Clinical performance diagnosing alleged exposure to falanga--a phantom study

BACKGROUND

Falanga torture involves repetitive blunt trauma to the soles of the feet and typically leaves few detectable changes. Reduced elasticity in the heel pads has been reported as characteristic sequelae and palpatory testing of heel pad elasticity is therefore part of medicolegal assessment of alleged torture victims.

OBJECTIVE

The goal was to test the accuracy of two experienced investigators in determining whether a heel pad model was soft, medium or hard. The skin-to-bone distance in the models varied within the human range.

METHOD

Two blinded investigators independently palpated nine different heel pad models with three different elasticities combined with three different skin-to-bone distances in five consecutive trials and categorized the models as soft, medium or hard.

RESULTS

Two experienced investigators were able to identify three known elasticities correctly in approximately two thirds of the cases. The skin-to-bone distance affected the accuracy.

CONCLUSION

The use of clinical examination in documenting alleged exposure to torture warrants a high diagnostic accuracy of the applied tests. The study implies that palpatory testing of the human heel pad may not meet this demand. It is therefore recommended that a device able to perform an accurate measurement of the viscous-elastic properties of the heel pad be developed.

Long-term consequences of falanga torture--what do we know and what do we need to know?

The long-term consequences of falanga are probably the best described consequences of exposure to specific forms of physical torture. Theories about casual lesions in the peripheral tissues of the feet have been put forward based on clinical observations along with international guidelines for the clinical assessment, but still knowledge is needed in several areas. A review of the literature on falanga is presented, mainly focusing on the clinical aspects and possible lesions caused by this specific form of torture that may influence the overall management of the condition. Finally, the article closes with a call for future research, which is needed in order to advance a knowledge-based development of the applied clinical practice.

Quantification of colour Doppler activity in the wrist in patients with rheumatoid arthritis--the reliability of different methods for image selection and evaluation

PURPOSE

The amount of colour Doppler activity in the inflamed synovium is used to quantify inflammatory activity. The measurements may vary due to image selection, quantification method, and point in cardiac cycle. This study investigated the test-retest reliability of ultrasound colour Doppler measurements in the wrist of patients with rheumatoid arthritis (RA) using different selection and quantification methods.

MATERIALS AND METHODS

14 patients with RA had their wrist scanned twice by the same investigator with an interval of 30 minutes. The images for analysis were selected either by the anatomical position only or by the anatomical position with maximum colour Doppler activity. Subsequently, the amount of colour Doppler was measured in an area defined by either the synovial tissue or by specific anatomical structures surrounding the synovial tissue.

RESULTS

The best test-retest reliability was obtained when the images were selected guided by colour Doppler and the subsequent quantification was done in an area defined by anatomical structures. With this method, the intra-class coefficient ICC (2.1) was 0.95 and the within-subject SD (SW) was 0.017, indicating good reliability. In contrast, poor test-retest reliability was found if the images were selected by anatomical position only and the quantification was done in an area defined by the synovial tissue (ICC [2.1] = 0.48 and SW = 0.049).

CONCLUSION

The study showed that colour Doppler measurements are reliable if the images for analysis are selected by anatomical position in combination with colour Doppler activity and the subsequent analysis is performed in an area defined by anatomical structures.

Clinical outcome and imaging changes after intraarticular (IA) application of etanercept or methylprednisolone in rheumatoid arthritis: magnetic resonance imaging and ultrasound-Doppler show no effect of IA injections in the wrist after 4 weeks

OBJECTIVE

To assess the magnetic resonance imaging (MRI) and ultrasound (US) changes in the wrist of patients with rheumatoid arthritis (RA) 4 weeks after an US guided intraarticular (IA) injection.

METHODS

Contrast enhanced MRI and US-Doppler were performed at baseline and 4 weeks after IA injection of either 40 mg methylprednisolone (n = 12) or 25 mg etanercept (n = 13) in 25 patients with RA taking disease modifying antirheumatic drugs with a therapy-resistant wrist joint. All injections were US guided.

RESULTS

There was an improvement in swollen target joint score (p < 0.001), tender target joint score (p < 0.002), and physician visual analog scale score (p < 0.001) after 4 weeks. Baseline MRI synovitis score was mean 5.08 (range 3-9) and was unchanged at followup in the whole group (p = 0.52) and between treatment groups (p = 0.43). MRI edema score (mean 4.46, range 0-29) in the total group was unchanged after 4 weeks (p = 0.13), whereas MRI erosion score increased in the total group from baseline, 17.88 (range 7-40), to 4 weeks, 18.25 (range 7-40) (p < 0.001). Neither US-Doppler color fraction (0.07) nor Resistive Index (RI) (p = 0.36) changed from baseline to 4 week followup.

CONCLUSION

In contrast to the clinical evaluation, imaging measures of relevance for the estimation of inflammation, US-Doppler, US RI, MRI synovitis, and bone-marrow edema did not change 4 weeks after a single IA injection of either methylprednisolone or etanercept in the wrist. Within the same period, erosive progression in some patients suggested that joints with active disease may deteriorate within as little as 1 month, and that this development is not arrested by 1 injection. Given the small sample size of our study further studies are required to confirm our results.

Contrast kinetics of the malignant breast tumour—Border versus centre enhancement on dynamic midfield MRI

PURPOSE

To quantify the border versus centre enhancement of malignant breast tumours on dynamic magnetic resonance mammography.

MATERIALS AND METHODS

Fifty-two women diagnosed with primary breast cancer underwent dynamic magnetic resonance mammography (Omniscan 0.2 mmol/kg bodyweight) on a midfield scanner (0.6 T), prior to surgery. The following five variables were recorded from the border and centre regions of the tumours: Early Enhancement, Time to Peak, Wash-in rate, Wash-out rate and Area under Curve. Information on histology type, oestrogen and progesterone receptor status was collected. Statistical analysis was performed in SAS 9.1 as paired samples t-tests.

RESULTS

Fifty of 52 malignant tumours displayed a faster Early Enhancement in the border region compared to the centre (p<0.0001). Significant differences between the border and centre values were found for Time to Peak, Wash-in rate, Wash-out rate and Area under Curve. Hormone receptor positive tumours displayed an over-all highly significant difference between border and centre enhancement, whereas no significant differences for any of the five variables were recorded in neither oestrogen nor progesterone hormone receptor negative tumours.

CONCLUSION

The border/centre enhancement difference in malignant breast tumours is easily visualized on midfield dynamic magnetic resonance mammography. The dynamic behaviour is significantly correlated to histological features and receptor status of the tumours.

Signal intensity of normal breast tissue at MR mammography on midfield: applying a random coefficient model evaluating the effect of doubling the contrast dose

PURPOSE

To prospectively investigate the effect on signal intensity (SI) of healthy breast parenchyma on magnetic resonance mammography (MRM) when doubling the contrast dose from 0.1 to 0.2 mmol/kg bodyweight.

MATERIALS AND METHODS

Informed consent and institutional review board approval were obtained. Twenty-five healthy female volunteers (median age: 24 years (range: 21-37 years) and median bodyweight: 65 kg (51-80 kg)) completed two dynamic MRM examinations on a 0.6T open scanner. The inter-examination time was 24 h (23.5-25 h). The following sequences were applied: axial T2W TSE and an axial dynamic T1W FFED, with a total of seven frames. At day 1, an i.v. gadolinium (Gd) bolus injection of 0.1 mmol/kg bodyweight (Omniscan) (low) was administered. On day 2, the contrast dose was increased to 0.2 mmol/kg (high). Injection rate was 2 mL/s (day 1) and 4 mL/s (day 2). Any use of estrogen containing oral contraceptives (ECOC) was recorded. Post-processing with automated subtraction, manually traced ROI (region of interest) and recording of the SI was performed. A random coefficient model was applied.

RESULTS

We found an SI increase of 24.2% and 40% following the low and high dose, respectively (P<0.0001); corresponding to a 65% (95% CI: 37-99%) SI increase, indicating a moderate saturation. Although not statistically significant (P=0.06), the results indicated a tendency, towards lower maximal SI in the breast parenchyma of ECOC users compared to non-ECOC users.

CONCLUSION

We conclude that the contrast dose can be increased from 0.1 to 0.2 mmol/kg bodyweight, if a better contrast/noise relation is desired but increasing the contrast dose above 0.2 mmol/kg bodyweight is not likely to improve the enhancement substantially due to the moderate saturation observed. Further research is needed to determine the impact of ECOC on the relative enhancement ratio, and further studies are needed to determine if a possible use of ECOC should be considered a compromising factor, if an MRM is indicated in a young woman.

Ultrasound in finger joints: findings in normal subjects and pitfalls in the diagnosis of synovial disease

PURPOSE

Grey-scale ultrasound may be used to visualise the amount of synovial tissue in patients with rheumatoid arthritis (RA). Different scoring systems have been developed. None of the scoring systems have been tested on a larger group of healthy joints, and it is therefore unknown to what extent synovial tissue is seen on grey-scale ultrasound in healthy joints. The objective of this study was to test two scoring systems on healthy volunteers.

MATERIALS AND METHODS

24 healthy men and women between 30 and 54 years underwent scanning of the MCP, PIP and DIP joints of their dominant hand. Each person was scanned in 69 positions. The images were graded on a scale from 0 to 4 with two scoring systems (I and II). Scores 0 - 1 were defined as normal and 2 - 4 as pathological. With scoring system I, only markedly hypoechoic synovium was graded. With scoring system II, marked hypoechogenicity was not a criterion.

RESULTS

With system I, 89 % of the joints obtained at least one pathological score. With system II, 95 % of the joints obtained at least one pathological score. With both systems, women obtained higher scores than men, and the number of high scores increased with increasing age.

CONCLUSION

An unacceptably high number of joints obtained pathological scores with both scoring systems in healthy volunteers. This indicates that many of the scores interpreted as pathological in patients with RA may just be normal findings, with increasing numbers in older patients.

Ultrasound Doppler of the Achilles tendon before and after injection of an ultrasound contrast agent--findings in asymptomatic subjects

The sensitivity of ultrasound Doppler has now reached a level at which perfusion can be detected even in normal, resting musculoskeletal tissues. To be able to distinguish normal from abnormal flow, the resistive index (RI) determined by spectral Doppler may be of value. Inflammation is associated with low RI values and a value of 1.00 is normal.

PURPOSE

In tissues with no detectable flow, it has been assumed that RI may be defined as 1.00. This study was performed to test if normal tendinous vessels could be visualised with a contrast agent, and if such vessels had normal RI.

MATERIALS AND METHODS

Ultrasound (US) was performed with a 14 MHz linear transducer. 22 asymptomatic tendons in 12 subjects were scanned, and only 5 ultrasonically normal tendons in 5 subjects were identified. In these 5 normal tendons, SonoVue was used to make vessels visible. The Achilles tendons and the peritendinous tissues were evaluated clinically.

RESULTS

In all 5 ultrasonically normal tendons, arteries could be detected with Doppler after contrast injection and in all cases with normal RI values. All vessels were located in the mid-portion of the tendon. 18 tendons were categorised as normal by the clinician.

CONCLUSION

After administration of a contrast agent, all Achilles tendons could be demonstrated to have arteries present in the mid-portion. The flow profile of these arteries was fully normal without diastolic component and with an RI of 1.00. This finding has implications for criteria of normality of tendons, which cannot be based exclusively on the presence or absence of Doppler activity. The majority of the tendons in this study had ultrasound abnormalities both on gray-scale and colour Doppler. It can be speculated that the abnormalities may be age-related degenerative changes and that age-stratified normal materials are needed to define normality. There was no consistency between US and clinical diagnosis.

Producing medico-legal evidence: documentation of torture versus the Saudi Arabian state of denial

Five British men were detained and allegedly tortured in Saudi Arabia in 2000 and 2001. Two were sentenced to death and three were sentenced to 12 to 18 years of imprisonment. They received clemency in 2003 and were deported to England. After their homecoming, the men have unsuccessfully attempted to sue Saudi Arabian officials who had been responsible for their false accusations and human rights abuses. Saudi Arabia denies any form of torture and ill treatment of the five men, who maintain their allegations against the authorities responsible in Saudi Arabia. This article provides medical documentation of torture of the five British men by comparing: 1. Alleged torture methods, 2. Histories of immediate effects of torture, 3. Objective medical observations using clinical examinations as well as ultrasound scans of the victims' feet. The article concludes that there is a high degree of consistency between the claims of torture and observations, despite Saudi Arabian denial.

A randomized, controlled study of a single intra-articular injection of etanercept or glucocorticosteroids in patients with rheumatoid arthritis

OBJECTIVE

Glucocorticosteroids are used successfully for both systemic and intra-articular treatment of arthritis. Inhibitors of tumour necrosis factor alpha (TNF-alpha) are effective when administered systemically and this study was performed to compare the effect of intra-articular injection of these two substances.

DESIGN

A randomized, parallel-group, double-blind study with an independent observer. Thirty-eight patients with flare of arthritis in a single joint (wrist, elbow, or knee) were given intra-articular 25 mg etanercept or 40 mg methylprednisolone guided by ultrasound. The primary end-point was the 4-week change in pain in the target joint. The study complied with Good Clinical Practice (GCP) and the Consolidated Standards for Reporting of Trials (CONSORT) statement.

RESULTS

At 4 weeks no difference in pain outcome between treatment groups was demonstrated by analysis of covariance (ANCOVA). Pain on the Visual Analogue Scale (VAS) for etanercept was baseline mean 40.9 (SD 19.6) mm, follow-up 32.7 (29.1) mm (p = 0.29), methylprednisolone baseline mean 47.1 (29.6) mm, follow-up 25.3 (24.7) mm (p<0.001). The investigator's evaluation was for etanercept baseline 30.6 (21.2) mm, follow-up 17.1 (15.5) mm (p = 0.054) and for methylprednisolone baseline 35.4 (26.4) mm, follow-up 11.9 (14.6) mm (p = 0.012). Joint swelling was for etanercept baseline 1.78 (0.73), follow-up 1.25 (0.77) (p = 0.015) and for methylprednisolone baseline 1.74 (0.73), follow-up 0.71 (0.77) (p<0.001). One serious adverse event was seen in a patient treated with methylprednisolone injection.

CONCLUSION

Although no difference between groups was demonstrated, the within-group effect of methylprednisolone was more marked than that of etanercept. Injections with 25 mg etanercept were well tolerated. However, the cost of etanercept will presumably limit its use to patients with adverse reactions to steroid.

Acute rotator cuff tear: do we miss the early diagnosis? A prospective study showing a high incidence of rotator cuff tears after shoulder trauma

The aim of this study was to evaluate the epidemiologic data of patients with an acute soft-tissue injury to the shoulder, with an emphasis on improving the early diagnosis of acute rotator cuff tears. This study included 104 patients, with a median age of 49 years (range, 19-75 years). The patients were evaluated clinically and with ultrasonography at a median of 13 days (range, 3-49 days) after the injury. A total of 60 patients (58%) had some degree of cuff lesion on the ultrasonographic examination. Of these patients, 33 (32%) had a full-thickness rotator cuff tear, 14 (13%) had a partial-thickness cuff tear in the tendon substance, and 13 (13%) had a partial cuff tear at the insertion site on the major tubercle. The injury mechanism or activity at the moment of injury did not correlate with the presence of a rotator cuff lesion, but we found a strong age correlation, with a prevalence of any rotator cuff tear, above 50%, for patients aged above 50 years and with a prevalence of full-thickness tears of 50% in the groups aged 50 to 59 years and aged 60 to 69 years. In conclusion, this study found a high incidence of rotator cuff lesions by further evaluation of patients undergoing consultation at the emergency department, with an inability to perform active abduction above 90 degrees and normal radiographs, after an acute shoulder trauma.

Tendinopathy and Doppler activity: the vascular response of the achilles tendon to exercise

BACKGROUND

Intratendinous Doppler activity has been interpreted as an equivalent of neovessels in the Achilles tendon and as a sign of tendinosis (AT).

AIM

To evaluate the vascular response as indicated by color Doppler activity after repeated loading of both symptomatic and non-symptomatic Achilles tendons.

MATERIAL AND METHODS

Ten non-trained, healthy subjects ran 5 km. Ultrasound (US) Doppler activity was determined before and after the exercise. Eleven patients with chronic AT performed 3 x 15 heavy-load eccentric exercise. The Achilles tendons were scanned before and immediately after the exercise.

RESULTS

Non-symptomatic: six Achilles tendons in five subjects had intratendinous Doppler activity before the exercise. All but two subjects (80%) had intratendinous Doppler activity after running. Symptomatic: all patients had Doppler activity in the tendons, with a median color fraction before eccentric exercise of 0.05 (range 0.01-0.33). The Doppler activity did not disappear after exercise. Tendons with a color fraction below the median at baseline increased significantly after the exercise (P=0.02).

CONCLUSION

The mere presence of Doppler in the Achilles tendon does not per se indicate disease. Eccentric exercise does not extinguish the flow during or after one training session in patients with chronic AT.

Safety of intra-articular injection of etanercept in small-joint arthritis: an uncontrolled, pilot-study with independent imaging assessment

This study was conducted to test the safety of intra-articular tumor necrosis factor alpha (TNF-alpha) antagonists in small joints with arthritis. A dose of 2-8 mg etanercept was given intra-articularly guided by ultrasonography (US) in 26 patients with a flare of arthritis in a particular joint (16 wrists, two elbows, two ankles, six finger joints). Primary end points were imaging analyses by independent investigators: US-Doppler measurements were performed in all patients before and after the injection and MRI before and after were obtained in nine patients. The only adverse event was a case of swelling of the hand lasting 2 days after a wrist injection. Two patients had a supplementary glucocorticoid injection and were excluded from efficacy analysis after 4 days and 3 weeks, respectively. VAS for pain decreased after 1 week in 23 of 25 patients (median 0.62), and after 1 month in 14 of 24 patients (median 0.60). No significant changes were seen in erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP). On MRI, all nine cases tested had a reduction in synovial thickness (P=0.008) and US Doppler signals diminished after treatment (resistance index (RI) P=0.02, pixels P=0.09). In conclusion, intra-articular injection of etanercept gave no noticeable adverse events.

Imaging of intratendinous distribution of glucocorticosteroid in the treatment of Achilles tendinopathy. Pilot study of low-field magnetic resonance imaging correlated with ultrasound

OBJECTIVE

Recently, a positive treatment effect of intratendinous injections of steroid in Achilles tendonitis (AT) has been described. Our aim was to test the localization and distribution of the injected steroid in both healthy (animal) tendons and in diseased human Achilles tendons.

MATERIAL AND METHODS

Four pig tendons were injected in vivo and harvested. The harvested tendons were placed in 0.2 Tesla MRI scanner, in order to select the optimal MRI sequences for tracking and localizing the bolus injection. Three patients with AT were treated with intratendinous steroid injection. Injections were placed in the pathologic areas of the tendon guided by ultrasound (US). MRI and US were performed at baseline and again immediately and 60 minutes after injection. A final follow-up MRI was performed 1 month after the injection.

RESULTS

In the animal model, significant recoil of the injected substance was seen in all cases. In all three patients the injection was readily distributed within the tendon and no recoil through the injection channel was found. One-month follow-up showed a total regression of hyperaemia on US as well as regression of intratendinous oedema on MRI in all 3 patients.

CONCLUSION

It is possible to demonstrate the distribution pattern of injected steroid in diseased Achilles tendons by MR-imaging. In contrast to the recoil experienced in the healthy tendon of the animal, the lack of recoil of the injected volume through the injection channel in the sick human tendon may be caused by a derangement of the fibre structure, which allows the extra volume to be distributed within the lesion. This indicates that the effect on AT of intra-tendinous injections of steroid is due to a local intra-tendinous action of the drug.

Intra-tendinous ossification with concomitant tendonitis and bursitis--ultrasound grey-scale and colour Doppler findings

A case report of a 62-year-old man with a 20-year history of tendon problems, who presented with a swollen and tender left Achilles tendon. Ultrasound (US) revealed a 2 x 1 x 0.9 cm intra-tendinous substance with acoustic shadowing. On a radiogram, ossification was found. Colour Doppler activity was present in both the bursa and the tendon. A US-guided injection of 40 mg Depomedrol was applied into the retrocalcaneal bursa. On follow-up two months later, the patient had no symptoms and US showed total regression of Doppler activity. The ossification was unchanged. US colour Doppler may be recommended for guidance and monitoring of treatment.

Ultrasound guided electrocoagulation in patients with chronic non-insertional Achilles tendinopathy: a pilot study

BACKGROUND

High resolution colour Doppler ultrasound shows intratendinous Doppler activity in patients with chronic Achilles tendinopathy. Treatment of this neovascularisation with sclerosing therapy seems to relieve the pain. However, the procedure often has to be repeated.

OBJECTIVE

To investigate the effect of electrocoagulation of the neovessels on tendon pain and tendon vascularity in patients with chronic Achilles tendinopathy.

METHODS

Colour Doppler ultrasound guided electrocoagulation was used on vessels in the ventral portion of the Achilles tendon in 11 patients (seven men, four women, mean age 41 years) with painful chronic mid-portion Achilles tendinosis. A unipolar coagulation device was used.

RESULTS

One patient dropped out after two months (dissatisfied with the results). The remaining 10 patients (91%) were satisfied. These 10 patients were still satisfied at six months of follow up and had returned to their previous level of activity. All 10 patients were "cured" after one treatment. The patient who dropped out received two treatments because of lack of progress. There was significantly reduced pain (Likert pain scale, 0-10) during activity, from a median of 7 (range 4 to 10) at baseline to 0 (0 to 8) at six months' follow up (p<0.005); and at rest, from 1.5 (1 to 5) to 0 (0 to 8) (p = 0.005). In all patients, vascularisation was unchanged at the six months follow up, with no significant change in semiquantitative or quantitative colour scoring.

CONCLUSIONS

Coagulation in the area with vessels entering the tendon appears to be effective treatment for painful chronic mid-tendinous Achilles tendinopathy. No effect on the intratendinous Doppler activity could be detected, suggesting that the effect is independent of changes in blood flow. Localisation of hyperaemia appears to be the key to the pathology and for targeting the treatment. One explanation could be that the effect is obtained by destruction of nerves accompanying the vessels.

Reproducibility and inter-reader agreement of a scoring system for ultrasound evaluation of hip osteoarthritis

OBJECTIVE

To evaluate the intra-reader and inter-reader agreements of ultrasonographic assessments of hip joints in patients with hip osteoarthritis.

DESIGN

Ultrasonography was performed on 100 patients with hip osteoarthritis at 14 MHz using a 8-15 MHz linear probe. Dynamic sweeps of the hip and representative still images were used for the analysis. A semiquantitative grading score was introduced in the evaluation of the ultrasound pictures and compared with an overall ultrasound evaluation. The evaluation was performed by a specialist in ultrasonography and a rheumatologist trained in musculoskeletal ultrasound examination. Clinical pain assessment and joint aspiration were obtained in parallel with the ultrasonography.

RESULTS

Intraobserver agreement represented by intraclass correlation coefficients (ICC) (exact agreement in percentage; unweighted kappa values) showed good to excellent correlation, 0.8 with regard to the osteophyte score, 0.78 with regard to the femoral head score, 0.71 with regard to the fluid score and 0.69 with regard to the synovial profile score. Interobserver agreement was fair to good with corresponding ICC 0.65, 0.63, 0.45 and 0.6, respectively. In comparison, the ICC for the global osteoarthritis and synovial assessments were 0.7 and 0.72, respectively, for the intraobserver rating and 0.56 and 0.58, respectively, for the interobserver rating.

CONCLUSIONS

This study suggests that ultrasound is a reproducible method for the assessment of changes in the osseous surface and synovium-related inflammation. The semiquantitative scoring system presented seemed to match the global assessment of a trained ultrasound investigator and might be used by less-trained investigators.

Indications of inflammation visualized by ultrasound in osteoarthritis of the knee

PURPOSE

Ultrasound examination of a group of patients with osteoarthritis (OA) of the knee for signs of inflammation.

MATERIAL AND METHODS

71 knees in 71 patients with osteoarthritis of the knee were examined with high-resolution gray-scale ultrasound combined with color and spectral Doppler. The medial, lateral, and antero-superior compartments were examined. Hyperemia was identified as presence of color Doppler signals in the synovial membrane. Low resistance flow was defined as a resistive index < 0.80 on spectral Doppler.

RESULTS

Synovial thickening was found in all knees; fluid in 61 patients; and hyperemia (color Doppler activity) in 51 patients. Of these, 44 had arterial flow on spectral Doppler - 36 with a low resistance flow. When present, fluid and color Doppler activity was found in all three compartments, but with uneven distribution.

CONCLUSION

The finding in the majority of cases of both effusions on B-mode US and Doppler activity confirms that there is a varying degree of inflammation in knee OA as diagnosed by the ACR criteria.

Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline

OBJECTIVE

Hyaluronic acid (HA) and corticosteroids are both widely used for intra-articular treatment of knee osteoarthritis (OA). We examined the effect of both drugs in intra-articular treatment for hip OA.

METHODS

One hundred and one patients with hip OA were included in a prospective double blind study, using a randomized controlled trial with a three-armed parallel-group design. Three ultrasound-guided, intra-articular injections were given at 14 days interval. The primary outcome measure was 'pain on walking', registered on a visual analogue scale (VAS). Evaluation was performed at baseline and after 14, 28 and 90 days. The study adhered to the Consolidated Standards of Reporting Trials. All analyses were based on intention-to-treat analyses, and used 'mixed-procedures' with the baseline-observation as covariate.

RESULTS

There were no significant interactions with respect to Treatment x Time for any of the analyzed outcome measures. There was a significant treatment effect for 'pain on walking' (P=0.044) due to a significant improvement following corticosteroid compared to saline with an effect-size of 0.6 (95% confidence interval: 0.1-1.1, P=0.021). By contrast, HA compared to saline had an effect size of 0.4 (-0.1 to 0.9; P=0.13). The peak-effect was obtained after 2 weeks. There was no difference between the treatment groups at endpoint. No significant side effects of the injections were observed.

CONCLUSIONS

Patients treated with corticosteroids experienced significant improvement during the 3 months of intervention, with an effect size indicating a moderate clinical effect. Although a similar significant result following treatment with HA could not be shown, the effect size indicated a small clinical improvement. A higher number of patients in future HA studies would serve to clarify this point.

Doppler ultrasound findings in healthy wrists and finger joints before and after use of two different contrast agents

OBJECTIVE

To examine the effect of contrast agents on Doppler ultrasound findings in the synovial membrane in the wrist and fingers of healthy volunteers.

MATERIALS AND METHODS

Eleven healthy subjects were included in the study (5 women and 6 men, mean age 38 years, range (20-60)). They had no clinical signs of inflammatory or degenerative joint diseases. A total of 66 joints were examined-6 joints for each subject: wrist and metacarpophalangeal (MCP) joints 1-5-before contrast injection and after Levovist and SonoVue injection with a 30 minute interval.

RESULTS

Colour Doppler activity was detected in 10/55 (18%) MCP joints before contrast injection and in 29/55 (53%) and 28/55 (51%) joints after Levovist (p<0.0001) and SonoVue injection (p = 0.0001), respectively. A significant increase in Doppler activity in the radial (p<0.05) and ulnar (p = 0.01) parts of the wrist joint was detected only after SonoVue injections. With spectral Doppler no difference was found in the resistive index (RI) in the vessels measured before as compared with those only detected after contrast injection.

CONCLUSION

The number of joints with colour Doppler activity in healthy volunteers was increased by the use of contrast agents. No changes in RI were detected. The value of contrast agents remains to be demonstrated in inflammatory diagnostics.

Interobserver reliability in musculoskeletal ultrasonography: results from a "Teach the Teachers" rheumatologist course

OBJECTIVE

To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography.

METHODS

The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results.

RESULTS

Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae.

CONCLUSIONS

Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.

Ultrasonography and articular cartilage defects in the knee: an in vitro evaluation of the accuracy of cartilage thickness and defect size assessment

The purpose of this cadaver study was to test the accuracy of ultrasonography in measuring cartilage thickness, and the extent and depth of induced cartilage defects on the medial and lateral femoral condyles of the knee in a clinically relevant setting. With the knees maximally flexed, cartilage thickness was measured at 24 marked sites in four knees with a 10 MHz probe. The areas of measurement were then excised and the thickness measured with a calliper gauge. In another seven cadaver knees, 21 cartilage defects were produced. The defect diameter varied from 4 to 8 mm. The depths of the defects were either a partial cartilage defect (grade 2), a defect to intact subchondral bone (grade 3), or a defect involving subchondral bone (grade 4) (classification by ICRS). The limits of agreement between ultrasonography and calliper gauge measurement for cartilage thickness were chi(diff)+/-2SD(diff)=0.0+/-0.4 mm. For cartilage defect diameter, the limits of agreement between ultrasonography and the slide ruler measurement were chi(diff)+/-2SD(diff)=-0.2+/-1.0 mm. For the depths of the lesions there was a 100% agreement between radiologist and actual lesion depth for the classification into International Cartilage Repair Society (ICRS) grades 2, 3, and 4. Our conclusion is that ultrasonography is capable of measuring accurately both cartilage thickness and the extent and depth of induced cartilage defects in a cadaver model.

Doppler ultrasound findings in healthy wrists and finger joints

OBJECTIVE

To evaluate the presence of flow by Doppler ultrasound (DUS) in the wrist and finger joints (carpometacarpal 1 (CMC1), metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints) of healthy controls.

METHODS

Twenty seven healthy volunteers (15 women, 12 men; mean age 45 years, range 18-93) with a total of 324 joints were examined by DUS. The synovial vascularisation was determined by colour Doppler and the spectral Doppler resistive index (RI). Patients were only included if no synovitis was suspected at the clinical examination and the values for biochemical analysis were within the normal range.

RESULTS

We found colour pixels in 15 of the 27 examined wrist scans and in 8 of these a measurable RI. In the CMC1 joint, colour pixels were found in 11 of the 27 scans and in 9 of these a measurable RI. For the MCP joints, colour pixels were found in 10 out of 135 scans and in 3 of these a measurable RI. The mean RI for all three types of joints was 0.85 and the mean pixel fraction varied from 0.05 to 0.08. Only one PIP joint scan was found to have colour pixels and a flow with an RI of 0.67.

CONCLUSION

Synovial vascularisation may be detected in healthy subjects using DUS. Newer US machines have higher Doppler sensitivity, and it is necessary to be able to distinguish normal from pathological synovial flow.

Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients

BACKGROUND

It is debated as to whether Achilles tendonitis (AT) has an inflammatory component. The intratendinous hyperaemia demonstrated with colour Doppler has been interpreted as neovascularisation. Glucocorticoid injection around the tendon is a common therapeutic procedure.

HYPOTHESES

The intratendinous hyperaemia seen with ultrasound (US) colour Doppler represents an inflammatory background. Glucocorticoid injections will be effective if administered inside the tendon where the inflammation seems to be.

STUDY DESIGN

An uncontrolled, prospective study with a minimum follow-up of 3 months.

METHODS

Six tendons in five patients were evaluated with grey-scale US and colour Doppler before and after US-guided intratendinous glucocorticoid injection. Pain at rest and at activity was evaluated on a visual analogue scale.

RESULTS

With colour Doppler all tendons had intratendinous flow. Pain and colour Doppler activity decreased during a mean follow-up of 182 days (range 92-309 days). One tendon relapsed after 199 days.

CONCLUSION

Intratendinous glucocorticoid injections seem to have a marked effect on both symptoms and colour Doppler findings, which may be taken as an indication of an inflammatory component in the disease. Colour Doppler adds significant information to grey-scale US with regard to diagnosis, location and follow-up of AT.

Estimation of inflammation by Doppler ultrasound: quantitative changes after intra-articular treatment in rheumatoid arthritis

OBJECTIVE

To evaluate the use of ultrasound, including quantitative Doppler analysis of synovial vascularisation, before and after intra-articular treatment with glucocorticosteroids in patients with rheumatoid arthritis (RA).

METHODS

51 patients with RA were followed prospectively after an intra-articular glucocorticosteroid injection. Disease modifying antirheumatic drug treatment was kept unchanged and no further injections given in this observation period. At baseline, disease activity was estimated clinically by target join pain on a 100 mm visual analogue scale, on which the target joint was scored 0-3 for swelling and tenderness, and by ultrasound measurements of grey scale pixels, colour Doppler pixels, and the spectral Doppler resistive index (RI) as indicators of synovial swelling and inflammation. After four weeks, the measurements were repeated on the same joint. An observer unaware of the sequence and patient number evaluated the ultrasound images.

RESULTS

At one month follow up after the glucocorticosteroid injection, a marked decrease in the fraction of colour pixels was seen in 41/51 patients (Student's t test p<0.001). Correspondingly, the RI increased indicating a diminished flow to the synovium (Student's t test p<0.01). Both the fraction of colour pixels and the RI values corresponded with the clinical evaluation and with the subjective effect of the treatment. The synovial membrane volume estimated by total amount of pixels showed a significant decrease by 31% after treatment.

CONCLUSION

Ultrasound-Doppler seems to be a promising tool for the estimation of synovial activity in arthritis. After intra-articular glucocorticosteroid, changes in RI and fraction of colour pixels may both be used as quantitative measurements of the blood flow.

Spectral Doppler and resistive index. A promising tool in ultrasonographic evaluation of inflammation in rheumatoid arthritis

PURPOSE

To evaluate the use of spectral Doppler in the longitudinal follow-up of inflammatory joint involvement in rheumatoid arthritis (RA) by comparing resistive index (RI) findings with color fraction and pain on a visual analog scale (VAS).

MATERIAL AND METHODS

Five patients on unchanged disease modifying anti-rheumatic drugs (DMARD) treatment were followed after an intra-articular corticosteroids injection and received no further injections in the observation period. They were followed clinically and by ultrasound using color Doppler pixels and the spectral Doppler RI as indicators of inflammation. At 1, 6 and 12 months the measurements were repeated on the same joint.

RESULTS

At 1-month follow-up after the corticosteroids injection, a marked decrease in the color fraction was seen in 4 out of 5 patients, while the fifth patient had a moderate decrease (Wilcoxon p < 0.05). The changes in RI showed correspondingly a marked increase in 4 out of 5 patients indicating a diminished flow to the synovium (Wilcoxon p < 0.05). The effect of the corticosteroid injection could still be seen after 1 year in 4 out of 5 patients. In RI, pixel fraction and VAS there was improvement compared with the baseline values; however, only the pixel fraction was statistically significant (Wilcoxon p < 0.05).

CONCLUSION

RI seems to be an objective alternative to pixel estimation of the degree of inflammation and treatment response in RA.

Doppler ultrasound and magnetic resonance imaging of synovial inflammation of the hand in rheumatoid arthritis: a comparative study

OBJECTIVE

To compare the quantitative and qualitative information obtained by Doppler ultrasound (US) measurements of the wrist joints and the small joints of the hand with the information obtained by postcontrast magnetic resonance imaging (MRI) and to correlate the imaging results with clinical observations in patients with rheumatoid arthritis (RA).

METHODS

Twenty-nine consecutive RA patients were studied; 196 joints (29 wrist and 167 finger joints) were examined by both US and MRI. Parameters of inflammation were the color fraction and the resistance index (RI) obtained with color Doppler US and the thickness of enhanced synovium (in mm) and the MRI score obtained with postcontrast MRI. Clinical examination and measurements of the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level were performed on the same day as the imaging studies.

RESULTS

There was a highly significant association between US indices of inflammation and postcontrast MRI scores. The mean values for both the color fraction and the RI were significantly different in the group without joint swelling compared with the other groups. The mean RI values were significantly different in the group without joint tenderness compared with the other groups. The mean thickness of enhanced synovium on postcontrast MRI was significantly different between the group without joint swelling and the other groups, but this difference was statistically significant only for the comparison of the group without joint tenderness versus the group with maximum tenderness. No association between the MRI or US estimates of inflammation and values on the visual analog scale for pain, Health Assessment Questionnaire, duration of morning stiffness, ESR, or CRP was found.

CONCLUSION

Estimates of synovial inflammatory activity by Doppler US and postcontrast MRI were comparable. Estimation of synovial inflammatory activity by the RI and color fraction parameters of US appears to be a promising method of detecting and monitoring inflammatory activity in patients with RA.

Simulation of RF data with tissue motion for optimizing stationary echo canceling filters

Blood velocity estimation is complicated by the strong echoes received from tissue surrounding the vessel under investigation. Proper blood velocity estimation necessitates use of a filter for separation of the different signal components. Development of these filters and new estimators requires RF-data, where the tissue component is known. In vivo RF-data does not have this property. Instead simulated data incorporating all relevant features of the measurement situation can be employed. One feature is the motion in the surrounding tissue induced by pulsation, heartbeat, and breathing. This study has developed models for the motions and incorporated them into the RF simulation program Field II, thereby obtaining realistic simulated data. A powerful tool for evaluation of different filters and estimators is then available. The model parameters can be varied according to the physical situation with respect to scan-site and the individual to be scanned. The nature of pulsation is discussed, and a relation between the pressure in the carotid artery and the experienced vessel wall motion is derived.

Effects of treatment with etanercept (Enbrel, TNRF:Fc) on rheumatoid arthritis evaluated by Doppler ultrasonography

OBJECTIVE

to estimate and visualise the efficacy of treatment with etanercept (Enbrel) in patients with rheumatoid arthritis (RA) using colour Doppler and spectral Doppler ultrasonography to determine the possible changes in synovial perfusion during a one year observation period.

METHODS

Eleven patients from the European multicentre trial of the efficacy and safety of etanercept were included in this study when transferred into the open label, long term safety, and efficacy study. Before a scheduled dosage increase to 50 mg/week they were examined clinically, serologically, and by ultrasonography using the colour Doppler pixels and the spectral Doppler resistance index (RI) as indicators of inflammation. The patients were re-examined at two weeks and at one year follow up

RESULTS

The clinical activity decreased significantly from baseline to week 2, but no significant changes were seen from baseline to one year. The number of coloured pixels in each region of interest decreased from baseline to week 2 with a median reduction of 60% (p=0.005). This effect on the perfusion in the synovium could not be found after one year of treatment. During the initial treatment we detected an increase in synovial RI by spectral Doppler. The median increase in peripheral resistance from baseline to week 2 as estimated by the mean RI was 22.6% (p=0.005). The increase in peripheral resistance was maintained to some extent after one year (mean RI increased by 18.8% p=0.074).

CONCLUSION

Ultrasonography seems to be a promising tool for the detection of treatment response using spectral Doppler and pixel estimation.

Guidance by ultrasound of intra-articular injections in the knee and hip joints

OBJECTIVE

To develop and assess a stable method for ascertaining the placement of intraarticular injections for osteoarthritis (OA) in the hip and knee.

METHODS

Injections into the hip or knee joint with e.g. hyaluronan or cortisone were performed under the guidance of ultrasound. For this purpose an Acuson Sequoia apparatus and a 8-15 MHz transducer were used. After perforation of the capsule with a 21 G needle, 0.5-1 ml of atmospheric air and 1 ml lidocain 1% was injected with simultaneous recording of the ultrasound signals. This procedure was undertaken before the injection of the medication through the in situ needle.

RESULTS

In the hip joint the injected air could readily ascertain the placement of the injection with a sharp echoic contrast forming on the ultrasound picture respecting the joint cavity. In the knee joint the procedure gave the best results in joints which have a small amount of fluid in either the suprapatellar bursa or in a pouch regularly observed over the lateral joint margin. However, also in some so-called 'dry' knee joints the air could be traced in the bursa by ultrasound.

CONCLUSION

By the injection of air, it is possible to test the placement of intraarticular injections in both hip and knee joints. This procedure will give a supplementary documentation of the injection as compared to a mere ultrasonographic demonstration of the position of the needle in the joint. The method is proposed as a tool for both learning purposes and quality assurance in daily therapy.

Ultrasound and Power Doppler findings in jumper's knee - preliminary observations

OBJECTIVE

to examine a group of high risk athletes, for signs of inflammation in jumper's knee (JK) by gray-scale ultrasonography (US) and color/Power Doppler findings in JK.

SUBJECTS AND METHODS

eighteen high-elite basketball players participated in the investigation after a match. Seven players were examined by ultrasound before the match as well. The players were clinically examined for signs of JK and filled in a questionnaire concerning previous and present knee symptoms.

RESULTS

clinical signs of JK were found in 13 knees. Of these knees, ten had hypoechoic areas and six had Power Doppler flow. Four players reported symptoms of JK and clinical examination suspected the same. Three of them had both hypoechoic areas and Power Doppler flow. Fourteen players were asymptomatic at the time of examination but both hypoechoic areas and Power Doppler flow was found in the patellar tendons of four players. No correlation was found between clinical findings, symptoms of JK and US findings - including Power Doppler. The risk of type II error in this material is considerable.

CONCLUSION

an association between gray-scale US and color/Power Doppler was found in JK which may suggest an inflammatory component to be a part of the pathogenesis of JK.

Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique

OBJECTIVE

To evaluate ultrasonographic methods, including the Doppler technique, as measures of synovial inflammation in finger joints of patients with rheumatoid arthritis.

METHODS

Ultrasonography was performed with a high frequency transducer (13 MHz). Evaluation of the sonographic data was conducted by two independent observers and included measurement of synovial area and thickness (grey tone ultrasound), vascularisation (power/colour Doppler), and indices of the intra- and extrasynovial arterial flow (spectral Doppler). The flow pattern was estimated by the indices of pulsatility (PI) and resistance (RI).

RESULTS

The sonographic measurements of joint space were reproducible with intraobserver, intraclass correlation coefficients (ICC) 0.82-0.97 (p<0.0001) and interobserver ICC 0.81 (p<0.0001). The mean (SD) fraction of the synovium vascularised in the patients was 0.15 (0.15). The synovial blood flow was characterised by a diastolic flow-that is, the flow persisting during the diastole. The mean (SD) PI was 1.92 (1.18) and RI 0.70 (0.13). The estimated vascular fraction correlated with the erythrocyte sedimentation rate (ESR) (r(s)=0.53, p=0.03). The relative Pi (rPi), an estimate of an abnormally low resistance to vascularisation, correlated with both ESR (r(s)=-0.557, p<0.05) and Health Assessment Questionnaire score (r(s)=-0.584, p<0.05). After an injection of contrast Levovist the vascular fraction increased, while no difference in PI and RI was observed.

CONCLUSION

Ultrasonography is a reliable tool for estimating the size of the joint space and the synovial activity measured by the degree of vascularisation and pattern of flow. Ultrasonography may be useful in monitoring the synovial inflammation in rheumatoid arthritis.

Percutaneous gastrostomy guided by ultrasound and fluoroscopy

Percutaneous gastrostomy, utilizing a dedicated catheterization kit, with a combination of ultrasonographic (US) and fluoroscopic guidance, was carried out in 27 patients. The main indication for gastrostomy was the need for nutritional support in malignant esophageal stricture. After distending the stomach with water via a nasogastric tube, the gastric antrum was punctured under US guidance and a guide wire was inserted, followed by fluoroscopically guided tract dilatation and insertion of a 2.5-mm Cope-loop catheter. In all patients but one (96%) the procedure was successfully completed in one or 2 attempts. Two complications occurred: one case of a small subcutaneous abscess near the puncture site, and one late incident of dislodgement of a catheter without string-loop fixation, which had been inserted at a catheter exchange after 6 weeks. Percutaneous gastrostomy guided by US and fluoroscopy is a safe and efficacious alternative to endoscopic and surgical gastrostomy.