Daily Rheumatologic Practice Research Articles

FRI0037 A Comparative Study of Ultrasonography of Interphalangeal Joints in Rheumatoid Arthritis Patients in Remission and in Healthy Subjects

BackgroundMusculoskeletal Ultrasound (US) is now becoming part of the daily practice of rheumatology. In fact, it is a useful tool in rheumatoid arthritis (RA) for detecting persisting infra-clinical synovitis in...

Sialometria: Aspectos de interesse clínico

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desquamated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mu- cus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration.Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glan- dular parenchyma by infectious processes, granulomatous diseases or autoimmune and in- flammatory conditions (such as Sjögren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conventional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited. However, new alternatives have shown great perspective in the treatment of this disorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evalua- tion of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequenc- es of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.

Sialometry: aspects of clinical interest

Whole saliva is a multiglandular secretion complex consisting of gingival fluid, desqua- mated epithelial cells, microorganisms, products of bacterial metabolism, food debris, leukocytes mucus from the nasal cavity and the pharynx. Saliva has many functions, including tissue repair, tamponage, protection, digestion, taste, antimicrobial action, maintaining tooth integrity and antioxidant defense system. A decrease in salivary flow (hyposalivation) is a common disorder and it is estimated that approximately 20% of the general population have this alteration.Hyposalivation may be due to diabetes mellitus, hypothyroidism, dehydration, impaired glandular parenchyma by infectious processes, granulomatous diseases or autoimmune and inflammatory conditions (such as Sjögren's syndrome and rheumatoid arthritis), radiotherapy of head and/or neck region, or it may be associated with mood disorders, adverse effects caused by the use of some medications or even be idiopathic. Conven- tional therapies for the treatment of reduced saliva flow with the use of chemical and gustatory secretagogues are still limited.However, new alternatives have shown great perspective in the treatment of this di- sorder. To diagnose a patient as having chronic hyposalivation is a challenge in clinical practice and methods of salivary flow assessment are little known by rheumatologists. The serial evaluation of salivary flow is important for the diagnosis and prognosis of certain oral and systemic conditions. This review addresses some aspects related to the role of saliva, the consequences of hyposalivation and methods of salivary flow rate measurement, useful concepts in the daily practice of rheumatology.

Australian and New Zealand national evidence-based recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis: an integration of systematic literature research and rheumatological expert opinion

To develop Australian and New Zealand (ANZ) recommendations for the investigation and follow-up of undifferentiated peripheral inflammatory arthritis (UPIA) using an evidence-based approach. Ten questions pertaining to the investigation and follow-up of patients with UPIA in daily rheumatological practice were defined by clinicians using a modified Delphi approach. A systematic literature search was conducted for each of the final questions. The results were presented to a workshop of 54 ANZ rheumatologists in May 2009. Discussions were held to develop consensus statements for each question, based on published evidence and clinical experience/expertise. Ten recommendations were made on diagnostic value of clinical features in the patient's history and examination, predictors of poor prognosis and persistence, synovial fluid analysis, serology, imaging and human leukocyte antigen B27 testing. The lack of specific research to inform recommendations presented a challenge. Dynamic discussion groups outlined individual experience in areas without good quality clinical trial evidence. The median strength of support for the final set of recommendations was 7/10 (interquartile range 6-8), ranging from 6 to 9 for individual statements. Ten ANZ recommendations for the investigation and follow-up of UPIA were formulated, based on available evidence and extensive clinical experience. The systematic literature review was of limited value while animated discussion of individual experience, with subsequent information exchange, highlighted the importance of merging clinical expertise with published literature to establish practical recommendations that can improve quality of care in rheumatology.

Doppler ultrasound imaging techniques for assessment of synovial inflammation

Doppler ultrasound imaging techniques for assessment of synovial inflammation Emilio Filippucci,1 Fausto Salaffi,1 Marina Carotti,2 Walter Grassi1 1Rheumatology Department, Polytechnic University of the Marche, Ancona, Italy; 2Department of Radiology, Polytechnic University of the Marche, Ancona, Italy Abstract: Ultrasound is an evolving technique, and the rapid progress made in ultrasound technology over the past ten years has dramatically increased its range of applications in rheumatology. One of the most exciting advances is the use of Doppler ultrasound imaging in the assessment of blood flow abnormalities at the synovial tissue level in patients with chronic inflammatory arthritis. This review describes the Doppler techniques available and their main applications in patients with inflammatory arthritis, discusses the evidence supporting their use, and outlines the latest advances in hardware and software. Spectral, color, and power Doppler allow sensitive assessment of vascular abnormalities at the synovial tissue level. Use of contrast agents enhances visualization of the small synovial vessels using color or power Doppler ultrasound and allows for accurate characterization of the rheumatoid pannus. Doppler techniques represent a unique method for assessment of synovial inflammation, showing blood flow characteristics in real time. They are safe, noninvasive, cost-effective, and have high sensitivity in revealing and monitoring synovitis. However, several questions still need to be answered. In the near future, the Doppler techniques described here, together with upcoming hardware and software facilities, will be investigated further and a consensus will be reached on their feasibility and appropriate use in daily rheumatologic practice. Keywords: power and color Doppler techniques, ultrasound, contrast media, synovitis, rheumatoid arthritis

AB1240 Ultrasound evaluation of rheumatoid nodules and their correlation with disease activity

BackgroundLittle is known about the correlation of rheumatoid nodules and disease activity; in fact, this has been evaluated neither in clinical trials nor in cohort studies.ObjectivesThe purpose of this study...

FRI0512 The us7 score is a sensitive-to-change method for evaluating joint inflammation in rheumatoid arthritis among rheumatologists with basic or intermediate level of ultrasound training

BackgroundMusculoskeletal ultrasound may be a useful method for monitoring activity in rheumatoid arthritis (RA). German US-7 score is a recently introduced scoring index to assess synovitis and erosions in patients...

AB1269 Can we simplify ultrasonography synovitis scoring system in rheumatoid arthritis?

BackgroundThe US is an imaging method that is becoming a sensitive tool and useful in the detection and follow-up of inflammatory activity and structural damage of joints in rheumatoid arthritis...

SAT0504 Ultrasound Learning Curve in Gout: a Disease-Oriented Training Programme

BackgroundUltrasound (US) has gained considerable interest among Rheumatologists in the assessment of patients with gout due to its usefulness in both clinical practice and research activity. While a solid and...

SAT0188 Clinical and Ultrasonographic Characteristics of Arthritis in Patients with Idiopathic Inflammatory Myopathies

BackgroundArthritis is frequently observed symptom in patients with idiopathic inflammatory myopathies (IIM) in clinical practice, but there is a lack of systematic reports of prevalence and/or characteristics of arthritis in...

AB1268 Are there different imaging results in early rheumatoid arthritis?

BackgroundThe ultrasound (US) is being increasingly applied to the analysis of RA and the actual detection of a joint inflammatory process is essential for the management and initial treatment of...

AB1275 Ultrasound evaluation of the hands and wrists joints: a proposal of a new 10-joint ultrasound score for diagnosis and assessment of early rheumatoid arthritis patients

BackgroundPrevious reports have described the use of ultrasound (US) scores to evaluate rheumatoid arthritis (RA). However, no previous studies have used the ultrasound assessment of the hand and wrist joints...

THU0321 Increased Frequency of Hand Osteoarthritis in Patients with Primary Sjogren’s Syndrome: Is there a Relationship between Two Diseases?

BackgroundThe distribution of arthritisin primary SjSis similarto that of rheumatoid arthritis (RA), primarily affecting the small joints of the hands. Unlike RA, erosive arthritis is rarely seen in primary SjS....

AB1420-HPR Rheumatology nursing: An italian experience of e-learning

BackgroundRheumatology nursing management is a relevant strategic challenge. The recent “EULAR recommendations for the role of the nurse in the management of chronic inflammatory arthritis” indicate specific goals for a...

AB1306 Isolated tenosynovitis is frequently detected by ultrasound in symptomatic ankles of RA patients with significantly shorter disease duration

BackgroundBecause recent advances in drug therapies for RA have increased the importance of early diagnosis, musculoskeletal ultrasonography (US) has become increasingly a part of daily rheumatologic practice as a sensitive...

Musculoskeletal ultrasonography in patients with rheumatoid arthritis

In the current paradigm for management of patients with rheumatoid arthritis (RA), obtaining clinical remission of symptoms remains the most important aim, but achieving radiographic remission is another key goal of treatment. Several parameters detectable by musculoskeletal ultrasonography can predict the development of severe RA, as well as monitor patients' responses to treatment; thus, musculoskeletal ultrasonography is widely used for evaluating patients with RA, both in clinical trials and in clinical practice. This Review describes the applications of musculoskeletal ultrasonography in patients with RA, focusing on the identification of ultrasonographic features that predict the development of erosions. Such predictive markers include high vascularity of synovitis, persistent synovitis, tenosynovitis of the extensor carpi ulnaris tendon, and erosive changes in the distal ulna. This article also describes ultrasonographic scores that could feasibly be integrated into daily rheumatology practice for the evaluation of patients with RA.

Role of rheumatology clinical nurse specialists in optimizing management of hand osteoarthritis during daily practice in secondary care: an observational study

BackgroundThe purpose of this study was to describe the effectiveness of a single one-hour consultation by a clinical nurse specialist in patients with hand osteoarthritis during daily rheumatology practice in secondary care.MethodsConsecutive patients diagnosed by rheumatologists to have primary hand osteoarthritis and referred to the clinical nurse specialist were eligible for entry into this study. The standardized 1-hour consultation consisted of assessments and education on hand osteoarthritis by a clinical nurse specialist. Before and 3 months after the consultation, assessments were done to evaluate treatment (use of assistive devices, acetaminophen), health-related quality of life (physical component summary [PCS] score of Short-Form 36), and hand pain/function (Australian/ Canadian Osteoarthritis Hand Index [AUSCAN]). Paired t-tests and McNemar tests were used to analyze differences between baseline and follow-up. Satisfaction was measured after consultation at follow-up using a multidimensional questionnaire comprising 13 items (rated on a four-point scale).ResultsA total of 439 patients were referred, with follow-up data available for 195 patients, comprising 177 (87%) females, and of mean age 59 ± 9.0 years. After consultation, the proportions of patients using assistive devices and/or acetaminophen increased significantly from 30% to 39% and from 35% to 49%, respectively. PCS improved significantly (P = 0.03) whereas AUSCAN hand pain/function showed no significant differences compared with baseline (P values 0.52 and 0.92, respectively). The proportions of patients reporting to be satisfied or fully satisfied ranged from 78% to 99% per item.ConclusionA single, comprehensive, standardized assessment and education by a clinical nurse specialist improved the physical dimension of health-related quality of life in hand osteoarthritis. Most patients were satisfied with the consultation. Further controlled trials are needed to determine the added value of the clinical nurse specialist in care for hand osteoarthritis.

Sonographisch geführte Gelenkpunktionen in der Rheumatologie

Joint and soft tissue injections are routinely performed in daily rheumatology practice to establish the diagnosis or as part of the treatment in patients suffering from rheumatic diseases. Consequently, joint injections have been included in the rheumatology further training curriculum. Despite numerous studies demonstrating a poor accuracy and outcome of joint injections guided only by clinical examination, most of the injection procedures are still performed in a "blind" fashion based on clinical judgment. Ultrasound has evolved as an established imaging method in rheumatology within the past decade and is considered the preferred imaging modality for joint interventions due to its availability and lack of radiation exposure. In this article the indications and important aspects of the practical management of ultrasound-guided injections performed in daily rheumatology practice are summarized.

Efficacy and tolerability of tocilizumab in rheumatoid arthritis patients seen in daily clinical practice in Japan: results from a retrospective study (REACTION study)

Tocilizumab, a humanized monoclonal antibody to the interleukin 6 (IL-6) receptor, was approved for use as rheumatoid arthritis (RA) therapy in Japan in 2008, but its efficacy and tolerability in daily practice has not yet been reported. We report the results of a multicenter retrospective study on the efficacy and safety of tocilizumab involving all patients (n = 229) who were started on tocilizumab therapy at three rheumatology institutes in Japan from April 2008 through to March 2009. Tocilizumab was infused every 4 weeks at a dose of 8 mg/kg according to the drug labeling. Among the 229 patients, 55% concomitantly received methotrexate (MTX) and 63% had previously received anti-tumor necrosis factor (TNF) therapy. Average disease activity score (DAS) 28 of all 229 patients significantly decreased from 5.70 to 3.25 after 24 weeks of therapy. A European League Against Rheumatism (EULAR) good response and DAS28 remission was achieved in 57.4 and 40.7% of the patients, respectively, at 24 weeks. White blood cell counts significantly decreased and liver enzymes and total cholesterol slightly but significantly increased; however, liver enzyme levels did not increase in patients without MTX. Tocilizumab was discontinued in 47 cases (20.5%) due to lack of efficacy (5.2%), adverse events (11.4%), and other reasons (3.9%). The overall retention rate at 24 weeks was 79.5%. Based on these results, we conclude that tocilizumab therapy in daily rheumatology practice appears to be highly efficacious and well tolerated among active RA patients, including the anti-TNF therapy-refractory population. Tocilizumab infusion is therefore applicable not only as an alternative approach for anti-TNF therapy-resistant patients, but also as primary biologic therapy for active RA patients.

Musculoskeletal ultrasound scoring systems: assessing disease activity and therapeutic response in rheumatoid arthritis

Several musculoskeletal ultrasound scoring methods exist to monitor rheumatoid arthritis disease activity and the therapeutic response to immunosuppressive therapies. Qualitative (0/1) and different semiquantitative (0–3) systems as well as quantitative measurements are used. The semiquantitative 4-grade system developed by Szkudlarek et al., which evaluates joint effusion, synovial thickening, bone erosion and power Doppler activity, is mostly applied. Thus far, an internationally accepted US sum scoring system does not exist. The novel seven-joint ultrasound (US7) score is the first US composite scoring system that combines soft tissue lesions (synovitis and tenosynovitis/paratenonitis) and destructive processes (erosions) in a single scoring system. By that, the implementation of the US7 score can quickly and easily give an overview of current disease activity in daily rheumatologic practice. Furthermore, its use in therapy monitoring is very helpful. This article reviews the development of different U...