Nerve sonography in the diagnostic evaluation of primary and secondary carpal tunnel syndrome in rheumatoid arthritis.

BACKGROUND AND PURPOSE: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and extra-articular manifestation of rheumatoid arthritis (RA). However, in patients with RA, it is not always possible to clinically distinguish an actual CTS from other RA-based complaints. METHODS: We evaluated the diagnostic role of nerve ultrasound (NUS) as supportive tool in the diagnostic process of CTS in patients with RA and tried to provide etiological clarification in cases of secondary CTS. Fifty-eight patients with RA and clinical suspicion of CTS were enrolled. All patients underwent a standardized clinical-neurological, electrophysiological (nerve conduction studies [NCS]), and NUS examination and completed the Boston CTS Questionnaire (BCTQ). RESULTS: In 96 of 116 hands examined, a clinical suspicion of CTS was documented. In 43 of 96 (44.8%) CTS-positive hands, the diagnosis was primarily confirmed by NCS, whereas in another 16 of 96 (30.2%) hands, the diagnosis could only be verified by NUS, leading to a diagnosis of CTS in 59 of 116 (50.8%) hands. In 19 of 59 (32.3%) CTS-positive hands, tenosynovial hypertrophy was observed, and in 7 of 59 (11.8%), a cystic mass was identified as the underlying cause of secondary CTS. A good correlation between NCS and NUS findings was documented, but no significant correlation was found between NCS, NUS, and clinical findings/BCTQ. CONCLUSIONS: In people with RA, a diagnosis of CTS purely on a clinical basis is nonspecific and should be supported by NCS and/or NUS. NUS markedly facilitates the diagnosis of CTS in these patients and enables differentiation between primary and secondary causes.

The Structured Delegation of Medical Care Services for Patients With Inflammatory Rheumatic Diseases.

BACKGROUND: In some areas of Germany, there is a shortage of specialist physicians for patients with inflammatory rheumatic diseases. Delegating certain medical care services to qualified, specialized rheumatological assistants (SRAs) might be an effective way to supplement the available capacity for specialized medical care. METHODS: Patients under stable treatment for rheumatoid arthritis (RA) or psoriatic arthritis (PsA) were included in this trial, which was designed to demonstrate, in a first step, the non-inferiority of a form of care involving delegation of physicians' tasks to SRAs (team-based care), in comparison to standard care, with respect to changes in disease activity at one year. "Non-inferiority," in this context, means either superiority or else an irrelevant extent of inferiority. In a second step, in case non-inferiority could be shown, the superiority of team-based care with respect to changes in patients' health-related quality of life would be tested as well. Disease activity was measured with the Disease Activity Score 28, and health-related quality of life with the EQ-5D-5L. This was a randomized, multicenter, rater-blinded trial with two treatment arms (team-based care and standard care). The statistical analysis was performed with mixed linear models (DRKS00015526). RESULTS: From September 2018 to June 2019, 601 patients from 14 rheumatological practices and 3 outpatient rheumatological clinics in the German states of North Rhine-Westphalia and Lower Saxony were randomized to either team-based or standard care. Team-based care was found to be non-inferior to standard care with respect to changes in disease activity (adjusted difference = -0.19; 95% confidence interval [-0.36; -0.02]; p <0.001 for non-inferiority). Superiority with respect to health-related quality of life was not demonstrated (adjusted difference = 0.02 [-0.02; 0.05], p = 0.285). CONCLUSION: Team-based care, with greater integration of SRAs, is just as good as standard care in important respects. Trained SRAs can effectively support rheumatologists in the care of stable patients with RA or PsA.

Diagnostic value of a 3-day course of prednisolone in patients with possible rheumatoid arthritis - the TryCort study.

BACKGROUND: In patients with tender and swollen finger joints, the differential diagnosis between rheumatoid arthritis (RA) and osteoarthritis (OA) of the hands can be initially difficult. This prospective study (the TryCort study) was performed to study the diagnostic value of prednisolone in differentiating between RA and hand OA. We present the results of this potentially diagnostic test in patients with possible RA in daily clinical practice by demonstrating the results of a pilot and a validation part of this 'prednisolone test' (pred-test). METHODS: We investigated the response to a 3-day course of 20 mg of prednisolone in patients with suspicion of RA. All patients received 1 g of paracetamol per day for 5 days for pain relief. On days 3-5, a morning dose of 20 mg of prednisolone was added. Hand pain was quantified on a 0-10 Numerical Rating Scale, and the subjective percentage of improvement (0-100%) was recorded. Thresholds for response to prednisolone were investigated in a pilot phase with differentiation in response between patients with RA and patients with OA of the hands, both with pain in the hands ≥4. In a validation phase, the best differentiating cut-off of the pilot phase was applied to discriminate responders from non-responders in consecutive patients with hand pain ≥4 referred because of suspected RA. Final diagnoses were made by the expert upon re-examination at week 12. Primary outcomes were the sensitivity and specificity of a positive test in relation to the diagnosis. RESULTS: A percentage of 40% subjective improvement of pain in the hands on day 3 discriminated best between RA and OA in the pilot phase. Among 95 patients with complete data in the validation phase, RA was diagnosed in about 50%. Patients with RA had more swollen joints, higher C-reactive protein levels and slightly higher Health Assessment Questionnaire scores. The pred-test was positive in 42.1% of all patients (40 of 95). The median percentage of improvement on day 5 was higher in RA than in non-RA: 50% (IQR 30-60%) vs. 20% (IQR 10-30%) (p < 0.001). The sensitivity and specificity of the pred-test were 0.6 (95% CI 0.5-0.8) and 0.8 (95% CI 0.7-0.9), respectively, and the positive and negative predictive values were 0.77 and 0.70, respectively. CONCLUSIONS: To our knowledge, this is the first evaluation of the widely used pred-test that has ever been performed. The pred-test had a moderate sensitivity and a good specificity. We conclude that rheumatologists may use this test in unclear clinical situations to better differentiate between inflammatory and other conditions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01395251 . Registered on 14 Jul 2011. EudraCT number: 2011-002633-19. Registered on 21 Dec 2011.

Monitoring ankylosing spondylitis: clinically useful markers and prediction of clinical outcomes.

Patient assessment in axial spondyloarthritis (axSpA) is multidimensional, and monitoring of disease activity, function and radiographic progression is complex. There is no simple 'gold standard' for measuring disease activity in all individual patients, as disease activity in axSpA is the sum of many different aspects and a complexity that cannot be represented by a single variable. Limited spinal mobility is a cardinal sign of ankylosing spondylitis and loss of spinal mobility has been reported to be a prognostic factor and most often evaluated with the Bath Ankylosing Spondylitis Functional Index. Imaging of the spine and assessment of safety aspects plays an important role in the monitoring of patients with axSpA. The timeframe for collecting information regarding disease activity, function and radiographic progression are recommended on an individual basis.