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Enrique CP, María SA, Gustavo RS, Igor R, Magali CM, Diana PO, Sofia AC, Juliana MM, Camilo SJ, Camilo RJ, Mesa C, Marlon P, Sebastián SCJ, Luis F GC, Cesar PT, Humberto CM, Pedro SM, John L. Assessment of enthesopathy in conventional pelvis radiography: Another tool for spondyloarthritis diagnosis beyond sacroiliitis. Semin Arthritis Rheum 2024; 67:152435. [PMID: 38642418 DOI: 10.1016/j.semarthrit.2024.152435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 04/22/2024]
Abstract
INTRODUCTION/OBJECTIVES Enthesitis is a cardinal feature of spondylarthritis (SpA), and the pelvis is a common site of enthesitis. This study aimed to establish the association between pelvic enthesis involvement on pelvic X-ray and SpA diagnosis through a radiographic enthesis index (REI) and to assess the reliability and accuracy of this REI. MATERIALS AND METHODS The participants were SpA patients and a control group composed of patients with chronic lumbar pain without SpA. Three blinded observers assessed each pelvic radiography three times. Three zones were used: Zone I (ZI), the iliopubic ramus; Zone II (ZII), the pubic symphysis, and Zone III (ZIII), the ischiopubic ramus. A grading system was created from 0 to 3 [Grade 0, normal; Grade 1, minimal changes (subcortical bone demineralization and/or periosteal wishkering, seen as radiolucency and trabeculation of the cortical bone upon tendon insertion); Grade 2, destructive changes (Grade 1 findings and erosions at the enthesis site); and Grade 3, findings of Grade 2 plus >2 mm whiskering out of the cortical bone) for the REI. The sum of the results of the three zones was called the total REI. For statistical analysis, we used the weighted kappa statistic adjusted for prevalence and bias using Gwet's agreement coefficient. RESULTS We enrolled 161 patients, 111 of them with SpA (39.6 % with axial SpA and 47.7 % with peripheral SpA) and 50 without SpA. In the SpA group, 36.7 % and 25.7 % had REI Grades 2 and 3 in ZIII, respectively, while only 6 % of the controls had these grades. For ZI, the frequency of Grades 1 to 3 was 42.3 % in the SpA group (8.1 %, 14.4 %, and 19.8 %, respectively), compared to only 2 % in the controls. ZII was unaffected in most of the patients with SpA (82.9 %) and in the controls (98 %). In the control group, Grade 0 was the most common REI grade in all three zones. The agreement was almost perfect for each zone and between the independent readers. The ROC-curve analysis showed that the highest performance areas were the total REI, ZIII, and ZI. Most (75 %) of the SpA patients without sacroiliitis on X-ray were REI-positive. The sensitivity of the REI for SpA diagnosis was 82 %, while the sensitivity of sacroiliitis on X-ray was 38.7 %. CONCLUSIONS The assessment of pelvic enthesis using the REI on pelvic radiography may be useful for SpA diagnosis. Total REI, ZIII, and ZI had the highest accuracy and almost perfect reliability. The REI is especially helpful in patients without sacroiliitis on imaging.
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Affiliation(s)
| | - Santos Ana María
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Rodríguez-Salas Gustavo
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Rueda Igor
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia; Bioscience programme, faculty of Medicine and Engineering, Universidad de La Sabana, Chía, Colombia
| | | | - Padilla-Ortiz Diana
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia
| | - Arias-Correal Sofia
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Mantilla Marta Juliana
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Santacruz Juan Camilo
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Rueda Juan Camilo
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia; Bioscience programme, faculty of Medicine and Engineering, Universidad de La Sabana, Chía, Colombia
| | - Cristian Mesa
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia
| | - Porras Marlon
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia
| | | | - Giraldo-Cadavid Luis F
- Universidad de La Sabana - Interventional Pulmonology, Fundación Neumológica Colombiana, Bogotá, Colombia
| | - Pacheco-Tena Cesar
- PABIOM Laboratory, Faculty of Medicine and Biomedical Sciences, Autonomous University of Chihuahua, 31125 Chihuahua, Mexico
| | - Cardiel Mario Humberto
- Hospital General "Dr. Miguel Silva", Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubiran, McMaster University, Universidad Michoacana de San Nicolas de Hidalgo Instituto de Física y Matemáticas
| | | | - Londono John
- Spondyloarthritis Study group (GESPA), Universidad de La Sabana, Chía, Colombia; Department of rheumatology, Hospital Militar Central, Bogotá D.C., Colombia.
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Er G, Palamar D, Akgün K, Asoğlu İ, Sarı H. The relationship between clinical parameters and ultrasonographic enthesitis assessment in patients with spondyloarthritis. Arch Rheumatol 2024; 39:242-254. [PMID: 38933722 PMCID: PMC11196222 DOI: 10.46497/archrheumatol.2024.10224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/10/2023] [Indexed: 06/28/2024] Open
Abstract
Objectives The study aimed to evaluate the role of ultrasonographic assessment of enthesitis in patients with spondyloarthritis (SpA) in terms of disease activity, functionality, and quality of life. Patients and methods Ninety SpA patients (57 males, 33 females; mean age: 37.5±9.7 years; range, 18 to 60 years) were included in cross-sectional study between November 2016 and January 2017. Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Ankylosing Spondylitis Disease Activity Score (ASDAS), Bath Ankylosing Spondylitis Functional Index (BASFI), Short Form-12 (SF-12), and Ankylosing Spondylitis Quality of Life (ASQoL) were utilized for clinical evaluation. The clinical evaluation of enthesitis was performed with the Spondyloarthritis Research Consortium of Canada (SPARCC) and Maastricht Ankylosing Spondylitis Enthesitis Score (MASES) via an algometer calibrated to 4 kg/cm2 of pressure. Ultrasound evaluation was performed according to Madrid Sonographic Enthesitis Index (MASEI). A total of 2,610 entheseal sites were examined clinically, and 1,080 were assessed ultrasonographically. Results A significant proportion of enthesitis (463/1,080) was detected on ultrasonographic evaluation but not with clinical enthesitis score (MASES and SPARCC). Although ultrasonographic entheseal evaluation detected enthesitis in at least one enthesis of all patients, 35 of the patients had no enthesitis with clinical examination. The sites most frequently involved in the entheses were the proximal patellar tendon and Achilles tendon. The MASEI score did not correlate with the MASES, SPARCC, BASDAI, SF-12, and ASQoL but moderately correlated with the C-reactive protein (CRP) level (r=0.348), ASDAS-CRP (r=0.294), and BASFI score (r=0.244). Conclusion The association of ultrasonography scores with CRP levels and ASDAS-CRP indicates that ultrasonography is effective in detecting inflammation. The MASEI score weakly correlates with functionality but not with quality of life. Ultrasonographic evaluation is invaluable and merits to be incorporated into SpA disease scoring system.
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Affiliation(s)
- Gunay Er
- Department of Physical Medicine and Rehabilitation, Prof. Dr. Cemil Taşçıoğlu Şehir Hastanesi, Istanbul, Türkiye
| | - Deniz Palamar
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa Medical Faculty, İstanbul University-Cerrahpaşa, Istanbul, Türkiye
| | - Kenan Akgün
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa Medical Faculty, İstanbul University-Cerrahpaşa, Istanbul, Türkiye
| | - İbrahim Asoğlu
- Department of Physical Medicine and Rehabilitation, Malatya Training and Research Hospital, Malatya, Türkiye
| | - Hidayet Sarı
- Department of Physical Medicine and Rehabilitation, Cerrahpaşa Medical Faculty, İstanbul University-Cerrahpaşa, Istanbul, Türkiye
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Fırat SN, Kuşkonmaz ŞM, Önder ÇE, Omma T, Genç H, Çulha C. Sonographic evaluation of subclinical entheseal involvement in patients with hypoparathyroidism: a case control study. J Endocrinol Invest 2023; 46:133-139. [PMID: 35982371 DOI: 10.1007/s40618-022-01891-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/29/2022] [Indexed: 01/12/2023]
Abstract
PURPOSE Hypoparathyroidism is a disease characterized by low serum calcium, increased serum phosphorus and low PTH levels. Although patients are treated with active vitamin D and calcium, a proper serum calcium phosphorus balance cannot always be achieved. Ectopic calcifications that develop in organs during treatment are the most common complications. To date, there is not any published study on enthesopathy in patients with hypoparathyroidism. The aim of this study was to evaluate subclinical enthesopathy in patients with hypoparathyroidism with ultrasound and to compare the results with those of the control group. METHODS The study included patients aged 18-65 years with postoperative hypoparathyroidism and hypothyroidism (group hypoP + hypoT), patients with postoperative hypothyroidism (group hypoT), and healthy age and sex-matched volunteers (group C). Ultrasonographic findings of enthesopathy in both extremities were documented according to the Glasgow Ultrasound Enthesitis Scoring System (GUESS). RESULTS GUESS scores in group hypoP + hypoT, were significantly higher when compared to the other groups. There was a statistically significant correlation between the total GUESS scores and total enthesophyte scores and the duration of hypoparathyroidism (p < 0.05, r = 0.43) (p < 0.05, r = 0.39) respectively. In the correlation analysis of all groups, a significant negative correlation was found between serum Ca and PTH levels and the total GUESS scores (p < 0.01, r = - 0.37; p < 0.01, r = - 0.54, respectively). CONCLUSION This study showed that GUESS scores were significantly higher in patients with hypoparathyroidism compared to those with hypothyroidism and control subjects. GUESS scores were positively correlated with disease duration. Patients with hypoparathyroidism need to be evaluated for subclinical enthesopathy during follow-up.
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Affiliation(s)
- S N Fırat
- Department of Endocrinology and Metabolism, University of Health Sciences Ankara Training and Research Hospital, HacettepeMah., Ulucanlar Cad., Altindag, 06230, Ankara, Turkey.
| | - Ş M Kuşkonmaz
- Department of Endocrinology and Metabolism, University of Health Sciences Ankara Training and Research Hospital, HacettepeMah., Ulucanlar Cad., Altindag, 06230, Ankara, Turkey
| | - Ç E Önder
- Department of Endocrinology and Metabolism, Niğde Ömer Halisdemir University Training and Research Hospital, Niğde, Turkey
| | - T Omma
- Department of Endocrinology and Metabolism, University of Health Sciences Ankara Training and Research Hospital, HacettepeMah., Ulucanlar Cad., Altindag, 06230, Ankara, Turkey
| | - H Genç
- Department of Physical Medicine and Rehabilitation, University of Health Sciences Ankara Training and Research Hospital, Ankara, Turkey
| | - C Çulha
- Department of Endocrinology and Metabolism, University of Health Sciences Ankara Training and Research Hospital, HacettepeMah., Ulucanlar Cad., Altindag, 06230, Ankara, Turkey
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Beyazal M, Beyazal MS, Çeliker FB, Devrimsel G, Yıldırım M. The Association of Achilles Sonoelastography Findings with Disease
Activity, Functional Status and Enthesitis Index in Patients with Axial
Spondyloarthritis. AKTUEL RHEUMATOL 2022. [DOI: 10.1055/a-1749-4695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Abstract
Background Sonoelastography (SE) is a new ultrasound (US)-based technique
able to assess tissue elasticity. Using conventional US, it is sometimes
difficult or even impossible to distinguish pathologic tissue because it often
presents with the same echogenicity as the surrounding healthy tissue. This
study aimed to evaluate SE findings in Achilles tendons of patients with axial
spondyloarthritis (axSpA) and to assess how these findings are associated with
disease-related parameters.
Material and Methods Sixty-four consecutive patients (37 men, 27 women;
mean age 39.7 years; range 20–65 years) with axSpA and 30 sex and
age-matched healthy controls were enrolled in the study. Disease activity was
evaluated using the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI),
whereas functional capacity was evaluated using the Bath Ankylosing Spondylitis
Functional Index (BASFI). Erythrocyte sedimentation rate (ESR), C-reactive
protein (CRP) and the Spondyloarthritis Research Consortium of Canada (SPARCC)
enthesitis index were recorded. All participants underwent an SE examination of
the Achilles tendon and measurement of the strain index (SI).
Results The mean right and left SI were significantly higher in axSpA
patients than in controls (2.96±0.94 vs. 1.90±0.45;
p<0.001; 2.95±0.95 vs. 1.92±0.48, p<0.001,
respectively). In axSpA patients, both right and left SI were significantly
correlated with the BASDAI, BASFI and SPARCC enthesitis indices, but not with
ESR or CRP.
Conclusion AxSpA patients had an increased SI compared with healthy
subjects and these values were associated with disease activity, functional
capacity and the enthesitis index. SE may be a useful tool for the evaluation of
Achilles tendons in patients with axSpA.
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Affiliation(s)
- Mehmet Beyazal
- Department of Radiology, Recep Tayyip Erdogan University Training and
Research Hospital, Rize, Turkey
| | - Münevver Serdaroğlu Beyazal
- Department of Physical Medicine and Rehabilitation, Recep Tayyip
Erdogan University Training and Research Hospital, Rize, Turkey
| | - Fatma Beyazal Çeliker
- Department of Radiology, Recep Tayyip Erdogan University Training and
Research Hospital, Rize, Turkey
| | - Gul Devrimsel
- Department of Physical Medicine and Rehabilitation, Recep Tayyip
Erdogan University Training and Research Hospital, Rize, Turkey
| | - Murat Yıldırım
- Department of Physical Medicine and Rehabilitation, Recep Tayyip
Erdogan University Training and Research Hospital, Rize, Turkey
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Renson T, Carron P, De Craemer AS, Deroo L, de Hooge M, Krabbe S, Jans L, Østergaard M, Elewaut D, Van den Bosch F. The value of magnetic resonance imaging for assessing disease extent and prediction of relapse in early peripheral spondyloarthritis. Arthritis Rheumatol 2021; 73:2044-2051. [PMID: 33982902 DOI: 10.1002/art.41783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 03/24/2021] [Accepted: 04/22/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE We aimed to assess the inflammatory burden in pSpA by lower-extremity MRI in an early remission-induction strategy study with TNF blockade. Furthermore, we sought to determine the value of MRI to predict disease relapse versus sustained remission after treatment discontinuation. METHODS Thirty-two early pSpA patients with lower limb involvement on clinical examination and confirmed by ultrasonography, participated in a remission-induction trial with a TNF-inhibitor (TNFi). Patients underwent MRI of joints and entheses of the lower extremities at baseline and at clinical remission, after which TNFi treatment was withdrawn. Images were evaluated for joint effusion, joint osteitis, entheseal soft tissue inflammation (STI), and entheseal osteitis. RESULTS Joint effusion and enthesitis on clinical examination and ultrasonography correlated well with MRI abnormalities. In addition, a substantial amount of subclinical involvement was seen on MRI, mainly in ankle joints and heel entheses. Inflammation scores were markedly lower in the subclinical joints and entheses versus those clinically involved. Inflammatory load on MRI decreased significantly upon TNFi treatment. Whereas 80% of the clinically involved joints at baseline showed no effusion on remission MRI, two out of three involved entheses at baseline showed residual inflammation. In addition, patients relapsing after treatment discontinuation displayed more entheseal STI on remission MRI compared to those maintaining drug-free remission. CONCLUSION Our findings delineate a differential response of synovitis and enthesitis, with enthesitis on MRI responding less upon TNFi treatment. Furthermore, residual entheseal inflammation might be indicative for the need for continuous therapy.
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Affiliation(s)
- Thomas Renson
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Philippe Carron
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Ann-Sophie De Craemer
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Liselotte Deroo
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Manouk de Hooge
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Simon Krabbe
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Valdemar Hansens Vej 1-23, 2600, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Nørregade 10, 1017, Copenhagen, Denmark
| | - Lennart Jans
- Department of Radiology, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Valdemar Hansens Vej 1-23, 2600, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Nørregade 10, 1017, Copenhagen, Denmark
| | - Dirk Elewaut
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
| | - Filip Van den Bosch
- Department of Internal Medicine and Pediatrics, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium.,VIB Center for Inflammation Research, Ghent University, Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium
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Sapundzhieva T, Karalilova R, Batalov A. Hand ultrasound patterns in rheumatoid and psoriatic arthritis: the role of ultrasound in the differential diagnosis. Rheumatol Int 2020; 40:837-848. [PMID: 32211929 DOI: 10.1007/s00296-020-04559-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 03/14/2020] [Indexed: 01/08/2023]
Abstract
Many rheumatic diseases may present with an inflammatory joint syndrome, affecting the small joints of the hands, of which rheumatoid (RA) and psoriatic arthritis (PsA) being one of the most common. The aim of this systematic review was to focus on the literature evidence regarding the added value of ultrasound (US) of the hand in the differential diagnosis between RA and PsA. Pubmed and Scopus were searched to identify original manuscripts, published in the last 20 years utilising ultrasonography to reveal specific hand US patterns. Studies were eligible if they: (1) included adults (over 18 years) with a diagnosis of RA/PsA; (2) were published in the English language; (3) were published in peer-reviewed journals; (4) included description of the US machine; (5) used US for assessment of hand joints, periarticular tissues and nails. The search yielded 322 published studies, of which 16 were deemed relevant and were included in the present study. Overall, there was heterogeneity with regard to the pathology examined. Based on the included studies analysis, hand US patterns have several basic features to be considered-location of gray scale (GS) inflammatory findings, involvement of periarticular soft tissue, distribution and extent of Doppler signal (intra- and peri-articular), bone reaction, shape and location of erosions, involvement of tendons without synovial sheath, involvement of enthesis and nail abnormalities. Future research could focus on determining the sensitivity and specificity of the different US detected hand patterns in patients with early arthritis.
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Affiliation(s)
- Tanya Sapundzhieva
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria. .,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria.
| | - Rositsa Karalilova
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria.,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria
| | - Anastas Batalov
- Department of Internal Diseases, Medical University of Plovdiv, Plovdiv, Bulgaria.,Rheumatology Clinic, University Hospital 'Kaspela', 64 Sofia Str, Block 2, Eight Floor, 4002, Plovdiv, Bulgaria
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Roth J, Stinson SE, Chan J, Barrowman N, Di Geso L. Differential pattern of Doppler signals at lower-extremity entheses of healthy children. Pediatr Radiol 2019; 49:1335-1343. [PMID: 31289909 DOI: 10.1007/s00247-019-04464-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/31/2019] [Accepted: 06/25/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography might be an important imaging method for assessing the pediatric enthesis. To diagnose pathology, knowledge of physiological findings is essential but limited. OBJECTIVE To provide a detailed ultrasonographic assessment of four lower-extremity entheses in healthy adolescents as a reference for the correct interpretation of findings in children with rheumatic diseases. MATERIALS AND METHODS The quadriceps tendon, proximal and distal patella tendon, and Achilles enthesis were examined in B-mode, Power and color Doppler in 41 boys and girls ages 11-14 years in neutral position and 30° flexion. We assessed Doppler signals at various distances from the enthesis and analyzed the data using a marginal logistic regression model with generalized estimating equation. We assessed agreement between observers using weighted kappa and we determined agreement on repeat scans using prevalence- and bias-adjusted kappa. RESULTS Doppler signals were predominantly in the quadriceps and distal patella tendon with odds ratios of 50.85 and 21.35 (P<0.001) compared to the Achilles tendon. They were within 2 mm or 5 mm of the enthesis (odds ratios [ORs] of 4.58 and 4.24, P<0.001), without significant difference between flexion and neutral position and between the right and the left legs. Agreement between first and second assessment was good, with aggregate kappas from 0.79 to 0.90. The inter-reader agreement was also good, with aggregate kappas ranging from 0.75 to 0.95. CONCLUSION We found a differential Doppler pattern in lower-extremity entheses, with signals present mostly in the quadriceps and distal patella entheses.
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Affiliation(s)
- Johannes Roth
- Division of Pediatric Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
| | - Sara E Stinson
- Division of Pediatric Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Jason Chan
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Luca Di Geso
- Department of Internal Medicine, Ospedale Provinciale Madonna del Soccorso, San Benedetto del Tronto, Marche, Italy
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8
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Ishida SN, Furtado RNV, Rosenfeld A, Proglhof JEP, Estrela GBQ, Natour J. Ultrasound of entheses in ankylosing spondylitis patients: The importance of the calcaneal and quadriceps entheses for differentiating patients from healthy individuals. Clinics (Sao Paulo) 2019; 74:e727. [PMID: 30970118 PMCID: PMC6448525 DOI: 10.6061/clinics/2019/e727] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/23/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To compare the ultrasonographic findings of entheses in ankylosing spondylitis (AS) patients with those of healthy control individuals and to assess the ability of ultrasound (US) to identify aspects related to the disease. METHODS A cross-sectional study involving 50 patients with AS and 30 healthy controls was performed. Clinical assessment included the use of a visual analog scale for pain, assessment of swelling of the enthesis, global assessments for patients and physician, use of a disease activity index, mobility and dysfunctional indices, erythrocyte sedimentation rate and clinical enthesitis index. US was performed for the following entheses by two experienced musculoskeletal radiologists: brachial triceps, distal quadriceps, proximal and distal patellar tendons, calcaneal tendon, and plantar fascia; the total and subitems of the Madrid Sonographic Enthesitis Index were used for evaluations. RESULTS Comparison between groups showed a statistically significant difference with worse scores in AS patients, with bone erosion of the calcaneal enthesis and bone erosion and thickening of the plantar fascia. The odds ratio for thickening of the plantar fascia in the AS group was 3.47, according to logistic regression analysis. The AS group also had worse scores regarding the presence of calcification in the quadriceps enthesis, with a fivefold increased risk. CONCLUSION US analysis showed that only entheses of the foot and quadriceps were able to differentiate AS patients from healthy individuals.
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Affiliation(s)
- Suellen Narimatsu Ishida
- Disciplina de Reumatologia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Rita Nely Vilar Furtado
- Disciplina de Reumatologia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
- Corresponding author. E-mail:
| | - André Rosenfeld
- Departamento de Diagnostico por Imagem, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | - Jorge Ernesto Passos Proglhof
- Departamento de Diagnostico por Imagem, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
| | | | - Jamil Natour
- Disciplina de Reumatologia, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, SP, BR
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Sidorcika TG, Linovs VA, Radzina MA, Rubins AJ, Rubins SA. ENTHESITIS AND PSORIATIC ONYCHOPATHY AS A FACTOR FOR PREDICTION OF PSORIATIC ARTHRITIS IN PSORIASIS. VESTNIK DERMATOLOGII I VENEROLOGII 2018. [DOI: 10.25208/0042-4609-2018-94-1-38-50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Psoriatic arthritis is a psoriasis-related spondyloarthropathy that occurs in 20–30 % of patients with psoriasis. Psoriatic arthritis affects the patient’s quality of life indicators and are more often associated with disabilities of working age than psoriasis skin form. Nail psoriasis has been proposed as a predictor for the development of psoriatic arthritis. The inflammation involving the entheses, called enthesitis, is an early inflammatory change seen in psoriatic arthritis, and nail changes appear to result from the close relationship between the nail and the enthesis of the distal interphalangeal extensor tendon, one of the main entheseal compartments affected in psoriatic arthritis. Various imaging studies have demonstrated that there is a considerable proportion of undiagnosed psoriatic arthritis among patients with psoriasis. Since early detection and treatment of psoriatic arthritis could, ultimately, allow the prevention of clinical and radiologic progression of the disease, there is the need to establish clinical indicators to detect this risk.
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Baraliakos X, Kiltz U, Appel H, Dybowski F, Igelmann M, Kalthoff L, Klink C, Krause D, Saracbasi E, Schmitz-Bortz E, Rahmeh F, Braun J. Chronic but not inflammatory changes at the Achilles' tendon differentiate patients with peripheral spondyloarthritis from other diagnoses - Results from a prospective clinical trial. RMD Open 2017; 3:e000541. [PMID: 29435361 PMCID: PMC5761299 DOI: 10.1136/rmdopen-2017-000541] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 11/23/2017] [Accepted: 11/24/2017] [Indexed: 12/12/2022] Open
Abstract
Background Imaging has an essential role in the new spondyloarthritis (SpA) classification criteria for axial but not for peripheral manifestations. We evaluated the impact of imaging findings for identification and treatment decisions in patients with peripheral spondyloarthritis (pSpA) and controls (non-SpA). Methods Patients with pSpA (Assessment of SpA international Society criteria, n=30) and non-SpA (n=30), aged <45 years, with painful heels or knees, were recruited. Conventional radiography, grey-scale ultrasound including power Doppler (US/PDUS) and MRI of symptomatic areas were performed to assess inflammatory and structural changes. Mann-Whitney U test was used for group comparisons. Results In total, 105 painful entheses (71 heels, 34 knees) in 60 patients were examined. Differences between diagnoses were found for symptom duration (pSpA: 17.2±27.5 vs non-SpA: 4.4±4.3 months), human leucocyte antigen B27 prevalence (67% vs 13%) and gender distribution (53.3% vs 20% male, respectively), all P<0.05. Logistic regression analysis for baseline differences showed that chronic changes (erosions and calcification) in the heel were more frequent in pSpA versus non-SpA by US/PDUS (62.5% vs 28.6% patients and 59.5% vs 26.5% entheses, P<0.05). Inflammatory changes in heel or knee by US/PDUS and MRI could not differentiate between non-SpA and pSpA. Conclusions Differentiation between pSpA and non-SpA was only possible based on structural but not inflammatory changes in the heels and knees of symptomatic patients. US/PDUS was superior to MRI for this purpose. These findings imply that pSpA is associated with erosive changes at enthesitic sites, while inflammation and susceptibility are of minor influence for the development of erosions and calcification to pSpA.
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Affiliation(s)
| | - Uta Kiltz
- Rheumazentrum Ruhrgebiet, Herne, Germany
| | - Heiner Appel
- Practice for Internal Medicine and Nephrology, Herne, Germany
| | | | | | - Ludwig Kalthoff
- Rheumatology Practice Ruhr, Herne, Germany.,Rheumatology Practice Bochum, Bochum, Germany
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Ruyssen-Witrand A, Jamard B, Cantagrel A, Nigon D, Loeuille D, Degboe Y, Constantin A. Relationships between ultrasound enthesitis, disease activity and axial radiographic structural changes in patients with early spondyloarthritis: data from DESIR cohort. RMD Open 2017; 3:e000482. [PMID: 28955496 PMCID: PMC5604709 DOI: 10.1136/rmdopen-2017-000482] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/13/2017] [Accepted: 08/14/2017] [Indexed: 11/06/2022] Open
Abstract
Background To search for association between ultrasound (US) enthesis abnormalities and disease activity, spine and sacro-iliac joints (SIJ) MRI inflammatory lesions and spine structural changes in a cohort of patients suspected for axial spondyloarthritis (SpA). Methods Patients: Of 708 patients included in the DESIR(Devenir des Spondyloarthrites Indifférenciées Récentes) cohort, 402 had an US enthesis assessment and were selected for this study. Imaging: Achilles, lateral epicondyles, superior patellar ligament, inferior patellar ligament entheses were systematically US scanned and abnormalities were summed in US structural and power Doppler (PDUS) scores. Spine radiographs, SIJ and spine MRI scans were centrally scored modified Stoke Ankylosing Spondylitis Spine Score (mSASSS), presence of MRI sacro-iliitis, Spondyloarthritis Research Consortium of Canada and Berlin scores. Analysis: The associations between the US structural/PDUS scores and disease activity, C reactive protein (CRP), MRI SIJ and spine inflammatory lesions and mSASSS were tested by Spearman's correlation tests. Results Among the 402 patients included (median age: 33.5 years, males: 48.5%), 55% had US enthesis structural abnormalities while 14% had PDUS abnormalities. There was no association between US scores and Bath Ankylosing Spondylitis Disease Activity Index, CRP or inflammatory lesions on SIJ and spine MRI. There was a correlation between US structural and PDUS scores and the mSASSS (respectively, r=0.151, p=0.005; r=0.143, p=0.007). The proportion of patients with syndesmophytes was higher in the case of US enthesophytes (26% of syndesmophytes vs 6% in the absence of US enthesophytes, p<0.0001). Conclusion While the US abnormalities do not seem to be a helpful tool for monitoring disease activity in axial SpA, US enthesophytes, strongly associated with axial syndesmophytes, might be a marker of interest for disease severity. Trial registration number NCT01648907, date of registration : 20 July 2012.
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Affiliation(s)
- Adeline Ruyssen-Witrand
- Department of Rheumatology, Purpan Teaching Hospital, Toulouse, France.,Inserm UMR1027, Toulouse, France.,Department of Rheumatology, Université Paul Sabatier Toulouse III, Toulouse, France
| | - Bénédicte Jamard
- Department of Rheumatology, Purpan Teaching Hospital, Toulouse, France
| | - Alain Cantagrel
- Department of Rheumatology, Purpan Teaching Hospital, Toulouse, France.,Department of Rheumatology, Université Paul Sabatier Toulouse III, Toulouse, France.,Inserm UMR 1043, Toulouse, France
| | - Delphine Nigon
- Department of Rheumatology, Purpan Teaching Hospital, Toulouse, France
| | | | | | - Arnaud Constantin
- Department of Rheumatology, Purpan Teaching Hospital, Toulouse, France.,Department of Rheumatology, Université Paul Sabatier Toulouse III, Toulouse, France.,Inserm UMR 1043, Toulouse, France
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Baraliakos X, Maksymowych WP. Imaging in the diagnosis and management of axial spondyloarthritis. Best Pract Res Clin Rheumatol 2016; 30:608-623. [PMID: 27931957 DOI: 10.1016/j.berh.2016.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 09/23/2016] [Accepted: 09/24/2016] [Indexed: 12/25/2022]
Abstract
Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosing axial spondyloarthritis (SpA) when the pelvic radiograph is normal or equivocal. Subchodral bone marrow edema (BME) is the primary feature of early SpA, although structural changes, particularly erosions, may also be seen at an early stage. It is unclear whether incorporation of structural lesions enhances the classification performance of a positive MRI definition based on BME alone. Neither spinal imaging nor contrast-enhanced imaging are useful for routine diagnostic evaluation. Fat metaplasia is a key intermediary in the pathway from inflammation to ankylosis, although the histopathology remains to be determined. Both active and structural lesions can be reliably detected and quantified on MRI. Tumor necrosis factor inhibitor therapies ameliorate inflammation; however, it is unclear whether complete suppression of inflammation is necessary to prevent structural damage. Structural lesions on MRI require further validation using computed tomography and prospective follow-up to determine their prognostic significance.
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Affiliation(s)
- Xenophon Baraliakos
- Department of Rheumatology, Rheumazentrum Ruhrgebiet, Ruhr-University Bochum, Herne, Germany
| | - Walter P Maksymowych
- Department of Medicine, Spondyloarthritis Research Consortium of Canada Center, University of Alberta, 8-130K Clinical Sciences Building, 11350 83 Avenue, Edmonton AB T6G 2G3, Alberta, Canada.
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Slobodin G, Rimar D, Boulman N, Kaly L, Rozenbaum M, Rosner I, Odeh M. Entheseal involvement in systemic disorders. Clin Rheumatol 2015; 34:2001-10. [PMID: 26354427 DOI: 10.1007/s10067-015-3068-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 08/30/2015] [Indexed: 12/11/2022]
Abstract
The objective of this study is to review the data on entheseal involvement in systemic disorders. A Pubmed search utilizing the indexing terms "enthesis" and "enthesitis" was conducted and the data pertinent to the aim of the review was extracted and organized in accordance with the preplanned structure of the manuscript. A number of cadaver-based studies, as well as studies using ultrasonography and magnetic resonance imaging, have detailed new distinct aspects of enthesis physiology and pathology in a variety of rheumatic and non-rheumatic systemic disorders. Major progress has been done in characterization of separate components of the enthesis organ, imaging of entheses, elaboration of the role and features of entheseal disease in spondyloarthropathies, juvenile idiopathic arthritis, osteoarthritis, familial Mediterranean fever, hyperuricemia, and other systemic conditions. The knowledge acquired and summarized herein shows that entheses can be affected in various ways in variety of medical disorders with different pathogenesis. Better understanding of the risk factors, mechanisms and natural history of enthesopathies is warranted. The current progress in the understanding of entheseal involvement in systemic disorders represents just the first step in resolving the entheses-related enigmas.
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Affiliation(s)
- Gleb Slobodin
- Internal Medicine A, Bnai Zion Medical Center, 47 Golomb St, Haifa, Israel. .,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel.
| | - Doron Rimar
- Rheumatology, Bnai Zion Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Nina Boulman
- Rheumatology, Bnai Zion Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Lisa Kaly
- Rheumatology, Bnai Zion Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Michael Rozenbaum
- Rheumatology, Bnai Zion Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Itzhak Rosner
- Rheumatology, Bnai Zion Medical Center, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Majed Odeh
- Internal Medicine A, Bnai Zion Medical Center, 47 Golomb St, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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Sudoł-Szopińska I, Kwiatkowska B, Prochorec-Sobieszek M, Maśliński W. Enthesopathies and enthesitis. Part 1. Etiopathogenesis. J Ultrason 2015; 15:72-84. [PMID: 26674568 PMCID: PMC4579704 DOI: 10.15557/jou.2015.0006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 05/05/2014] [Accepted: 05/07/2014] [Indexed: 01/02/2023] Open
Abstract
The pathologies of tendon and ligament attachments are called enthesopathies. One of its types is enthesitis which is a characteristic sign of peripheral spondyloarthropathy. Clinical diagnosis of enthesitis is based on rather non-specific clinical signs and results of laboratory tests. Imaging examinations are highly promising. Numerous publications prove that enthesitis can be differentiated from other enthesopathic processes in an ultrasound examination or magnetic resonance imaging. However, some reports indicate the lack of histological criteria, specific immunological changes and features in imaging examinations that would allow the clinical diagnosis of enthesitis to be confirmed. The first part of the publication presents theories on the etiopathogenesis of enthesopathies: inflammatory, mechanical, autoimmune, genetic and associated with the synovio-entheseal complex, as well as theories on the formation of enthesophytes: inflammatory, molecular and mechanical. The second part of the paper is a review of the state-of-the-art on the ability of imaging examinations to diagnose enthesitis. It indicates that none of the criteria of inflammation used in imaging medicine is specific for this pathology. As enthesitis may be the only symptom of early spondyloarthropathy (particularly in patients with absent HLA-B27 receptor), the lack of its unambiguous picture in ultrasound and magnetic resonance scans prompts the search for other signs characteristic of this disease and more specific markers in imaging in order to establish diagnosis as early as possible.
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Affiliation(s)
- Iwona Sudoł-Szopińska
- Department of Radiology, Institute of Rheumatology, Warsaw, Poland ; Department of Diagnostic Imaging, Second Faculty, Warsaw Medical University, Poland
| | | | - Monika Prochorec-Sobieszek
- Department of Diagnostic Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland ; Department of Pathophysiology, Immunology, and Pathological Anatomy, Institute of Rheumatology, Warsaw, Poland
| | - Włodzimierz Maśliński
- Department of Pathophysiology, Immunology, and Pathological Anatomy, Institute of Rheumatology, Warsaw, Poland
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Dreyer L, Jacobsen S, Juul L, Terslev L. Ultrasonographic abnormalities and inter-reader reliability in Danish patients with systemic lupus erythematosus - a comparison with clinical examination of wrist and metacarpophalangeal joints. Lupus 2014; 24:712-9. [PMID: 25467390 DOI: 10.1177/0961203314561666] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 11/05/2014] [Indexed: 01/29/2023]
Abstract
OBJECTIVES We aimed to determine 1) ultrasound (US) abnormalities in patients with systemic lupus erythematosus (SLE) with and without hand arthralgia at the day of examination compared with clinical evaluation and healthy controls, and 2) inter-observer reliability of the US abnormalities. METHODS Thirty-three female SLE patients were twice examined with US by three trained examiners. Using B-mode and Doppler US, unilateral wrist and metacarpophalangeal (MCP) joints were examined for synovitis and erosions as well as signs of hand tenosynovitis using a GE Logiq 9 US machine with Doppler settings for slow flow. All patients also underwent clinical joint evaluation and were compared with 11 healthy controls (HC). RESULTS Among the patients with SLE 16 (48%) had signs of wrist synovitis, which was only observed in one HC (p = 0.03). Corresponding figures for any MCP joint were 12 (36%) and 0 (p = 0.06). In SLE patients, 18% had hand tenosynovitis and 6% bone erosions. Wrist synovitis was detected by US in 16 SLE patients (81%) with arthralgia compared with 17 patients without (18%) (p = 0.0005). Any US abnormalities were observed in 44% of 25 wrists without tenderness at clinical examination and in 46% of 26 wrists without swelling. Corresponding percentages for MCP2 joints were 27% and 21%. Inter-observer reliability of the US findings was good to excellent for examination of hand joints and tendons. CONCLUSIONS A majority of SLE patients with hand arthralgia showed US signs of synovitis, erosions and tenosynovitis indicating subclinical disease. Even SLE patients without clinical signs of joint inflammation demonstrated US abnormalities. Good to excellent inter-observer reliability was found in US evaluation of hands in patients with SLE.
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Affiliation(s)
- L Dreyer
- Department of Rheumatology, Copenhagen University Hospital, Gentofte, Denmark Department of Infectious Diseases and Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - S Jacobsen
- Department of Infectious Diseases and Rheumatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - L Juul
- Department of Rheumatology, Copenhagen University Hospital, Gentofte, Denmark
| | - L Terslev
- Center for Rheumatology and Spine Diseases, Copenhagen University Hospital, Glostrup, Denmark
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Enthesitis in psoriatic arthritis. Semin Arthritis Rheum 2013; 43:325-34. [DOI: 10.1016/j.semarthrit.2013.04.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 04/01/2013] [Accepted: 04/11/2013] [Indexed: 12/18/2022]
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Diagnostic value of pelvic enthesitis on MRI of the sacroiliac joints in spondyloarthritis. Eur Radiol 2013; 24:866-71. [DOI: 10.1007/s00330-013-3074-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 10/15/2013] [Accepted: 11/04/2013] [Indexed: 10/26/2022]
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