Rita Nely Vilar Furtado

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 …

Effectiveness of radiation synovectomy with samarium-153 particulate hydroxyapatite in rheumatoid arthritis patients with knee synovitis: a controlled randomized double-blind trial

OBJECTIVES: The aim of the present study was to investigate the effectiveness of Samarium153-particulate hydroxyapatite radiation synovectomy in rheumatoid arthritis patients with chronic knee synovitis. METHODS: Fifty-eight rheumatoid arthritis patients (60 knees) with chronic knee synovitis participated in a controlled double-blinded trial. Patients were randomized to receive either an intra-articular injection with 40 mg triamcinolone hexacetonide alone (TH group) or 40 mg triamcinolone hexacetonide combined with 15 mCi Samarium153-particulate hydroxyapatite (Sm/TH group). Blinded examination at baseline (T0) and at 1 (T1), 4 (T4), 12 (T12), 32 (T32), and 48 (T48) weeks post-intervention were performed on all patients and included a visual analog scale for joint pain and swelling as well as data on morning stiffness, flexion, extension, knee circumference, Likert scale of improvement, percentage of improvement, SF-36 generic quality of life questionnaire, Stanford Health Assessment Questionnaire (HAQ), Lequesne index, use of non-steroidal anti-inflammatory drugs or oral corticosteroids, events and adverse effects, calls to the physician, and hospital visits. RESULTS: The sample was homogeneous at baseline, and there were no withdrawals. Improvement was observed in both groups in relation to T0, but no statistically significant differences between groups were observed regarding all variables at the time points studied. The Sm/TH group exhibited more adverse effects at T1 (p<0.05), but these were mild and transitory. No severe adverse effects were reported during follow-up. CONCLUSION: Intra-articular injection of Samarium153-particulate hydroxyapatite (15 mCi) with 40 mg of triamcinolone hexacetonide is not superior to triamcinolone hexacetonide alone for the treatment of knee synovitis in patients with rheumatoid arthritis at 1 y of follow-up.

Effect of Facet Joint Injection Versus Systemic Steroids in Low Back Pain: A Randomized Controlled Trial.

Study Design. Randomized clinical trial. Objective. To compare the effectiveness of facet joint injection versus systemic steroid in patients with a diagnosis of facet joint syndrome. Summary of Background Data. The term facet joint syndrome has been used to define back pain originating from the facet joints. Treatment is mainly conservative, although interventions, including intra-articular injections and medial branch nerve blocks are used to manage facet-mediated pain. Several studies have evaluated the effectiveness of these interventions. Results of facet joint injection, however, are conflicting. Methods. Sixty subjects with a diagnosis of facet joint syndrome were enrolled in the study. They were randomized into experimental and control groups. The experimental group was administered with intra-articular injection of 6 lumbar facet joints with triamcinolone hexacetonide; the control group was administered with triamcinolone acetonide intramuscular injection of 6 lumbar paravertebral points. Visits were taken at baseline and at 1, 4, 12, and 24 weeks after interventions. Outcome measures were used: pain visual analogue scale, pain visual analogue scale during extension of the spine, Likert scale, improvement percentage scale, Roland-Morris, 36-Item Short Form Health Survey, and accountability of medications taken. Homogeneity was tested using the Student t, Pearson &khgr;2, and Mann-Whitney tests. Analysis of variance was used to analyze differences in the groups over time and the Student t test to analyze differences between groups at each time evaluation. Results. The groups were similar at baseline. Comparisons between the groups showed, in analysis of variance analysis, an improvement in the experimental group regarding diclofenac intake and quality of life, in the “role physical” profile, assessed by 36-Item Short Form Health Survey. In the analysis at each time point, an improvement in the experimental group was also found in the Roland-Morris questionnaire, in the improvement percentage scale and in the response to treatment, assessed by the Likert scale. Conclusion. Both treatments were effective, with a slight superiority of the intra-articular injection of steroids over intramuscular injection. Level of Evidence: 2

Oro‐facial evaluation of women with rheumatoid arthritis

Rheumatoid arthritis (RA) is an aggressive articular autoimmune disease that causes deformities and disability. The temporomandibular joint (TMJ) might be affected by this disease. Few controlled studies have evaluated bite force (BF) and oro-facial manifestations of this disease. To characterise oro-facial alterations in patients with RA, correlate these results with clinical and disease activity parameters and correlate BF with hand strength (HS). A cross-sectional study of 150 women was performed, (75 RA patients (RA group) and 75 healthy individuals (control group). The presence of articular sounds, pain on palpation of masseter, temporal and TMJ lateral pole, changes in occlusion, range of mandibular motion, measurement of BF in the incisor and molar regions and assessment of HS were evaluated. In relation to oro-facial evaluation there were statistical differences between the groups. There was correlation between BF and HS, in the RA group, this correlation was consistent in patients with natural teeth. Patients with RA had lower scores (P < 0·05) in the HAQ, DASH and OHIP-14 questionnaires than the control group. Inverse correlations were found between BF and HAQ, but not between BF and DAS-28, DASH and OHIP-14 questionnaires in the RA group. The women with RA presented more signs and symptoms in the oro-facial region and had a lower BF than the women in the control group. BF was inversely correlated with the overall function (evaluated by the HAQ) in the patients with RA, and there were correlations between BF and HS in the RA patients and in the control group.

Effectiveness of Triamcinolone Hexacetonide Intraarticular Injection in Interphalangeal Joints: A 12-week Randomized Controlled Trial in Patients with Hand Osteoarthritis.

Objective. To evaluate the effectiveness and tolerance of intraarticular injection (IAI) of triamcinolone hexacetonide (TH) for the treatment of osteoarthritis (OA) of hand interphalangeal (IP) joints. Methods. Sixty patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH/lidocaine (LD; n = 30) with TH 20 mg/ml and LD 2%, or just LD (n = 30). The injected joint was immobilized with a splint for 48 h in both groups. Patients were assessed at baseline and at 1, 4, 8, and 12 weeks by a blinded observer. The following variables were assessed: pain at rest [visual analog scale (VAS)r], pain at movement (VASm), swelling (physician VASs), goniometry, grip and pinch strength, hand function, treatment improvement, daily requirement of paracetamol, and local adverse effects. The proposed treatment (IAI with TH/LD) was successful if statistical improvement (p < 0.05) was achieved in at least 2 of 3 VAS. Repeated-measures ANOVA test was used to analyze intervention response. Results. Fifty-eight patients (96.67%) were women, and the mean age was 60.7 years (± 8.2). The TH/LD group showed greater improvement than the LD group for VASm (p = 0.014) and physician VASs (p = 0.022) from the first week until the end of the study. In other variables, there was no statistical difference between groups. No significant adverse effects were observed. Conclusion. The IAI with TH/LD has been shown to be more effective than the IAI with LD for pain on movement and joint swelling in patients with OA of the IP joints. Regarding pain at rest, there was no difference between groups. Trial registration number: ClinicalTrials.gov (NCT02102620).

Sonographic Assessment of Healthy Peripheral Joints Evaluation According to Demographic Parameters

To describe quantitative and semiquantitative sonographic joint measurements in healthy adults and compare them with demographic parameters.

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.

Hand ultrasound: Comparative study between “no rhupus” lupus erythematosus and rheumatoid arthritis

Abstract Objective. To compare hand US between systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) patients. Methods. Hands (1st–5th metacarpophalangeal [MCP] and 1st–5th proximal interphalangeal [PIP] joints) and wrists (radiocarpal and distal radioulnar joints) of 62 “no rhupus” SLE and 60 RA patients were compared through US (linear probe, 6–18 MHz). The findings were compared to clinical, functional, serological outcomes, and disease activity indices. Results. 2108 and 2040 joint recesses were evaluated in SLE and AR patients, respectively. Synovitis was found in 46.8% and 75% of wrists, 83.9% and 86.7% of MCPs and 58.1% and 70% of PIPs in the SLE and RA groups, respectively. More significant US findings were found in RA group. Greater values of synovitis (mm) in RA group were only found in the joint recesses of wrist (p < 0.001–0.002). In SLE group, US findings were associated with “puffy hands,” Health Assessment Questionnaire score and dynamometry. Twenty-two SLE patients (35.5%) had erosion in any of joints studied. SLE patient subgroup with US erosion was associated with hematological involvement and Jaccouds arthropathy. Conclusions. US of “no rhupus” SLE and RA patients is different, especially in wrists. In SLE patients the clinical variable most associated with US findings was “puffy hands.”

Effectiveness of intra-articular injection in wrist joints according to triamcinolone hexacetonide dose in rheumatoid arthritis: a randomized controlled double-blind study.

ObjectiveThe aim of this study was to compare the effectiveness in the medium term between low and high doses of triamcinolone hexacetonide used in intra-articular injection in medium-sized joints of rheumatoid arthritis (RA) patients. MethodsA randomized double-blind study was carried out in rheumatoid arthritis patients with wrist painful refractory synovitis. Sixty wrists were included and randomized to receive low dose (20 mg) or high dose (40 mg). The outcomes assessed in T0, T1, T4, T8, and T12 weeks were visual analog scale for pain and for swelling, chronic disease activity index, goniometry, simplified Stanford Health Assessment Questionnaire, and side effects. ResultsBaseline mean (standard deviation) values were pain visual analog scale of 6.1 (1.6) and 6.3 (1.7), P = 0.562; swelling visual analog scale of 5.9 and 6.4, P = 0.466; chronic disease activity index of 17.8 and 16.8, P = 0.366; and Health Assessment Questionnaire of 0.8 and 0.7, P = 0.238, in the high- and low-dose groups, respectively. Both groups improved pain and swelling assessed by the visual analog scale, P < 0.001, in the intragroup analysis. Chronic disease activity index, goniometry, and Health Assessment Questionnaire also improved equally over time in both groups in the intragroup analysis (P < 0.001, 0.001, and 0.002, respectively). No serious side effects were detected. ConclusionsHigh and low triamcinolone hexacetonide doses had good effectiveness in wrist-blinded intra-articular injection of rheumatoid arthritis patients, without statistical difference between them.

Interphalangeal Joint Sonography of Symptomatic Hand Osteoarthritis: Clinical and Functional Correlation.

To assess the correlation between inflammatory sonographic findings (grayscale synovial hypertrophy and power Doppler) and clinical and functional assessments in hand osteoarthritis (symptomatic interphalangeal joints) and to correlate the intraobserver and interobserver reliability of these findings.