Rheumatology Research Articles

Artefacts in musculoskeletal ultrasound

Artefacts in musculoskeletal (MSK) ultrasound (US) comprise artefacts that mimic an abnormality while scanning normal structures and artefacts that occur together with abnormal conditions at grey-scale and Doppler imaging. Some of these can be avoided by correct scanning technique while other artefacts are the result of inherent characteristics of different tissues which may help in making a correct diagnosis. The origin and examples of common grey-scale and power/colour Doppler artefacts in ultrasound are explained with particular reference to MSK ultrasound. The commonly encountered Doppler artefacts such as the flash/twinkle artefacts and pseudo flow artefacts and their importance for image interpretation are discussed. Anisotropy is the sonographic artefact that is direction dependent and can be mistaken for a partial tear while scanning a tendon or nerve. Aliasing and random noise are well known artefacts, which depend upon grey-scale and overall gain. Mirror image artefacts refer to any highly reflecting smooth surface which may act as an acoustic mirror. In rheumatology, the mirrors will nearly always be bone surfaces. Blooming artefact displays colour outside of a vessel and makes vessels appear larger. Artefacts can also be due to ultrasound beam characteristics (side-lobe artefact), multiple echoes (reverberation, comet-tail, and mirror artefacts), and attenuation errors and enhancement, among others. Not all artefacts are confusing or unwanted. Certain artefacts are beneficial in assisting with the diagnosis. A better understanding of proper imaging techniques will allow correction or minimization of many of these artefacts.

Sonography of common rheumatic diseases

There has been a major sea change in the care of rheumatology patients with the advent of bedside ultrasound (US). US not only offers an ionizing free form of imaging but can also evaluate the vascularity of structures without using contrast. Sonography has generated much excitement with the depiction of disease processes affecting anatomical structures, and in some cases, has changed our views of the pathophysiology. It has also enabled establishing the diagnosis when the clinical picture is unclear. In this article, the role of US in major rheumatic syndromes will be outlined with high-quality sonographic images.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review.

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process. (www.actabiomedica.it)

Bone and calcium metabolism associated with malignancy. Paraneoplastic rheumatologic musculoskeletal manifestations.

Patients with malignant tumors may present with joint pain or arthritis(paraneoplastic arthritis). It needs to be carefully determined whether these symptoms are related to the malignant tumor, due to a concomitant rheumatoid disease, due to an adverse reaction to treatment, or due to a relapse. It can be relatively easy to diagnose paraneoplastic syndrome when there is clearly a malignant tumor present or typical symptoms are exhibited. However, clinicians should be aware that these paraneoplastic syndrome phenomena can occur before the malignant tumor is diagnosed. An occult malignancy should be suspected when a patient is elderly and exhibits atypical clinical symptoms of a rheumatic disease;is poorly responsive to usual treatment;or has general symptoms such as weight loss or exhibits suggestive physical findings. In particular, hematological malignancies require careful observations as they do not surface quickly.

Use and scope of ultrasonography in rheumatology in India

Musculoskeletal ultrasound (MSUS), once a sole territory of radiologists, has over the past decade been increasingly exploited by rheumatologists in clinical practice and as a research tool. Technical expansion in the field of ultrasonography has made MSUS a powerful tool in the early identification of inflammatory and noninflammatory rheumatic disease, monitoring disease, predicting therapeutic responses and guidance for procedures such as diagnostic fluid aspiration and peri- or intra-lesional therapeutic injections. US can be performed readily in the clinic, with an assessment of multiple joints at the same appointment, providing a “one-stop” answer to many MS problems. MSUS is widely accepted as an adjunct to clinical examination among rheumatologists in Europe and is rapidly gaining acceptance in the United States. In India, US is under the purview of the preconception and prenatal diagnostics techniques Act, which does not acknowledge the multiple role of point-of-care ultrasonography. There are some other critical issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS in India.

Discharge Summaries: A Neglected Education in Residency Program in Iran

Discharge summary (DS) is an essential document in patients’ medical records, and its information is critical during the care of patients. So, inaccurate DS increases the risk of medical errors (1, 2). In teaching hospitals with residency programs, residents are usually responsible for writing DSs. Failure to pay attention to the education of writing and creating DS in the curriculum of medicine leads residents to be unfamiliar with the requirements and contents of DSs. However, there is no national instructions or guidelines for creating a complete and accurate DS. Lack of teaching to residents on how to write a DS is the gap in medical education and may jeopardize the continuity of care. A preliminary study on hospital DSs at Golestan University of Medical Sciences (GoUMS) revealed the fact that the quality of the DSs was not appropriate in terms of accuracy and completeness. To overcome this defect, the Internal Medicine Department at GoUMS has developed a program called the “Discharge Conference” for the residents of Internal Medicine. The purpose of “Discharge Conference” is to review the DSs and to teach how to record and document it properly. Contrary to the morning reports, in which the cases of previous nights are surveyed, at the “Discharge Conference”, the patients’ DSs recorded by residents are reviewed, critically. From September 2017, the “Discharge Conference” has been held on the first Sunday of each month for about 2 hours. In addition to all residents of Internal Medicine, medical interns also attend the conference. Under the supervision of an attending professor, the DSs are presented by the second year Internal Medicine residents. In each conference, summaries of the discharged patients from Internal Medicine wards (nephrology, rheumatology, endocrinology, gastroenterology, hematology, and pulmonary) are selected, reviewed, and scrutinized, and the requirements of a good DS are taught. After one year of implementing the program, the evaluation of the results showed that the quality of DSs has increased significantly and this program enhances the residents’ skills to write and create a complete and accurate DS. Several studies have shown that teaching how to write a discharge summary increases the quality of DSs and the recording skills of residents (1, 3, 4). Therefore, DS curriculum is essential to be included in medical education program, and the lack of appropriate training program in this field can lead to adverse events and increase medical errors. In conclusion, if “Discharge Conference” takes place on a planned, targeted, and regular basis, it will be an appropriate educational program for training residents on how to write DSs. It is suggested that “Discharge Conference” be considered as a part of the residency programs.Conflict of Interest: None Declared.

Regional sonology of the upper limb - II: Wrist and hand

With the advent of musculoskeletal ultrasound (US), there has been a paradigm shift in the way rheumatological conditions are detected, quantified and managed. Small joints of the wrist and hand play an important role in the diagnosis and characterization of inflammatory arthritis. Successful scanning of the wrist and hand requires good scanning equipment, thorough knowledge of anatomy and scanning protocols. The dorsal recesses of the wrist, metacarpophalangeal joint, proximal interphalangeal joint and the distal interphalangeal joint are scanned to look for joint effusion, synovial hypertrophy and cortical erosions. The extensor tendons of the wrist and hand have a synovial sheath at the level of the distal radius. The flexor tendons and the median nerve along the volar aspect of the wrist pass through a fibro-osseous tunnel known as the carpal tunnel. US pathologies commonly encountered in inflammatory arthritis have been very well defined in literature, so that there is better reproducibility of the tests and reduction in the inter-observer variation.

Severe Takayasu Arteritis Complicated by Mesenteric Ischemia

Takayasu arteritis (TA) is an idiopathic large vessel vasculitis which occurs mostly in young Asian females. The authors report an atypical presentation of TA in a woman who presented with signs and symptoms of limb claudication and mesenteric ischemia. This case illustrates the potential severity of this disease and the difficulty in its diagnosis and treatment. A 46-year-old Caucasian woman was admitted to the hospital with right lower limb claudication, aroused for small distances, in association to ischemic ipsilateral foot ulcers. She also reported recurrent episodes of abdominal pain, vomiting and diarrhea which leaded to an overall weight loss of 10 kg in a period of a year. Non-invasive vascular testing revealed a right ankle-brachial index of 0.17 and a left ankle-brachial index of 0.37. The abdominal aortography and the computed tomography (CT) angiography showed an occlusion of the superior mesenteric artery and irregularities of the aortic lumen. Oclusions in the right internal iliac artery and in the distal common femoral artery were found in the pelvic aortography. Lower limbs arteriography revealed multiple stenoses. The histological result from the femoral endarterectomy was consistent with large vessel vasculitis. The diagnosis of TA was established according to the American College of Rheumatology Criteria, based on the patient’s symptoms, physical and imaging findings. Despite aggressive immunosuppressive therapy with prednisolone and infliximab, an atypical refractory massive mesenteric ischemia occurred, leading to patient’s death. TA is a rare disease with variable presentation. Since this disease is associated with high morbidity and mortality, an early diagnosis is essential for the best prognosis. Critical mesenteric ischemia and peripheral limb ulcers are rare presentations. As mesenteric ischemia can be potentially fatal, early aggressive immunosuppressive therapy and resection of the affected bowel segment are usually required. J Med Cases. 2017;8(12):383-387 doi: https://doi.org/10.14740/jmc2945w

The effect of chamomile tea consumption on inflammation among rheumatoid arthritis patients: randomized clinical trial

Background: Rheumatoid arthritis (RA) is a joint inflammatory disease, which proinflammatory cytokines and oxidant spices accelerate inflammatory response in patients. Drugs and supplements which can modulate the inflammation can slow the disease progression, and minimize the joints destruction. Anti inflammatory effect of Chamomile on severity of disease was measured by Disease Activity Score (DAS-28) tool in the study. Patients and method: The study was a randomized, placebo-controlled, double blind clinical trial. The participants were selected from Tabriz university rheumatology clinic clients. According to rheumatologist diagnosis, 44 patients have the inclusion criteria in this study which fulfilled the American college of rheumatology (ACR-2010) criteria, were included.The patients were randomized in two groups, receiving 6 g/day Chamomile tea as 2 teabags twice a day for 42 days or placebo teabags, containing as similar. DAS-28 as an identified variable was calculated. For this, erythrocyte sedimentation rate (ESR) was measured before and after the study. Also all the patients were clinically examined, in order to determine the tender joints and swollen joints number. They reported the pain by Visual Analogue Scale (VAS). Nutrition intake was measured at both times in order to minimize the cofounders. Results: Groups were matched at the beginning in demographic characteristics, such weight height, age and BMI. During the intervention BMI didn’t change, but tender joints number and ESR changed significantly (P=0.000 and P=0.018, respectively). Conclusion: This study showed that Chamomile could decrease the inflammation similar to cell studies before. It can be a complementary treatment for RA patients.

Polymorphisms in the Growth Differentiation Factor 5 (GDF 5) Gene in Knee Osteoarthritis.

To identify the frequency of the rs143383 SNPin the GDF5 gene, which is located in the 5'-untranslated region of Turkish population with knee osteoarthritis (OA). Acase-control study. Orthopedics and Traumatology Department, Bozok University Medical Faculty, Yozgat, Turkey, from 2012 to 2014. Patients diagnosed with OA(n=94) and patients who did not have joint complaints (n=279) were enrolled in this study. Patients diagnosed with osteoarthritis according to the 1986 American College of Rheumatology osteoarthritis criteria and Kellgren and Lawrence scores were investigated, based on age, gender, and X-ray findings. Blood samples were taken for the identification of GDF5 (rs143383) SNPs by PCR/RFLP, according to a standard protocol. This study included 373 patients. The OAgroup (25.2%; n=94) was characterized by specific genotypes: TT (39.4%; n=37); heterozygotes (TC; 45.7%; n=43); and homozygotes (CC; 14.9%; n=14). The control group (74.8%; n=279) was comprised of TT(26.5%; n=74), TC (54.8%; n=153), and CC (18.6%; n=52) genotypes. An analysis of rs143383 SNP of the GDF5 gene polymorphism revealed that the rs143383 TTgenotype had a higher risk for OA(crude OR=1.798, 95% CI=1.010-2.941, p=0.021). This study demonstrated that there is a correlation of +104T/C polymorphism in the 5'-UTR of GDF5 with knee OAin a Turkish population.

Interventional Rheumatology, an Unsettled Issue

Interventional Rheumatology, an Unsettled Issue

Training rheumatology nurse specialists: Are we doing the job right?

Training rheumatology nurse specialists: Are we doing the job right?

Clinical characteristics of chronic intestinal pseudo-obstruction: an analysis of 43 cases

Objective To analyze the clinical characteristics of chronic intestinal pseudo-obstruction (CIPO). Methods Clinical data of 43 patients with CIPO admitted in Peking Union Medical College Hospital from January 2012 to December 2016 were retrospectively reviewed. The clinical manifestations, laboratory examinations, images, treatment and prognosis of CIPO patients were analyzed. Results There were 14 males and 29 females with an mean age of (41.9±16.1)years. Among 43 patients, 32 were admitted in Gastroenterology Department, 6 in General Medicine Department and 5 in Rheumatology Department. Twenty two cases were primary CIPO and 21 cases were secondary. The main clinical manifestations were abdominal distension (93.0%), abdominal pain (67.4%), vomiting (67.4%), diarrhea (46.5%) and constipation (41.9%). All 43 patients had decreased body weight and body mass index (BMI); 23.3% (10/43) patients were complicated with anxiety and depression. 53.5% (23/43) patients presented anemia and 55.8% (24/43) patients presented hypoalbuminemia. All patients with CIPO underwent abdominal X-ray, which showed intestinal obstruction; but there was no evidence of mechanical obstruction. The average length of hospital stay was (28.4±13.9) d. Twenty three cases underwent gastric decompression; 28 cases (65.1%) received parenteral nutrition, and 21 cases (48.8%) received enteral nutrition; and 9 abdominal operations were performed in 8 patients. Conclusion When clinical symptoms of intestinal obstruction appear without mechanical cause, CIPO should be considered and secondary factors should be screened. Unnecessary surgery should be avoided in CIPO patients. Key words: Intestinal pseudo-obstruction; Disease attributes; Chronic

Brucellosis presenting as fever of unknown origin admitted in a general hospital of non-endemic area: a clinical analysis of 11 cases

Objective To analyze the clinical characteristics of brucellosis presenting as fever of unknown origin in non-endemic area. Methods Clinical data of 11 patients with fever of unknown origin, who were admitted in a general hospital of non-endemic area from Jan 2013 to Jan 2017 and diagnosed as brucellosis by blood culture, were retrospectively analyzed. Results There were 8 males and 3 females aged 40-70 years.The patients were admitted with or without accompanied symptoms.The patients were initially presented in rheumatology (1 case), neurology (1 case), emergency (4 cases), hematology (1 case), orthopedics (2 cases) and pneumology (2 cases) departments, respectively.The time from onset to presentation was 0.5-7.0 months.The clinical manifestations were nonspecific, and blood cultures of Brucella were positive between 2 to 5 weeks with a mean of 3 weeks. Time to diagnosis was 1 to 9 months with a mean of 4 months.All patients were transferred to infectious hospital when the diagnosis was confirmed.The telephone follow-up showed that none of the patients had fever after discharged. Conclusion Brucellosis should not be neglected in the differential diagnosis of FUO in non-endemic area, and blood culture is important for a definitive diagnosis. Key words: Fever of unknown origin; Brucellosis; Blood culture

Mediterranean Journal of Rheumatology September 2017 Highlights.

Mediterranean Journal of Rheumatology September 2017 Highlights.

Significance of undercarboxylated osteocalcin in the diagnosis of Kawasaki disease with coronary artery lesions

Objective To investigate the changes and diagnostic significance in plasma undercarboxylated osteocalcin in children with Kawasaki disease (KD), especially with coronary artery lesions (CALs). Methods The data of 36 KD children were collected, who were inpatients at Department of Cardiovascular and Rheumatology, Shanxi Province Children′s Hospital from January 2015 to December 2015, including 20 boys and 16 girls, aged (2.3±1.1) years old.According to the course of the disease, KD children were divided into an acute stage group and a subacute stage group.Based on the echocardiography findings, KD children were subdivided into CALs group and no coronary artery lesions (NCALs) group.Twenty-five healthy children from the physical examination during the same period were selected as the healthy control group, 13 boys and 12 girls, aged (2.6±1.0) years old.Plasma undercarboxylated osteocalcin level was measured by double antibody sandwich enzyme-linked immunosorbent method.Sigmaplot 12.5 software was used to analyze the data statistically, and the receiver-operating characteristic (ROC) curve was used to evaluate the diagnostic effect of plasma undercarboxylated osteocalcin in KD with CALs. Results The levels of plasma undercarboxylated osteocalcin in the healthy control group, the acute stage group and the subacute stage group were (16.4±1.6) μg/L, (14.2±1.6) μg/L, (14.3±1.7) μg/L, respectively.Compared with the healthy control group, the plasma undercarboxylated osteocalcin level in the acute stage and the subacute stage were significantly lower, the differences were statistically significant (q=6.088, 5.687, all P 0.05). The levels of plasma undercarboxylated osteocalcin in acute stage group with CALs and acute stage group with NCALs were (12.9±1.2) μg/L, (15.0±1.4) μg/L.Compared with healthy control group, the plasma undercarboxylated osteocalcin levels of children with CALs and with NCALs were obviously decreased, the differences were statistically significant (q=8.711, 3.891, all P 0.05). There was a sensitivity of 79%, specificity of 82%, positive predictive value of 88% and negative predictive value of 70% for the 15.7 μg/L undercarboxylated osteocalcin for diagnosing KD.There was a sensitivity of 83%, specificity of 88%, positive predictive value of 83% and negative predictive value of 88% for the 13.7 μg/L undercarboxylated osteocalcin for diagnosing KD with CALs. Conclusions Osteocalcin is related to the pathogenesis and development of KD.Plasma undercarboxylated osteocalcin contributes to the diagnosis of KD with CALs. Key words: Undercarboxylated osteocalcin; Kawasaki disease; Coronary arterial lesions; Atherosclerosis

Diagnosis of polymyalgia rheumatica usually means a favourable outcome for your patient.

Polymyalgia rheumatica (PMR) is a unique disease of elderly people, traditionally diagnosed based on a clinical picture. A typical case is a combination of severe musculoskeletal symptoms and systemic inflammatory response with spectacular response to corticosteroids treatment. The severity of symptoms may be surprising in older patients where immunosenescence is normally expected. However, PMR may be diagnosed in haste if there is a temptation to use this diagnosis as a shortcut to achieve rapid therapeutic success. Overdiagnosis of PMR may cause more problems compared to underdiagnosis. The 2012 PMR criteria proposed by European League against Rheumatism/American College of Rheumatology aim to minimize the role of clinical intuition and build on more objective features. However, questions arise if this is possible in PMR. This has been discussed in this review.

Connective tissue disease associated interstitial pneumonia: a challenge for both rheumatologists and pulmonologists.

Interstitial lung disease (ILD) can be either idiopathic, the result of exposure or may be associated with extrapulmonary diseases. Among the latter, connective tissue diseases (CTDs) make up the largest part. The identification, follow-up and treatment of CTD-associated ILD (CTD-ILD) are a challenge for every physician as ILD can occur before, during and after the diagnosis of CTD. Early detection of pulmonary involvement is an essential task for the treating rheumatologist and recognition of the underlying CTD can pose a challenge for the treating pulmonologist. Multidisciplinary engagement towards the patient is therefore indispensable for optimal clinical care. (Sarcoidosis Vasc Diffuse Lung Dis 2017; 34: 326-335).

Screening for Celiac Disease in Rheumatology: HLA First?

HLA genes have been shown to be strongly associated with a large repertoir of autoimmune diseases including Rheumatoid Arthritis (RA), Juvenile idiopathic arthritis (JIA) and Celiac Disease (CD). The present article will discuss what is the place of performing celiac disease associated serology in face of a rheumatologic patient, when gluten enteropaty is suspected. More specifically, should HLA be done prior to the serology? Unnecessary serial serological CD screening in such rheumatology patients could be avoided by performing an HLA typing, as a long-life marker of genetically CD-susceptible patients.

Extra Intestinal Manifestations of Celiac Disease and Associated Disorders

Celiac disease (CD) is one of the most common causes of chronic malabsorption in all over the world. CD damage the small intestine epithelial layer. Reduction of absorptive surface area and digestive enzymes, cause impairment of absorption of micronutrients such as fat-soluble vitamins, iron and vitamin B12 and folic acid. Sensitivity to gluten is the main pathophysiologic cause of CD and it is characterized by intraepithelial lymphocytosis, crypt hyperplasia and villous atrophy. CD has diverse clinical features includes anemia, fatigue, weight loss, diarrhea, abdominal pain, bloating, osteoporosis and depression. CD is commonly seen in association with extra intestinal manifestations, such as the typical skin lesions and the neurologic symptoms. Because of the broad spectrum of its presentations, the diagnosis may not be so obvious or easy.Having greater awareness and lower threshold for testing for CD are necessary for diagnosis of this disease. When CD is suspected, serologic testing is required for screening and subsequently duodenal biopsies are necessary to confirm the diagnosis. In this review article we want to review the extra intestinal manifestations of CD and also describe the association between CD and other disorders. It is useful for better diagnosis of CD and improvement of treatment of associated conditions. Future studies should focus on the extra intestinal presentations and associated disorders of gluten sensitivity as they could help better understanding the pathogenesis of gluten sensitivity. In this review article we describe these issues: 1. CD and psychiatric disorders; 2. CD and neurologic disorders; 3. CD and cardiac manifestation; 4. CD and liver disease; 5. CD and Endocrine disease; 6. CD and Dermatologic disease; 7. CD and Rheumatologic disorders; 8. CD and Ophthalmologic disease; 9. CD and Reproductive problems; 10. CD and associations with some other disease.