Karine Rodrigues da Luz

Ultrasound-guided intra-articular injections in the wrist in patients with rheumatoid arthritis: a double-blind, randomised controlled study

Intra-articular (IA) injections with glucocorticoid are a valuable therapeutic intervention for patients with rheumatoid arthritis (RA) and wrist synovitis. Jones et al have demonstrated that half of the wrist blind injections were considered to be extra-articular.1 Musculoskeletal ultrasound (US) allows for the proper real-time allocation of the needle during the injections, limiting the risk of damage to the cartilage, tendons, nerves and peripheral blood vessels.2 In this study we compare the efficacy of blind and US-guided IA injections in patients with RA with wrist synovitis. The accuracy of the techniques used to inject the drug into wrist joint is …

Interobserver reliability of ultrasonography in the assessment of cartilage damage in rheumatoid arthritis

Objectives To evaluate the interobserver reliability of ultrasonography (US) in the assessment of cartilage damage at metacarpophalangeal (MCP) joint level in patients with rheumatoid arthritis (RA). Methods US examinations were performed on 80 MCP joints of 20 patients with RA using a MyLab70 XVG (Esaote Biomedica, Genoa, Italy), equipped with a broadband linear probe (6–18 MHz). For each patient, second and third MCP joints of both hands were examined independently on the same day by two rheumatologists (an experienced musculoskeletal sonographer and an investigator with limited US training). A multiplanar scanning technique on dorsal, lateral and volar aspects of the MCP joints was adopted. All US pathological findings were documented on at least two perpendicular scanning planes. Each joint was assessed by quadrant for the presence or absence of cartilage damage. Cartilage damage was also scored per quadrant on a five-grade semiquantitative scoring system on which investigators reached a consensus prior to the study. Results Exact agreement between investigators was found in 173 out of 200 quadrants (86.5%) with regard to presence or absence of cartilage damage. Percentages of exact agreement for cartilage damage semiquantitative assessment at dorsal, lateral and volar quadrants were 72.5%, 52.5% and 85%, respectively, while unweighted κ values were 0.561, 0.366 and 0.766, respectively. Conclusions The present study demonstrated moderate to good interobserver reproducibility of a semiquantitative scoring system based on qualitative morphological changes for cartilage damage at MCP joint level in patients with RA.

Efetividade da infiltração intra-articular guiada por imagem: comparação entre fluoroscopia e ultrassom

OBJECTIVE Compare the effectiveness of ultrasound and fluoroscopy to guide intra-articular injections (IAI) in selected cases. MATERIAL AND METHODS A prospective study in our outpatient clinics at the Rheumatology Division at Universidade Federal de São Paulo (UNIFESP), Brazil, was conducted to compare the short-term (4 weeks) effectiveness of ultrasound and fluoroscopy-guided IAI in patients with rheumatic diseases. Inclusion criteria were: adults with refractory synovitis undergoing IAI with glucocorticoid. All patients had IAI performed with triamcinolone hexacetonide (20mg/ml) with varying doses according to the joint injected. RESULTS A total of 71 rheumatic patients were evaluated (52 women, 44 whites). Mean age was 51.9 ± 13 years and 47 of them (66.2%) were on regular DMARD use. Analysis of the whole sample (71 patients) and hip sub-analysis (23 patients) showed that significant improvement was observed for both groups in terms of pain (P < 0.001). Global analysis also demonstrated better outcomes for patients in the FCG in terms of joint flexion (P < 0.001) and percentage change in joint flexion as compared to the USG. Likert scale score analyses demonstrated better results for the patients in the USG as compared to the FCG at the end of the study (P < 0.05). No statistically significant difference between groups was observed for any other study variable. DISCUSSION AND CONCLUSION Imaging-guided IAI improves regional pain in patients with various types of synovitis in the short term. For the vast majority of variables, no significant difference in terms of effectiveness was observed between fluoroscopy and ultrasound guided IAI.

Vacinação em pacientes imunossuprimidos e com doenças reumatológicas auto-imunes

Vaccination is a way to prevent infectious diseases. Infections are more prevalent among patients with rheumatic diseases when compared to the general population. This higher prevalence may be due to an immune system deficiency associated with the underlying condition or to the use of immunessupressive therapy. Vaccination is an effective measure to reduce morbidy and mortality in these patients. The aim of this article is to review safety and efficacy issues concerning different vaccines for immunocompromised patients and patients with autoimmune rheumatic diseases. In general, vaccines with killed bacteria or virus are safe for patients with autoimmune rheumatic diseases, even when they are taking immunessupressive therapy. The vaccination is effective to most patients because they usually accomplish an effective immune response. Administration of attenuated vaccines with live bacteria or virus to immunocompromised patients is contraindicated.

Novo sistema de escore ultrassonográfico (US10) musculoesquelético das articulações das mãos e punho para avaliação de pacientes com artrite reumatoide em fase inicial.

OBJECTIVE To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables. METHODS Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0-1) and semi-quantitatively (grades 0-3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP). RESULTS Mean duration of symptoms was 7.58±3.59 months. Significant correlations (p<0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p<0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up. CONCLUSION The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

Estratégia de troca entre agentes anti-TNF-alfa não melhora a capacidade funcional em pacientes com artrite reumatoide de longa evolução

OBJETIVOS: Avaliar a resposta clinica apos a estrategia de troca entre agentes antifator de necrose tumoral alfa (anti-TNF-alfa) em pacientes com artrite reumatoide (AR). PACIENTES E METODOS: Foram incluidos 99 pacientes com diagnostico de AR (American College of Rheumatology, 1987), em uso de terapia anti-TNF-alfa, para avaliacao da resposta terapeutica apos 24 semanas. A estrategia de troca foi feita se, apos 12 a 24 semanas, houvesse relato de evento adverso serio (T: toxicidade) ou se nao ocorresse reducao maior que 0,6 do indice de atividade da doenca (DAS28) inicial (RI: resposta inadequada). Nesse ultimo caso, o paciente foi considerado como falencia primaria (FP). Falencia secundaria (FS) foi definida se houvesse perda de resposta apos melhora inicial. Remissao (DAS28 0,2 do questionario de avaliacao da saude (HAQ) inicial] foram avaliadas por analise de regressao linear. P < 0,05 foi considerado significante. RESULTADOS: A estrategia de troca foi realizada em 39 (39,4%) pacientes, especialmente por FP (24,3%), FS (35,1%) e T (40,5%). A taxa de retencao ao primeiro agente foi de 60,1%, e o tempo medio para a troca foi de 14,2 ± 10,9 meses. Apos a troca, houve tendencia a queda do DAS28 (4,7 ± 1,4; P = 0,08), mas nao do HAQ (1,2 ± 0,77; P = 0,11). Cerca de 43% deles alcancaram boa/moderada resposta EULAR. O principal determinante da troca foi o DAS28 inicial mais elevado, independente de idade, tempo de doenca e capacidade funcional. CONCLUSAO: A estrategia de troca entre agentes anti-TNF-alfa e valida para o controle da atividade de doenca, embora com baixa probabilidade de remissao e sem melhora significativa da capacidade funcional

A new musculoskeletal ultrasound scoring system (US10) of the hands and wrist joints for evaluation of early rheumatoid arthritis patients

OBJECTIVE To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables. METHODS Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0-1) and semi-quantitatively (grades 0-3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP). RESULTS Mean duration of symptoms was 7.58±3.59 months. Significant correlations (p<0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p<0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up. CONCLUSION The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

Tratamento de pacientes com úlceras isquêmicas secundárias à esclerose sistêmica com N-acetilcisteína endovenosa

Os repetidos episodios de isquemia-reperfusao observados na esclerose sistemica (ES) acarretam aumento na atividade de radicais livres, o que pode estar implicado nas anormalidades vasculares e inflamatorias descritas nessa enfermidade. A N-acetilcisteina sob forma endovenosa e uma potente droga antioxidante e, como tal, poderia ter efeito benefico para o tratamento das lesoes vasculares da ES. Relatamos o tratamento com N-acetilcisteina endovenosa de tres pacientes com diagnostico de ES e com ulceras ativas de extremidades (digitos ou artelhos). Dois pacientes apresentavam duas ulceras digitais e o terceiro paciente, tres ulceras em artelhos no inicio do tratamento. Todos os pacientes apresentaram diminuicao no diâmetro de pelo menos uma ulcera apos o tratamento. Duas pacientes apresentaram cicatrizacao de uma ulcera. Esses resultados preliminares sugerem que a N-acetilcisteina endovenosa parece ser uma boa opcao terapeutica para o tratamento de ulceras de extremidades em pacientes com ES e justificam a elaboracao de ensaios controlados duplo-cego com placebo.

Intra-articular injection with triamcinolone hexacetonide in patients with rheumatoid arthritis: prospective assessment of goniometry and joint inflammation parameters

OBJECTIVES To evaluate local joint variables after intra-articular injection with triamcinolone hexacetonide in rheumatoid arthritis patients. METHODS We blindly and prospectively (baseline, 1, 4, 12 and 24 weeks) evaluated metacarpophalangeal, wrist, elbow, shoulder, knee and ankle joints after triamcinolone hexacetonide intra-articular injection by the following outcome measures: visual analogue scale 0-10cm (VAS) for rest pain (VASR); VAS for movement pain (VASM); VAS for joint swelling (VASSw); flexion (FlexG) and extension (ExtG). RESULTS 289 patients (635 joints) were studied. VASSw (p<0.001) and VASR (0.001<p<0.016) improved from T0 to T4, T12 and T24 for all joints. VASM improved from T0 to T4 (p<0.021) for all joints; T0 to T12 (p<0.023) for MCF and knee; T0 to T24 (p<0.019) only for MCF and knee. FlexG improved from T0 to T4 (p<0.001) for all joints; T0 to T12 (p<0.001) and T0 to T24 (p<0.02) only for MCF and knee. ExtG improved from T0 to T4 (p<0.001) for all joints except for elbow; T0 to T12 (p=0.003) for wrist, metacarpophalangeal and knee; and T0 to T24 (p=0.014) for MCF and knee. CONCLUSION VASSw responded better at short and medium term after IAI with triamcinolone hexacetonide in our sample of RA patients.