[Thumb troubles in rheumatoid arthritis]

Thumb involvement may play a relevant role in inducing a severe functional impairment in rheumatoid arthritis. The aim of this sonographic vignette is to show the value of sonography in detailing anatomic changes involving the thumb during a phase of active synovitis. The patient was a 50-year old man who presented with a 3-year history of rheumatoid arthritis. He complained of a 4-week history of a marked recrudescence inflammatory thumb involvement associated with clinical signs of carpal tunnel syndrome. Sonographic images were obtained with a real-time ultrasound system equipped with a 13 MHz linear transducer. Sonographic examination on longitudinal dorsal scan of the metacarpophalangeal joint of the thumb showed a moderate joint cavity widening with two evident bone erosions, one at the metacarpal head and the other one at the basis of the proximal phalanx. The longitudinal volar scan of the first metacarpophalangeal joint confirmed the presence of synovitis detecting a marked joint cavity widening, with aspect of synovial proliferation. The flexor pollicis longus tendon was severely involved (marked tendon sheath widening, synovial proliferation, loss of the normal homogeneous fibrillar echotexture, and a large intratendinous tear). Sonography allowed the depiction of a wide range of otherwise undetectable pathologic changes in the standard clinical setting.

Minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale

OBJECTIVES

To determine the minimal clinically important difference (MCID) of changes in chronic musculoskeletal pain intensity that is most closely associated with improvement on the commonly used and validated measure of the patient's global impression of change (PGIC), and to estimate the dependency of the MCID on the baseline pain scores.

METHODS

This was a prospective cohort study assessing patient's pain intensity by the numerical rating scale (NRS) at baseline and at the 3 month follow-up, and by a PGIC questionnaire. A one unit difference at the lowest end of the PGIC ("slightly better") was used to define MCID as it reflects the minimum and lowest degree of improvement that could be detected. In addition we also calculated the NRS changes best associated with "much better" (two units). In order to characterize the association between specific NRS change scores (raw or percent) and clinically important improvement, the sensitivity and specificity were calculated by the receiver operating characteristic (ROC) method. PGIC was used as an external criterion to distinguish between improved or non-improved patients.

RESULTS

825 patients with chronic musculoskeletal pain (233 with osteoarthritis of the knee, 86 with osteoarthritis of the hip, 133 with osteoarthritis of the hand, 290 with rheumatoid arthritis and 83 with ankylosing spondylitis) were followed up. A consistent relationship between the change in NRS and the PGIC was observed. On average, a reduction of one point or a reduction of 15.0% in the NRS represented a MCID for the patient. A NRS change score of -2.0 and a percent change score of -33.0% were best associated with the concept of "much better" improvement. For this reason these values can be considered as appropriate cut-off points for this measure. The clinically significant changes in pain are non-uniform along the entire NRS. Patients with a high baseline level of pain on the NRS (score of >7 cm), who experienced either a slight improvement or a higher level of response, had absolute raw and percent changes greater that did patients in the lower cohort (score of less than 4 cm).

CONCLUSIONS

These results are consistent with the recently published findings generated by different methods and support the use of a "much better" improvement on the pain relief as a clinically important outcome. A further confirmation in other patient populations and different chronic pain syndromes will be needed.

Health-related quality of life in patients with hip or knee osteoarthritis: comparison of generic and disease-specific instruments

Health-related quality of life (HRQL) assessment is receiving increased attention as an outcome measure in osteoarthritis (OA). The aims of the study were to assess the health status impact of hip and knee OA in the general older population and to compare the metric properties of the WOMAC disease-specific questionnaire (Western Ontario and McMaster Universities) with generic measures [i.e., the Short Form 36 (SF-36) in patients with OA of the lower extremities]. This cross-sectional survey included a total of 244 patients (99 male, 145 female), aged 50 years and over, with symptomatic OA of the hips (107 patients) and knees (137 patients). All patients completed the WOMAC and the SF-36 questionnaires and were assessed for radiographic damage and for the presence of specific comorbid conditions. The overall impact on health was substantial for both groups of patients with OA of the lower extremities. The most striking impact was seen in OA of the hip for SF-36 "physical function" (p=0.03) and "physical role" (p=0.04), as well as WOMAC "physical function" (p=0.001). Furthermore, impairment of HRQL was only weakly associated with increasing radiographic changes. The SF-36 overall scores showed a better gradient with comorbidities than the WOMAC. This investigation has confirmed that WOMAC is the instrument of choice for evaluating patients with lower limb OA. For a more general insight into patient's health and in particular cross-sectional studies of the elderly, where comorbidity is common, the SF-36 should also be used. This study also provides an estimate of the impact of OA of the hip and knee on HRQL.

Grey scale and power Doppler sonographic changes induced by intra-articular steroid injection treatment

OBJECTIVE

To investigate the ability of high resolution grey scale sonography (GSS) and power Doppler sonography (PDS) to assess short term soft tissue changes induced by intra-articular steroid injection in the small joints of patients with chronic synovitis.

METHODS

20 patients with clinically active synovitis of a small joint unresponsive to systemic drug treatment underwent a sonographic guided intralesional injection with triamcinolone acetonide. Clinical examinations were carried out by a trained rheumatologist. GSS and PDS examinations were performed independently by two examiners unaware of the results of the clinical examination. Joint cavity widening and power Doppler signal were evaluated and graded on a semiquantitative scale ranging from 1 to 4. Clinical and sonographic follow up examinations were carried out 2 weeks after the injection with triamcinolone acetonide.

RESULTS

All intra-articular injections were successfully carried out and documented under sonographic guidance. In 19/20 patients, baseline sonographic examinations clearly detected morphological and perfusional signs of synovitis. At follow up examinations, clinical and sonographic scores had improved significantly.

CONCLUSION

GSS and PDS appear to be a useful adjunctive tool for assessing short term soft tissue changes induced by intra-articular injection treatment with triamcinolone acetonide in small joints of patients with chronic arthritis.

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 2: Clinical indications for musculoskeletal ultrasound in rheumatology

Rheumatologists remain divided on whether they should introduce musculoskeletal ultrasound (MSUS) into their clinical practice. A central issue in the application of MSUS in clinical rheumatology is the need for proof of clinical relevance and improved patient care. There is now accumulating evidence that MSUS improves clinical diagnosis and intervention skills. High-resolution ultrasound is superior to clinical examination in the diagnosis and localization of joint and bursal effusion and synovitis. MSUS is the imaging modality of choice for the diagnosis of tendon pathology. MSUS is seven times more sensitive than plain radiography in the detection of rheumatoid erosions, allowing earlier diagnosis of progressive rheumatoid arthritis. Ligament, muscle, peripheral nerve and cartilage pathology can also be readily demonstrated by MSUS. There is exciting evidence that MSUS may potentially be used by rheumatologists to non-invasively diagnose and monitor not just joint and muscle disease but also nerve compression syndromes, scleroderma, vasculitis and Sjögren's syndrome. Joint aspiration and injection accuracy can be improved by MSUS, with initial evidence confirming improved efficacy. As the number of rheumatologists performing MSUS increases and the technical capabilities of MSUS improve, there is likely to be a growing number of proven clinical indications for the application of MSUS in rheumatology practice. This paper reviews the evidence for the application of MSUS in rheumatology.

Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response

The aim of this study was to evaluate the ability of power Doppler sonography (PDS) with ultrasound contrast agent to assess the synovial perfusion changes induced by intra-articular steroid injection therapy in the knee joints of patients with rheumatoid arthritis (RA). Eighteen RA patients (16 women, 2 men) with a history and signs of active knee synovitis were studied. Tenderness was evaluated using Thompson's modified index of synovitis activity. All patients underwent joint aspiration followed by intra-articular injection of 40 mg of triamcinolone hexacetonide. Gray-scale ultrasonography and PDS with an intravenous ultrasound contrast agent (Levovist) examinations were carried out before and 3 weeks after the intra-articular steroid injection. The calculation of the time--intensity curves provided a quantitative estimation of the synovial perfusion. The median values of the index of synovitis activity decreased significantly from 7.0 (95% confidence interval (CI) 6.0-8.0) to 3.0 (95% CI 2.0-4.0) ( p<0.01) 3 weeks after the intra-articular steroid injection. All patients showed a reduction of PDS signal after intra-articular steroid therapy and the baseline and follow up median values of the area underlying time-intensity curves were 7.48 (95% CI 5.79-8.73) and 2.45 (95% CI 1.92-3.61), respectively. The comparison between baseline and follow-up median values of the area under the curves showed a statistically significant reduction of PDS findings ( p<0.01). At follow-up examinations the changes in the index score of the synovitis activity were significantly correlated to the changes in the values of the area underlying time-intensity curves ( r=0.785; p<0.01). A significant correlation was also observed between baseline values of the area underlying time-intensity curves and C-reactive protein (CRP) ( r=0.548; p=0.023). In conclusion, PDS with an intravenous ultrasound contrast agent has been shown to be able to detect changes in synovial perfusion after intra-articular steroid injection and may be an additional useful method in the evaluation of synovial inflammation and in the assessment of the therapeutic response.

Musculoskeletal ultrasound--a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology

As we begin the 21st century, musculoskeletal ultrasound (MSUS) is routinely used by an increasing number of rheumatologists throughout Europe and there is a growing interest in the application of MSUS in rheumatological practice in the UK. MSUS allows high-resolution, real-time imaging of articular and periarticular structures and has the advantages of being non-radioactive, inexpensive, portable, highly acceptable to patients and repeatable. There are a number of critical issues that need to be addressed in order to develop the role of MSUS within rheumatology. These include issues of equipment costs, training and certification and the relationship of rheumatologists and radiologists in advancing the field of MSUS. Rheumatologists must demonstrate the relevance of MSUS in their clinical practice through high-quality research. Emerging technologies such as power Doppler and 3D imaging will further improve imaging capabilities and the range of clinical applications of MSUS systems. This paper reviews how MSUS in rheumatology has evolved and the controversies and issues that rheumatologists must now address in developing MSUS as an indispensable, everyday clinical tool.

[Levofloxacin-induced bilateral rupture of the Achilles tendon: clinical and sonographic findings]

The fluoroquinolones are antibiotics widely used in the clinical practice. The concomitant use of corticosteroids and fluoroquinolones in elderly patients is recognised as a risk factor for developing clinically relevant tendon lesions. Fluoroquinolone-induced tendinopathy is underreported in the literature. A 67-year-old man, came to our observation complaining of 5 days history of bilateral heel pain. The patient had a medical history of sarcoidosis and was treated with a daily dose of 5 mg of prednisone. He was initially given oral levofloxacin (500 mg/die) for 10 days, because of an acute respiratory infection. Two days before the end of the antibiotic therapy, he developed bilateral heel pain. He denied any history of trauma. Physical examination revealed swelling and marked tenderness with mild palpation of the Achilles tendons at the calcaneal insertion. The ultrasound evaluation of the Achilles tendons revealed the following main abnormalities: diffuse thickening, loss of the "fibrillar" echotexture, blurred margins, and bilateral partial tendon tears. Bilateral Achilles tendon pain and rupture has been described as a rare adverse effect of fluoroquinolone treatment. Most of the fluoroquinolone-induced tendinopathies of the Achilles tendon are due to ciprofloxacin. To the best of our knowledge, this is the first description of bilateral Achilles tendon rupture due to levofloxacin. The risk/benefit ratio of the fluoroquinolones should be carefully considered and these drugs should be prescribed cautiously in elderly patients treated with corticosteroids. This case can be regarded as a representative example of the potential clinical efficacy of sonography in daily rheumatological practise.

[Sonographic monitoring of gout]

OBJECTIVE

To assess the role of grayscale and power Doppler sonography in short-term monitoring of acute gouty synovitis.

METHODS

Clinical and sonographic assessments were performed in a patient with gout. Clinical and sonographic evaluations were performed within the first day of the acute onset of synovitis of the first metatarsophalangeal joint of the left foot and 7 and 14 days after the baseline assessments. The patient was treated only with colchicine.

RESULTS

At baseline, both grayscale and power Doppler sonography revealed clearly evident findings of acute synovitis (joint cavity widening, thickening of periarticular soft tissues and power Doppler signal). After seven days, a complete clinical remission occurred. Ultrasound examination revealed marked improvement with respect to the basic findings, even if all the sonographic features of joint inflammation were still detectable. Two weeks after the onset of the acute attack, clinical remission was maintained and all the sonographic features of synovitis disappeared.

CONCLUSION

Sonography is a sensitive and reliable tool for assessing and short-term monitoring of acute gouty attack.

Radiographic assessment of osteoarthritis: analysis of disease progression

Osteoarthritis (OA) is one of the most prevalent and disabling chronic conditions affecting older adults, and is a significant public health problem among adults of working age. The knee is the most frequently involved joint site associated with disability in OA. Diagnosis of OA is primarily based on history and physical examination, but radiographic findings, including asymmetric joint space narrowing (JSN), subchondral sclerosis, osteophyte formation, subluxation, and distribution patterns of osteoarthritic changes are all helpful when diagnosis is uncertain. Structural morphological changes on X-rays are also considered the primary outcome variables for assessing the progression of OA. The development of new methods for prevention and treatment of OA requires improved understanding of the factors that influence its progression. The ability to assess progression quantitatively is a necessary first step in understanding factors that influence the disease process. Depending on the joint studied, several indices are currently used for assessing radiological progression of OA, including individual radiographic features (e.g., marginal osteophytes), composite indices (e.g., Kellgren and Lawrence scoring systems), and quantitative measures (e.g., joint space width measurement). Unfortunately, the review of studies evaluating the longitudinal rate of JSN indicates that the yearly change may be very small and of doubtful clinical significance. This emphasizes the need for further refinement in the definition of radiographic outcomes in prospective clinical trials. This review focuses on the available scoring methods used for the sites most frequently involved in OA (hand, knee, hip) and their various advantages and disadvantages.

[Hidden bone erosions]

The aim of this pictorial essay was to demonstrate the diagnostic efficacy of high-resolution sonography in detecting bone erosions in a patient with rheumatoid arthritis. Standard X-Ray of the feet did not reveal clearly evident erosions. Ultrasonography was able to detect the presence of bone erosions of the metatarsal heads of both the first toes and of the V toe of the left foot. Because the appearance of bone erosions on radiographs of a patient with a recent onset arthritis indicates a poor prognosis, the possibility of demonstrating small hidden erosions at the level of the early targets of the disease is of relevant practical value.

Sonographic training in rheumatology: a self teaching approach

OBJECTIVE

To evaluate a self teaching approach to be followed by a novice without previous practical experience in musculoskeletal ultrasonography.

METHODS

The novice was given short general training (two hours) by an experienced sonographer focusing on the approach to the ultrasound equipment, and asked to obtain the best sonographic images of different anatomical areas as similar as possible to the "gold standard" pictures in the online version of the guidelines for musculoskeletal ultrasonography in rheumatology (free access at http://www.sameint.it/eular/ultrasound). At the end of each scanning session, both novice and tutor scored "blindly" all the images from 0 (the lowest quality) to 10 (the highest quality), with a minimum quality score of 6 considered acceptable for standard clinical use. The tutor then explained how to improve the quality of the pictures. Fourteen consecutive inpatients (seven with rheumatoid arthritis, three with psoriatic arthritis, two with reactive arthritis, and two with osteoarthritis) and five healthy subjects were examined. Ultrasound examinations were performed with a Diasus (Dynamic Imaging Ltd, Livingston, Scotland, UK) using two broadband linear probes of 5-10 and 8-16 MHz frequency.

RESULTS

Sonographic training lasted one month and included 30 scanning sessions (24 hours of active scanning). 243 images were taken of the selected anatomical areas. The mean time required to produce each image was 6 minutes (SD 4.2; range 1-30). At the end of the training, the novice scored >/=6 for each standard scan.

CONCLUSION

A novice can obtain acceptable sonographic images in 24 non-consecutive hours of active scanning after an intensive self teaching programme.

Imaging modalities for identifying the origin of regional musculoskeletal pain

Regional musculoskeletal pain is one of the most common complaints in daily rheumatological practice. Conventional radiology remains the cornerstone of diagnostic imaging in these patients despite the advent of new, fascinating imaging techniques. Ultrasonography may have a relevant impact on final diagnosis or therapeutic choices. It is highly sensitive to the identification of fine, soft-tissue changes and it should be considered as an integral part of the clinical examination in most patients. Scintigraphy is indicated when multifocal processes have to be excluded and when high sensitivity is required. Computed tomography is an excellent tool for the assessment of osseous based abnormalities. Magnetic resonance has several characteristics of the ideal diagnostic tool. However, its appropriateness in the evaluation of many regional musculoskeletal conditions is a matter for discussion. An appropriate diagnostic programme for patients with regional musculoskeletal pain has to be focused on the strengths and weaknesses of various imaging techniques.

[Juvenile chronic arthritis and imaging: comparison of different techniques]

OBJECTIVE: The aim of this study was to compare imaging findings obtained with different techniques in a patient with juvenile chronic arthritis. METHODS: The patient was a 12 years-old child with a 7-months history of arthritis of the first metatarsophalangeal joint of the right foot. The involved area was explored with the following imaging techniques: X-ray, technetium bone scintigraphy, magnetic resonance, gray-scale and power-Doppler ultrasonography. RESULTS: No abnormalities were detected with conventional X-ray. Scintigraphy showed an abnormal uptake of the radionuclide in the first metatarsophalangeal joint of the right foot. Magnetic resonance without contrast revealed clearly evident features of an active process of synovitis. Ultrasonography was able to detect the presence of joint effusion, synovial proliferation, bone erosion of the first metatarsal head. Power-Doppler examination revealed evident signs of soft tissue hyperaemia. CONCLUSIONS: Comparative assessment of different imaging techniques in this patient with recent-onset juvenile chronic arthritis indicates that high resolution ultrasonography provides the most detailed evaluation of the joint involvement with respect to the other imaging techniques.

Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience

OBJECTIVE

To investigate the intra-articular vascularisation of the synovial pannus in the knee of patients with rheumatoid arthritis (RA) with power Doppler ultrasonography (PDS) and an echo contrast agent and correlate the area under the time-intensity curves with the clinical findings and laboratory measures of disease activity.

METHOD

Forty two patients with RA (31 women, 11 men) with history and signs of knee arthritis, classified according to a modified index of synovitis activity (active, moderately active, and inactive), were studied. Clinical and functional assessment (number of swollen joints, intensity of pain, general health-visual analogue scale, disability index-Health Assessment Questionnaire, Ritchie articular index) and a laboratory evaluation were made on all patients. Disease activity was evaluated using the disease activity score (DAS) and the chronic arthritis systemic index (CASI) for each patient. All patients were examined with conventional ultrasonography and PDS before injection of intravenous ultrasound contrast agent (Levovist). The quantitative estimation of the vascularisation of the synovial membrane was performed with time-intensity curves and calculation of the area under the curves.

RESULTS

The mean (SD) value of the area underlying time-intensity curves was 216.2 (33.4) in patients with active synovitis, 186.8 (25.8) in patients with moderately active synovitis, and 169.6 (20.6) in those with inactive synovitis. The mean value of the areas differed significantly between the patients with active and those with inactive synovitis (p<0.01). The mean value of the area under the curve of the entire group was weakly correlated with the number of swollen joints (p=0.038), but a strong correlation was found with composite indexes of disease activity such as the DAS (p=0.006) and CASI (p=0.01). No correlation was found with age, disease duration, and other laboratory and clinical variables.

CONCLUSION

PDS may be a valuable tool to detect fractional vascular volume and to assist clinicians in distinguishing between inflammatory and non-inflammatory pannus. The transit of microbubbles of ultrasound contrast across a tissue can be used to estimate haemodynamic alterations and may have a role in assessing synovial activity and the therapeutic response to treatment of synovitis of the knee joint.

Pool film boiling experiments on a wire in low gravity: preliminary results

This paper reports preliminary results for pool film boiling on a wire immersed in almost saturated FC72 recently obtained during an experimental campaign performed in low gravity on the European Space Agency Zero-G airplane, (reduced gravity level 10(-2)). This is part of a long-term research program on the effect of gravitational and electric forces on boiling. The reported data set refers to experiments performed under the following conditions: (1) Earth gravity without electric field, (2) Earth gravity with electric field, (3) low gravity without electric field, and (4) low gravity with electric field. Although a decrease of gravity causes a heat transfer degradation, the electric field markedly improves heat exchange. This improvement is so effective that, beyond a certain field value, the heat flux is no longer sensitive to gravity. Two main film boiling regimes have been identified, both in normal and in low gravity: one is affected by the electric field and the other is practically insensitive to the field influence.

[Sonographic findings for synovial fluid]

OBJECTIVE

The aim of this pictorial essay was to evaluate the sonographic features of synovial fluid in patients with arthritis.

METHODS

Sixty-nine patients with active synovitis (rheumatoid arthritis, psoriatic arthritis, osteoarthritis, septic arthritis, crystal arthropathies, post-traumatic arthritis) were studied. Sonographic evaluation was performed with a AU-5 Harmonic, Esaote Biomedica (Genoa, Italy) equipped with a 10-14 MHz broadband linear transducer and a Diasus Dynamic Imaging Ltd.(Livingston, Scotland UK) equipped with a 8-16 MHz broadband linear transducer.

RESULTS

Six main different sonographic patterns were detected: 1) Anechoic: increased amount of homogeneous anechoic synovial fluid (exudative synovitis). 2) Cloudy: echogenic structures (proteinaceous material). 3) Mixed: anechoic synovial fluid and proteinaceous material. 4) "Snow-storm" aspect: multiple mildly and heterogeneous echoic spots (9 out of 10 patients with acute gouty synovitis). 5) Dotted: multiple sparkling hyperechoic dots without posterior acoustic shadow (10 out of 12 patient with chondrocalcinosis). 6) Granular: irregular turbid aspect of the synovial fluid. It was present in 3 patient with septic arthritis.

CONCLUSIONS

The results of this study indicate that high resolution ultrasonography is able to detect different features of synovial fluid. Further studies are needed to assess both sensitivity and specificity of ultrasonography in "in vivo" synovial fluid examination.

Intralesional therapy in carpal tunnel syndrome: a sonographic-guided approach

OBJECTIVE

The aim of this pictorial essay is to show a representative example of sonographic-guided injection in carpal tunnel syndrome associated with tenosynovitis of the finger flexor tendons.

METHODS

Images were obtained using a real-time ultrasound system (AU4-idea; Esaote Biomedica, Genoa, Italy) equipped with a 13-MHz linear transducer. The best injection site was detected using a fine metal clip placed between the skin and the transducer. The images here were obtained in a patient with rheumatoid arthritis and carpal tunnel syndrome secondary to tenosynovitis of the finger flexor tendons.

RESULTS

Steroid injection within the carpal tunnel under sonographic control was easily performed. All steps of the needle placement within the widened tendon sheath were carefully evaluated on the monitor screen. Marked clinical improvement occurred shortly thereafter (3 days) and increased over the next 6 weeks.

CONCLUSION

A detailed assessment of the carpal tunnel and a correct, safe placement of the needle for steroid injection can be quickly performed under sonographic guidance.

Microvascular involvement in systemic sclerosis: capillaroscopic findings

OBJECTIVE

To show the most representative capillaroscopic findings in patients with systemic sclerosis (SSc).

METHOD

Capillaroscopic evaluation was performed with a videomicroscope at 100 times and 200 times magnification. Representative images of the nailbed microcirculation were obtained in 20 healthy subjects and in 75 patients with SSc.

RESULTS

Capillary abnormalities were seen at the nailfold in more than 90% of patients with SSc. Capillary involvement included several morphologic changes, which are easily distinguished from the pattern of healthy controls. Architectural disruption of the nailfold microvascular network, enlarged loops, neoformation of capillaries, loss of capillaries, and avascular areas are the main abnormalities detected in SSc patients.

CONCLUSIONS

Nailfold capillary microscopy is one of the most valuable tools for the early diagnosis of SSc and related disorders. Rheumatologists and internists should be able to recognize these abnormalities because of their diagnostic relevance.

Sonographically guided procedures in rheumatology

OBJECTIVE

To provide some representative examples of sonographically guided arthrocentesis and intralesional injection therapy.

METHODS

Sonographic evaluation was performed with high-frequency linear (13 MHz) and mechanical sector (20 MHz) transducers. The images were obtained in representative patients with rheumatoid arthritis and posttraumatic subacromial bursitis.

RESULTS

Sonographically guided intralesional injection is a rapid and reliable procedure, especially in patients with arthritis, tenosynovitis, and bursitis. After target localization, needle placement can be performed under continuous sonographic monitoring. Sonographic guidance is particularly useful when fluid collections are small (less than 5 mm) and deep or when the inflammatory process is adjacent to anatomic structures that could be seriously damaged by the injection.

CONCLUSIONS

Over the last few years, the rapid technologic advancements in ultrasonography have dramatically increased the potential applications of sonographically guided procedures. The simplicity and reliability of the technique might warrant rheumatologists to undergo sonographic training.

Ultrasonography in the evaluation of bone erosions

OBJECTIVE

To demonstrate the diagnostic efficacy of ultrasonography in depicting erosions in patients with rheumatoid arthritis and to compare sonographic and radiographic findings.

METHODS

Sonographic images were obtained with an AU-4 Idea Esaote Biomedica (Genoa, Italy) equipped with a 13 MHz linear transducer.

RESULTS

The images reported in this essay are representative examples of the ability of ultrasonography to detect and characterise even minimal bone margin changes in rheumatoid arthritis.

CONCLUSION

Ultrasonography with very high frequency transducers can depict bone erosions in early target areas of bone resorption. However, further studies are needed to validate this technique and to evaluate the relation between sonographic findings and those obtained with other imaging techniques (standard radiology, magnetic resonance).

Sonographic imaging of the distal phalanx

OBJECTIVE

To investigate the potential role of ultrasonography (US) with very high frequency transducers in assessing distal phalanx involvement in some rheumatic diseases.

METHODS

We performed sonographic evaluation with an Esaote AU-4 Idea (Esaote Biomedica, Genoa, Italy) equipped with a 13-MHz linear transducer. The images were obtained in asymptomatic healthy subjects and representative patients with psoriatic arthritis, osteoarthritis of the distal interphalangeal joint (Heberden's nodes), erosive osteoarthritis, gout, rheumatoid arthritis, systemic sclerosis, and posttraumatic synovial cyst.

RESULTS

US with very high frequency transducers allowed a careful identification of the following anatomic details: joint space, extensor and flexor tendons, bone margin, periarticular and peritendinous soft tissues, nail, and blood vessels. Several pathological changes were depicted in different rheumatic disorders. These included joint space widening, tendon sheath widening, dislocation of the joint surfaces, irregularity of the bone margin, and urate and calcium deposits within periarticular soft tissues.

CONCLUSIONS

Very high frequency US is able to depict the anatomic substrate of distal phalanx involvement in several rheumatic diseases, adding useful information to clinical examination of the hand.

Synovitis of small joints: sonographic guided diagnostic and therapeutic approach

OBJECTIVE

The aim of this pictorial essay is to describe the sonographic guided approach to investigation and local injection therapy of a small joint in a patient with psoriatic arthritis (PA).

METHODS

Sonographic pictures are obtained using a high frequency ultrasonography apparatus equipped with a 13-MHz transducer.

RESULTS

Ultrasonography allows a careful morphostructural assessment of soft tissue involvement in PA patients. Sonographic findings include joint cavity widening, capsular thickening, synovial proliferation, synovial fluid changes, tendon sheath widening. Ultrasound guided placement of the needle within the joint and injection of corticosteroid under sonographic control can be easily performed.

CONCLUSIONS

High frequency ultrasonography is a quick and safe procedure that allows a useful diagnostic and therapeutic approach in patients with arthritis of small joints.

Sonographic imaging of normal and osteoarthritic cartilage

OBJECTIVES

This study was undertaken to describe representative sonographic features of normal and osteoarthritic cartilage.

METHODS

Sonographic evaluation was performed with real-time ultrasound equipment, using 7.5-, 10-, 13-, 15-, and 20-MHz transducers. Normal and osteoarthritic cartilage has been studied in healthy subjects and in patients with osteoarthritis.

RESULTS

Ultrasonography allows a safe, quick, and careful evaluation of both normal and osteoarthritic cartilage. A spectrum of images ranging from loss of cartilage transparency to marked narrowing of the cartilage layer can be depicted clearly in patients with osteoarthritis. Loss of clarity of the cartilaginous band and loss of the normal sharpness of the synovial space-cartilage interface are the earlier features of cartilage damage.

CONCLUSIONS

Although the value of ultrasonography in the evaluation of articular cartilage remains to be determined, this imaging method can be regarded as a useful bedside procedure for initial diagnostic screening of osteoarthritic femoral condylar cartilage.

Corticosteroid prescribing in rheumatoid arthritis and psoriatic arthritis

Corticosteroid usage was assessed in rheumatoid arthritis (RA) and psoriatic arthritis (PA) patients in Italy. A multicentre, observational study was undertaken in 10 Italian rheumatological centres from 1990 to 1992 using a computerised clinical data bank. Nine hundred and seven RA patients and 180 PA patients were studied; 510 (56.2%) RA patients and 44 (24.4%) PA patients were using corticosteroids. The percentage of patients taking corticosteroids ranged from 20.5 to 85.4% for RA patients and from 0 to 55% for PA patients for the different centres. Methylprednisolone was the most prescribed corticosteroid, both in RA patients (63.2%) and in PA patients (65.9%). The average methylprednisolone daily dose was 5.7+/-3.6 mg in RA patients and 4.5+/-1.4 mg in PA patients. The data provide evidence that corticosteroids are taken in an unexpectedly high percentage of patients with RA and PA in Italy.

Clinical diagnosis found in patients with Raynaud's phenomenon: a multicentre study

A multicentre observational study was conducted in order to detect the major clinical diagnosis found in 761 patients with Raynaud's phenomenon (RP) attending 50 Italian centres for rheumatology and internal medicine. Systemic sclerosis was the most frequent condition associated with secondary RP, occurring in 216 (28.4%) patients. The other most frequent clinical diagnoses included systemic lupus erythematosus (52 cases: 6.8%) and rheumatoid arthritis (38 cases: 5%). Other RP-related diseases (hypertension, Sjögren's syndrome, mixed connective tissue disease, undifferentiated connective tissue disease, fibromyalgia, carpal tunnel syndrome, cryoglobulinemia, dermatopolymyositis, vasculitis, thoracic outlet syndrome, hypothyroidism, diabetes mellitus) occurred in less than 5% of cases. A total of 130 (48%) out of 268 patients with primary RP showed one or more clinical features indicating a fairly high risk of evolving into fully established systemic sclerosis. None of these patients fulfilled the ACR criteria for systemic sclerosis. This study shows that over 50% of patients with RP attending 50 Italian centres for rheumatology and internal medicine had a connective tissue disease. The large number of patients with primary RP and isolated clinical features of connective tissue disease indicates that more efforts should be focused on developing new criteria for the classification of RP.

The clinical features of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by progressive damage of synovial-lined joints and variable extra-articular manifestations. Tendon and bursal involvement are frequent and often clinically dominant in early disease. RA can affect any joint, but it is usually found in metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints, as well as in the wrists and knee. Articular and periarticular manifestations include joint swelling and tenderness to palpation, with morning stiffness and severe motion impairment in the involved joints. The clinical presentation of RA varies, but an insidious onset of pain with symmetric swelling of small joints is the most frequent finding. RA onset is acute or subacute in about 25% of patients, but its patterns of presentation also include palindromic onset, monoarticular presentation (both slow and acute forms), extra-articular synovitis (tenosynovitis, bursitis), polymyalgic-like onset, and general symptoms (malaise, fatigue, weight loss, fever). The palindromic onset is characterized by recurrent episodes of oligoarthritis with no residual radiologic damage, while the polymyalgic-like onset may be clinically indistinguishable from polymyalgia rheumatica in elderly subjects. RA is characteristically a symmetric erosive disease. Although any joint, including the cricoarytenoid joint, can be affected, the distal interphalangeal, the sacroiliac, and the lumbar spine joints are rarely involved. The clinical features of synovitis are particularly apparent in the morning. Morning stiffness in and around the joints, lasting at least 1 h before maximal improvement is a typical sign of RA. It is a subjective sign and the patient needs to be carefully informed as to the difference between pain and stiffness. Morning stiffness duration is related to disease activity. Hand involvement is the typical early manifestation of rheumatoid arthritis. Synovitis involving the metacarpophalangeal, proximal interphalangeal and wrist joints causes a characteristic tender swelling on palpation with early severe motion impairment and no radiologic evidence of bone damage. Fatigue, feveret, weight loss, and malaise are frequent clinical signs which can be associated with variable manifestations of extra-articular involvement such as rheumatoid nodules, vasculitis, hematologic abnormalities, Felty's syndrome, and visceral involvement. Although there is no laboratory test to exclude or prove the diagnosis of rheumatoid arthritis, several laboratory abnormalities can be detected. Abnormal values of the tests for evaluation of systemic inflammation are the most typical humoral features of RA. These include: erythrocyte sedimentation rate, acute phase proteins and plasma viscosity. Erythrocyte sedimentation rate and C-reactive protein provide the best information about the acute phase response. The C-reactive protein is strictly correlated with clinical assessment and radiographic changes. Plain film radiography is the standard investigation to assess the extent of anatomic changes in rheumatoid arthritis patients. The radiographic features of the hand joints in early disease are characterized by soft tissue swelling and mild juxtaarticular osteoporosis. In the the past 10 years, ultrasonography has gained acceptance for studying joint, tendon and bursal involvement in RA. It may improve the early clinical assessment and the follow-up of these patients, showing such details as synovial thickening even within finger joints. Other imaging techniques, such as magnetic resonance, computed tomography and scintigraphy may provide useful information about both the features and the extent for anatomic damage in selected rheumatoid arthritis patients. The natural history of the disease is poorly defined; its clinical course is fluctuating and the prognosis unpredictable. RA is an epidemiologically relevant cause of disability. An adequate early treatment of RA may alter the diseas

NSAID gastropathy: state of the art

Non-steroidal anti-inflammatory drugs (NSAIDs) give rise to a wide range of gastrointestinal side-effects. These are reviewed and it is stressed that some safety measures are possible only if the risk factors are considered. The relations between dyspeptic symptoms and gastrointestinal lesions are also debated. It is suggested that the ulcerogenic potential of various molecules must be carefully evaluated, especially in elderly patients.

Increased capillary permeability in systemic sclerosis: help or hindrance?

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Finger tendon involvement in rheumatoid arthritis. Evaluation with high-frequency sonography

OBJECTIVE

To characterize finger tendon involvement in patients with rheumatoid arthritis (RA).

METHODS

The finger tendons of 20 RA patients were studied by ultrasonography using a high-frequency (13-MHz) transducer.

RESULTS

Eighteen patients (90%) showed finger tendon abnormalities: widening of the flexor tendon sheath (80%), loss of the normal fibrillar echotexture (60%), irregularity of the extensor (30%) and flexor (50%) tendon margins, tendon tear (10%), synovial cyst (20%).

CONCLUSION

High-frequency sonography is helpful in assessing even minimal finger tendon lesions in RA patients.

Influence of nifedipine on plasma membrane fluidity and oxidative burst of polymorphonuclear leucocytes

It has been demonstrated that the calcium antagonist nifedipine inhibits the reactive oxygen species (ROS) production by polymorphonuclear leucocytes (PMNLs) activated with phorbol myristate acetate (PMA), but the mechanism underlying this effect is still unknown. In the present study we investigated the influence of nifedipine on the PMNL plasma membrane using 1-(4-trimethylaminophenyl)-6-phenyl-1,3,5,hexatriene (TMA-DPH) fluorescence polarization (P) and on PMA- and N-formyl-methionyl-leucyl-phenylalanine (FMLP)-induced ROS production, measured by luminol-dependent chemiluminescence (CL). The plasma membrane fluidity of untreated PMNLs, expressed as P, was 0.371 +/- 0.008. After preincubation of 15 min, nifedipine induced a significant change in P values only at a concentration of 10(-4) M (P = 0.00018). After preincubation of 60 min significant changes in P values were also observed at concentrations of 10(-6) M (P = 0.023) and 10(-7) M (P = 0.023). PMA-induced ROS production by PMNLs was markedly inhibited by nifedipine. Nifedipine also determined a striking change in the FMLP-induced CL response, characterized by both an overall inhibition of PMNL activity and a modification of the kinetics of the oxidative burst (rapid increase in ROS production followed by a pronounced drop in the PMNL response). Such a pattern was found at concentrations of 10(-4) M (preincubation time: 15 min), 10(-6) M and 10(-7) M (preincubation time: 60 min). These findings indicate that nifedipine directly interacts with the PMNLs by inducing a marked decrease in plasma membrane fluidity and an inhibition of the oxidative burst.

Acute effects of single dose nifedipine on cold-induced changes of microvascular dynamics in systemic sclerosis

Calcium-channel blockers are widely used in the treatment of systemic sclerosis (SSc), but their in vivo influence on microcirculation is not fully elucidated. We evaluated the acute effect of nifedipine on the cold-induced changes of microvascular dynamics in SSc. Eleven SSc patients and seven healthy volunteers were studied. Dynamic aspects of the nailfold microcirculation (appearance time at the nailfold, transcapillary diffusion, interstitial distribution and interstitial clearance of sodium fluorescein given i.v.) were quantitatively assessed by a computer-aided fluorescence videomicroscope. Fluorescent light intensities (FLIs) at predefinite pericapillary and interstitial sites were measured under three experimental conditions: (1) baseline; (2) after cold test; (3) after single oral administration of 10 mg of nifedipine 5 min before cold exposure. The interval between the intravenous injection of sodium fluorescein and the first appearance of the dye at the nailfold significantly increased after cold exposure in the SSc patients (224.1 +/- 182.3 s vs 27.5 +/- 25.1 s at baseline) (P = 0.0026), but not in the controls (28.0 +/- 13.3 s vs 29.6 +/- 12.4 s at baseline). The effect of cold exposure on the appearance of the dye was not significantly antagonized by nifedipine (112.7 +/- 91.8 s) in the SSc patients (P = 0.07). Cold exposure significantly decreased transcapillary diffusion and interstitial distribution of sodium fluorescein in the SSc patients (P < 0.016), but not in the controls. The cold-induced changes of FLI values were antagonized by nifedipine in the SSc patients (P < 0.016), but not in the controls.(ABSTRACT TRUNCATED AT 250 WORDS)