Allister Taggart

High-resolution ultrasonography of the first metatarsal phalangeal joint in gout: a controlled study

Objective: To compare high-resolution ultrasound (HRUS) with conventional radiography in the detection of erosions in the first metatarsophalangeal joints (1st MTPJs) of patients with gout and to identify the characteristic sonographic features of gout. Methods: HRUS examination of the 1st MTPJs of both feet was performed by two independent sonographers. The presence of joint and soft-tissue pathology was recorded. x Ray examination of the feet was performed on the same day and reported by the same radiologist. Results: 39 male patients with gout and 22 age-matched control subjects (14 with an inflammatory arthropathy and 8 disease free) were studied. The agreement on erosion between HRUS and x ray was poor, κ = 0.229 (non-weighted), with McNemar’s test being significant (p<0.001) indicating a large number of false negative x rays. 22 MTPJs in patients with gout had never been subjected to a clinical attack of acute gout. In these MTPJs, there were 10 erosions detected by HRUS and 3 erosions on x ray. HRUS features significantly more prevalent in the patients with gout were hard and soft tophus-like lesions (p<0.01) and the double contour sign (p<0.01). Conclusions: These data show that HRUS may assist in the management of gout in two ways: first, by aiding in the diagnosis by identifying the sonographic features that may be representative of the disease, and, second, by allowing the early detection of erosive joint damage and/or tophaceous deposits even in clinically silent joints.

Efficacy and safety of combination etanercept and methotrexate versus etanercept alone in patients with rheumatoid arthritis with an inadequate response to methotrexate: The ADORE study

Objective: To evaluate the efficacy and safety of etanercept (ETN) monotherapy compared with combination ETN and methotrexate (MTX) treatment in patients with rheumatoid arthritis who had an inadequate response to MTX monotherapy. (The response was defined by the presence of Disease Activity Score-28 joint count (DAS28) ⩾3.2 or a combination of ⩾5 swollen joints, ⩾5 painful joints and erythrocyte sedimentation rate ⩾10 mm/h.) Methods: Patients with active rheumatoid arthritis taking MTX ⩾12.5 mg/week for ⩾3 months were included in this 16 week, randomised, open-label study. Patients were randomly assigned to either ETN (25 mg subcutaneous injection twice weekly) added to the baseline dose of MTX or ETN monotherapy. Results: 315 patients were randomised to ETN (n = 160) or ETN plus MTX (n = 155). The primary end point, DAS28 (4) improvement of >1.2 units, was achieved by 72.8% and 75.2% of patients treated with ETN and those treated with ETN plus MTX, respectively, with no significant difference (p = 0.658) between the two groups. The European League Against Rheumatism response criteria of good or moderate response was attained by 80.0% of patients in the ETN group and by 82.4% of patients in the ETN plus MTX group. American College of Rheumatology 20%, 50% and 70% response rates achieved by both groups were also similar: 71.0% v 67.1%, 41.9% v 40.1% and 17.4% v 18.4%, respectively. The rates of adverse and serious adverse events were similar between the treatment groups. Conclusion: Both the addition of ETN to MTX and the substitution of ETN for MTX in patients with rheumatoid arthritis who had an inadequate response to MTX resulted in substantial improvements in clinical signs and symptoms and were generally well-tolerated treatment strategies for improving clinical signs and symptoms of rheumatoid arthritis.

New onset systemic lupus erythematosus in a patient receiving etanercept for rheumatoid arthritis.

The management of severe rheumatoid arthritis (RA) has been revolutionised by the introduction of the biological agents infliximab (Remicade—a chimeric anti-tumour necrosis factor (TNF) α antibody), and etanercept (Enbrel—a soluble TNFα receptor). Both these agents lower the effective level of TNFα, and have been shown to be effective in the management of active RA, either alone (etanercept) or in combination with methotrexate (infliximab).1,2 Full blown drug-induced systemic lupus erythematosus (SLE) has been reported with infliximab,3 but not (until very recently) with etanercept,4 although antinuclear antibodies and autoimmune skin rashes have been reported with etanercept.5,6 We report a case of new onset SLE in a patient receiving etanercept. Treatment of a 51 year old woman with severe seropositive erosive RA with methotrexate, sulfasalazine, Myocrisin (sodium aurothiomalate), d-penicillamine, hydroxychloroquine, and leflunomide had previously failed and she continued to require repeated …

E-learning in ultrasonography: a web based approach

Objective: To propose e-learning methods that address the fundamental problems related to sonographic training in rheumatology. Methods: The project was designed for rheumatologists with strong motivation to learn ultrasound. A modular approach was constructed, consisting of a basic 3-day residential course, followed by a 6-month period of web-based tutoring, and culminating in a final 2-day residential course with a formal assessment of competency. Results: The website (http://www.e-sonography.com) was accessed by all 60 participants. A mean of 20 (range 10–80) log-on sessions were registered for each participant, and a mean of 250 min (range 60–600 min) of web access was recorded. A total of 163 sonographic images were submitted by 18 (30%) participants. The majority of the images focused on the following anatomical areas: shoulder 49 (30%), hand 34 (21%) and knee 20 (12%). A total time investment of approximately 14 h was made by the US tutors over the 6-month period for interaction with the participants. Conclusions: The e-learning methods described in this report represent the first attempt to adopt a novel technique to circumvent several of the inherent barriers to the many facets of teaching musculoskeletal ultrasound to a wide audience.

Steroid injection for inferior heel pain: a randomised controlled trial

Background Plantar fasciitis is a common cause of heel pain. The aim of this study was twofold: to compare steroid injection with placebo injection and to compare ultrasound guided with unguided steroid injection in the management of this condition. Methods 65 patients with inferior heel pain were recruited between November 2008 and June 2011. Heel pain was measured using a visual analogue scale (VAS) at baseline and follow-up 6 and 12 weeks after injection. Results 22 patients were randomised to ultrasound guided steroid injection, 21 patients to palpation guided steroid injection and 22 to ultrasound guided placebo injection. There was a significant difference in VAS scores between the groups at 6 and 12 weeks (p=0.018 and p=0.004, respectively). There was a 19.7 (95% CI 2.5 to 37.0) difference in mean VAS scores at 6 weeks between the ultrasound guided steroid group and the placebo group and a 24.0 (95% CI 6.6 to 41.3) difference between the unguided steroid group and the placebo group at 6 weeks. At 12 weeks, the mean difference was 25.1 (95% CI 6.5 to 43.6) and 28.4 (95% CI 11.1 to 45.7) respectively between both steroid injection groups and the placebo group. There was no difference in VAS scores following steroid injection between the ultrasound guided and the unguided groups at either time point. Plantar fascia thickness was significantly reduced after injection in both active treatment groups (p=0.00). Conclusions In this study, steroid injection showed a clear benefit over placebo at 6 weeks and this difference was maintained at 12 weeks. Trial Registration No ISRCTN79628180 (www.controlled-trials.com).

Multicentric reticulohistiocytosis: a lesson in screening for malignancy

recently been reported, which is present when other autoantibodies are not [4, 5]. A study to define the diagnostic utility of myositis autoantibody testing for predicting the risk of cancer-associated myositis in particular, has recently been published which, amongst other findings, associated anti-155/140 with both dermatomyositis and cancer-associated myositis [6]. The negative ANA and negative anti-155/140 antibody (N. McHugh, personal communication) make a ‘classic’ autoimmune cause unlikely in this case. The contribution of DC immunotherapy to the disease in this case is, again, uncertain though the temporal relationship between the end of the DC therapy and the development of the dermatomyositis strongly suggests that these events were linked. The treatment is promising, particularly for malignancy, with clinical responses sometimes coinciding with a specific cytotoxic T-cell response to antigens present in the DC vaccine. However, the variables in vaccination procedure make the planning of large-scale clinical trials between centres difficult. These variables include the mode of DC preparation, the subtype, maturation and activation status of the cells, dosing and timing intervals, route of administration and mode of antigen loading. The co-administration of cytokines and other immune system enhancers (such as Newcastle disease virus) will promote autoimmunity, and though this is listed as a side-effect of the procedure, there are no specific reports of an association with dermatomyositis. Anecdotally, we felt that the patient did not mount the expected immune response to his lifethreatening infection, and felt that his immunotherapy may have contributed to this through attenuation of his immune response.

Comment on: A case of certolizumab-induced interstitial lung disease in a patient with rheumatoid arthritis

Zhen Xiao, Hongdong Hang, Hui Dai and Bin Yan Gynaecology & Obstetrics Department and Department of Renal Disease, 1st Affiliated Hospital of Dalian Medical University, Dalian, Liaoning, People’s Republic of China. Accepted 28 October 2013 Correspondence to: Bin Yan, Gynaecology & Obstetrics Department, 1st Affiliated Hospital of Dalian Medical University, no. 222, Zhongshan Road, Xigang District, Dalian, Liaoning 116011, People’s Republic of China. E-mail: seriousdoc@163.com