Valoración ecocardiográfica integral en un caso de miocardiopatía de takotsubo por privación de opiáceos / Comprehensive echocardiographic assessment of takotsubo cardiomyopathy case due to opioids withdrawal

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Uso de ecocontraste en el diagnóstico de rotura de una fístula coronaria / Use of echo-contrast in the diagnosis of coronary fistula rupture

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The added value of musculoskeletal ultrasound to clinical evaluation in the treatment decision of rheumatoid arthritis outpatients: physician experience matters.

BACKGROUND: Musculoskeletal ultrasound improves the accuracy of detecting the level of disease activity (DA) in RA patients, although its impact on the final treatment decision in a real clinical setting is uncertain. The objectives were to define the percentage of clinical scenarios from an ongoing cohort of RA outpatients in which the German Ultrasound Score on 7 joints (GUS-7) impacted the treatment and to explore if the impact differed between a senior rheumatologist (SR) vs. a trainee (TR). METHODS: Eighty-five consecutive and randomly selected RA outpatients underwent 170 assessments, 85 each by the SR and the TR. Initially, both physicians (blinded to each other) performed a rheumatic assessment and recommended a preliminary treatment. Then, the patients underwent the GUS-7 evaluation by an experienced rheumatologist blinded to clinical evaluations; selected joints of the clinically dominant hand were assessed by gray-scale and power Doppler (PD). In the final step, the TR and the SR integrated the GUS-7 findings with their previous evaluation and reviewed their recommendations. The patients received the final recommendation from the SR to avoid patient confusion. The study was approved by the Internal Review Board and all the patients signed informed consent. GUS-7 usefulness was separately evaluated by the SR and the TR according to a visual analogue scale (0 = not useful at all, 10 = very useful). Descriptive statistics were used. RESULTS: The patients were primarily middle-aged females (91.4%) with (mean ± SD) disease duration of 7.5 ± 3.9 years. The majority of them (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission. In 34 of 170 clinical scenarios (20%), the GUS-7 findings modified the final treatment proposal; 24 of these scenarios were determined by the TR vs. 10 by the SR: 70.5% vs. 29.5%, p = 0.01. Treatment changes (increase, decrease and joint injection) were similar between both specialists. As expected, the TR rated the GUS-7 usefulness higher than the SR, particularly in the clinical scenarios where the GUS-7 findings impacted treatment. CONCLUSIONS: Musculoskeletal ultrasound added to standard rheumatic assessments impacted the treatment proposal in a limited number of patients; the impact was greater in the TR.

Early disease activity suppression and younger age predict excellent outcome of recent-onset rheumatoid arthritis patients treated with conventional disease modifying anti-rheumatic drugs.

OBJECTIVES: Sustained remission (SR) is the target of treatment offered to patients with rheumatoid arthritis (RA). The objective of the present paper is to describe predictors of favourable outcomes in a cohort of early RA patients. METHODS: Data from 89 patients with 3 years of consecutive assessments and traditional treatment were analysed. SR was defined as ≥ 6 consecutive months with 2011 ACR/EULAR remission criteria. Excellent outcome (EO) was defined according to patient's perception. Descriptive statistics, logistic regression models and Cox regression were used. RESULTS: At baseline, patients were predominantly females (n=78), had rheumatoid factor (n=70) and (mean ± SD) age of 38.8 ± 13.6 years. After (mean ± SD) 37.1 ± 2.5 months, 75 patients achieved ≥ 1 SR state and 35 an EO. The former had lower disease activity, disability and comorbidity and better functional status at baseline than their counterparts (p ≤ 0.05); they also accumulated lesser disability (p ≤ 0.03). Lower C-reactive protein and disease activity and lesser comorbidity predict SR (p ≤ 0.04). Patients with EO were younger, better educated, had lower disease activity, better functional status and lesser comorbidity at baseline than their counterparts (p ≤ 0.05). They achieved a first sustained remission state (p ≤ 0.001) sooner and accumulated lesser disability and incident erosive disease (p ≤ 0.002). Younger age and lower disease activity were prognosticators of EO (p ≤ 0.02). When age, baseline disease activity and time to first SR were investigated as predictors of EO, younger age (HR:0.95, 95% CI: 0.91-0.98, p=0.003) and earlier SR (HR:0.49, 95% CI: 0.39-0.61, p ≤ 0.001) were relevant. CONCLUSIONS: Younger patients with lower disease activity achieved earlier SR which, in addition to age, was predictor of EO.