Alessandra Gabba

Hand tendon involvement in rheumatoid arthritis: an ultrasound study.

OBJECTIVE To assess the prevalence and the distribution of tendon involvement in the hands and wrists of patients with rheumatoid arthritis (RA) describing in detail the ultrasound (US) morphostructural and vascular tendon abnormalities. METHODS Ninety consecutive RA patients were included in the study. The following tendons were scanned bilaterally: flexor pollicis longus tendon, flexor digitorum superficialis, and profundus tendons of the II to the V fingers (at both finger and carpal tunnel levels), flexor carpi radialis tendon, and extensor tendons of the 6 compartments on the dorsal aspect of the wrist. The presence of US findings indicative of tenosynovitis and tendon damage was investigated. RESULTS Tenosynovitis was found in at least 1 anatomic site of 44 (48.8%) of 90 patients. Tendon damage was found in at least 1 anatomic site of 39 (43.3%) of 90 patients. The focal tendon echotexture derangement was found in 294 of 5400 (5.4%) tendons, the partial and complete tears in 14 (0.3%), and in 3 (0.06%) tendons, respectively. The most frequently involved tendons were the flexor tendons of the II, III, and IV fingers and the extensor carpi ulnaris tendon. CONCLUSIONS The present study provides evidence in favor of the ability of US to reveal a relatively high frequency of tendon involvement at the hand and wrist level in RA patients. These data can both facilitate US examinations in daily clinical practice and direct further investigations in the US assessment of tendon involvement in RA.

Joint and tendon involvement in systemic lupus erythematosus: an ultrasound study of hands and wrists in 108 patients

OBJECTIVE To estimate the prevalence of, and identify factors associated with, hand and wrist US alterations in a large cohort of SLE patients. METHODS One hundred and eight consecutive SLE patients were recruited and classified according to arthropathy type and the musculoskeletal item of the British Isles Lupus Assessment Group (BILAG) 2004 score. US examinations were performed on hand and wrist flexor tendons, wrist extensor tendons, second and third MCP and wrist joints bilaterally using a multi-planar scanning technique. RESULTS US examination showed joint involvement in 42/108 (38.8%) subjects, tendon involvement in 44/108 (40.7%) and both in 22/108 (20.3%). Patients with rhupus syndrome (n = 8) carried a higher incidence of inflammatory changes (87%) and erosions (87%) compared with the six with Jaccouds arthropathy (50% and 17%, respectively) and the 94 with non-deforming X-ray non-erosive arthropathy (37% and 21%, respectively). Power Doppler signal was prevalent in patients scoring A (n = 4) or B (n = 9) on the musculoskeletal item of the BILAG 2004, and was significantly more frequent at the joint (92%) and tendon (54%) level than in the 26 patients scoring C (19%, P = 0.0007 and 15%, P = 0.016, respectively) and in the 69 scoring D (3%, P < 0.0001 and 3%, P < 0.0001). US changes in patients who scored C or D were more expressed at the tendon level (50% and 29%, respectively) than at the joint level (35% and 9%, respectively). CONCLUSION The picture of musculoskeletal US in SLE depends on arthropathy subtype and disease activity. US examination could be a valid and reliable tool to monitor musculoskeletal features and therapeutic outcomes in SLE patients.

Power Doppler ultrasonographic evaluation of enthesitis in psoriatic arthritis. A multi-center study

Joint Bone Spine - In Press.Proof corrected by the author Available online since samedi 26 novembre 2011

Rituximab treatment for 'rhupus syndrome': clinical and power-Doppler ultrasonographic monitoring of response. A longitudinal pilot study.

Objective To evaluate the safety and efficacy of rituximab in patients suffering from rhupus unresponsive to therapy with non-biological disease-modifying anti-rheumatic drugs (DMARDs). Methods Six patients fulfilling criteria for both rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) and with a DAS28 score >5.1 were enrolled to receive two fortnightly 1000 mg rituximab doses at baseline and after 28 weeks. All patients underwent clinical, laboratory, and power- Doppler (PD) ultrasonographic (US) assessment at baseline and after 14, 28 and 56 weeks. Results A sustained improvement in DAS28, SLEDAI, HAQ, laboratory markers and ultrasound indices together with a significant reduction in the daily dose of prednisone were observed throughout follow-up. Conclusion Rituximab may be a safe and effective therapeutic option in refractory rhupus patients.

Ultrasound-detected tenosynovitis independently associates with patient-reported flare in patients with rheumatoid arthritis in clinical remission: results from the observational study STARTER of the Italian Society for Rheumatology

OBJECTIVES This study aimed to estimate the prevalence of US-detected tenosynovitis in RA patients in clinical remission and to explore its clinical correlates. METHODS A total of 427 RA patients in clinical remission were consecutively enrolled from 25 Italian rheumatology centres. Tenosynovitis and synovitis were scored by US grey scale (GS) and power Doppler (PD) semi-quantitative scoring systems at wrist and hand joints. Complete clinical assessment was performed by rheumatologists blinded to the US results. A flare questionnaire was used to assess unstable remission (primary outcome), HAQ for functional disability and radiographic erosions for damage (secondary outcomes). Cross-sectional relationships between the presence of each US finding and outcome variables are presented as odds ratios (ORs) and 95% CIs, both crude and adjusted for pre-specified confounders. RESULTS The prevalence of tenosynovitis in clinical remission was 52.5% (95% CI 0.48, 0.57) for GS and 22.7% (95% CI 0.19, 0.27) for PD, while the prevalence of synovitis was 71.6% (95% CI 0.67, 0.76) for GS and 42% (95% CI 0.37, 0.47) for PD. Among clinical correlates, PD tenosynovitis associated with lower remission duration and morning stiffness while PD synovitis did not. Only PD tenosynovitis showed a significant association with the flare questionnaire [OR 1.95 (95% CI 1.17, 3.26)]. No cross-sectional associations were found with the HAQ. The presence of radiographic erosions associated with GS and PD synovitis but not with tenosynovitis. CONCLUSIONS US-detected tenosynovitis is a frequent finding in RA patients in clinical remission and associates with unstable remission.

Musculoskeletal manifestations as determinants of quality of life impairment in patients with systemic lupus erythematosus

Objective The objective of this study was to identify determinants of health-related quality of life (HRQoL) impairment in patients with systemic lupus erythematosus (SLE). Methods Overall, 101 SLE patients were recruited; 37 healthy subjects and 35 rheumatoid arthritis (RA) patients served as controls. HRQoL was evaluated using three patient reported outcomes (PROs): the Short Form-36 version 2 (SF-36v2) health survey, the fatigue scale version 4 (FACITv4) and the Heath Assessment Questionnaire (HAQ). A large set of demographic and clinical variables, including SLE arthritis subtypes, was evaluated searching for factors independently associated with worse QoL. Multivariate models were applied to identify factors independently associated with outcomes. Bonferroni’s corrected p values < 0.05 were considered significant. Results SLE patients showed worse results than healthy controls (p < 0.01) in all SF-36v2 domains and, with reference to the mental QoL, also than RA patients (p < 0.01). Jaccoud’s deformities, active arthritis, and fibromyalgia were the only factors independently associated with worse results in both physical and mental components summary of the SF-36v2 (p < 0.01) and FACITv4 fatigue scale (p < 0.01). Fragility fractures, deformities, and active arthritis negatively affected disability perception measured by the HAQ (p < 0.01). No statistically significant differences in perceived HRQoL were highlighted between patients with deforming and erosive arthritis. However, they had significantly worse results than patients with non-deforming non-erosive arthritis across all investigated PROs (p < 0.01). Conclusion In order to limit musculoskeletal manifestations as a source of impaired QoL in SLE patients, therapeutic strategies targeted to successfully manage active arthritis and fibromyalgia and to prevent deforming damage are needed.

Multiple Septic Bursitis and Spontaneous Achilles Tendon Tear in Systemic Lupus Erythematosus

To the Editor: We describe a 31-year-old woman who was admitted because of fever and polyarthritis of 1 week’s duration. Six months before, she was diagnosed with systemic lupus erythematosus (SLE) on the basis of nonerosive polyarthritis, painless oral ulcers, positive antinuclear antibody (IFI-Hep2) titer of 1:10,240 with homogeneous pattern, and anti-dsDNA (Farr assay) value of 146 IU/l (normal 0–7 IU/l). At admission she denied any dyspnea, chest pain, rash, dysuria, diarrhea, or intravenous drug abuse. She was receiving methylprednisolone 32 mg/qd, hydroxychloroquine 400 mg/qd, and methotrexate 15 mg/week plus folic acid, but she also reported that in the last month her doctor prescribed a course of 3 consecutive daily pulses of methylprednisolone 500 mg, because of exacerbation of articular manifestations. On examination she presented with hyperpyrexia (up to 40°C), shaking chills, and severe inflammation of the left ankle retrocalcaneal region and the bilateral metatarsophalangeal joints (Figure 1). Musculoskeletal manifestations appeared to be out of proportion to SLE disease activity. Heart and chest examinations were unremarkable. She reported itching and painful defecation without blood-streaked stools and mucopurulent discharge. Figure 1. Erythema and swelling of the left retrocalcaneal region, the left first and third, and the right first and fifth metatarsophalangeal joints. Perineal inspection demonstrated perianal fissures and erythema, suggesting a bacterial skin infection, in the absence … Address correspondence to Dr. Piga; E-mail: matteopiga{at}alice.it

The Italian MSUS Study Group recommendations for the format and content of the report and documentation in musculoskeletal ultrasonography in rheumatology

OBJECTIVE The objective of this study was to draw up a set of recommendations for the format and content of the musculoskeletal ultrasonography (MSUS) report in rheumatology. METHODS A panel of rheumatologists, members of the MSUS Study Group of the Italian Society of Rheumatology, met in order to identify the main discrepancies in the MSUS report. A set of 15 recommendations was then defined, aimed at resolving the main discrepancies. They consisted of information about the motivations for the MSUS examination, the equipment, the US modalities and scanning technique, a list of the examined structures and findings, the scoring/grading systems, the number of images and main findings to include and conclusions. Subsequently a Delphi-based procedure was started in order to obtain agreement on a core set of recommendations. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%. RESULTS Three complete rounds were performed. The response rate was 85.2% for the first round, 78.3% for the second and 88.9% for the third. Finally, consensus was obtained for 14 of 15 statements. These 14 statements represent the recommendations of the group for the format and content of the report and documentation in MSUS in rheumatology. CONCLUSION To the best of our knowledge, our group has produced the first recommendations for the format and content of the report and documentation in MSUS in rheumatology. The report is an integral part of the MSUS examination and its use in a homogeneous form can help in the correct interpretation of the findings.

SAT0061 Concurrent Ultrasound-Detected Synovitis and Tenosynovitis Predict Flare in Patients with Rheumatoid Arthritis in Clinical Remission

Background Subclinical synovial inflammation detected by ultrasonography (US) in patients with rheumatoid arthritis (RA) in clinical remission relates to disease flare. The impact of tenosynovitis in this context is not known. Objectives To evaluate the association between US-detected tenosynovitis and synovitis in RA patients in clinical remission and flare over 12-months. Methods STARTER is a multicentre cohort study of the US Study Group of the Italian Society for Rheumatology. Participants were selected on the basis of a reliability exercise and the availability of high-end equipment. Patients with RA in clinical remission underwent clinical evaluation and US synovitis (-S) and tenosynovitis (-T) were assessed categorically for Grey Scale (GS) and power Doppler (PD) at 11 joints, extensor and flexor tendons in both hands and wrists. Patients were seen at 6 and 12 months. Flare within 12 months was defined as increase of >1.2 or >0.6 if final DAS28>3.2. The relationship between the presence of GS-T/-S, PD-T/-S was evaluated by logistic models, presented as odds ratios (OR) and 95% confidence interval (CI), adjusted for pre-specified confounders. Results 361 patients (72.3% f, mean age (sd) 56.1 (13.3), median disease duration (IQR) 7.1 years (3.6–13.5)) were included. 98/326 (30.6%) patients had a flare within 12 months. Considering US variables separately, only PD-S significantly predicted flare (OR 1.87 (1.12,3.14)). When the model included both –T and –S, only the concurrent presence of –T and –S predicted flare (PD-T+-S: OR 2.06 (1.04, 4.07); GS-T+-S: OR 2.27, (1.01,5.10)), while isolated –S and –T did not. Conclusions In patients with RA in clinical remission, US-detected synovial and tenosynovial inflammation identifies patients at risk of flare. US might help decisions on management in this population. Disclosure of Interest None declared

The predictive role of ultrasound-detected tenosynovitis and joint synovitis for flare in patients with rheumatoid arthritis in stable remission. Results of an Italian multicentre study of the Italian Society for Rheumatology Group for Ultrasound: the STARTER study

Objective To define the role of ultrasound (US) for the assessment of patients with rheumatoid arthritis (RA) in clinical remission, including joint and tendon evaluation. Methods A multicentre longitudinal study has been promoted by the US Study Group of the Italian Society for Rheumatology. 25 Italian centres participated, enrolling consecutive patients with RA in clinical remission. All patients underwent complete clinical assessment (demographic data, disease characteristics, laboratory exams, clinical assessment of 28 joints and patient/physician-reported outcomes) and Power Doppler (PD) US evaluation of wrist, metacarpalphalangeal joints, proximal interphalangeal joints and synovial tendons of the hands and wrists at enrolment, 6 and 12 months. The association between clinical and US variables with flare, disability and radiographic progression was evaluated by univariable and adjusted logistic regression models. Results 361 patients were enrolled, the mean age was 56.20 (±13.31) years and 261 were women, with a mean disease duration of 9.75 (±8.07) years. In the 12 months follow-up, 98/326 (30.1%) patients presented a disease flare. The concurrent presence of PD positive tenosynovitis and joint synovitis predicted disease flare, with an OR (95% CI) of 2.75 (1.45 to 5.20) in crude analyses and 2.09 (1.06 to 4.13) in adjusted analyses. US variables did not predict the worsening of function or radiographic progression. US was able to predict flare at 12 months but not at 6 months. Conclusions PD positivity in tendons and joints is an independent risk factor of flare in patients with RA in clinical remission. Musculoskeletal ultrasound evaluation is a valuable tool to monitor and help decision making in patients with RA in clinical remission.