In their interesting study, Szkudlarek et al (1) demonstrated that musculoskeletal ultrasonography of selected small finger and toe joints achieved high interobserver agreement rates for the identification of synovitis and bone erosions. This is an important issue, and we thank the authors for performing this study, especially because one of the main disadvantages of musculoskeletal ultrasound was considered to be operator dependence, which was disproven in this study. However, we think that the study raises some points with regard to preselection of the joints and the scoring systems introduced.The authors decided to evaluate 5 preselected joints (the second and third metacarpophalangeal [MCP] joints, the second proximal interphalangeal [PIP] joint, and the first and second metatarsophalangeal [MTP] joints), because they thought that the accessibility of these joints for assessment with ultrasound was representative of all small joints of the hands and feet. However, the distribution of joint involvement does change in patients with rheumatoid arthritis: the second and third MCP joints are clinically involved more often than are the fourth and fifth MCP joints (2). Also, more erosions have been described in the second and fifth MCP joints compared with the third and fourth MCP joints (3). Furthermore, the accessibility and therefore the interpretation of pathologic findings of the second MCP joint is easier than in other finger joints. Because the patient cohort was rather small and an ultrasonographic examination of all PIP and MCP joints takes about 10-15 minutes (4), we would suggest an examination of all of these joints, which is supplemented by the authors' statement that the "agreements varied from joint to joint probably reflecting the anatomic localization and availability for examination" (1).Semiquantitative scoring systems are frequently used in radiology (e.g., magnetic resonance imaging evaluation of synovitis and bone lesions) (5). However, we believe the ultrasonographic scoring systems introduced for calculating interobserver agreement may have some limitations. We perform ultrasonographic examinations of finger and toe joints from the dorsal and volar sides and in 2 planes (see ref. 6), but in the report by Szkudlarek et al (1), we did not see a clear description of whether the authors performed the examination according to a standardized protocol. Our experience shows that synovitis and effusion can be detected predominantly from the volar side. It would have been of great interest to see the typical anatomic landmarks (e.g., metacarpal head, tendon, synovial membrane) as well as a statement about the orientation (volar or dorsal view, proximal or distal) and specification (MCP, PIP, or MTP) of the joints in the figures. It therefore remains unclear whether synovitis and effusion appear similar or equal in all 3 joint regions.In the study by Szkudlarek et al, synovitis was classified on a 4-grade scale (0-3), with a score of 1 defined as "filling the angle between the periarticular bones, wit...

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The Ro60, Ro52 and La antibody profile is fixed at an early stage of disease and in most patients hardly changes. Patients with fluctuating levels tend to have a co-ordinated expression of these autoantibodies.

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BackgroundAdrenal, thyroid, and parathyroid gland hormonal changes are recognized in children with homozygous (HbSS) sickle-cell anemia (SCA), but are not clear in adult patients with SCA.AimTo assess the metabolic and endocrine abnormalities in adult patients with SCA and evaluate left ventricular (LV) systolic and diastolic functions compared with patients with no SCA and further study the relationship between serum levels of cortisol, free thyroxine (T4), and testosterone with serum ferritin.Materials and methodsThe study was conducted on 82 patients with adult HbSS SCA compared with a sex- and age-matched control group. The serum levels of cortisol, parathyroid hormone (PTH), testosterone, thyroid-stimulating hormone (TSH), and free T4 were compared. Blood levels of hemoglobin, reticulocyte count, lactate dehydrogenase (LDH), calcium, alkaline phosphatase (ALP), vitamin D3, and ferritin were also compared. Pulsed Doppler echo was performed to evaluate the LV mass, wall thickness, and cavity dimensions with diastolic filling velocities of early (E) and atria (A) waves. Biometric data were analyzed as mean ± standard deviation between the two groups. Multiple regression analysis was performed between serum levels of ferritin as independent variable and testosterone, cortisol, and thyroid hormones.ResultsA total of 82 adult patients with HbSS SCA were enrolled who had a mean age of 21±5.7 years, with 51 males (62%). Patients with SCA compared with the control group had significantly lower hemoglobin, body mass index, cortisol, vitamin D3, testosterone, and T4. Furthermore, there were significantly high levels of reticulocyte count, PTH, TSH, ferritin, LDH, ALP, and uric acid. The incidence of subclinical hypothyroidism and adrenal insufficiency was 7% and 4.8%, respectively, with hypogonadism 9.8% and vitamin D3 deficiency 61%. There were inverse relationships between ferritin as independent variable and serum levels of testosterone, T4, and cortisol, with regression coefficients of −0.49 (P<0.001), −0.33 (P<0.001), and −0.11 (P<0.92), respectively.ConclusionPatients with adult SCA had a high prevalence of in vivo hypoadrenialism (4.8%), hypogonadism (9.8%), and hypothyroidism (7%). There were significant inverse relationships between serum ferritin as independent variable and cortisol, testosterone, and T4. Pulsed Doppler echocardiography showed increased LV mass, with a restrictive LV diastolic pattern suggestive of diastolic dysfunction.

BACKGROUNDAdult patients with sickle-cell disease (SCD) often have multiple bone compactions causing tissue hypoxia and osteonecrosis. The impact on bone abnormalities lesion detected by bone mass density is not well defined.AIM:The study is a cross sectional, perspective was designed to assess the prevalence of abnormal BMD in adult Bahraini patients with SCD and to assess the predictive risk of different metabolic variables such as serum level of vitamin D3, testosterone, and parathyroid hormone in addition to lactate dehydrogenase (LDH), hemoglobin (Hb), and reticulocyte count for the development of abnormal bone density on dual X-ray absorptiometry (DXA) scan.METHODThe study was conducted over the period of 12 months from first of January 2012 to end of December 2012. All patients were evaluated clinically for severity of SCD and abnormal bone mass density (BMD) using DXA scan. Blood samples were withdrawn for measuring the serum level of vitamin D3, testosterone, and parathyroid hormone in addition to Hb, LDH, and reticulocyte count. Multiple logistic regression analysis was used to assess risk prediction of different variables for the development of abnormal BMD on DXA with T-score ≤−2.5 standard deviation (SD).RESULTSThe study included Bahraini patients with SCD (n = 55, age 29.24 ± 9.47 years, male 60% and female 40%) compared with an age-matched healthy control group (n = 55, age 28.82 ± 8.64 years, with 62% male and 38% female). Of the 55 patients with SCD compared with the control group, there were 33 (58%) patients with low BMD and 2 (3%) in the control. Among the 33 patients with SCD and with low BMD, there were 20 (36%) with osteoporosis (T-score of ≤−2.5 SD) and 13 (24%) with osteopenia (T-score of <−1 to −2.5 SD). The most affected site of low BMD was lumbar spine (55%), followed by the radius (30%) and neck of the femur (15%). SCD patients with osteoporosis compared with the healthy subjects had significantly lower body surface area (BSA, m2) of 1.4 ± 0.3 vs. 1.63 ± 0.5 BMI, low level of vitamin D3 of 21.11 ± 6.95 ng/mL vs. 46.2 ± 15.19 (P < 0.001), lower testosterone level of 1.34 ± 0.54 vs. 2.18 ± 0.56 ng/mL (P < 0.001), higher reticulocyte count (P < 0.001), and higher LDH level (P < 0.001). The low serum level of vitamin D3 (<20 ng/mL) and low testosterone of <0.9 ng/mL had risk prediction (odds ratio) of 1.14 and 1.2, respectively, for abnormal BMD in SCD. In the risk prediction of other variables of parathormone (PTH), LDH, and reticulocyte, were not significant.CONCLUSIONThe prevalence of abnormal bone mass density (BMD) is high (60%) in Bahraini patients with SCD. There is significant low serum level of vitamin D3 and low testosterone hormone in those with very low bone mass density (BMD) (osteoporosis and T-score <−2.5). The low serum level of vitamin D3 (<20 ng/mL) and low testosterone of <0.9 ng/mL had risk prediction (odds ratio) of 1.14 and 1.2, respectively, for abnormal BMD in SCD.

The Ro60, Ro52 and La antibody profile is fixed at an early stage of disease and in most patients hardly changes. Patients with fluctuating levels tend to have a co-ordinated expression of these autoantibodies.

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