Bone status evaluation with calcaneal ultrasound in children with chronic rheumatic diseases. A one year followup study

OBJECTIVE

To evaluate at baseline and after one year the bone status in children with chronic rheumatic diseases (CRD) using quantitative ultrasound techniques.

METHODS

We evaluated bone status in 67 children, 52 female, 15 male, age range 2.80 to 18.10 years; 46 juvenile idiopathic arthritis, 11 juvenile dermatomyositis, and 10 systemic lupus erythematosus. Twenty-seven of 67 patients were taking only nonsteroidal antiinflammatory drugs (NSAID), 11 were given NSAID and methotrexate (MTX), 15 were also receiving steroids (prednisone), and 14 patients were given steroids and alendronate. Broadband ultrasound attenuation (BUA) by bone was determined at the left calcaneus using two 12.5 mm diameter, 1 MHz transducers mounted in hand-held calipers linked to a pediatric contact ultrasound bone analyzer.

RESULTS

At baseline in the whole patient group mean BUA values and Z scores were significantly lower than in controls: 41.84 +/- 21.64 vs 61.69 +/- 17.42 dB/MHz (p < 0.001); Z score -0.91 +/- 1.07 vs 0.09 +/- 0.62 in controls (p < 0.001). At one year followup in the patient group BUA values were significantly increased compared to baseline (BUA 46.43 +/- 21.51 dB/MHz; p = 0.002); no significant difference was found in Z score. The 15 children receiving steroids in addition to NSAID and MTX showed a decrease in BUA value at one year (NS), while Z scores were significantly reduced compared to baseline (-1.45 +/- 1.40 vs -1.08 +/- 1.11; p < 0.05). The 14 patients in the group receiving NSAID and MTX who also received alendronate showed significant increases in BUA (56.93 +/- 19.32 vs 44.21 +/- 15.67; p < 0.001) and Z score (-0.87 +/- 1.19 vs -1.56 +/- 0.82; p < 0.002).

CONCLUSION

Contact ultrasound bone analysis at the calcaneus is a useful tool in the assessment and monitoring of bone status in children with CRD.

Infliximab treatment for rheumatic disease: clinical and radiological efficacy

Infliximab is a chimeric anti-tumour necrosis factor alpha (TNFalpha) monoclonal antibody with high affinity and binding specificity for human TNFalpha. Results from several well designed, controlled clinical trials show repeated infusions of infliximab with concomitant methotrexate (MTX) treatment can reduce the signs and symptoms of rheumatoid arthritis (RA). This combination of infliximab and MTX also slows the radiological progression of joint damage, decreases functional disability, and improves qualify of life. These remarkably positive results have led to the investigation of infliximab treatment for other rheumatic diseases. Recently, controlled studies have shown treatment with infliximab can benefit patients with active spondyloarthropathy. TNFalpha has fast become an important therapeutic target in rheumatology.

[Imaging in rheumatology]

SUMMARY

Conventional radiography, ultrasonography, scintigraphy, computed tomography, and magnetic resonance imaging (MRI) are important diagnostic tools in rheumatology additional to clinical investigation. Radiography provides information both of the juxtaarticular and the abarticular bone. It is relevant in the diagnosis of rheumatoid arthritis, osteoarthritis, spondylarthropathies, and osteoporosis, and for the investigation of other regions like the thorax. Sonography is superior to radiography to delineate soft tissue structures such as effusions, tenosynovitis, tendinitis, paratendinitis, bursitis, and soft-tissue tumors, but also to evaluate bone surfaces. It helps to perform injections and punctures. Furthermore it is a new diagnostic tool for the diagnosis of temporal arteritis, Takayasu's arteritis, and Sjögren's syndrome. Echocardiography, abdominal and pleural sonography are also frequently used. MRI is useful to detect soft tissue lesions and bone lesions. It is helpful to depict synovial membrane, tendon, tendon sheaths, ligaments, cartilage, destructive joint processes, and rupture of synovial cysts. MRI is an established imaging technique in diagnosis of sacroiliitis and cervical arthritis as well as in diagnosis of osteonecrosis. It is an important diagnostic modality for demonstrating early arthritis. MRI is also of interest in diagnosis of neurological disorders of connective tissue diseases or vasculitis in rheumatology. Bone scintigraphy is an established imaging technique in diagnosis of skeletal diseases as well as in diagnosis of tumors. "Hot spots" are seen in locations of high bone turn over. Scintigraphy is also helpful to localize or exclude inflammation.

[Anterior chest wall examination reviewed]

Anterior chest wall involvement is not infrequently observed within inflammatory arthropaties, particularly if one considers seronegative spondyloarthritides and SAPHO syndrome. Physical examination is unreliable and conventional X-rays analysis is an unsatisfactory tool during diagnostic work-up of this region. Scintigraphic techniques yield informations both on the activity and on the anatomical extent of the disease while computerized tomography visualize the elementary lesions, such as erosions, which characterize the process. Moreover, when available, magnetic resonance imaging couple the ability to finely visualize such lesions with the possibility to show early alterations and to characterize the "activity" of the disease, presenting itself as a powerful tool both for diagnosis and follow-up. This review briefly shows the applications of imaging techniques for the evaluation of the anterior chest wall focusing on what has been done in the SAPHO syndrome which can be considered prototypical for this regional involvement since it is the osteo-articular target mainly affected by the disease.

Use of imaging in the differential diagnosis of rheumatic diseases in children

Imaging studies are important adjuncts in the evaluation of children with suspected rheumatic diseases. They are best used as follow-up investigations to exclude specific differential diagnoses, based upon a careful history and physical examination. Often, repeated examination over a period of time, sometimes months, is necessary before a diagnosis can be made. The addition of selected imaging studies can be important in the common circumstance where no diagnosis is made, but the physician must assure the child and family that all appropriate efforts have been made to exclude important illnesses.

Ultrasound and clinical evaluation of quadricipital tendon enthesitis in patients with psoriatic arthritis and rheumatoid arthritis

Enthesitis is an inflammatory lesion of the tendon, ligament and capsular insertions into the bone, and it is a fundamental element in the diagnosis of spondyloarthropathies. Sonography is the method of choice for studying periarticular soft tissues because it is capable of detecting both the early (oedema, thickening) and the late alterations (erosions and enthesophytes); it is also an inexpensive, biologically harmless and easily repeatable technique. The aim of this study was to compare the prevalence of quadricipital enthesitis in psoriatic arthritis (PsA) and rheumatoid arthritis (RA) patients, and to document any clinical and echostructural differences in this lesion between the two diseases. The results show that enthesitis is more frequent in PsA patients, more than half of whom are asymptomatic. Knee inflammation was found in the PsA patients with enthesitis regardless of the concomitant presence of joint effusion; none of the RA patients suffered from enthesitis alone. Quadricipital enthesitis is more frequent in male patients. There was no significant correlation between the presence of peripatellar psoriatic lesions and enthesitis. Sonographic examinations of patients with enthesitis revealed that those with RA had dominantly inflammatory lesions, whereas PsA patients also showed major new bone deposition.

Arthrodesis by percutaneous fixation: patellofemoral arthrodesis in rabbits without debridement of the joint

Arthrodesis is usually performed with joint resection or at least with removal of cartilage. Our recent experience with successful fusion in all 11 rheumatoid ankles treated only with percutaneous fixation questions the necessity of debridement of the joint before arthrodesis. In this rabbit study we tested the hypothesis that joints fuse because of rigid fixation. 9 skeletally mature loop-ear dwarf female rabbits were operated on. With the knee in about 45 degrees of flexion, two 1.5 mm cortical screws were inserted through the patellofemoral joint in an anterior-posterior direction with the lag screw technique. 3 rabbits were excluded due to technical problems. Of the remaining 6 rabbits, 5 underwent bony fusion and 1 fibrous healing. Fusion was confirmed with Micro-CT in 2 cases and by histological examination in all 5 cases. In those 5 cases, bony fusion was seen in almost all areas with close contact. Therefore, fusion occurred not only in relation to the screws, but also between the screws and in the periphery of the patella. Our findings show that bony fusion can occur in a healthy joint without joint resection or debridement.

[Three-dimensional techniques in orthopedic ultrasonography]

Three-dimensional ultrasonography is not yet an established method in soft tissue and joint diagnostics as it is in obstetrics. Although a spatial view on the object is fascinating, problems occur in handling. No standard is defined for acquisition or visualisation. For the acquisition of the volume mainly 3D-arrays and image correlation techniques are used. For visualisation planar views of sections out of the volume, but also spatial views in a transparency or surface mode are used. Investigations on feasibility for soft tissue or joints show a higher accuracy, validity and reproducibility for 3D-sonography. Due to the low differences of the acoustic impedance visualisation is confusing in a transparency mode and needs a time consuming postprocessing in a surface mode. Future developments address to the field of faster acquisition ("real time 3D"), higher geometric precision and easier visualisation by automated segmentation. By the three-dimensionality of the data set applications in telematics, navigation and simulation ("sonographic training") are expected.

Aseptic spondylodiskitis in rheumatic diseases

Aseptic diskitis is relatively common. Several rheumatic diseases involving the spine may have this complication. As this condition mimic infectious diskitis, it is important to recognize it. Clinically, it is characterised by vertebral pain of an inflammatory nature, occasionally accompanied by fever and an increase in the erythrocyte sedimentation rate. Radiologically, the decrease in the articular space and the irregularity of the vertebral plates are of particular importance. Although uncommon, it is necessary to bear in mind this possibility when the etiological search for a possible infectious diskitis proves fruitless. A MEDLINE (1986-2000) and PUBMED (1966-2000) search of relevant articles was performed. Descriptors used were aseptic diskitis, spondylodiskitis, pseudodiskitis and pseudoarthrosis.

Efficacy of extracorporeal shock wave treatment in calcaneal enthesophytosis

OBJECTIVE

To evaluate the efficacy of extracorporeal shock wave treatment (ESWT) in calcaneal enthesophytosis.

METHODS

60 patients (43 women, 17 men) were examined who had talalgia associated with heel spur. A single blind randomised study was performed in which 30 patients underwent a regular treatment (group 1) and 30 a simulated one (shocks of 0 mJ/mm(2) energy were applied) (group 2). Variations in symptoms were evaluated by visual analogue scale (VAS). Variations in the dimension of enthesophytosis were evaluated by x ray examination. Variations in the grade of enthesitis were evaluated by sonography.

RESULTS

A significant decrease of VAS was seen in group 1. Examination by x ray showed morphological modifications (reduction of the larger diameter >1 mm) of the enthesophytosis in nine (30%) patients. Sonography did not show significant changes in the grade of enthesitis just after the end of the treatment, but a significant reduction was seen after one month. In the control group no significant decrease of VAS was seen. No modification was observed by x ray examination or sonography.

CONCLUSION

ESWT is safe and improves the symptoms of most patients with a painful heel, it can also structurally modify enthesophytosis, and reduce inflammatory oedema.

Beneficial effects of nicorandil versus enalapril in chronic rheumatic severe mitral regurgitation: six months follow up echocardiographic study

BACKGROUND AND AIM OF THE STUDY

It is possible that vasodilator therapy may retard left ventricular (LV) dilatation and functional deterioration in chronic mitral regurgitation (MR). The study objectives were to evaluate comparatively the efficacy of nicorandil (a new, balanced vasodilator) and enalapril therapy on LV volume, mass and function in mildly symptomatic, chronic rheumatic severe MR.

METHODS

Eighty-seven mildly symptomatic rheumatic patients with severe MR were enrolled in this prospective, randomized study. All patients underwent serial echocardiography study at entry, and again at six months. Eighty patients completed the study.

RESULTS

At six months, the nicorandil and enalapril patient groups each had a significant reduction in LV end-systolic volume index (57.4 +/- 24.8 versus 43.2 +/- 20.7 ml/m2, p = 0.003; 50.0 +/- 19.0 versus 40.4 +/- 14.2 ml/m2, p = 0.006, respectively) and LV mass index (218.0 +/- 88.0 versus 188.0 +/- 76.0 g/m2, p = 0.05; 217.2 +/- 48.0 versus 186.2 +/- 45.0 g/m2, p = 0.002 respectively). Both nicorandil and enalapril caused significant improvement in ejection fraction (63.8 +/- 7.0 versus 71.0 +/- 6.7%, p <0.0001; 63.2 +/- 6.9 versus 67.5 +/- 6.4%, p = 0.002, respectively) and a reduction in LV end-systolic stress (152.9 +/- 29.0 versus 126.0 +/- 25.0 dyne/cm2, p = 0.001; 150.0 +/- 30.2 versus 138.0 +/- 29.0 dyne/cm2, p = 0.002, respectively). However, nicorandil caused a greater reduction in absolute LV end-systolic volume index (13.3 +/- 10.1 versus 9.6 +/- 5.9 ml/m2, p = 0.02), and a greater improvement in absolute ejection fraction (7.2 +/- 4.7 versus 4.2 +/- 2.6%, p = 0.0005) than enalapril.

CONCLUSION

It is concluded that nicorandil is equivalent to enalapril in improving LV volume, mass, end-systolic stress and ejection fraction in mildly symptomatic chronic rheumatic severe mitral regurgitation over a period of six months.

Enthesopathy: clinical recognition and significance

Enthesopathy is a common clinical finding denoting pathology at the 'entheses', i.e. attachment sites of muscles, tendons, joint capsules, ligaments and fascia to the bone. Inflammatory enthesopathy or enthesitis is a sine qua non of seronegative spondyloarthropathies (SSA). It can also be occupational, metabolic, drug induced, infective or degenerative. Bursitis closely mimics enthesitis. Ultrasound with high frequency transducers is a simple, cost-effective and feasible test to detect enthesopathy which is amenable to treatment with local steroid injections, physiotherapy and non-steroidal anti-inflammatory drugs, in addition to treatment of the primary disease. Unrecognized and untreated, it can lead to considerable morbidity.

Comparison of quantitative calcaneal ultrasound and dual energy X-ray absorptiometry in the evaluation of osteoporotic risk in children with chronic rheumatic diseases

Osteoporosis is a common complication in children with chronic rheumatic diseases (CRD). Although dual energy X-ray absorptiometry (DXA) is increasingly being used to determine bone mineral density (BMD) in children, it exposes the subject to ionizing radiation and does not provide a measure of true bone density; in fact, in growing bones the increase in BMD is mainly caused by the increase in bone size. In recent years, quantitative ultrasound techniques (QUS) have been used in radiation-free assessment of bone density and "bone quality" by measurement of the ultrasound waves attenuation by bone (BUA). In the present study we made a direct comparison of BUA in the calcaneum, determined by the pediatric contact ultrasound bone analyzer (CUBA) with lumbar BMD measured by DXA, in a group of 6-18-year-old patients with CRD. The study group consisted of 53 patients affected with juvenile rheumatoid arthritis (n = 29), systemic lupus erythematosus (n = 13), and juvenile dermatomyositis (n = 11). Mean age was 13.02 +/- 2.69 years. In 22 patients (19 girls, 3 boys) both DXA and CUBA were repeated after 1 year in order to assess the mean percentage rate of BMD and BUA change over this time. Both lumbar spine BMD and calcaneal BUA measurements were lower in the CRD patients compared with a control group (P < 0.001). Calcaneal BUA was significantly correlated (r = 0.83, P < 0.001) with lumbar spine BMD. Age and sex correction (Z-score) did not change the relationship between BUA and BMD (r = 0.80, P < 0.001). A significant correlation between the mean percentage of variation (delta%) of BMD and BUA (r = 0.76, P < 0.001) was also demonstrated in the 22 patients who were evaluated prospectively. Portability, ease of use, lower cost, and absence of radiation make CUBA a promising means of evaluating BMD in children.

Evidence of subclinical intestinal inflammation by 99m technetium leukocyte scintigraphy in patients with HLA-B27 positive juvenile onset active spondyloarthropathy

OBJECTIVE

The concept that gut inflammation is implicated in the pathogenesis of spondyloarthropathies (SpA) has long been considered. Subclinical intestinal inflammation has been reported in adult patients with SpA by histological examination of intestinal biopsies. We assessed the presence of gut inflammation by abdominal 99mTc-hexamethyl propylene amine oxime (99mTc-HMPAO) labeled leukocyte scintigraphy in a group of children and adolescents with HLA-B27 positive SpA without gastrointestinal (GI) symptoms, and correlated the scintigraphic results to disease activity.

METHODS

Abdominal scintigraphy with 99mTc-HMPAO labeled leukocytes was performed in 27 HLA-B27 positive children and adolescents with SpA without GI symptoms. Patients were divided into 2 groups according to the presence of active or inactive joint disease: Group A, 17 patients with active disease, and Group B, 10 patients with inactive disease. Patients with positive abdominal scintigraphy underwent complete bowel investigation by means of small bowel barium follow-through, abdominal ultrasound scan, and ileocolonoscopy with mucosal biopsies.

RESULTS

Thirteen of 27 patients (48%) had scintigraphy indicating the presence of bowel inflammation. All patients with abnormal scan had active joint disease, whereas no patient with inactive disease had a positive intestinal uptake of labeled leukocytes. Bowel investigation revealed the presence of aspecific mucosal inflammatory changes in the majority of patients with positive scintigraphy.

CONCLUSION

The presence of intestinal leukocyte uptake only in patients with active joint disease, even if intestinal inflammatory changes were minimal and clinical gut manifestations were absent, supports the role of gut inflammation in the pathogenesis of joint disease in HLA-B27 positive patients with SpA.

Arthrosonography in the evaluation of osteoarticular and soft-tissue structures in rheumatology

BACKGROUND

Real-time ultrasonography is a widely available, reliable, diagnostically sensitive and specific noninvasive modality which allows measuring of the thickness of different anatomical landmarks which form joints, of the periarticular soft tissue and connective tissue structures, of their echogenicity and the amount of joint effusion. The present study was designed to assess the clinical and diagnostic applicability of high-frequency ultrasonography in rheumatology.

METHODS

We used SONOACE 1500 (Medison Europe GmbH) with a 7.5 MHz transducer.

RESULTS

We demonstrate the most characteristic ultrasonographic patterns which have diagnostic significance in the seven most common rheumatologic disorders.

DISCUSSION

The pathological ultrasonographic patterns of the joints, periarticular and soft-tissue structures in rheumatologic disorders we present give an insight into the clinical applicability of arthrosonography and its inherent advantages over the conventional radiological examination--namely, ultrasonography is noninvasive, uses no radiation, which allows reproducibility and follow-up, widely available and relatively inexpensive and as such can be performed at bedside or on an outpatient basis.