant adverse effects were observed. CONCLUSION: The IAI with TH/LD has been shown to be more effective than the IAI with LD for pain on movement and joint swelling in patients with OA of the IP joints. Regarding pain at rest, there was no difference between groups. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT02102620).

[Intra-articular injections of triamcinolone hexacetonide in rheumatoid arthritis: short and long-term improvement predictors]. / Infiltrações intra-articulares de triancinolona hexacetonida na artrite reumatóide: preditores de melhora a curto e longo prazo.

OBJECTIVES: Identify good response predictors to intra-articular injection (IAI) with triamcinolone hexacetonide (TH). METHODS: This study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection). ASSESSMENT: A "blinded" observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0-10 cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response. RESULTS: We studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain=6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: "elbow and metacarpophalangeal (MCP) IAI, and functional class II". Under multivariate analysis, "males" and "non-whites" were the predictors with the best response to IAI at T4, while "elbow and MCP IAI", "polyarticular injection", "use of methotrexate" and "higher total dose of TH" obtained the best response at T24. CONCLUSION: Several predictors of good response to IAI in patients with RA were identified. The best-response predictors for TH IAI of long term were "apply elbow and MCP IAI" and "apply polyarticular injection".