Muskuloskelettale Punktion, Injektion und Infiltration: Standpunkt von Schweizer Rheumatologen

Zusammenfassung: Punktion, Injektion und Infiltration von Gelenken und Weichteilen gehören zu den grundlegenden Tätigkeiten der Rheumatologie. Da sich Indikationen und praktisches Vorgehen historisch entwickelt haben, ist die kritische Prüfung und ggf. die Anpassung etablierter Praktiken im Licht neuer wissenschaftlicher Erkenntnisse und technischer Errungenschaften zentral. Die wichtigsten Indikationen für eine Punktion sind die Infektsuche und die Druckentlastung bei Erguss. Gute Indikationen für Glukokortikoidinjektionen sind das entzündete, nichtinfizierte Gelenk und die aktivierte Arthrose. Kritisch hinterfragt werden müssen die seit Jahrzehnten etablierten, bis vor Kurzem kaum hinterfragten, im Einzelfall nicht selten repetitiv durchgeführten Infiltrationen bei mechanischer Enthesopathie am Epicondylus humeri radialis (Tennisellenbogen) oder der Plantarfaszie (Fasziitis plantaris). Bei diesen führen insbesondere wiederholte Glukokortikoidinfiltrationen zu einem schlechteren Verlauf als ohne Injektio

Ultraschall und Arthritis

Zusammenfassung: Die Arthrosonographie ist ein etabliertes und validiertes diagnostisches Verfahren in der Rheumatologie. Durch ihren hohen Weichteilkontrast ist die Sonographie in der Lage, Weichteilveränderungen wie z.B. Synovialisveränderungen zu detektieren. Knorpel- oder Knochenveränderungen im Rahmen einer rheumatoiden Arthritis (RA), einer Spondyloarthritis oder einer Kristallarthritis können teilweise nur sonographisch oder in vielen Fällen zu einem früheren Zeitpunkt als mit der konventionellen Bildgebung erfasst werden. Die Aktivität entzündlicher Veränderungen kann mit Hilfe der Doppler- und Power-Dopplersonographie gut dargestellt werden. In der Früharthritisdiagnostik gewinnt die Sonographie zunehmend an Bedeutung, insbesondere bei undifferenzierter Arthritis und bei unauffälligem Röntgenbefund. Neben der Diagnostik der Früharthritis und dem Therapiemonitoring einer RA erlaubt die Sonographie die Darstellung pathognomonischer Veränderungen bei seronegativen Spondyloarthritiden und Kristallablagerungserkrankungen wie Gicht, Chondrokalzinose und Apatitose. Sonographiegesteuerte diagnostische und therapeutische Interventionen zeichnen sich durch eine extrem hohe Treffsicherheit und Verbesserung der klinischen Wirksamkeit verglichen mit ungesteuerten Verfahren aus. Zusammenfassend nimmt die Sonographie zunehmend einen zentralen Stellenwert ein in der Abklärung und Behandlungssteuerung bei entzündlichen Gelenkerkrankunge

Observational study of a patient and doctor directed pre-referral questionnaire for an early arthritis clinic

We evaluated a combined physician and patient questionnaire designed for identifying early rheumatoid arthritis (RA) and spondyloarthritis (SpA) in a cohort of 220 patients supposed for admission to an early arthritis clinic (EAC). The documents including personal and basis demographic data, referral diagnosis, questions related to RA and SpA classification criteria, functional limitations and previous diagnostic and therapeutic attempts were fax-transmitted to referring practices and returned before first EAC appointment. 125 referrals before introduction of the questionnaire served as controls. We found that a functional impairment of the hands provided more accurate prediction of RA than reports on morning stiffness or joint swelling. No clinical data proved predictive for SpA. We observed an unintended increase in the prescription of analgesics/NSAID and corticosteroids. In conclusion, questionnaires as designed here may provide substantial information for diagnosis of RA, but also imply the risk of unmeant therapeutic attempt

High-resolution ultrasound confirms reduced synovial hyperplasia following rituximab treatment in rheumatoid arthritis

Objective. To assess the response of RA patients to rituximab (RTX) treatment using a sensitive imaging technique for synovitis. Methods. Twenty-three RA patients were treated with two 1000-mg infusions of the B-cell depleting antibody, RTX, in an observational protocol. Clinical response was assessed by the European League Against Rheumatism (EULAR) response criteria. High-resolution grey-scale and colour-coded power Doppler (PD) ultrasonography was performed at baseline and 6 months after RTX. The second to fifth MCP and PIP joints were bilaterally examined with joints in a neutral 0 position from a palmar view and scored from 0 to 3. Results. Median disease activity score (DAS28) improved from 5.03 to 3.56 (P = 0.001), which corresponded to a EULAR moderate response in 11 of 23 patients and a EULAR good response in another 6 patients. Improved control of disease activity by RTX was also indicated by tapering of median daily corticosteroid doses from 10 to 5 mg, without flare ups. Mean grey-scale scores correlated with the swollen joint count at baseline (r = 0.484, P = 0.022) and month 6 (r = 0.519, P = 0.011). Mean grey-scale scores improved upon RTX from a 0.90 median (range 0.13-1.87) to 0.75 (range 0.19-1.50, P = 0.023). Frequency of PD positive joints was low (6.1%) at baseline and did not significantly change following RTX treatment. Conclusions. High-resolution grey-scale ultrasonography (US) examination confirmed reduced synovial hyperplasia, but the applied PD method displayed no significant changes. Therefore, only grey-scale US is recommended in follow-up examinations after RTX treatmen

The Role of Expenditures in Predicting Adequate Yearly Progress for Special Needs Students in Ohio

Although there exists a large body of research concerning the relationship between expenditure and student achievement, a lack of research exists analyzing this relationship as it pertains specifically to students with disabilities

Consequences of different diagnostic ‘gold standards' in test accuracy research: Carpal Tunnel Syndrome as an example

Test accuracy studies assume the existence of a well-defined illness definition and clear-cut diagnostic gold standards or reference standards. However, in clinical reality illness definitions may be vague or a mere description of a set of manifestations, mostly clinical signs and symptoms. This can lead to disagreements among experts about the correct classification of an illness and the adequate reference standard. Using data from a diagnostic accuracy study in carpal tunnel syndrome, we explored the impact of different definitions on the estimated test accuracy and found that estimated test performance characteristics varied considerably depending on the chosen reference standard. In situations without a clear-cut illness definition, randomized controlled trials may be preferable to test accuracy studies for the evaluation of a novel test. These studies do not determine the diagnostic accuracy, but the clinical impact of a novel test on patient management and outcom

Aspects of Isometric Contractions and Static Balance in Women with Symptomatic and Asymptomatic Joint Hypermobility

Objective: The aim of the current study was to identify the differences in strength, balance and muscle activity between women with normal mobility and those with generalized joint hypermobility (GJH) with and without symptoms. Methods: A total of 195 women, 67 normomobile (NM) and 128 hypermobile (HM), were included in this explorative cross-sectional study, whereby 56 were classified as symptomatically hypermobile (HM-s) and 47 as asymptomatically hypermobile (HM-as). Peak force (Fmax) and rate of force development (RFD) were measured during single-leg maximal voluntary isometric contractions of the knee extensor and flexor muscles in a sitting position. Balance was investigated on a force plate by calculating the anterior-posterior and medio-lateral sway while maintaining a single-leg stance for 15 seconds. During the sway measurements, muscle activity of six leg muscles was recorded using surface electromyography. The NM and HM groups were compared using independent samples t-tests, whereas the NM, HM-s and HM-as groups were compared using one-way ANOVAs with Tukey post-hoc tests (significance level p ≤ 0.05). Results: While no statistically significant differences were found for Fmax, RFD and postural sway between the three groups, semitendinosus muscle activity showed a difference between the NM and HM (p=0.019) as well as between the NM and HM-as groups (p=0.020). Conclusions: No clinically meaningful differences were found between the three groups. This might be possibly due to the fact that the performance measurements were not sensitive and the motor tasks not challenging enough to detect differences in neuromuscular behavior of the investigated groups

[Musculoskeletal puncture, injection and infiltration: swiss rheumatologists' point of view]

Arthrocentesis, injection and infiltration of joints and soft tissues belong to the basic procedures in rheumatology. The indications and the practical performance are based on experience and tradition. Nowadays, a crucial reappraisal and adaption of indications and technical aspects appear important in the light of new evidence and technical developments. The main indications for puncture remain the search of an infectious arthritis and reduction of intra-articular pressure due to effusion. Good indications for the injection of glucocorticoids are inflammation in sterile joints and activated osteoarthritis. The local infiltration with corticosteroids in mechanically induced enthesopathies at the lateral epicondyle of the humerus or at the plantar fascia have to be questioned in the light of recent publications which show that this common practice is associated with a poorer outcome than without injection