Small Joints Of Hands Research Articles

Clinical, electrophysiological, and ultrasound evaluation for early detection of musculoskeletal hand disorders and nerve entrapment in mobile phone users

IntroductionSmartphone overuse may lead to musculoskeletal manifestations, such as carpal tunnel syndrome (CTS) and arthritis of hand joints, with an increased median nerve cross-sectional area (CSA). ObjectiveThe aim of this study is the early detection of musculoskeletal hand disorders using ultrasound techniques, and to detect nerve entrapment using clinical evaluation, ultrasound, and electrophysiological studies, in university employees younger than 35 years using mobile phones. Function is assessed using the Michigan Hand Outcomes Questionnaire (MHQ). Materials and methodsCross-sectional controlled study included 74 smartphone users classified into two groups according to a smartphone addiction scale (SAS), into high and low smart phone users, with 35 non-smartphone users with matched age and gender as a control group. A clinical assessment of nerve entrapment symptoms was performed, and the Michigan Hand Outcomes Questionnaire (MHQ), with a total score from 0 to100, was used to assess hand function. Electrodiagnostic studies of median and ulnar nerves were used to detect early nerve entrapment. Bilateral ultrasound was performed in order to assess the median nerve CSA and involvement of thumb and small hand joints. The data collected were analysed using the SPSS program version 20. ResultsCSAs of median nerves were significantly higher in the dominant hand of high smartphone users than in low and non-smartphone users (p<0.001). There was a significant positive correlation between CSA and SAS (r=0.45), visual analogue scale (VAS) (r=0.61), and duration of smartphone use (r=0.80), with negative correlation with MHQ (r=−0.63). Significant differences in were found in the electrophysiological studies of median and ulnar nerves. The mean ultrasound score for both hands was higher in the high smartphone users compared to low smartphone users (15.08±4.17 vs. 6.46±1.38, p<.001). ConclusionsThere is increased median nerve CSAs among high smartphone users associated with prolongation of both sensory and motor latencies and slow conduction velocities. Caution should be exercised when using mobile phones, in order to minimise the risk of developing hand musculoskeletal disorders.

Musculoskeletal manifestations of childhood cancer and differential diagnosis with juvenile idiopathic arthritis (ONCOREUM): a multicentre, cross-sectional study.

Presenting symptoms of childhood cancers might mimic those of rheumatic diseases. However, the evidence available to guide differential diagnosis remains scarce. Preventing wrong or delayed diagnosis is therefore important to avoid incorrect administration of glucocorticoid or immunosuppressive therapy and worsening of prognosis. As such, we aimed to assess the prevalence and characteristics of presenting musculoskeletal manifestations in patients at cancer onset and to identify the factors that differentiate childhood malignancies with arthropathy from juvenile idiopathic arthritis. We did a multicentre, cross-sectional study at 25 paediatric haemato-oncology centres and 22 paediatric rheumatology centres in Italy. We prospectively recruited patients who were younger than 16 years that were newly diagnosed with cancer or juvenile idiopathic arthritis. We excluded patients with glucocorticoid pre-treatment (>1 mg/kg per day of oral prednisone or equivalent for ≥2 consecutive weeks). We collected data for patients with a new diagnosis of cancer or juvenile idiopathic arthritis using an electronic case report form on a web-based platform powered by the Cineca Interuniversity Consortium. The primary outcome was to describe the frequency and characteristics of musculoskeletal manifestations at cancer onset; and the secondary outcome was to identify factors that could discriminate malignancies presenting with arthropathy, with or without other musculoskeletal symptoms, from juvenile idiopathic arthritis using multivariable logistic regression analysis. Between May 1, 2015, and May 31, 2018, 1957 patients were eligible, of which 1277 (65%) had cancer and 680 (35%) had juvenile idiopathic arthritis. Musculoskeletal symptoms occurred in 324 (25% [95% CI 23·0-27·8]) of 1277 patients with cancer, of whom 207 had arthropathy. Patients with malignant bone tumours had the highest frequency of musculoskeletal symptoms (53 [80%] of 66), followed by patients with Langerhans histiocytosis (16 [47%] of 34), leukaemia (189 [32%] of 582), soft-tissue sarcomas (16 [24%] of 68), and neuroblastoma (21 [19%] of 109). In the 324 patients with cancer and musculoskeletal symptoms, the most common complaints were joint pain (199 [61%]), followed by limb bone pain (112 [35%]). Joint involvement had a prevalent monoarticular pattern (100 [48%] of 207) and oligoarticular pattern (86 [42%] had 2-4 joints involved and 20 [10%] had >4 joints involved), with the most frequently involved joints being the hip (88 [43%] of 207) and knee (81 [39%]). On multivariable analysis, limb bone pain was the independent variable most strongly associated with cancer (odds ratio [OR] 87·80 [95% CI 18·89-408·12]), followed by weight loss (59·88 [6·34-565·53]), thrombocytopenia (12·67 [2·40-66·92]), monoarticular involvement (11·30 [4·09-31·19]), hip involvement (3·30 [1·13-9·61]), and male sex (2·40 [1·03-5·58]). Factors independently associated with juvenile idiopathic arthritis were morning stiffness (OR 0·04 [95% CI 0·01-0·20]), joint swelling (0·03 [0·01-0·09]), and involvement of the small hand joints (0·02 [0-1·05]). Our study provides detailed information about presenting musculoskeletal manifestations of childhood cancers and highlights the clinical and laboratory features that are most helpful in the differential diagnosis with juvenile idiopathic arthritis. Associazione Lorenzo Risolo.

OP0189 MACROPHAGE PET/CT IMAGING OF THE FEET CAN CONTRIBUTE TO EARLY PREDICTION OF THERAPY OUTCOME IN RHEUMATOID ARTHRITIS

Background:Treat-to-target strategies for rheumatoid arthritis (RA) have shown significant improvements in therapy outcomes. Nevertheless, it usually takes a minimum of 12 weeks before clinical assessment of treatment response can be made. Quantitative positron emission tomography (PET) has shown potential to predict clinical response at a very early stage in the treatment in RA patients.(1) In particular, macrophage imaging by [11C]-(R)-PK11195 PET allows for highly sensitive and specific imaging of RA disease activity.(2,3)Objectives:To determine whether quantitative assessment using [11C]-(R)-PK11195 PET/CT imaging at 0-2 weeks is associated with subsequent clinical response to therapy with methotrexate and step-down prednisolone (COBRA-light) therapy in therapy-naive RA patients.Methods:Whole body [11C]-(R)-PK11195 PET/CT scans were performed at baseline and after two weeks of treatment in thirty-five clinically active and therapy-naive RA patients and at least two clinically inflamed joints. All patients were DMARD-naïve and received medication according to the COBRA-light schedule. (4) Clinical follow up with DAS44 assessment was performed at 0, 2 and 13 weeks of treatment. PET/CT scans were visually assessed by two experienced readers blinded to clinical data and quantitatively analyzed using in-house software. Regions of interest (ROIs) with a fixed size per joint (on both visual PET positive and negative joints) were placed on shoulders, elbows, hips, knees and hand and feet joints, with the CT-scan as anatomical reference. Standardized uptake values (SUVs) normalized for body weight were calculated in these ROIs to determine the amount of tracer uptake per joint. SPSS version 22.0 was used to perform regression analyses. The sum of visually positive joints and the average SUV in hand joints, feet joints and all joints in the body were compared with DAS44 scores.Results:Included patients were mostly male (51%) and aged 54 ± 12. Baseline DAS44 was 3.2 ± 1.0; all but one of the thirty-five patients demonstrated visually enhanced tracer uptake in one or more joints on PET/CT. A total of 171 (out of 1470) joints (12%) were visually PET positive at baseline. Over 90% of PET positive sites were located either in the wrists (15%), small hand joints (37%), or small feet joints (40%; Figure 1A). After 2 weeks, the number of PET positive joints had decreased to 100, with the highest decrease in quantitative uptake in feet joints (Figure 1B). Notably, both visual and quantitative PET data at baseline and differences between baseline and 2 weeks did not correlate with DAS44 at 13 weeks (DAS44-13wks). However, at 2 weeks, the average SUV in the feet (SUVfeet-2wks) – but not average SUVhands-2wks or average SUVtotalbody-2wks – was significantly correlated with DAS44-13wks (R2 = 0.14, p = 0.04). DAS44-2wks and SUVfeet-2wks both contributed independent information to the prediction DAS44-13wks (combined R2 = 0.297, p &lt; 0.01).Figure 1.Changes in [11C]-(R)-PK11195 uptake in MTP joints of a RA patient, before (A) and 2 weeks after initiation of COBRA light treatment (B).Conclusion:Quantitative macrophage PET assessment in feet joints after 2 weeks of COBRA light treatment in early RA patients correlates with clinical response after 3 months of treatment. This correlation further increases when combined with the DAS44 score at 2 weeks. Therefore, quantitative, non-invasive macrophage PET/CT, especially when combined with early clinical assessment, may be useful for early assessment of response to treatment. Further studies will help optimize timing and focus of the PET examination in prediction of treatment response.

POS0257 TOWARDS A SIMPLIFIED FLUID-SENSITIVE MRI-PROTOCOL IN SMALL JOINTS OF THE HAND IN EARLY ARTHRITIS PATIENTS: RELIABILITY BETWEEN MDIXON AND REGULAR FSE FAT SATURATION MRI-SEQUENCES

Background:MRI facilitates early recognition of rheumatoid arthritis (RA) by depicting inflammation. Contrast-enhanced T1-weighted and T2-weighted fat-suppressed sequences have been sensitive and thus recommended, but are hampered by invasiveness, costs and long scan time. Therefore we introduced a modified Dixon-sequence (mDixon) which is more patient-friendly, reduces cost, and scan times by 83%. However, it is not known if this mDixon-sequence is reliable in relation to regular MRI-sequences with and without contrast (T1- and T2-weighted, respectively).Objectives:We determined the reliability between regular MRI-sequences with and without contrast (T1- and T2-weighted, respectively) and mDixon-MRI in early arthritis patients.Methods:29 early arthritis patients underwent regular fat-suppressed-MRI (T1- and T2-weighted) and mDixon-sequences, of metacarpophalangeal-2-5 and wrist-joints. Two readers scored erosions, osteitis, synovitis and tenosynovitis. Intraclass correlation coefficients (ICCs) between readers, and comparing the two sequences, were studied. Spearman correlations were determined.Results:Performance between the two readers with the regular-MRI sequences, was good to excellent (ICCs all ≥0.88). The between reader ICC was also good to excellent for the mDixon-MRI (ICCs all ≥0.76). Next, ICCs between the two sequences was investigated to determine the reliability of mDixon. ICCs were good to excellent for total RAMRIS score 0.87 (95%CI 0.74-0.94), for erosions 0.88 (95%CI 0.69-0.95), and total inflammation score 0.84 (95%CI 0.69-0.82). The individual MRI-inflammation scores, had ICCs for osteitis 0.97 (95%CI 0.93-0.98), for tenosynovitis 0.78 (95%CI 0.58-0.89), and for synovitis 0.57 (95%CI 0.26-0.77). In addition, scores were highly correlated for total RAMRIS, erosions, and total MRI-inflammation score (ρ=0.82, ρ=0.81, ρ=0.80, respectively).Conclusion:Regular-MRI sequences and mDixon-MRI perform equally well, this suggests that mDixon-sequence is reliable to detect joint inflammation. Thus, this is the first step towards an simplified and abridged MRI-protocol in small hand-joints in early arthritis patients. The ultimate goal will be implementation of this mDixon-MRI sequence. Validation in larger studies is warranted.Disclosure of Interests:None declared

Capabilities of ultrasonography in the diagnosis of early rheumatoid arthritis and hand osteoarthritis

Objective: to compare results of ultrasound examination (US) of the wrist joints (WJ) and small joints of hands with the clinical signs in patients with early rheumatoid arthritis (eRA) and hand osteoarthriti (OAH).Patients and methods. The study included 42 patients with eRA (group 1) and 38 patients with OAH (group 2). The average age of patients with eRA was 48.60±14.86 years, the duration of clinical manifestations was 7.45±1.77 months, of patients with OAH – 54.97±12.45 years and 8.26±1.83 months, respectively. The ratio of men and women in both groups was approximately the same, the majority were women. All patients with eRA had clinical and instrumentally confirmed signs of OA: I, II, and III radiological stages of OA according to Kellgren–Lawrence were detected in 10 (23.80%), 23 (54.76%) and 9 (21.43%) patients respectively. In erosive OA II and III X-ray stage was diagnosed in 16 (42.10%) and 22 (57.90%) patients, respectively. All patients underwent ultrasound of the joints, as well as a general clinical examination, which included an assessment of the number of painful joints, the number of swollen joints, and a general assessment of pain intensity using a visual analogue scale (100 mm). RA activity was determined using the DAS28 index. We also studied laboratory parameters – the levels of CRP, rheumatoid factor and antibodies to cyclic citrullinated peptide in blood serum.Results and discussion. Comparison of the two groups of patients showed that ultrasound in B-mode and power Doppler mode with eRA and OAH showed more pronounced inflammatory and destructive changes in the wrist joints and small joints of the hands, with the exception of the distal interphalangeal joints (DIPJ). In addition, only in patients of the 1st group there was a close correlation between the enhancement of the Doppler signal and levels of inflammatory markers. Conclusion. eRA compared with OAH is characterized by more pronounced ultrasound signs of inflammatory and destructive changes in the wrist joins and small joints of the hands, with the exception of DIPJ.

Knuckle pads mimic early psoriatic arthritis.

Knuckle pads or Garrod's nodes are a rare, non-inflammatory condition. They consist of benign, well-circumscribed fibro-adipose tissue over the small joints of hands and feet. Knuckle pads may be under-diagnosed and mistaken for early arthritis. The rheumatologist should perform an accurate differential diagnosis in which he can be helped by ultrasound and by other colleagues, such as the dermatologist. Ultrasound is considered useful in the assessment of the thickening of the subcutaneous tissue, located usually on the extensor site of proximal interphalangeal and metacarpophalangeal hand joints. Dermoscopy may play a role in detecting epidermal and dermal changes. We hereby report the case of a female patient with knuckle pads mimicking psoriatic arthritis.

More than meets the naked eye: an unusual psoriatic arthritis mimicry and the important role of dermoscopic examination

BackgroundPsoriatic arthritis (PsA) can manifest in various forms. This includes mimicry of other diseases. We describe an unusual mimicry of PsA.Case presentationWe report a case of a middle-aged lady who presented with severe pain and morning stiffness over the small joints of the left hand for 3 months and painless deformity of the affected joints 1 year before. She was under treatment for pruritic rash over her ankles and knees for the past 1 year as well. Physical examination revealed a fixed flexion deformity, swelling and tenderness of the left ring and little fingers’ distal interphalangeal (DIP) joints. Left hand radiograph showed sclerotic joint margin, narrowed joint space and marginal osteophytes of the affected DIP joints. Dermoscopic examination showed red- violaceous, flat-topped papules and plaques with minimal scales on both ankles; hyperpigmented scaly plaques over both knees and vertical fingernail ridges. Serum autoimmune screening and inflammatory markers were unremarkable. Left ankle skin biopsy showed features consistent of psoriasis. PsA was diagnosed. Weekly titrated oral methotrexate and topical steroid were started. The patient showed significant improvement after 1 month of treatment.ConclusionPsA is a great mimicker. Dermoscopy is an accessible and valuable tool to assess skin lesions in greater detail. Clinicians should be aware of coexisting diseases or misdiagnosis when patients do not respond to treatment.

Bone Erosions Detected by Ultrasound Are Prognostic for Clinical Arthritis Development in Patients With ACPA and Musculoskeletal Pain.

Anti-citrullinated protein antibodies (ACPA) often precede onset of rheumatoid arthritis (RA) by years, and there is an urgent clinical need for predictors of arthritis development among such at-risk patients. This study assesses the prognostic value of ultrasound for arthritis development among ACPA-positive patients with musculoskeletal pain. We prospectively followed 82 ACPA-positive patients without clinical signs of arthritis at baseline. Ultrasound at baseline assessed synovial hypertrophy, inflammatory activity by power Doppler, and erosions in small joints of hands and feet. We applied Cox regression analyses to examine associations with clinical arthritis development during follow-up (median, 69 months; range, 24–90 months). We also compared the ultrasound findings among the patients to a control group of 100 blood donors without musculoskeletal pain. Clinical arthritis developed in 39/82 patients (48%) after a median of 6 months (range, 1–71 months). One or more ultrasound erosions occurred in 13/82 patients (16%), with none in control subjects (p < 0.001). Clinical arthritis development was more common among patients with baseline ultrasound erosions than those without (77 vs. 42%, p = 0.032), and remained significant in a multivariable Cox regression analysis that included previously described prognostic factors (HR 3.9, 95% CI 1.6–9.4, p = 0.003). Ultrasound-detected tenosynovitis was more frequent among the patients and associated with clinical arthritis development in a univariable analysis (HR 2.5, 95% CI 1.1–5.7, p = 0.031), but did not remain statistically significant in multivariable analysis. Thus, bone erosions detected by ultrasound are independent predictors of clinical arthritis development in an ACPA-positive at-risk population.Trial Registration: Regional Ethics Committee in Linköping, Sweden, Dnr M220-09. Registered 16 December 2009, https://etikprovningsmyndigheten.se/.

Comparison of Ultrasonography and X-Rays for the Diagnosis of Synovitis and Bony Erosions in Small Joints of Hands in Early Rheumatoid Arthritis: a Prospective Study

Comparison of Ultrasonography and X-Rays for the Diagnosis of Synovitis and Bony Erosions in Small Joints of Hands in Early Rheumatoid Arthritis: a Prospective Study

Clinical, electrophysiological, and ultrasound evaluation for early detection of musculoskeletal hand disorders and nerve entrapment in mobile phone users

IntroductionSmartphone overuse may lead to musculoskeletal manifestations, such as carpal tunnel syndrome (CTS) and arthritis of hand joints, with an increased median nerve cross-sectional area (CSA). ObjectiveThe aim of this study is the early detection of musculoskeletal hand disorders using ultrasound techniques, and to detect nerve entrapment using clinical evaluation, ultrasound, and electrophysiological studies, in university employees younger than 35 years using mobile phones. Function is assessed using the Michigan Hand Outcomes Questionnaire (MHQ). Materials and methodsCross-sectional controlled study included 74 smartphone users classified into two groups according to a smartphone addiction scale (SAS), into high and low smart phone users, with 35 non-smartphone users with matched age and gender as a control group. A clinical assessment of nerve entrapment symptoms was performed, and the Michigan Hand Outcomes Questionnaire (MHQ), with a total score from 0 to100, was used to assess hand function. Electrodiagnostic studies of median and ulnar nerves were used to detect early nerve entrapment. Bilateral ultrasound was performed in order to assess the median nerve CSA and involvement of thumb and small hand joints. The data collected were analysed using the SPSS program version 20. ResultsCSAs of median nerves were significantly higher in the dominant hand of high smartphone users than in low and non-smartphone users (p<0.001). There was a significant positive correlation between CSA and SAS (r=0.45), visual analogue scale (VAS) (r=0.61), and duration of smartphone use (r=0.80), with negative correlation with MHQ (r=−0.63). Significant differences in were found in the electrophysiological studies of median and ulnar nerves. The mean ultrasound score for both hands was higher in the high smartphone users compared to low smartphone users (15.08±4.17 vs. 6.46±1.38, p<.001). ConclusionsThere is increased median nerve CSAs among high smartphone users associated with prolongation of both sensory and motor latencies and slow conduction velocities. Caution should be exercised when using mobile phones, in order to minimise the risk of developing hand musculoskeletal disorders.

Does Hydroxychloroquine Improve Glycemic Status and Lipid Profile in Rheumatoid Patients with Diabetes Mellitus – An Observational Study

Rheumatoid arthritis is an autoimmune disease, causing chronic inflammation of small joints in hands and feet. The chronic inflammation and corticosteroid use in rheumatoid patients predispose them to insulin resistance and diabetes. Hydroxychloroquine, a proven drug in rheumatoid arthritis, seems to be beneficial in diabetes and also reduces the risk of cardiovascular events. This study was done to find out the role of hydroxychloroquine on the glycemic status and lipid profile in Rheumatoid patients having treatment with Diabetes mellitus. 50 patients with both RA and DM in the middle age group were categorized into HCQ and Non-HCQ group. Both the groups were followed up for 6 months. Their glycemic status and lipid profile were compared by measuring FBS, PPBS, HbA1C, triglycerides, total cholesterol, VLDL, LDL and HDL. Statistical analysis was done by student t test. The mean FBS, PPBS, HbA1C values in HCQ Group patients decreased significantly from 155.16, 200.12 and 8.26 to 135.80, 174.60 and 7.49 respectively in the follow-up period. In the Non-HCQ group, there was no significant change in mean FBS and PPBS after 6 months. Mean HbA1C increased from 8.13 to 8.33 in Non-HCQ group. Triglycerides, total cholesterol, VLDL and LDL also were found to be reduced in patients who had taken HCQ. In Rheumatoid patients with diabetes, use of HCQ improves their glycemic status and reduces the lipid abnormalities.

Hand Full of Sausages-Forme Frustae of Severe Psoriatic Arthritis: A Case Report

Dactylitis or sausage shaped digits is one of the hallmark features of psoriatic arthritis which occurs in association with psoriasis. This is a report of 50-year-old female, known case of psoriasis vulgaris, presented with complaints of red, painful and swollen digits of both hands since two weeks. She also complained of pain and restricted movements of all small joints of hands since two days. On examination, all the digits were erythematous, tender and swollen. Investigations revealed elevated Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP), negative rheumatoid factor and x-ray hands showed joint space narrowing and soft tissue swelling. Based on Classification Criteria for Psoriatic Arthritis (CASPAR) with score of 3/6, psoriatic arthritis was diagnosed. Further evaluation of other joints revealed features of sacroiliitis in x-ray pelvis. Psoriatic dactylitis involving all digits and as an initial symptom of psoriatic arthritis is rarely reported in literature. Dactylitis involving all the digits may be a forerunner of severe psoriatic arthritis.

Chemokine and Cytokine Profiles in Patients with Hand Osteoarthritis.

Background: The development of hand osteoarthritis (HOA) and its progression into the erosive subset are unclear, but inflammation is suspected to be the main source. To verify the involvement of inflammation in HOA pathogenesis, we evaluate serum inflammatory mediators and their association with HOA-related clinical features in patients. Methods: 153 participants (50 non-erosive HOA patients, 54 erosive HOA patients, and 49 healthy control subjects) were included in this study. All patients underwent clinical examination, which included assessment of tender and swollen small hand joints, ultrasound (US) examination, and self-reported measures (e.g., AUSCAN or algofunctional indexes). Serum inflammatory mediators were quantified using human cytokine 27-plex immunoassay. We employed linear modelling, correlation analysis, and resampling statistics to evaluate the association of these mediators to HOA. Results: We identified increased levels of nine inflammatory mediators (e.g., eotaxin, monocyte chemoattractant protein 1, interleukin-8, and tumour necrosis factor) in HOA patients compared to healthy controls. Increased mediators correlated with ultrasound findings as well as with clinically tender and swollen joint counts in patients with erosive HOA. However, none of the mediators distinguished between erosive and non-erosive HOA subtypes. Conclusion: Our findings support the hypothesis on the involvement of inflammation in HOA.

A review on clinical varieties of vatarakta as per morbid doshas

Vatarakta is one of the main diseases in the present era characterized by severe pain, tenderness, inflammation and burning sensation in the affected joints. It is a tridoshaja vyadhi, with vata pradhanyata and rakta as main dushya. In this article clinical varieties of vatarakta as per morbid doshas has been mentioned. Vatarakta is one of the commonest disease now a days which is characterized by severe pain, tenderness, inflammation, burning sensation in affected joints. Mainly small joints of hand and feet are affected. Ayurvedic literature contains brief description about nidanpanchaka of Vatarakta. In Ayurveda Vatarakta said to be caused by faulty and irregular dietary habits like fast food, spicy, oily and heavy diet, Rukshahara, Viruddhashan, Vishamashan along with Jalkrida, Jagaran, Divasvaap, Atyadhvagamana, Vegavrodh, travelling by vehicles over long distance, continuous sitting or standing for long time, these are “Hetus”(Causative factors) of Vatarakta. These hetus are responsible for vitiation of Vata and Rakta, as the name suggest dosha Vata and dushya Rakta both are equally responsible for disease Vatarakta, due to vitiated rakta there is margavrodh which causes obstruction in the way of vata which creates inflammation, stiffness and pain in the small joints. Vata and Rakta get vitiated and form vatarakta disease. Mainpathogenic factors are vata and rakta in pathogenesis of Vatarakta.

A Study of Handgrip Strength in Patients with Rheumatoid Arthritis: Its Correlations with Functional and Anthropometric Variables

Background: Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that primarily affects the small joints of hand. In the present study, hand grip strength was estimated on purposively selected 205 patients with RA aged 25-65 years. Correlations of handgrip strength have also been studied with some anthropometric and functional variables in patients with RA. Materials and methods: The subjects were assessed for handgrip strength (both dominant and non dominant), two functional variables, i.e. pain and pain today, and eight anthropometric variables namely, height, weight, BMI, hand and upper arm circumferences, forearm, upperarm and total arm length with standard techniques. Results: It was observed that the patients with RA had significantly lesser (p&lt;0.001) handgrip strength than controls. It was also found that both younger and older patients had significantly lesser (p&lt;0.001) handgrip strength than their control counterparts. Handgrip strength of patients with RA showed significant positive correlations with height and hand circumference, and significant negative correlations with pain today, forearm and upper arm length Conclusion: It might be concluded that handgrip strength had significant reduction in patients with RA as compared to controls. Moreover, handgrip strength had significant correlations with some functional and anthropometric variables.

FRI0029 EFFECTIVENESS OF A NURSE LED TREAT TO TARGET (T2T) MODEL IN ACHIEVING REMISSION FOR EARLY RHEUMATOID ARTHRITIS PATIENTS IN A REAL-WORLD SETTING

Background:Rheumatoid Arthritis (RA) is a chronic, inflammatory and systemic autoimmune disease, affecting multiple joints particularly small joints in hands and feet.1For the past two decades, there has been significant change in approach for the diagnosis and treatment of RA. Now early diagnosis and aggressive management of RA is considered key role for preventing permanent damage to joints.2Treat to Target (T2T) strategy has been proven to be very effective in achieving pre-decided outcome either clinical remission (CR) or low disease activity(LDA).3Objectives:To assess the outcome of nurse led T2T strategy in Early RA patients within first 2 years of treatment.Methods:This was Observational Prospective Study, based on data collected in our ANP led Early Inflammatory Arthritis clinic. All patients diagnosed with inflammatory arthritis were managed following a T2T protocol. Every patient had predefined target set according to co-morbidities, preexisting osteoarthritis and duration of disease. Patients were followed up at varying intervals depending on clinical need until the steroid free target was achieved or for up to 2 years. Clinical Disease Activity Index (CDAI) tool was used to assess disease activity.Data collected included age, gender, diagnosis, Rheumatoid factor and/or Anti CCP positivity, erosions on x ray at the time of diagnosis and Health Assessment Questionnaire (HAQ-DI). For this analysis, only patients meeting the 2010 ACR/EULAR criteria4for the diagnosis of RA were included.The primary analysis in this study was the proportion of patients who achieved CR or LDA using different DMARDs used alone or in combination and the clinical determinants of this outcome.Results:Out of 417 patients with Early Inflammatory Arthritis, 300 met criteria for RA. 27 were lost to follow up (3 deaths) and 44 remained on the T2T pathway. For the 229 patients completing the pathway, mean age was 43.25 years (SD 9.405), Female gender 146 (63.75%), Anti CCP positive in 160 (69.86%), Rheumatoid Factor (RF) positive in 154 (67.24%), Both RF and Anti CCP positive 141 (61.57%), CDAI at baseline was 22.65 (SD 22.19) and Mean HAQ-DI at presentation 1.19 (SD 0.629). There were 18.34% (42) of patients who had erosive changes on x-ray at presentation.). Outcome of T2T strategy showed that 151 (65.93%) achieved clinical remission and 78(34.06%) achieved low disease activityConclusion:Remission in patients who were less than 40 years of age was 100% as opposed to 49% above the age of 40 years. This difference was found to be statistically significant with a p value of &lt;0.05 (Table 1).Table 1.Treat to target outcomes with analysed variables.Group CharactersRemissionn (%)Low disease activity n (%)TotalP valueFemale92 (63.01)54 (36.99)1460.215Male59 (71.08)24 (28.92)83RF +103 (66.88)51 (33.12)1540.666RF -48 (64)27 (36)75CCP +105 (65.63)55 (34.37)1600.760CCP -44 (67.79)21 (32.31)65&lt; 40 years76 (100)0 (0)760.000&gt;40 years75 (49.02)78 (50.98)153Further to this, Methotrexate monotherapy was the dominant DMARD used to achieve remission and/or low disease activity in more than 50 % of the RA patients (Figure 1).

Urban disease ecology and its spatial variation of Chikungunya in Madurai City, Tamilnadu, India: a geo-medical study

Medical Geography today draws on the concepts and techniques of geography, and epitomes the interdisciplinary nature of urban health discipline. Chikungunya is one of the Vector-borne diseases and today it continues to remain an important public health problem in Madurai city. It is a mosquito-borne viral infection caused by the Chikungunya Virus (CHKV). The sudden onset of very high fever along with a rash and severe arthralgia especially in the small joints of hands and toes are the characteristics of the disease. The study area, Madurai is the oldest and second-largest city in Tamil Nadu situated on the banks of river Vaigai in the south-central part of Tamil Nadu, India. The main objectives were to identify the major disease zones concerning Chikungunya cases and to observe the related urban ecological and environmental conditions. The study also aimed to derive a conceptual framework towards strengthening, control and sustainable development of the urban landscape. The data collected were taken by using the method of stratified Random sampling and a total of 600 samples were collected. Standard score (Z-score) technique was used to describe the relationship between the sets of variables and total conditions of selected urban environmental variables. It includes mapping of the disease using GIS software of Arc GIS. Apart from this, the multi-variant statistical technique, factor analysis is used to find the major associations and interrelationship between Chikungunya and people. The twelve factors rotated by explaining the varimax procedure registered more than 89.83 percent of the total variance. Among these, the first factor alone accounted for 33.52 percent of the total variance and eigenvalue of 21.45 was qualified as the primary factor. Our study concludes that in Madurai city’s built-up area, a landscape environment of transmission of Chikungunya epidemics with a high prevalence is noted since it is associated with urban environmental factors.

EP13 A standard case of reactive arthritis? Plot twist!

Abstract Background A 49 year old male patient presented to the acute medical unit with history of acute onset high grade fever with polyarthritis involving right knee, left elbow, both ankles and small joints of right hand preceded by 2 days of diarrhoea and vomiting. He had temperature of 38°C, BP: 156/77 mmHg, Pulse rate: 98/min. Initial blood tests: CRP: 312, ESR: 51, and leucocytosis (WBC count: 17.9 with neutrophilia: 13.1). The medical team considered diagnosis of multifocal septic arthritis and initiated IV flucloxacillin empirically. He had past medical history of recently treated extra pulmonary tuberculosis three months prior to admission. Methods CT thorax abdomen and pelvis scan was organised to rule out reactivation of tuberculosis/Poncet’s arthritis. CT revealed generalised lymphadenopathy and bilateral hip effusions. At this point, a Rheumatology opinion was requested, a synovial fluid aspiration from the right knee, the most affected joint, was performed. The turbid sample had numerous pus cells, but negative gram stain and negative cultures after prolonged culture. AFB stain was negative. He was improving systemically but had intermittent fevers and CRP remained high (155mg/l). Synovial fluid sample was sent for 16S PCR testing and Streptococcus pyogenes ribosomal DNA was detected. Testing for serum ASO titres revealed elevated titres (32000 IU/mL). In conjunction with microbiology team, we augmented antibiotics to IV Gentamicin and IV Ceftriaxone. A careful history revealed transient throat infection of 6 hours duration 10 days prior to onset of arthritis. Urinary dipstick and ACR revealed proteinuria (ACR 84.8). This is under close follow-up with renal team who feel that post Streptococcal Glomerular Nephritis is likely but deferred renal biopsy. 2 DECHO study ruled out valve abnormality. A right inguinal lymph node biopsy was attempted; however, tissue sample was unsuitable. Hepatitis screen was negative and Antibody panel (ANA, ANCA were negative, RF: borderline positive (26) were unremarkable. He received total duration of 31 days of antibiotics. CRP eventually improved to 13, on follow up, in view of persisting arthritis, orals steroids (15mg OD) was prescribed for three weeks. Results Thus, we achieved a compelling diagnosis of acute rheumatic fever, with possible focus in the throat and probably bacteraemic spread to the right knee. PCR analysis of synovial fluid in context of negative culture guided antibiotic therapy choice, duration and cautious approach for immunosuppression. The patient’s story evolved with development of proteinuria suggestive of possible post streptococcal glomerulonephritis which is under follow up. Conclusion Rheumatologists are faced with challenge of reviewing ill patients with joint effusions in whom empirical antibiotics have been started. In this scenario, joint aspiration yields lower positive culture results. 16S PCR analysis can help in guiding antibiotic choice and duration with negative culture. Disclosures A. Desai None. E. Justice None. M. Rahman None. A. Johnson None.

Rheumatoid Arthritis Related Interstitial Lung Disease: Patterns of High-resolution Computed Tomography.

Background and aimRheumatoid arthritis (RA) is a chronic inflammatory systemic disease characterized by bilateral involvement of mostly small joints of hands and feet. There can be various extra-articular manifestations of the disease including lung parenchymal disease. Pulmonary involvement in RA patients leads to increased morbidity and mortality. The overall burden of RA related pulmonary disease is underestimated due to the limitation of resources in underdeveloped countries. High-resolution computed tomography (HRCT) is an important tool used to diagnose different abnormalities in RA related interstitial lung disease (ILD). The objective of the study was to evaluate HRCT findings in patients of RA related ILD and categorize the radiological findings according to clinical findings.MethodThis descriptive prospective observational study was conducted at Mayo Hospital, Lahore from June 2014 to June 2015. Patients of RA suspected of lung disease after selection underwent HRCT chest on 128-slice Hitachi CT scanner (Hitachi Global, Tokyo, Japan) in the radiology department. Images were reconstructed and evaluated by experienced radiologists. Findings were recorded on a questionnaire. Data was analyzed on SPSS version 21 (IBM Corp, Armonk, US).ResultsOut of the 54 patients scanned, interlobular septal thickening was the most common finding found in 22 of the patients. Ground-glass opacification was recognized in 21 patients, honeycombing in nine and bronchiectasis in two patients. Regarding zonal predilection of disease pattern, lower zones of lungs were found involved in most of the cases. The disease was found to be bilateral in 15 patients. Based on these findings, usual interstitial pneumonitis (UIP) was diagnosed in six patients and non-specific interstitial pneumonitis (NSIP) in 14 others.ConclusionThis study concluded that HRCT images are very useful in diagnosing interstitial lung disease related to rheumatoid arthritis.

Клинические особенности псориатического артрита в детском возрасте

Study Objective: to present literature review of clinical parameters and course of psoriatic arthritis (PsA) in children, and results of PsA patients examination in University Clinical Children Hospital of I.M. Sechenov First Moscow State Medical University. Study Design: open prospective study. Materials and Methods. We analysed medical records of 83 children with PsA aged 3 to 17 years who were examined and managed in University Clinical Children Hospital of I.M. Sechenov First Moscow State Medical University in 1989 – 2019. Study Results. Confirmed PsA was diagnosed in 59 (71%) children, suspected PsA — in 24 (29%) children; 44 (53%) children got ill before they were 6.5 years old. In 24 (29%) patients, disease started with skin involvement; in 59 (71%) patients, articular syndrome was the first manifestation of disease. In the group of patients with confirmed psoriasis, the most common was plaque psoriasis: it was diagnosed in 45 (76.3%) out of 59 children; guttate psoriasis was found in 8 (13.5%) children, isolated nail plaque psoriasis — in 3 (5.1%) patients, and palm and foot psoriasis — in 3 (5.1%) children. Psoriasis of the scalp was diagnosed in 23 (39%) subjects. In 8 (13.5%) patients, skin syndrome was associated with mild infiltration and scant desquamation. 18 (21.7%) out of 83 children had skin involvement together with nail bed involvement. Psoriasic onychodystrophy was diagnosed in 19 (23%) children (onycholysis, “oil patches” on fingers and toes); 15 (18.1%) children had “thimble syndrome”. On disease onset, 68.7% of children had oligoarticular, sometimes asymmetric articular syndrome; 18.1% had symmetric rheumatoid-like disease, 13.2% — psoriasic spondylitis. After 5 years of follow-up, articular syndrome transformed: 41.2% of patients had symmetric rheumatoid-like disease, 24.1% — asymmetric oligoarthritis, 24.1% — spondylarthritis with peripheral joint involvement, and 10.8% — arthritis mutilans. Most commonly PsA affected knee, talocrural joints, small hand joints – 41%, 31.3%, 29%, respectively. Conclusion. Clinical manifestations of PsA varied a lot. Our patients did not have a second peak. Almost one third of children had skin changes prior to arthritis development. Onset of disease was associated with asymmetric oligoarthritis prevalence. Later, articular syndrome changed, and symmetric rheumatoid-like disease prevailed. Keywords: children, psoriatic arthritis, psoriasis, juvenile idiopathic arthritis, Vancouver diagnostic criteria.