Procedures In Rheumatology Research Articles

Ultrasound-guided interventions in rheumatology.

Over the last few years, percutaneous procedures have undergone great advances, thanks to the ultrasound (US) guidance, due to the technical improvements in the US field, combined with the greater availability, good portability, and reduced cost of US devices. The direct target visualization and the real-time imaging performance enabled by US-guidance account for an improved accuracy in needle placement in several rheumatology interventions. So, ultrasound-guided procedures contribute to several diagnostic or therapeutic procedures such as fluid aspiration or treatment instillations of common joints, tendons, and bursas. In clinical practice, this fact is especially important in the case of depth areas like the hip, small anatomical structures as tendon sheaths or nerves in tenosynovitis or nervous blocks, or complex anatomical structures like the spine's facet joints. The US-guide is an essential tool for performing diagnostic procedures as synovial biopsy. US can also be combined with other imaging techniques, like the establishment portal arthroscopy for instance. Compared to older blind procedures, US-guided injections are more accurate and safer, and they result in better clinical outcomes in terms of joints improvement in function and decreased risk of damages caused by needle misplacement. With the ultrasound guided treatment, we can avoid the instillation of therapeutic products outside the predetermined target, which may be sometimes potentially harmful. The aim of this article is to describe the main generalities of ultrasound-guided procedures in rheumatology, their main advantages and disadvantages, and their particularities in joints where they are most frequently used, such as the shoulder, hip, and knee.

Evaluation of aseptic technique used in interventional rheumatology: survey among Moroccan and Tunisian rheumatologists

The objective of our study was to evaluate the aseptic technique used in interventional rheumatology by Moroccan and Tunisian rheumatologists. We performed an online survey among rheumatologists from Morocco and Tunisia. The questionnaire included 15 questions with single and multiple-choice answers and three open sections for freetext comments. An online survey was prepared and sent to 380 rheumatologists. One hundred and four rheumatologists (27.36%) replied to the survey. More than half of the participants (56.7%) were from Tunisia and 43.3% were from Morocco. Interventional procedures on superficial joints were performed by all participants. Ultrasonography was used by 41.3% of respondents to guide interventional procedures. Regarding the aseptic precautions taken to avoid infection, the majority of participants used povidone iodine to clean the skin and only 8.7% wore a mask. Hand washing alone without gloves wearing was done by 19.2% of participants. 2.9% of participants reported a history of iatrogenic septic arthritis and the duration of practice was the only factor associated with its occurrence (P=0.007). Our study showed that aseptic technique used during interventional rheumatologic procedures is heterogeneous. However, the majority of participants were aware of its necessity to avoid iatrogenic septic arthritis.

Ultrasound-Guided Procedures in Rheumatology Daily Practice: Feasibility, Accuracy, and Safety Issues.

The aims of this study were to describe in detail the ultrasound (US)-guided procedures in our daily rheumatology practice, to evaluate the feasibility and accuracy of US-guided procedures, and to test the efficacy of our disinfection protocol in preventing infectious complications. This was a cross-sectional and monocentric study. Information regarding patients' age, sex, body mass index, rheumatic disease, US pathological findings, aspirated and/or injected anatomical site, US equipment (ie, probe type and frequency), and needle type was consecutively collected for each US-guided procedure in a third-level rheumatology center. A total of 643 US-guided procedures were performed, with a mean of 5.2 procedures per working-day. In 94.2% of the patients, only one procedure was carried out, whereas in 5.8%, more than one. The mean time was 7 ± 2.5 minutes. Ultrasound-guided procedures were highly accurate (accuracy rate higher than 95%) and safe (adverse events were reported in 0.8%). Our disinfection protocol was effective in preventing infectious complications. Probes with frequency values between 8 to 13 MHz and 20-, 21-, and 22-gauge needles were the most frequently used at shoulder, knee, wrist, elbow, and ankle level. High-frequency linear probes (ranging between 18 and 22 MHz) and 23- and 25-gauge needles were used for injecting small joints of the hands and feet. Convex low-frequency probe (2-7 MHz) and 18- and 20-gauge needles were the most used for performing hip joint aspirations and/or injections. This study reports useful information for setting up a service providing US-guided procedures in rheumatology and supports the feasibility, accuracy, and safety of US-guided procedures.

Rheumatologic skills development: what are the needs of internal medicine residents?

Given the burden of rheumatic disease in our society and the anticipated future shortage of rheumatologists, all internal medicine (IM) residencies need to train internists who are capable of caring for patients with rheumatic diseases. The objective of this study was to perform a targeted needs assessment of the self-confidence of IM residents in the evaluation and care of patients with rheumatologic diseases. A 16-item, web-based, self-assessed confidence survey tool was administered to participating post graduate year (PGY)1 (N = 83) and PGY3 (N = 37) residents. The categories of questions included self-confidence in performing a rheumatologic history and exam, performing common rheumatologic procedures, ordering and interpreting rheumatologic laboratory tests, and caring for patients with common rheumatologic diseases. Resident demographics, prior rheumatology exposure, and career plans were also queried. PGY3 residents had higher self-assessed confidence than PGY1 residents in all categories. Self-assessed confidence in joint procedures was consistently low in both groups and when compared to other categories. Prior exposure to a rheumatology course or elective was not consistently associated with higher self-assessed confidence ratings across all categories. PGY3 residents showed less interest in rheumatology as a career than PGY1 residents, although the interest in the topic of rheumatology was not statistically different. Our needs assessment shows a low level of self-assessed confidence in rheumatology knowledge and skills among IM residents. Despite improvement with PGY year of training, self-assessed confidence remains low. To improve resident's skills and self-confidence in rheumatology, more curricular innovations are needed. Such innovations should be assessed for overall effectiveness.

Ultrasound-guided procedures in rheumatology. What is the evidence?

Ultrasound (US) is a cost-effective, noninvasive, and accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. It can play a relevant role in invasive procedures performed by the rheumatologist, potentially ensuring a higher degree of accuracy. However, US-guided injections are still underused, and the conventional blind injection the most commonly adopted approach. In this article, we analyze the current evidence supporting the use of US-guided procedures, emphasizing comparative studies between conventional and US-guided procedures and their benefits in the daily rheumatological practice.

Correlation of articular involvement, skin disfigurement and unemployment with depressive symptoms in patients with systemic sclerosis: a hospital sample

Systemic sclerosis (SSc) is a connective tissue disease associated with increased functional impairment, body image distress due to skin lesions, and psychosocial comorbidity, particularly depression. Prevalence of depressive symptoms in SSc patients ranges from 36% to 65% and it contributes to the worsening of any aspect of the disease. The aim of this study was to investigate the prevalence and clinical and non-clinical correlates of depressive symptoms in a sample of outpatients with SSc. Seventy-eight consecutive SSc outpatients were recruited from February 2005 to July 2007. Socio-demographic and SSc-related clinical data were collected, including a modified Rodnan Skin Score, the Valentini Disease Activity Index and psycho-metric assessment of disability and pain. Depressive symptoms were assessed using the Beck Depression Inventory (BDI). Two questions on perception of support from relatives and impact of disfigurements were also directly addressed to subjects. The BDI mean score was 10.5 (±8.3), with 36 subjects (46.2%) scoring above clinical significance. Unemployment, increased disability, pain, disease activity and articular involvement were significantly associated with more depressive symptoms. Older age, unemployment and more depressive symptoms were also related with complaints of disfigurements due to skin involvement. Depression is an influential prognostic factor in SSc. The present study contributes to the knowledge of the relationship between depression and clinical features routinely collected in rheumatology settings in order to develop a standardized assessment of psychosocial distress in routine rheumatologic procedures.

Rheumatology Practice Profiles in Teaching and Community Settings in Puerto Rico

University-based fellowship training programs may not always provide the required experience to manage common and less complex medical conditions usually seen at the community setting. Few studies have addressed this concern. The purpose of this study was to compare the demographic features, diagnoses, and rheumatologic procedures in patients seen at the University of Puerto Rico Medical Sciences Campus Adult Rheumatology Training Program practice and 3 community-based rheumatology practices in Puerto Rico. Claim forms submitted to health care insurance companies in 2007 from the university and community practices were evaluated. Demographic parameters, primary diagnoses (per International Classification of Diseases, Ninth Revision), medical visits, and rheumatologic procedures (per Current Procedural Terminology 4) were examined. Variables were analyzed by χ and Student t tests. A total of 11,373 claim forms were reviewed: 1952 from the university setting and 9421 from the community-based practices. Younger age and female sex were more common in visits from the university-based setting. Autoimmune diseases were reported more commonly at the university setting (65.3% vs 37.6%, P < 0.001). Conversely, osteoarthritis (24.4% vs 9.8%, P < 0.001), fibromyalgia syndrome (7.4% vs 1.9, P < 0.001), and regional rheumatic pain syndromes (7.2% vs 1.4%, P < 0.001) were seen more frequently at community practices. Hospital/emergency room visits (11.8% vs 0.3%, P < 0.001) were more frequent at the university setting, whereas joint (13.3% vs 2.9%, P < 0.001) and periarticular injections (6.2% vs 1.7%, P < 0.001) were performed more frequently at the community practices. Several differences were found in the profile of demographic parameters, diagnoses, medical visits, and rheumatologic procedures between patients seen at the University of Puerto Rico Medical Sciences Campus rheumatology practice and 3 community-based practices. Efforts may be required to diversify and increase the exposure of rheumatology fellows to patients with conditions commonly seen at the community setting.

Screening for the presence of FMR1 premutation alleles in women with fibromyalgia

Fibromyalgia is a chronic condition characterized by widespread pain, fatigue, non-restorative sleep and cognitive difficulties that affects 2–4% of the general population. Recently a possible relationship between the FMR1 premutation and fibromyalgia has been pointed out. In attempt to gather more data we screened for the FMR1 CGG expansion 700 DNA samples from unrelated fibromyalgia patients. This data might be useful for evaluating the incorporation of this test in rheumatologic procedures for women with fibromyalgia. The observed frequency of FMR1 premutation carriers (3 of 700, 0.4%) is not significantly different from the estimated rate in the general female population (1/250–1/400) (P=0.539, P=0.716). Clinical examination of the FMR1 premutation carriers identified revealed that all of them had important neurological symptoms with regard to muscular symptoms, neurocognitive alterations and neurovegetative impairments. With regard to other clinical aspects of the disease the cases apparently did not differ from the average fibromyalgia patients. On the basis of our results an FMR1 screening among fibromyalgia female patients would not be recommended. However it would be worthwhile to further evaluate the different clinical presentations that fibromyalgia patients might present based on their FMR1 premutation carrier status.

Kapillarmikroskopie in Klinik, Praxis und Forschung

Die Kapillarmikroskopie gehört zu den ältesten bildgebenden Verfahren in der Rheumatologie. Empfehlungen zur Nomenklatur und Durchführung wurden unlängst publiziert. Zertifizierte Fortbildungskurse wurden etabliert. Die Möglichkeit der einfachen digitalen Archivierung und Befundungsstandards erhöhen die Qualität der Untersuchung weiter. Somit kann die Kapillarmikroskopie vermehrten Einsatz durch den Rheumatologen in Screening, Praxis, Klinik und Forschung finden.

Quality and impact of information about interventional rheumatology: A study in 119 patients undergoing fluoroscopy-guided procedures

Objective To evaluate the quality of patient information about fluoroscopy-guided rheumatologic procedures, and to look for an impact on the patient's experience of the procedure. Methods One hundred and nineteen patients completed questionnaires before and after undergoing fluoroscopy-guided interventions. We looked for associations between the information supplied by the rheumatologist who recommended the procedure and pain, anxiety, awareness of potential complications, and the match between patient expectations and actual experience. Results 62.8% of patients reported receiving information about the procedure. Only 20.5% reported receiving specific information about potential adverse events, although 80.9% felt this information would have been useful. Most patients (74.8%) would have liked to receive additional information. Only 10.1% patients were given written information. Mean (±SD) anticipated pain severity as assessed in the waiting room before the procedure on a 0–10 scale was 4.5 ± 2.4 in women and 4.2 ± 2.3) in men. Actual pain severity during the procedure as assessed on the same scale was 2.7 ± 2.6 in women and 2.2 ± 1.6 in men. The level of information about the procedure did not influence anticipated or actual pain severity. Anxiety was reported by 59.8% patients and was more common in women ( P < 0.001), in patients given written information ( P = 0.05), and in patients undergoing their first intervention ( P = 0.05). Information was perceived as alleviating anxiety by 69.9% patients, and 77.3% of patients felt they would experience less anxiety if they had the procedure a second time. Only 21.2% patients were able to name a potential adverse event, and this proportion was not influenced by receiving written information. A mismatch between expectations about the procedure or its duration and actual experience was reported by 17 (17/69, 24.6%) and 34 (34/98, 34.7%) patients, respectively, with no significant differences across study subgroups. Conclusion Information about interventional rheumatology procedures is required for ethical principles and legislation. Patients increasingly expect detailed information, which may increase the likelihood that the procedure unfolds smoothly. Our results indicate a need for optimizing patient information. Standardized written material deserves to be evaluated as a means of better meeting the informational needs of patients.

Autoevaluación de fortalezas, debilidades y confianza de los médicos de atención primaria en el abordaje de enfermedades reumatológicas

Rheumatologic diseases are common and frequently managed by primary care physicians. To assess strengths, weaknesses and self confidence of primary care physicians in the management of rheumatic diseases. A self assessment and anonymous questionnaire was mailed to primary care physicians of two Chilean regions. Using a 10 points Likert scale, they were asked about personal interest, undergraduate training, continuous medical education, availability of medical literature, complementary laboratory tests and consultation with a rheumatologist. Medical skills, knowledge, therapeutic approach and performance of rheumatologic procedures were evaluated under the item confidence. Three hundred forty seven out of 763 physicians (45%) answered the questionnaire. Their age range extended from 25 to 75 years, 59% were male, 58% were Chilean and 74% worked in the Metropolitan region. The worst evaluated parameters were availability of literature with a score of 2.2+/-2, access to consultation with a rheumatologist (3.8+/-2.2) and to continuous medical education (4.3+/-2.7). Physicians had a better confidence in their knowledge (6.7+/-1.5) and in their therapeutic approach (6.1+/-1.5). The worst confidence score was for shoulder injection therapy (3.4+/-2.6). Continuous medical education correlated with knowledge but not with clinical skills. Primary care physicians perform a bad assessment of their skills in rheumatology. They have a low level of confidence in their clinical skills to perform rheumatologic procedures. Continuous medical education improves confidence in knowledge but not in skills.

O uso do ultra-som (US) na reumatologia

Nos ultimos anos, a ultra-sonografia tem consolidado o seu papel como importante meio de diagnostico por imagem na avaliacao de doencas com comprometimento do sistema musculoesqueletico. O desenvolvimento de novas tecnologias aplicadas na utilizacao do ultra-som (US), como novos transdutores, softwares e o Doppler, tornou possivel a visualizacao de estruturas intra-articulares e da vascularizacao sinovial. Atualmente, alem de auxiliar no diagnostico de lesoes de partes moles e identificacao de colecoes liquidas, o ultra-som tem sido empregado na avaliacao de estruturas articulares comprometidas por doencas reumaticas e como guia para a realizacao de procedimentos em reumatologia.

Clinical academic rheumatology: Getting more than you pay for

Rheumatology is among the least compensated specialties in medicine today. This is a significant problem for clinical rheumatologists in academic medicine who are often expected to earn their salaries through clinical practice alone. Additionally, academic rheumatologists usually cannot generate revenue through office laboratory monitoring, radiographs, or bone densitometry to supplement their income (i.e., downstream income). The purpose of our study was to examine revenue generated from downstream income to a university by a clinical-academic rheumatologist. Consecutive outpatients (n = 127) seen predominantly by one academic rheumatologist over one month of clinic were followed for 18 months. The total physician compensation for patient visits was calculated and compared with the revenue generated from laboratory tests, radiologic studies, consultations, and specific rheumatologic treatments and procedures performed or ordered. Medicare reimbursement rates for 2003 were used as compensation standards for all charges. Physician office visit billing generated 36,297 US dollars from 730 office visits. The total amount of downstream income from these office visits was 363,813 US dollars (47,386 US dollars from laboratory tests, 35,582 US dollars from radiologic studies, 8,159 US dollars from rheumatologic procedures, 261,584 from rheumatologic infusions, and 11,101 US dollars from initial consultations). Therefore, 10.02 US dollars of downstream revenue was generated for every 1.00 of office visit compensation applied to the academic rheumatologist's salary. Although academic rheumatologists struggle to bill their salaries through seeing more patients, they are clearly a bargain for a university hospital because they generate >10.00 US dollars for every 1.00 US dollars they receive for an office visit.

Role of gene therapy in tissue engineering procedures in rheumatology: the use of animal models

Tissue engineering is not only the application of cells and scaffolds to generate a new tissue but should also bring into play biological principles to guide cellular behavior. A way to modify cellular behavior is genetic modification of the cells used for tissue engineering (gene therapy). In the field of rheumatic diseases, cellular modification by overexpressing anabolic factors, such as insulin-like growth factor-I or transforming growth factor β, or inhibitors of catabolic cytokines or proteolytic enzymes can protect tissues form further destruction and stimulate tissue repair. To test the effect of transgenes on tissue engineering adequate test systems have to be available. Initial testing can be done in simple in vitro systems. However, animal models are unavoidable to study the interaction between the environment and tissue engineering. Optimal models to study gene therapy in combination with tissue engineering in the field of rheumatology are not available at this moment. Arthritis models are mainly developed in small animals while high-quality tissue engineering experiments ask for a large animal model. Development of animal models that can be used for tissue engineering experiments and mimic end stage arthritic diseases is needed.

Sonographically guided procedures in rheumatology

Objective: To provide some representative examples of sonographically guided arthrocentesis and intralesional injection therapy. Methods: Sonographic evaluation was performed with high-frequency linear (13 MHz) and mechanical sector (20 MHz) transducers. The images were obtained in representative patients with rheumatoid arthritis and posttraumatic subacromial bursitis. Results: Sonographically guided intralesional injection is a rapid and reliable procedure, especially in patients with arthritis, tenosynovitis, and bursitis. After target localization, needle placement can be performed under continuous sonographic monitoring. Sonographic guidance is particularly useful when fluid collections are small (less than 5 mm) and deep or when the inflammatory process is adjacent to anatomic structures that could be seriously damaged by the injection. Conclusions: Over the last few years, the rapid technologic advancements in ultrasonography have dramatically increased the potential applications of sonographically guided procedures. The simplicity and reliability of the technique might warrant rheumatologists to undergo sonographic training. Semin Arthritis Rheum 30:347-353. Copyright © 2001 by W.B. Saunders Company

Laboratory Diagnostic Procedures in the Rheumatic Diseases

The second edition of this book on laboratory procedures in rheumatology is indeed welcome. There are 12 chapters, all by eminent and wellqualified experts, and the entire spectrum of the subject is well covered. Dr. Cohen is to be congratulated for his editorial skills and his astute selection of collaborators, because all of the sections are well done and carefully balanced, with little or no overlap. Each section contains a succinct discussion of clinical uses and interpretations of the tests, and then a section on detailed methodology for those who want to establish the test in their laboratory. At the end of each section, a selective but comprehensive bibliography is available for the reader who needs more detailed information. Among the chapters, it is difficult to avoid commenting favorably on each. Dr. Cohen and two of his colleagues from Boston have done a masterful job of reviewing synovial fluid analyses.