Stephen A Wright

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.

A randomised interventional trial of ω-3-polyunsaturated fatty acids on endothelial function and disease activity in systemic lupus erythematosus

Objective: To determine the clinical effect of dietary supplementation with low-dose ω-3-polyunsaturated fatty acids on disease activity and endothelial function in patients with systemic lupus erythematosus. Methods: A 24-week randomised double-blind placebo-controlled parallel trial of the effect of 3 g of ω-3-polyunsaturated fatty acids on 60 patients with systemic lupus erythematosus was performed. Serial measurements of disease activity using the revised Systemic Lupus Activity Measure (SLAM-R) and British Isles Lupus Assessment Group index of disease activity for systemic lupus erythematosus (BILAG), endothelial function using flow-mediated dilation (FMD) of the brachial artery, oxidative stress using platelet 8-isoprostanes and analysis of platelet membrane fatty acids were taken at baseline, 12 and 24 weeks. Results: In the fish oil group there was a significant improvement at 24 weeks in SLAM-R (from 9.4 (SD 3.0) to 6.3 (2.5), p<0.001); in BILAG (from 13.6 (6.0) to 6.7 (3.8), p<0.001); in FMD (from 3.0% (−0.5 to 8.2) to 8.9% (1.3 to 16.9), p<0.001) and in platelet 8-isoprostanes (from 177 pg/mg protein (23–387) to 90 pg/mg protein (32–182), p = 0.007). Conclusions: Low-dose dietary supplementation with ω-3 fish oils in systemic lupus erythematosus not only has a therapeutic effect on disease activity but also improves endothelial function and reduces oxidative stress and may therefore confer cardiovascular benefits.

Hand Arthritis in Systemic Lupus Erythematosus: An Ultrasound Pictorial Essay

A small minority of systemic lupus erythematosus (SLE) patients may develop a deforming arthritis, typically with a non-erosive (Jaccoud’s) pattern, although erosive features indistinguishable from rheumatoid arthritis may also occur. High-resolution ultrasonography (HRUS) allows detailed ‘real time’imaging of joint and tendon morphostructural changes involving the hand in patients with several rheumatic diseases. The main aim of this pictorial essay is to provide the first descriptive HRUS and power Doppler (PD) findings of joint and tendon involvement of the hand and wrist in patients with SLE arthritis. Seventeen patients with SLE and hand involvement were examined. HRUS of the wrist, 2nd and 3rd MCP joints, 3rd PIP joint and 2nd, 3rd and 4th finger flexor tendons were studied in the dominant hand for each patient. Sixteen (94%) patients had joint effusion or synovial hypertrophy in the wrist. Twelve (71%) patients had joint effusion or synovial hypertrophy in 2nd or 3rd MCPJs. Eight (47%) patients had erosion at 2nd or 3rd MCPJs. In three cases erosions were not present radiologically. Eleven (65%) patients had evidence of tenosynovitis. In SLE, HRUS with PD detects a high prevalence of inflammatory pathology in the tendons and synovium of the hand and wrist, and a high prevalence of MCP joint erosions. HRUS offers a sensitive, real-time and readily repeatable assessment of soft-tissue, inflammatory and bony changes in SLE hands.

Microcirculatory hemodynamics and endothelial dysfunction in systemic lupus erythematosus.

Objective—Impaired flow-mediated dilation (FMD) occurs in disease states associated with atherosclerosis, including SLE. The primary hemodynamic determinant of FMD is wall shear stress, which is critically dependent on the forearm microcirculation. We explored the relationship between FMD, diastolic shear stress (DSS), and the forearm microcirculation in 32 patients with SLE and 19 controls. Methods and Results—DSS was calculated using (mean diastolic velocity×8×blood viscosity)/baseline brachial artery diameter. Doppler velocity envelopes from the first 15 seconds of reactive hyperemia were analyzed for resistive index (RI), and interrogated in the frequency domain to assess forearm microvascular hemodynamics. FMD was significantly impaired in SLE patients (median, 2.4%; range, −2.1% to 10.7% versus median 5.8%; range, 1.9% to 14%; P<0.001). DSS (dyne/cm2) was significantly reduced in SLE patients (median, 18.5; range, 3.9 to 34.0 versus median 21.8; range, 14.1 to 58.7; P=0.037). A strong correlation between FMD and DSS, rs=0.65, P=0.01 was found. Postischemic RI was not significantly different between the 2 groups; however, there were significant differences in the power-frequency spectrums of the Doppler velocity envelopes (P<0.05). Conclusions—These data suggest that in SLE, altered structure and function of the forearm microcirculation contributes to impaired FMD through a reduction in shear stress stimulus.

Colour Doppler ultrasound of the ocular circulation in patients with systemic lupus erythematosus identifies altered microcirculatory haemodynamics

We assessed whether quantitative analysis of Doppler flow velocity waveforms is able to identify subclinical microvascular abnormalities in SLE and whether eigenvector analysis can detect changes not detectable using the resistive index (RI). Fifty-four SLE patients with no conventional cardiovascular risk factors, major organ involvement or retinopathy were compared to 32 controls. Flow velocity waveforms were obtained from the ophthalmic artery (OA), central retinal artery (CRA) and common carotid artery (CA). The waveforms were analysed using eigenvector decomposition and compared between groups at each arterial site. The RI was also determined. The RI was comparable between groups. In the OA and CRA, there were significant differences in the lower frequency sinusoidal components (P < 0.05 for each component). No differences were apparent in the CA between groups. Eigenvector analysis of Doppler flow waveforms, recorded in proximity of the terminal vascular bed, identified altered ocular microvascular haemodynamics in SLE. Altered waveform structure could not be identified by changes in RI, the traditional measure of downstream vascular resistance. This analytical approach to waveform analysis is more sensitive in detecting preclinical microvascular abnormalities in SLE. It may hold potential as a useful tool for assessing disease activity, response to treatment, and predicting future vascular complications.

Wave reflection signatures: identifying early microvascular abnormalities in type 2 diabetes

Microvascular changes occur early in diabetes mellitus. Doppler ultrasound enables non-invasive identification of ocular microvascular haemodynamics through interrogation of blood flow velocity waveforms. Wave decomposition permits the spectrum of sinusoidal components comprising flow velocity waveforms to be quantified. We hypothesised that comprehensive interrogation of waveforms would be more sensitive in identifying microvascular abnormalities than traditional analysis employing the resistive index. Thirty-four subjects with type 2 diabetes and 20 healthy controls between 30 and 70 years old were recruited. Doppler flow velocity waveform signals were captured from the ophthalmic and carotid arteries under standardised conditions. The signals were analysed using a wave decomposition algorithm and the sinusoidal components of average waveforms were compared between groups at both arterial sites. The diabetes group displayed significant differences in the lower frequency sinusoidal components of both the ophthalmic artery (p<0.001) and, to a lesser extent, the carotid artery (p<0.05) waveforms compared with controls, with no difference noted in the resistive index at either site. We conclude that wave decomposition analysis of Doppler flow velocity waveforms, recorded in proximity of the terminal vascular bed of interest, can identify subtle microvascular haemodynamic abnormalities not detected by traditional methods of analysis. Br J Diabetes Vasc Dis 2011;11:243-248

Discussion paper - Fibromyalgia syndrome and bone health

Abstract Fibromyalgia syndrome is a chronic musculoskeletal disorder characterised by widespread pain, sleep disturbance, headache, stiffness and fatigue. There are a number of potential detrimental factors on bone health in patients with fibromyalgia syndrome including immobility, depression, lack of sunlight and poor nutrition. In this article, the literature relating to fibromyalgia syndrome and bone health is reviewed, and evidence is provided for the potential role of physiotherapy in treating fibromyalgia and maintaining bone health.

Vitamin D status and disease activity in systemic lupus erythematosus in Northern Ireland

L. C. Breslin, E. M. Duffy, H. G. Mulholland, S. A. Wright, M. S. Barnes, R. Hodd, J. M. W. Wallace and A. L. Bell Northern Ireland Centre for Food and Health, University of Ulster, Coleraine BT52 1SA, UK, Cancer Epidemiology & Prevention Research Group, Queen’s University Belfast, Royal Victoria Hospital Site, Belfast BT12 6BJ, UK and Musculoskeletal Education and Research Unit, Musgrave Park Hospital, Belfast BT9 7JB, UK