Ultrasonography (US) is a valuable tool for confirming the diagnosis of carpal tunnel syndrome (CTS) as it enables the detection of changes in the median nerve shape and rule out anatomic variants as well as space-occupying lesions such as ganglion cysts or tenosynovitis. This work was carried out aiming at: 1. Ultrasonography assessment of the median nerve and its neurovascular blood-flow in CTS patients before and after management. 2. Verify the possibility of using baseline US parameters as a biomarker to predict likely outcomes and frame a treatment plan for CTS patients.233 CTS subjects diagnosed based on clinical and electrophysiological (NCS) testing were included in this work. US measures at the tunnel inlet included: cross sectional area, flattening ratio and neural Power Doppler (PD) signals. Patients who had severe NCS outcomes or neurological deficit were referred for open surgical decompression; the remaining patients were given the choice of either conservative or surgical management. The main outcome variable was improvement >70% in CTS symptoms. Assessments were carried out at baseline, 1-week, 1-month and 6-months post treatment. Results revealed an inverse relation between the neural vasculature and CTS severity defined by NCS (r = − 0.648). In CTS cases treated conservatively, the US measures started to improve within 1-week, whereas in the surgically treated cohort there was an initial phase of post-operative nerve measures increase, before settling at 1-month time of follow-up. The risk of poor outcomes was significantly higher (RR 3.3) in patients with high median nerve flattening ratio. This risk was most marked in the cohort with nerve flattening associated with longer duration of illness (RR 4.3) and low PD signal (RR 4.1). The results revealed that in addition to the diagnostic value of US in CTS, the detection of increased median nerve neuro-vasculature has a good prognostic value as an indicator of early median nerve affection.
This study aims to identify the clinical predictors of arthritis in patients with psoriasis and to evaluate the use of musculoskeletal ultrasonography (US) as a predictor for inflammatory structural progression in psoriatic patients. Measures of association (odds ratio (OR)) were tested, in a prospective, cohort 1-year follow-up study, between structural deterioration and the presence of baseline inflammation, or its persistence. One hundred twenty-six psoriatic patients were prospectively evaluated both clinically and by US at 0, 6, and 12 months for synovitis/ joint damage, enthesitis, and onychopathy. X-ray was performed at 0 and 12 months. One hundred twelve sex and age-matched pasoriatic patients without histories of musculoskeletal symptoms were included as control group. Structural deterioration was observed in 47% of the 5,292 evaluated joints. Clinical variables associated with arthritis risk: BMI > 25 (OR = 1.7), body surface area (OR = 1.13), family history (OR = 5.72) and nail involvement (OR = 2.25). BMI > 30 was significantly correlated (P < 0.01) with shorter time for the onset of arthritis. Baseline synovial score/PD score ≥ 2 was associated with increased risk of structural progression: OR = 1.98 versus 2.61 versus 2.66 (P < 0.001) for the clinical versus US-gray scale (GS) versus US-power Doppler (PD) evaluation, respectively. An increased probability for structural progression in the presence of enthesitis was observed (OR = 2.79 and 3.50) for both US-GS and US-PD, whereas OR was 2.46 for clinical examination. Onychopathy was associated with structural joint damage (OR = 2.30). In multivariate logistic regression analysis, persistent of synovitis/enthesitis at 6 months of therapy was predictive of subsequent structural progression. Family history of psoriatic arthritis, large BMI (>25), high percentage of psoriatic body surface area, and nail involvement were significantly associated with early onset psoriatic arthritis. Baseline GS score of ≥2, PD score of ≥2, presence of enthesitis, enhanced vascularity at enthesitis, higher GUESS score, and onychopathy, all at base line as well as persistent synovitis and enthesitis at 6 months are predictors of progressive early psoriatic arthritis. Regular ultrasonographic monitoring of these patients is mandatory to assess the progression of their arthritis status.
This study aims to assess clinical, lab/immunological or imaging (joint ultrasonography) markers able to predict disease relapse in RA patients in sustained remission when tapering or stopping their treatment. One hundred fifty-seven RA patients in clinical remission (DAS-28 <2.6 for >6 months), receiving treatment with sDMARDs and bDMARD therapy, were randomly allocated into any of five groups: Group 1: continue full dose DMARDs and taper biologic therapy by 50 % (31 patients); Group 2: taper both DMARDs and biologic therapy dose by 50 % (32 patients); Group 3: taper DMARDs by 50 % and stop biologic therapy (31 patients); Group 4: stop both DMARDs and biologic therapy (31 patients); Group 5: continue medications without change (31 patients). Forty joints were assessed ultrasonographically (DAS-28 joints + ankles + metatarsophalangeal joints) and prospectively monitored for 12 months. The primary endpoint was sustained remission for 12 months. Patients were considered as having a relapse when the DAS-28 score was >3.2 and anti-rheumatic treatment was escalated. The frequency of relapse was 41.9 % in Group 1, 59.3 % in Group 2, 67.7 % in Group 3, 77.4 % in Group 4 and 6.5 % in Group 5. Relapse rates were significantly higher in patients whose ultrasound scores raised within 3 months of stopping their medications (P < 0.001 for both GS and PD scores). Cox regression identified ACPA positivity (at baseline) and progression of functional disability (at 2 months) as predictors for relapse. Tapering therapy is feasible in RA patients. Tailored dynamic approach is advised. Joint ultrasonographic assessment, ACPA positivity and worsening functional disability predicted relapse within a short term after discontinuation of the treatment. RA patients whose DAS-28 score was <2 were more likely to remain in remission.
Using US as a sensitive tool for joint affection assessment, the combination of biologic and DMARDs therapies retards joint damage, independently of its effects on disease activity, contrasting synthetic DMARDs monotherapy.
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