Daniela Fodor

Steroid injection for hip osteoarthritis: efficacy under ultrasound guidance

OBJECTIVE To determine the efficacy of IA corticosteroid (CS) injection in pain reduction for hip OA under ultrasound (US) guidance. METHODS Forty patients [mean age 62.78 (8.16) years] fulfilling ACR criteria for hip OA, with synovitis detected at US, gave their consent for IA US-guided CS injection because of pain refractory to conventional therapy. At baseline, at 1 and 3 months, patients filled up a visual analogue scale (VAS) pain on walking, performed the Lequesne index and were checked by US for synovitis. Results were compared with age-matched controls. The occurrence of side effects both short and long term was monitored. RESULTS IA steroid deposition was performed under US guidance. After 1 and 3 months, walking pain VAS was significantly reduced vs baseline (P < 0.001) and had high correlation with Lequesne index. Synovial hypertrophy was reduced in 75% of the hips after 1 and 3 months vs baseline (P < 0.001). In the group of controls, hip walking pain VAS, Lequesne index and synovial hypertrophy were not changed at 3 months vs baseline (P > 0.05). Transient facial rash was present in 16 patients during the first 24-48 h after injection. No side effects were reported. CONCLUSION US-guided steroid injections in hip OA is an efficacious and safe therapeutic approach to achieve pain control and reduction of synovial hypertrophy avoiding the use of X-ray-guided procedure.

Inter-observer reliability of ultrasound detection of tendon abnormalities at the wrist and ankle in patients with rheumatoid arthritis

OBJECTIVE To assess inter-observer reliability in US detection of tendon inflammatory and structural changes at wrists and ankles in RA patients. METHODS Fourteen consecutive RA patients underwent bilateral US assessment of the extensor carpi ulnaris (ECUT) and tibialis posterior tendons (TPTs) by two blinded rheumatologists, with different level of experience in musculoskeletal (MS) US. Grey scale and power Doppler (PD) US assessment was focused on detection of tenosynovitis, tenosynovial and intra-tendon PD signal and structural lesions (i.e. tendinosis, tendon erosion, partial or total rupture). RESULTS The frequency of US findings detected by Investigator 1 was 28.6% for inflammatory changes and 51.8% for structural damage changes while Investigator 2 detected 34 and 53.6% for the corresponding abnormalities. A high overall agreement (82.7%) was found for inflammatory pathology and 89.7% for structural lesions in all tendons. Mean kappa (κ) values for all tendons and pathology was moderate (κ = 0.42), with fair level of agreement for the wrist region (0.27-0.34) and moderate to good values for the ankle region (κ = 0.47-0.62). Subclinical abnormalities were detected in 37.5% of the tendons by Investigator 1 and 28.6% of the tendons by Investigator 2. CONCLUSIONS MSUS showed high overall agreement and fair to moderate inter-observer κ-values between investigators with different levels of experience in detection of tendon pathology at the wrist and ankle in RA patients. Further standardization of scanning method and pathology definitions may improve MSUS reproducibility.

The value of osteopontin in the assessment of bone mineral density status in postmenopausal women.

Background Osteopontin (OPN) has been implicated in bone remodeling by activating the resorption process. We aimed to study the relationship between OPN, bone mineral density (BMD), bone turnover markers, vitamin D, and osteoporotic vertebral fractures in postmenopausal women. Materials and Methods Serum levels of OPN, osteocalcin, collagen type 1 cross-linked C-telopeptide (CTX), bone alkaline phosphatase, and vitamin D were assessed in 214 postmenopausal women. Bone mineral density was assessed by dual-energy x-ray absorptiometry in lumbar spine and femoral neck, and osteoporotic vertebral fractures by radiographs. Results Osteopontin levels were significantly higher in osteoporosis group versus osteopenic and normal group (all P < 0.05). The cutoff values of OPN for osteoporosis diagnosis were of 9.47 μg/L at the lumbar spine (area under the curve, 0.67; 95% confidence interval, 0.58–0.75; P < 0.001) and 10.15 μg/L at the femoral neck (area under the curve, 0.69; 95% confidence interval, 0.624–0.77; P = 0.0001), respectively. Postmenopausal women with osteoporosis-related vertebral fractures had significantly higher levels of OPN than those without vertebral fractures (15.69 ± 13.26 vs 12.63 ± 12.46 μg/L; P = 0.02). Significant negative correlations were found between OPN and BMD, which persisted after the adjustment for age at the lumbar spine. Osteopontin levels were directly correlated with bone turnover markers (osteocalcin, bone alkaline phosphatase, and CTX). No significant correlation was found between OPN and vitamin D. Multiple regression analysis showed that age, waist circumference, and CTX were independent predictors of serum OPN levels. Conclusions High levels of OPN in postmenopausal women are associated with low BMD, increased levels of bone turnover markers, and osteoporotic vertebral fractures. These findings suggest that OPN might play some role in the pathophysiology of postmenopausal osteoporosis and warrant further clinical investigations.

EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis

The increased information provided by modern imaging has led to its more extensive use. Our aim was to develop evidence-based recommendations for the use of imaging in the clinical management of the most common arthropathy, osteoarthritis (OA). A task force (including rheumatologists, radiologists, methodologists, primary care doctors and patients) from nine countries defined 10 questions on the role of imaging in OA to support a systematic literature review (SLR). Joints of interest were the knee, hip, hand and foot; imaging modalities included conventional radiography (CR), MRI, ultrasonography, CT and nuclear medicine. PubMed and EMBASE were searched. The evidence was presented to the task force who subsequently developed the recommendations. The strength of agreement for each recommendation was assessed. 17 011 references were identified from which 390 studies were included in the SLR. Seven recommendations were produced, covering the lack of need for diagnostic imaging in patients with typical symptoms; the role of imaging in differential diagnosis; the lack of benefit in monitoring when no therapeutic modification is related, though consideration is required when unexpected clinical deterioration occurs; CR as the first-choice imaging modality; consideration of how to correctly acquire images and the role of imaging in guiding local injections. Recommendations for future research were also developed based on gaps in evidence, such as the use of imaging in identifying therapeutic targets, and demonstrating the added value of imaging. These evidence-based recommendations and related research agenda provide the basis for sensible use of imaging in routine clinical assessment of people with OA.

Bone mineral density, vertebral fractures and body mass index in postmenopausal women with abdominal aortic calcification.

Abstract Background: Evidence suggest that there are connections between osteoporosis and cardiovascular diseases. Objectives: The aim of the study was to analyze the relationship between radiological measurements of abdominal aorta calcifications (AAC) and bone mineral density (BMD) in postmenopausal women. Methods: In this cross-sectional study were included 125 postmenopausal women 50–84 years of age. BMD of the spine and hip was measured by dual energy X-ray absorptiometry (DXA). AAC were assessed by lateral radiographs of lumbar spine (L1–L4), using the antero-posterior severity score (0–24). Vertebral fractures were evaluated from T4 to L4 using Genant’s semiquantitative method. Results: Forty-one (32.8%) patients had osteoporosis and 61 (48.8%) had AAC with a mean score of 3.1. Postmenopausal women with AAC were older and had significantly lower femoral neck and trochanteric BMD than subjects without AAC (all p < 0.01). There were no significant differences in the frequency of fractures between subjects with AAC and those without AAC (p > 0.05). In univariate analysis, age, height, weight, femoral and trochanter BMD were significantly associated with the severity of AAC score. In multiple regression analysis, femoral neck BMD, but not lumbar spine, trochanter BMD or age, was an independent predictor of AAC. Conclusions: Reduced femoral neck BMD is negatively associated with the presence of AAC in postmenopausal women. The association between BMD and AAC seems to be age-independent, which suggests a common pathogenesis for bone loss and vascular calcifications.

The 2017 EULAR standardised procedures for ultrasound imaging in rheumatology

Background In 2001, the European League Against Rheumatism developed and disseminated the first guidelines for musculoskeletal (MS) ultrasound (US) in rheumatology. Fifteen years later, the dramatic expansion of new data on MSUS in the literature coupled with technological developments in US imaging has necessitated an update of these guidelines. Objectives To update the existing MSUS guidelines in rheumatology as well as to extend their scope to other anatomic structures relevant for rheumatology. Methods The project consisted of the following steps: (1) a systematic literature review of MSUS evaluable structures; (2) a Delphi survey among rheumatologist and radiologist experts in MSUS to select MS and non-MS anatomic structures evaluable by US that are relevant to rheumatology, to select abnormalities evaluable by US and to prioritise these pathologies for rheumatology and (3) a nominal group technique to achieve consensus on the US scanning procedures and to produce an electronic illustrated manual (ie, App of these procedures). Results Structures from nine MS and non-MS areas (ie, shoulder, elbow, wrist and hand, hip, knee, ankle and foot, peripheral nerves, salivary glands and vessels) were selected for MSUS in rheumatic and musculoskeletal diseases (RMD) and their detailed scanning procedures (ie, patient position, probe placement, scanning method and bony/other landmarks) were used to produce the App. In addition, US evaluable abnormalities present in RMD for each anatomic structure and their relevance for rheumatology were agreed on by the MSUS experts. Conclusions This task force has produced a consensus-based comprehensive and practical framework on standardised procedures for MSUS imaging in rheumatology.

Ultrasonography of the metacarpophalangeal joints in healthy subjects using an 18 MHz transducer.

AIM To evaluate the metacarpophalangeal (MCP) joints (MCP2 and 5) in healthy subjects by ultrasonography (US) using a high frequency transducer (18 MHz) and to verify the interobserver agreement. MATERIAL AND METHODS We enrolled 50 healthy volunteers (37 women, age between 30-58 years, mean age 41.7 years, divided into 3 groups according to age: 30-39, 40-49, and 50-58 years). The subjects were successively evaluated by 4 rheumatologists: 2 experienced (team A) and 2 beginners (team B) in US. Seven dorsal and palmar longitudinal scanning positions and a supplementary scan for MCP cartilage were performed. The bone surface (erosions, osteophytes), the intra-articular content (synovial thickening and vascularization, 4 grade scale), and the aspect of the metacarpal head cartilage were analyzed. The anterior palmar recess was measured. The time for examination was recorded. RESULTS Erosions were detected in 7% of joints by team A and 2% by team B (p<0.05, kappa agreement 0.567) in subjects over 40 years. The agreement by team A in the detection of the erosions was very good (kappa value 0.83). A moderate positive correlation was obtained between the presence of erosions and age (r= 0.401, p=0.004). Osteophytes were identified only on the dorsal scan in subjects over 50 years (in 3.5% of joints team A, 1.5% team B, p>0.05, kappa value 0.421). No grade 1 synovitis was observed by team A but 4 joints with grade 1 synovitis were identified by team B (p<0.05) from the dorsal scan. The dimensions of the palmar recess had large distribution (MCP 2 between 0.55-1.3 mm; MCP 5 between 0.6-1.2 mm). No statistical significant differences were obtained when comparing the dimensions of the two hands, the values obtained in age-groups (all p>0.05). No statistical significant correlations were obtained between the dimensions of palmar recess and the body mass index or dominant hand (all p>0.05). No pathological findings were found in the examination of the metacarpal head cartilage. Power Doppler investigation found the presence of grade 1 signal in 2.5% joints by team A and 1.5% by team B (p>0.05) only in the dorsal scans. The mean time for examination was 7.8+/-1.74 min in team A and 13.78+/-2.96 min in team B (p<0.05). CONCLUSIONS In healthy subjects pathological findings are occasionally encountered, especially erosions and osteophytes. Using an 18 MHz transducer the aspect of grade 1 synovitis was not encountered in healthy non-inflammatory MCP joints. There is a permanent need for standardized training and examination in musculoskeletal US.

The Importance of Homozygous Polymorphisms of Methylenetetrahydrofolate Reductase Gene in Romanian Patients with Idiopathic Venous Thromboembolism

BACKGROUND Methylenetetrahydrofolate reductase (MTHFR) polymorphisms have recently raised the interest as a possible thrombophilic factors. AIMS We aimed to assess the frequency of the methylenetetrahydrofolate reductase (MTHFR) C677T and A1298C polymorphisms in idiopathic venous thromboembolism (VTE) in a Romanian population and the associated risk of VTE. STUDY DESIGN We performed a case-control transversal study including 90 patients diagnosed with VTE and 75 sex- and age-matched controls. METHODS MTHFR C677T and A1298C polymorphisms were detected using PCR-RFLP method. RESULTS The homozygous MTHFR 677TT genotype, present in 18.8% of patients with VTE versus 6.6% of controls, was significantly associated with VTE (p= 0.021, OR= 3.26, 95%CI (1.141-9.313)). The heterozygous MTHFR A1298C genotype, presenting the highest prevalence in the VTE group (34.4%) as well as in controls (37.3%), was not associated with VTE (p=0.7). No associations were found for heterozygous MTHFR C677T (with a frequency of 32.2% in VTE and 37.3% in controls, p=0.492), respective homozygous MTHFR A1298C genotype (with a frequency of 1.1% in VTE and 2.6% in controls, p=0.456). CONCLUSION Among MTHFR polymorphisms, only homozygosity for MTHFR 677TT may be considered a risk factor for VTE; the MTHFR A1298C polymorphism is not significantly associated with an increased risk of VTE.

Unilateral temporal myositis heralding polymyositis: ultrasonographic and elastographic findings. Case report.

Temporal myositis is a rare inflammatory disease of the temporal muscle. We report a case of unilateral temporal myositis, in which a polymyositis was diagnosed two years thereafter. Although focal myositis may rarely herald polymyositis, isolated temporal myositis preceding inflammatory myopathies has not been described, to our knowledge. In the setting of a temporal pain and swelling, ultrasonography may help in diagnosis, biopsy guidance, disease extension, and progression assessment. Further studies are necessary to establish the role of elastography in differentiating between muscle inflammation and hypertrophy.

Concepts in diagnosing, scoring, and monitoring tenosynovitis and other tendon abnormalities in patients with rheumatoid arthritis- the role of musculoskeletal ultrasound.

In the last years, important advancements have been made in implementing high resolution imaging related information inside the global management algorithm in RA patients. Musculoskeletal ultrasound has already proven its utility in visualizing directly the joint synovial tissue, the synovial vascularization and in monitoring the response to therapy. Recently, much attention has been given to the presence of tenosynovitis, as a constant, complementary but different facet of the inflammatory involvement in RA. Tenosynovitis identification in early RA stages may allow adequate treatment adjustment in early and established disease in order to prevent and/ or slow down the development of structural damage at tendon and joint level.