Digital ulcers (DUs) are frequent and recurrent complication in systemic sclerosis (SSc) and are the main cause of pain, impaired function of the hand and disability in SSc. The current study is a retrospective analysis of 60 SSc patients (47 patients with limited cutaneous SSc, 8 patients with diffuse cutaneous SSc and 5 patients with overlap syndrome, mean age 54.5±14.2 years, 52 women and 8 men). The frequency and evolution of DUs as well as the applied therapeutic strategies were analyzed. During the follow-up for a period between 6 months and 6 years, DUs at the fingers were registered in 35% of patients (21/60), more often in patients with diffuse cutaneous SSc (75%, 6/8) as compared with patients with limited cutaneous SSc (29%, 14/47, p<0.05) and overlap syndrome (20%, 1/5). The most frequently observed DUs were ischemic lesions at the fingerpads (85.7%, 18/21) and ulcerations over bony prominences of the fingers (23%, 5/21), which may be found simultaneously. More rare types of DUs were necrotic lesions (14%, 3/21). Thirty-eight percents (8/21) of the patients with DUs showed signs of inflammation. In one patient (4.76%, 1/21) an osteomyelitis developed and an amputation of a finger's distal phalanx was performed. DUs at the toes were significantly less frequent as compared with DUs at the fingers (10%, 6/60, p<0.05). The period of healing of the DUs is prolonged and in the studied group was 3.39±2.39 months. The treatment regimen in SSc patients with DUs included vasodilators, local antiseptic treatment, antiplatelet drug; anticoagulant in cases with development of necrotic lesions, antibiotics in cases of infection or necrotic lesions, and other symptomatic therapies. In conclusion, DUs are a common complication in SSc and require complex therapeutic measures for achievement of a positive outcome.
Changes in clinical presentation, radiographic progression (RP), bone mineral density (BMD), bone turnover (BT), and cartilage turnover (CT) markers were compared in two groups of patients with hip osteoarthritis (HOA) over a period of 7 years. Each group consisted of 150 patients, including a control group on standard-of-care therapy (SC) with simple analgesics and physical exercises, and a study group (SG) on standard-of-care therapy supplemented by vitamin D3 and intravenous administration of zoledronic acid (5 mg) yearly for 3 consecutive years. Patient groups were homogenized regarding the following: (1) radiographic grade (RG), including 75 patients with hip OA RG II according to the Kellgren–Lawrence grading system (K/L), and 75 with RG III on K/L; (2) radiographic model (RM), as each of the K/L grades was subdivided into three subgroups consisting of 25 patients of different RMs: atrophic (‘A’), intermediate (‘I’), and hypertrophic (‘H’); (3) gender-equal ratio of men and women in each subgroup (Female/Male = 15/10). The following parameters were assessed: (1) clinical parameters (CP), pain at walking (WP-VAS 100 mm), functional ability (WOMAC-C), and time to total hip replacement (tTHR); (2) radiographic indicators(RI)—joint space width (JSW) and speed of joint space narrowing (JSN), changes in BMD (DXA), including proximal femur (PF-BMD), lumbar spine (LS-BMD), and total body (TB-BMD); (3) laboratory parameters (LP)—vitamin D3 levels and levels of BT/CT markers. RV were assessed every 12 months, whereas CV/LV were assessed every 6 months. Results: Cross-sectional analysis (CsA) at baseline showed statistically significant differences (SSD) at p < 0.05 in CP (WP, WOMAC-C); BMD of all sites and levels of CT/BT markers between the ‘A’ and ‘H’ RM groups in all patients. Longitudinal analysis (LtA) showed SSD (p < 0.05) between CG and SG in all CP (WP, WOMAC-C, tTHR) parameters of RP (mJSW, JSN), BMD of all sites, and levels of CT/BT markers for all ‘A’ models and in 30% of ‘I’-RMs (those with elevated markers for BT/CT at baseline and during the observation period). Conclusion: The presence of SSD at baseline (‘A’ vs. ‘H’) supported the thesis that at least two different subgroups of HOA exist: one associated with ‘A’ and the other with ‘H’ models. D3 supplementation and the intravenous administration of bisphosphonate were the treatment strategies that slowed down RP and postponed tTHR by over 12 months in the ‘A’ and ‘I’ RM with elevated BT/CT markers.
Digital ulcers (DUs) are among the most frequent and disabling vascular complications in patients with systemic sclerosis (SSc). The etiology and pathogenesis of DUs differs depending on the lesion localization. For this reason the underlying etiologic and pathogenetic factors will guide the therapeutic decision. The main pathogenic mechanism that contributes to the development of fingertip DUs is ischemia owing to SSc-related vasculopathy. DUs over bony prominences are mainly a result of skin fibrosis, epidermal thinning and mechanical friction. At the areas of subcutaneous calcinosis DUs can develop as a result of mechanical friction and inflammation. Thus, in cases of DUs over bony prominences and calcinosis, avoidance of trauma and skin care are main measures of primary prophylaxis. In pure ischemic DUs, a combination of vasodilators (calcium channel blockers (CCBs), intravenous prostanoid, phosphodiesterase inhibitors) and antiplatelet drugs should be applied. Despite the lack of controlled trials addressing the administration of antiplatelet agents and anticoagulants in DUs in the context of SSc, the current knowledge about the platelet and coagulation dysfunction leads to their frequent administration from the leading experts in the field of SSc. In our opinion, as more powerful agents, anticoagulants should be considered in severe cases of development of digital gangrenes. Analgetics and antibiotics may be indicated and local treatment is a mandatory care. Currently, the EUSTAR recommendations for the treatment of RP and DUs in SSc include CCBs, intravenous prostanoids and endothelin receptor antagonists. Although for the inclusion of other options in the official recommendations, their efficacy should be confirmed by controlled clinical trials, they are routinely used in the leading scleroderma-centers based on the current knowledge about the pathogenesis of development of DUs in SSc.
Background: Differentiating between a seronegative rheumatoid arthritis (RA) and psoriatic arthritis (PsA) presenting only with involvement of the small joints of the hands can be challenging. Implementing musculoskeletal ultrasound (US) to reveal specific patterns of joint and tendon involvement may have an added value in the management of early arthritis. Objective: The aim was to investigate whether a seven-joint US score was able to distinguish between patients with RA and PsA. Materials and methods: One hundred and forty-one patients with RA, 65 patients with PsA and 45 healthy controls (HC) were included in the current study. US assessment of the wrist, second and third metacarpophalangeal, second and third proximal interphalangeal joint, second and fifth metatarsophalangeal joint was performed, and the following scores were calculated: synovitis and tenosynovitis/paratenonitis scores on gray scale ultrasound (GSUS) and on power Doppler (PD) US, erosion score, US7 score. Results: RA patients had significantly higher median scores of GS synovitis, PD synovitis, erosions and US7 than PsA patients (p < 0.001). PsA patients had significantly higher median scores of GS tenosynovitis/paratenonitis and PD tenosynovitis/paratenonitis (p < 0.001). All US scores were significantly higher for both patient groups as compared to the HC group (p < 0.001). Conclusion:: Sonographic evaluation by a seven-joint score can be helpful in the differentiation between rheumatoid and psoriatic arthritis.
Background The arthrocentesis of the hip joint usually is performed in two ways – “blind” arthrocentesis based on anatomic landmarks and image-guided arthrocentesis with visualization of needle insertion and direction. Objectives The aim of the study was to compare the accuracy of blind and image-guided arthrocentesis of hip joints. Methods 96 patients with uni- or bilateral, radiologically proven hip osteoarthritis (OA) were included in the study. The total number of 187 hip joints were injected. The patients were divided into three groups according to the radiological grade of hip OA (scale of Kellgren – Lawrence) as follows: 1) 79 patients/131 hip joints - grade II; 2) 27 patients/31 hip joints - grade III; 3) 20 patients/25 hip joints - grade IV. The BMI and the presence of flexor-adductor contractures were registered. The influence of these two factors on the accuracy of the arthrocentesis was analysed. The used devices in the study were AXIOM Iconos R 200 for fluoroscopically-guided arthrocenteses and Philips HD-7 for sonografically-guided arthrocenteses. One blind arthrocentesis by lateral approach was applied for each patient (187 joints). The position of the needle was verified by injecting 1 ml contrast Ultravist with a subsequent fluoroscopic control. In case of need the needle was redirected under fluoroscopic control and the respective drug (local corticosteroid or lubricant) was injected. In 7 days, in the same patients (187 joints), it was performed the next arthrocentesis under sonographic guidance using anterior-parasagittal approach with injecting 1 ml contrast. The position of the needle was also verified and redirected if needed under fluoroscopic control with subsequent injecting of the active substance. Successful arthrocenteses were those, in which the fluoroscopic control verified a correct positioning of the needle and presence of contrast media intraarticularly. All arthrocenteses with the presence of the contrast extraarticularly, despite the visualized correct positioning of the needle, were considered as unsuccessful. Results The successful blind arthrocenteses in OA patients with radiological grade II were 74% (97/131), while unsuccessful injections were 26% (34/131). All arthrocenteses in the group, performed with sonographic guidance were successful – 100% (131/131). In the patients with radiological grade III, successful blind arthrocentesis were performed in 61.3% (19/31) and unsuccessful applications - in 38.7% (12/31). All sonografically-guided arthrocenteses in this group were also successful - 100% (31/31). In the group patients with radiological grade IV the successful blind arthrocenteses were achieved in 40% (10/25 hip joints) and unsuccessful in 60% (15/25). In this group, successfully accomplished sonografically-guided arthrocenteses were 93% (23/25), and unsuccessful - 6% (2/25). Conclusions The results from the study demonstrate, that there is no significant correlation between the presence of flexor-adductor contractures and the accuracy of blind arthrocentesis. O...
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