Painless and painful synovitis have similar ultrasound and clinical outcomes: one-year cohort study in longstanding rheumatoid arthritis women patients.

OBJECTIVES: We aimed to compare the painless synovitis evolution with painful synovitis, based on bone erosion by ultrasonography over a year in women with longstanding rheumatoid arthritis. Ultrasound inflammatory measurements and radiographic, functional and clinical findings were also compared between groups at the end of the same follow-up. METHODS: A prospective cohort study was rolled out, involving 60 women with RA, divided into two groups: painless and painful, with 30 patients in each group. The wrist and MCPs joints were assessed by ultrasound and plain x-ray, initially and after 12 months (T0 and T12). There was also a clinical assessment (activity scores, functional tests, disease and treatment progression variables) at 6 and 12 months. RESULTS: Patients' average age was 58.0±12.8 and average length of disease 16.4±9.8 years. Initially, the demographic characteristics were similar between groups, however, the painful group had worse clinical and functional scores. There were no statistically significant differences in the majority of US bone erosions and US inflammatory measurements, nor in radiographic progression variables between the groups. Over one year, pinch strength test and DAS 28 remained worse in the painful group (p<0.05). Clinical worsening variables and change of treatment evolved similarly between the groups, on T6 and T12. CONCLUSIONS: According to the study, the painless group progressed similarly to the painful one over a year, as regards bone erosion, ultrasound inflammatory measurements, radiographic findings, clinical worsening and change of treatment in female longstanding RA patients.

Articular Ultrasound in Asymptomatic Volunteers: Identification of the Worst Measures of Synovial Hypertrophy, Synovial Blood Flow and Joint Damage Among Small-, Medium- and Large-Sized Joints.

Articular ultrasound of 6500 joint recesses was performed for the purpose of identifying which joint had the highest measurements among small-sized (SSJ), medium-sized (MSJ) and large-sized (LSJ) joints. Quantitative measurements of synovial hypertrophy (QSR) and semiquantitative measurements of synovial hypertrophy (SSH), power Doppler (SPD) and bone erosion (SBE) (score: 0-3) were made. Higher measurements (p < 0.01) of QSR were obtained in the second metatarsophalangeal joint (MTP), talonavicular joint, and hip. The highest SSH scores (2/3) were obtained in the second MTP, talonavicular joint, hip and knee; the highest SPD scores (1/2/3) in the first MTP, second MTP, dorsal second metacarpophalangeal (MCP) and radiocarpal recesses; and the highest SBE scores (2/3) in the radiocarpal, ulnocarpal and posterior recesses of the glenohumeral joint. In conclusion, higher measurements of synovial hypertrophy were found in the first and second MTPs (SSJ), talonavicular recess (MSJ) and hip (LSJ). Synovial blood flow was frequent in the first MTP and radiocarpal recess. Bone erosion stood out only in the glenohumeral joint.

A new musculoskeletal ultrasound scoring system (US10) of the hands and wrist joints for evaluation of early rheumatoid arthritis patients.

OBJECTIVE: To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables. METHODS: Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0-1) and semi-quantitatively (grades 0-3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP). RESULTS: Mean duration of symptoms was 7.58±3.59 months. Significant correlations (p<0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p<0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up. CONCLUSION: The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

A new musculoskeletal ultrasound scoring system (US10) of the hands and wrist joints for evaluation of early rheumatoid arthritis patients / Novo sistema de escore ultrassonográfico (US10) musculoesquelético das articulações das mãos e punho para avaliação de pacientes com artrite reumatoide em fase inicial

ABSTRACT Objective: To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables. Methods: Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0–1) and semi-quantitatively (grades 0–3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP). Results: Mean duration of symptoms was 7.58 ± 3.59 months. Significant correlations (p < 0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p < 0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up. Conclusion: The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

RESUMO Objetivo: Propor um novo sistema de escore ultrassonográfico das articulações da mão e punho (US10) para a avaliação de pacientes com artrite reumatoide (AR) e correlacionar o US10 com variáveis clínicas, laboratoriais e funcionais. Métodos: Foram submetidos 48 pacientes com AR em fase inicial a avaliações clínicas e laboratoriais, bem como a exames cegos de ultrassom (US) no início do estudo e com 3, 6 e 12 meses. O sistema US10 proposto envolveu a avaliação do punho e das articulações metacarpofalângicas e interfalângicas proximais do segundo e terceiro dígitos. O escore consistiu em parâmetros inflamatórios (proliferação sinovial [PS], Power Doppler [PD] e tenossinovite [TN]) e parâmetros de danos articulares (erosão óssea [EO] e danos na cartilagem [DC]). PS, PD, EO e DC foram pontuados qualitativamente (0 a 1) e semiquantitativamente (graus 0 a 3). A tenossinovite foi pontuada como presença/ausência. A avaliação envolveu também o escore 28-Joint Disease Activity (DAS28), o Health Assessment Questionnaire (HAQ) e o nível de proteína C-reativa (PCR). Resultados: A duração média dos sintomas foi de 7,58 ± 3,59 meses. Foram encontradas correlações estatisticamente significativas (p < 0,05) entre os parâmetros de inflamação e a PCR no início do estudo e entre as mudanças nessas variáveis ao longo do estudo. Foram encontradas também correlações significativas (p < 0,05) entre o escore DAS28 e a PD e TN no início do estudo e entre as mudanças no escore DAS28 e PS e TN em todo o seguimento. Além disso, foram encontradas correlações significativas entre as mudanças no escore dos parâmetros de inflamação e no escore HAQ ao longo do seguimento. Conclusão: O sistema de escore US10 proposto provou ser uma ferramenta útil para monitorar a inflamação e o dano articular em pacientes com AR em fase inicial, demonstra correlações significativas com as alterações longitudinais na atividade da doença e no estado funcional.

Sonographic assessment of healthy peripheral joints: evaluation according to demographic parameters.

OBJECTIVES: To describe quantitative and semiquantitative sonographic joint measurements in healthy adults and compare them with demographic parameters. METHODS: A cross-sectional study was conducted. Bilateral sonographic measurements of small, medium, and large joints were performed in 130 healthy volunteers, stratified into 5 age groups (A, 18-29; B, 30-39; C, 40-49; D, 50-59; and E, 60-80 years). Quantitative synovial hypertrophy measurements and semiquantitative synovial hypertrophy, power Doppler, bone erosion (score 0-3), and articular cartilage (score 0-4) measurements were performed by a blinded radiologist using a 6-18-MHz linear array transducer. The sonographic measurements were correlated with demographic parameters. The significant P value was set at .05. RESULTS: A total of 6500 joint recesses were studied; the mean age ± SD of the participants was 44.8 ± 14.6 years, and 76.9% were women. The highest quantitative synovial hypertrophy values were found in the hip (6.4 mm) and talonavicular joint (2.6 mm). The joint recesses with a greater frequency of hypothetical pathologic semiquantitative scores were second metatarsophalangeal (78.8%) and first metatarsophalangeal (69.3%) for synovial hypertrophy, radiocarpal (17.7%) and first metatarsophalangeal (15.8%) for power Doppler, and posterior glenohumeral (23.1%) and ulnocarpal (4.2%) for bone erosion. The highest quantitative synovial hypertrophy values and the lowest semiquantitative synovial hypertrophy, power Doppler, bone erosion, and articular cartilage scores were observed in age group E (P < .046). There were positive correlations between the sonographic measurements and height, age, weight, and body mass index in 30.4%, 34.8%, 43.5%, and 47.8%, respectively, of all the joint recesses studied. CONCLUSIONS: Sonographic changes in healthy peripheral joints were observed predominantly in the oldest group.

Joint lavage associated with triamcinolone hexacetonide injection in knee osteoarthritis: a randomized double-blind controlled study.

Compare the medium-term effectiveness and tolerance between joint lavage (JL) in combination with triamcinolone hexacetonide (TH) intra-articular injection (IAI) and IAI with TH alone for treatment of primary osteoarthritis (OA) of the knee. A randomized, double-blind, controlled study was carried out on 60 patients with primary OA of the knee, randomized into two intervention groups: JL/TH group, joint lavage in combination with TH intra-articular injection and TH group, TH intra-articular injection. Patients were followed for 12 weeks by a blind observer using the following outcome measurements: visual analogue scale for pain at rest and in movement, goniometry, WOMAC, Lequesne's index, timed 50-ft walk, perception of improvement, Likert scale for improvement assessment, use of nonsteroidal anti-inflammatory drugs and analgesics, and local side effects. There were no statistical differences in the inter-group analysis for any of the variables studied over the 12-week period. Although both groups demonstrated statistical improvement in the intra-group evaluation (except for Likert scale according to patient and the use of anti-inflammatory drugs). In the Kellgren-Lawrence scale (KL) 2 and 3 sub-analysis, there was a statistical difference regarding joint flexion among patients classified as KL 2, favoring the TH group (p=0.03). For the KL 3 patients, there were statistical differences favoring the JL/TH group regarding Lequesne (p=0.021), WOMAC pain score (p=0.01), and Likert scale according to the patient (p=0.028) and the physician (p=0.034). The combination of joint lavage and IAI with TH was not more effective than IAI with TH alone in the treatment of primary OA of the knee. However, KL 3 patients may receive a major benefit from this combination.

Validation of the Brazilian-Portuguese version of the Gesture Behavior Test for patients with non-specific chronic low back pain.

OBJECTIVE: To develop a Brazilian version of the gesture behavior test (GBT) for patients with chronic low back pain. METHODS: Translation of GBT into Portuguese was performed by a rheumatologist fluent in the language of origin (French) and skilled in the validation of questionnaires. This translated version was back-translated into French by a native-speaking teacher of the language. The two translators then created a final consensual version in Portuguese. Cultural adaptation was carried out by two rheumatologists, one educated patient and the native-speaking French teacher. Thirty patients with chronic low back pain and fifteen healthcare professionals involved in the education of patients with low back pain through back schools (gold-standard) were evaluated. Reproducibility was initially tested by two observers (inter-observer); the procedures were also videotaped for later evaluation by one of the observers (intra-observer). For construct validation, we compared patients' scores against the scores of the healthcare professionals. RESULTS: Modifications were made to the GBT for cultural reasons. The Spearman's correlation coefficient and the intra-class coefficient, which was employed to measure reproducibility, ranged between 0.87 and 0.99 and 0.94 to 0.99, respectively (p < 0.01). With regard to validation, the Mann-Whitney test revealed a significant difference (p < 0.01) between the averages for healthcare professionals (26.60; SD 2.79) and patients (16.30; SD 6.39). There was a positive correlation between the GBT score and the score on the Roland Morris Disability Questionnaire (r= 0.47). CONCLUSIONS: The Brazilian version of the GBT proved to be a reproducible and valid instrument. In addition, according to the questionnaire results, more disabled patients exhibited more protective gesture behavior related to low-back.

Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study.

OBJECTIVE: To study the effectiveness and side effects of polyarticular corticosteroid injection compared to systemic administration in patients with rheumatoid arthritis (RA), and to examine the differential response to injection among joints. METHODS: Sixty-nine RA patients presenting with 6-12 swollen joints were enrolled to participate in a randomized trial consisting of polyarticular injection in 6-8 swollen joints of intraarticular (IA) triamcinolone hexacetonide (IA group) or intramuscular (IM) mini-pulse therapy with triamcinolone acetonide in equivalent doses (IM group). Blind examination at baseline (T0), Weeks 1 (T1), 4 (T4), 12 (T12), and 24 (T24) postintervention included American College of Rheumatology improvement criteria ACR20%, 50% and 70%, visual analog scale for articular pain, pain on movement, joint count, range of motion, morning stiffness, quality of life (Medical Outcome Study Short Form-36), use of nonsteroidal antiinflammatory drugs and oral corticosteroid, blood pressure, adverse effects, calls to the physician, and hospital visits. RESULTS: Significantly better results were observed for IA compared to IM patients as follows: ACR20% (61.7% vs 28.5% at T1; 73.5% vs 42.8% at T4), ACR50% (29.4% vs 5.7% at T1; 44.1% vs 20% at T4), ACR70% (11.7% vs 0% at T1), patient's evaluation of disease activity, lower tender joint count, lower blood pressure, lower number of adverse effects, calls to the physician, and hospital visits (p < 0.05). Less significant adrenocorticotropic hormone reduction was observed for IA group at T4 and T12 (p < 0.05). Elbows and metacarpophalangeal joints had the best response to corticosteroid injection. CONCLUSION: In the short term, polyarticular IA injection was better than IM corticosteroid, as shown by ACR improvement criteria and number of adverse effects.

Esclerodermia localizada familiar: relato de caso / Localized familial scleroderma: report of a case

A esclerodermia localizada (EL) é uma entidade caracterizada por infiltração e espessamento da pele, de distribuição assimétrica, sem envolvimento de órgãos internos, mas que pode levar, em alguns casos, a importante comprometimento estético do paciente. São reconhecidas cinco variantes morfológicas desta entidade: morféia em placa, morféia generalizada, morféia profunda, morféia em bollous e morféia linear. Casos familiares de EL são bastante raros, tendo sido documentados até hoje na literatura em apenas oito famílias. Neste trabalho os autores relatam mais uma família na qual dois irmãos apresentaram simultaneamente morféia generalizada. Caso 1 - J.P.S., 10 anos, masc., pardo, vinha havia um ano da primeira consulta apresentando manchas cutâneas "café com leite" de consistência endurecida e aspecto esclerótico, de tamanhos variados, em tronco e membros. O restante do exame físico era normal, assim como os exames laboratoriais, exceto por eosinofilia mantida (25 por cento) em leucograma. Biópsia de pele compatível com esclerodermia. Iniciada d-enicillamida (d-PA) 250 mg e, posteriormente, vit. E 800 mg por dia. Houve melhora progressiva das lesões cutâneas, permanecedo com hipercronia nas áreas afetadas. Caso 2 - D.S.S., 14 anos, fem., parda, irmã do paciente 1, havia 6 meses da primeira consulta referia manchas cutâneas hipercrômicas endurecidas e múltiplas em abdome e dorso. O exame físico, exceto o cutâneo, também era normal, assim como exames laboratoriais e toda a investigação reumatológica realizada. A biópsia de pele foi compatível com esclerodermia. A paciente foi tratada apenas com vit. E 800mg por dia, com regressão total do endurecimento das lesões após seis meses. Em ambos os casos permaneceu a hipercromia das áreas afetadas. Os autores, neste relato, acrescetam mais um caso familiar de EL e fazem uma revisão de literatura

Comprometimento da coluna cervical nas artropatias inflamatórias / Cervical spine involvement in inflammatory arthropathies

As artropatias inflamatórias, principalmente a artrite reumaóide (AR), podem acometer a coluna cervical em vários estágios da evolução dessas enfermidades. O acometimento da coluna cervical nesses casos pode dar-se na junção craniovertebral, nas articulações subaxiais e, como é mais conhecido, na articulaão atanto-axial. Neste último caso temos a subluxação atlanto-axial (SAA) como achado mais frequente e de maior risco, dada a possibilidade de compressão neurológica regional. Vários são os métodos de imagens que podem ser utilizados no estudo dessa região. A radiografia simples ajuda na detecção da SAA e na avaliação das articulações subaxiais; a tomografia computadorizada é um exame indicado no estudo de fraturas vertebrais, de erosões ósseas e na avaliação das articulações interapofisárias; e a ressonância magnética é atualmente exame obrigatório quando se deseja estudar a relação entre osso e partes moles quando nos referimos ao comprometimento inflamatório entre atlas, dente do áxis e tecido neurológico. Neste artigo, os autores fazem uma revisão do comprometimento da coluna cervical nas várias doenças inflamatórias e discorrem sobre as indicações e limitações dos métodos de diagnóstico por imagem