Abstract Objective: to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over 1-year. Methods: A randomized, double-blind study. 60 patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for 1-year, at baseline and 1, 4, 8, 12, and 48 weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response. Results: Sixty patients completed the follow-up. There were nine missed assessments. 97% were women; mean age of 61-years (SD = 8.2), and approximately 5-years of disease (SD = 3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades I and II, and the other half grades III and IV. The two groups evolved similarly at 48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p = 0.04 and p < 0.001, respectively) at 48-weeks. Radiographically there was no statistical difference between groups (KL, p = 0.564; erosive OA, p = 0.999; worsening, p = 0.573). Conclusion: The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint.

OBJECTIVES: To compare the ultrasonographic findings of entheses in ankylosing spondylitis (AS) patients with those of healthy control individuals and to assess the ability of ultrasound (US) to identify aspects related to the disease. METHODS: A cross-sectional study involving 50 patients with AS and 30 healthy controls was performed. Clinical assessment included the use of a visual analog scale for pain, assessment of swelling of the enthesis, global assessments for patients and physician, use of a disease activity index, mobility and dysfunctional indices, erythrocyte sedimentation rate and clinical enthesitis index. US was performed for the following entheses by two experienced musculoskeletal radiologists: brachial triceps, distal quadriceps, proximal and distal patellar tendons, calcaneal tendon, and plantar fascia; the total and subitems of the Madrid Sonographic Enthesitis Index were used for evaluations. RESULTS: Comparison between groups showed a statistically significant difference with worse scores in AS patients, with bone erosion of the calcaneal enthesis and bone erosion and thickening of the plantar fascia. The odds ratio for thickening of the plantar fascia in the AS group was 3.47, according to logistic regression analysis. The AS group also had worse scores regarding the presence of calcification in the quadriceps enthesis, with a fivefold increased risk. CONCLUSION: US analysis showed that only entheses of the foot and quadriceps were able to differentiate AS patients from healthy individuals.

Resumo Objetivos: Descrever a competência dos reumatologistas brasileiros na reumatologia intervencionista (RI); avaliar a associação entre essa capacidade e variáveis demográficas e de treinamento. Métodos: Fez-se um estudo transversal com 500 reumatologistas brasileiros. Os participantes foram avaliados por questionário autoadministrado, constituído por dados demográficos, treinamento, prática em consultório e conhecimento em dados de RI. Resultados: Analisaram-se os dados de 463 participantes. A média foi de 40,2 anos (± 11,2). Desses, 70% fizeram injeções periarticulares (IPA) e 78% intra-articulares (IIA). A amostra foi dividida em três grupos: não intervencionista, pouco intervencionista e muito intervencionista. O grupo não intervencionista apresentou (p < 0,001 - 0,04) maior média de idade, menor proporção de vínculo universitário, menor história de treinamento, maior proporção de graduados na Região Sudeste do país e maior proporção de graduados nas décadas de 1980 a 1989. O grupo muito intervencionista apresentou (p < 0,001 - 0,018) maior proporção de reumatologias que atendem pacientes adultos, maior proporção de vínculo universitário, maior tempo de treinamento de prática de procedimentos complexos, maior proporção de graduados no sul do país, treinados e com consultório particular nessa região. As variáveis mais frequentemente associadas ao subgrupo muito intervencionista foram realização de IIA axial (OR: 7,4, p < 0,001), biópsia sinovial (OR: 5,75, p = 0,043), IIA guiada por imagem (OR: 4,16, p < 0,001), viscossuplementação (OR = 3,41, p < 0,001), lavagem articular (OR = 3,22, p = 0,019), biópsia da glândula salivar (OR = 2,16, p = 0,034) e mais de seis meses de treinamento (OR: 2,16; p = 0,008). Conclusões: Fazer procedimentos invasivos mais complexos e ter mais de seis meses de treinamento em RI foram as variáveis associadas a um maior perfil intervencionista.

Abstract Objectives: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. Methods: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. Results: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p < 0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p < 0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p < 0.001), synovial biopsy (OR: 5.75, p = 0.043), image-guided IAI (OR: 4.16, p < 0.001), viscosupplementation (OR = 3.41, p < 0.001), joint lavage (OR = 3.22, p = 0.019), salivary gland biopsy (OR = 2.16, p = 0.034) and over 6-month training (OR: 2.16, p = 0.008). Conclusions: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.

Resumo Objetivos: Avaliar variáveis articulares locais após a injeção intra-articular (IIA) de hexacetonido de triancinolona (HT) em pacientes com artrite reumatoide (AR). Métodos: Avaliaram-se de modo cego e prospectivo (inicial, 1, 4, 12 e 24 semanas) as articulações metacarpofalângica (MCF), punho, cotovelo, ombro, joelho e tornozelo após a IIA de HT à procura das seguintes medidas de desfecho: escala visual analógica (EVA) de 0 a 10 cm para dor em repouso (EVAr); EVA para dor ao movimento (EVAm); EVA para inchaço das articulações (EVAi); flexão (FlexG) e extensão (ExtG). Resultados; Estudaram-se 289 pacientes (635 articulações). A EVAi (p < 0,001) e a EVAr (0,001 < p < 0,016) melhoraram de T0 a T4, T12 e T24 em todas as articulações. A EVAm melhorou de T0-T4 (p < 0,021) em todas as articulações; T0-T12 (p < 0,023) na MCF e no joelho; T0-T24 (p < 0,019) apenas na MCF e no joelho. A FlexG melhorou de T0-T4 (p < 0,001) em todas as articulações; T0-T12 (p < 0,001) e T0-T24 (p < 0,02) apenas na MCF e no joelho. A ExtG melhorou de T0-T4 (p < 0,001) em todas as articulações, exceto no cotovelo; T0-T12 (p = 0,003) no punho, na MCF e no joelho; e T0-T24 (p = 0,014) na MCF e no joelho. Conclusão: A EVAi respondeu melhor em curto e médio prazos após a IIA de HT na presente amostra de pacientes com AR.

Abstract Objectives: To evaluate local joint variables after intra-articular injection with triamcinolone hexacetonide in rheumatoid arthritis patients. Methods: We blindly and prospectively (baseline, 1, 4, 12 and 24 weeks) evaluated metacarpophalangeal, wrist, elbow, shoulder, knee and ankle joints after triamcinolone hexacetonide intra-articular injection by the following outcome measures: visual analogue scale 0–10 cm (VAS) for rest pain (VASR); VAS for movement pain (VASM); VAS for joint swelling (VASSw); flexion (FlexG) and extension (ExtG). Results: 289 patients (635 joints) were studied. VASSw (p < 0.001) and VASR (0.001 < p < 0.016) improved from T0 to T4, T12 and T24 for all joints. VASM improved from T0 to T4 (p < 0.021) for all joints; T0 to T12 (p < 0.023) for MCF and knee; T0 to T24 (p < 0.019) only for MCF and knee. FlexG improved from T0 to T4 (p < 0.001) for all joints; T0 to T12 (p < 0.001) and T0 to T24 (p < 0.02) only for MCF and knee. ExtG improved from T0 to T4 (p < 0.001) for all joints except for elbow; T0 to T12 (p = 0.003) for wrist, metacarpophalangeal and knee; and T0 to T24 (p = 0.014) for MCF and knee. Conclusion: VASSw responded better at short and medium term after IAI with triamcinolone hexacetonide in our sample of RA patients.

RESUMO Introdução: A infiltração intra-articular de corticosteroides (IIC) para tratamento de pacientes com artrite idiopática juvenil (AIJ) é cada vez mais usada em reumatologia pediátrica. Objetivos: Descrever a evolução clínica dos pacientes submetidos à IIC em nosso setor de reumatologia pediátrica. Métodos: Estudo retrospectivo de pacientes com AIJ submetidos à IIC de janeiro/2008 a dezembro/2012, com seguimento mínimo de seis meses após a infiltração. Boa resposta à IIC foi definida como inatividade na articulação infiltrada por, no mínimo, seis meses. Resultados: Foram submetidos a 88 pacientes a 165 IICs. Desses, 75% eram meninas e 35,2% apresentavam AIJ oligoarticular persistente. A média de idade ao diagnóstico foi de 6,8 anos e à IIC de 12,2 anos. Em relação aos pacientes, a menor idade ao diagnóstico (p = 0,037) e a ocorrência de uveíte no curso da doença (p = 0,015) foram associados à boa resposta à IIC. Das 165 IICs, 63% apresentaram boa resposta e as articulações permaneceram inativas por um tempo médio de 18,1 meses. O tipo de articulação infiltrada (p = 0,001), menores valores na escala visual analógica global do médico (p = 0,015) e dos pais/paciente (p = 0,01) foram associados a uma boa resposta à IIC. Nove efeitos adversos (5,4%) foram observados. Conclusão: Em nosso estudo, mais da metade das articulações mostrou boa resposta à IIC. Os pacientes com menor idade ao diagnóstico e uveíte durante o curso da doença tiveram boa resposta à IIC. Os joelhos, punhos e cotovelos foram as articulações que mais bem responderam à IIC. A IIC mostrou ser um procedimento seguro.

ABSTRACT Introduction: Intra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. Objectives: To describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. Methods: Retrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. Results: Eighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p = 0.037) and the occurrence of uveitis in the course of the disease (p = 0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p = 0.001), lesser values stated in the overall visual analog scale by the physician (p = 0.015) and by parents/patient (p = 0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. Conclusion: In our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

Objetivos: Identificar fatores preditivos de resposta à infiltração intra-articular (IIA) com triancinolona hexacetonida (TH). Métodos: Este estudo foi realizado em pacientes de artrite reumatóide (AR) (segundo critérios do American College of Rheumatology) submetidos à IIA (infiltração mono, pauci ou poliarticular). Avaliação: Um observador “cego” avaliou prospectivamente as articulações uma semana (T1), quatro semanas (T4), 12 semanas (T12) e 24 semanas (T24) após IIA. As medidas de desfecho foram Escala Visual Analógica (0-10 cm) em repouso, em movimento e para articulações edemaciadas. As variáveis clínicas e demográficas e aquelas relacionadas à infiltração no início do estudo foram analisadas de acordo com a resposta à IIA. Resultados: Foram estudados 289 pacientes com AR (635 articulações) com média de idade de 48,7 (± 10,68) anos; 48,5% eram caucasianos, EVA para dor global = 6,52 (± 1,73). Na análise univariada, as variáveis relativas às melhores respostas em seguida à IIA (melhora >70%) foram: “IIA no cotovelo e metacarpofalangeanas (MCF)” e “classe funcional II”. Na análise multivariada, “homens” e “não brancos” foram os preditores com melhor resposta à IIA na T4, enquanto “IIA no cotovelo e MCF”, “infiltração poliarticular”, “uso de metotrexato” e “dose total maior de TH” obtiveram a melhor resposta na T24. Conclusão: Foram identificados diversos fatores preditivos de boa resposta à IIA em pacientes com AR. Os preditores de melhor resposta para IIA de TH em longo prazo foram “aplicar IIA no cotovelo e MCF” e “aplicar infiltração poliarticular”.

Objectives: Identify good response predictors to intra-articular injection (IAI) with triamcinolone hexacetonide (TH). Methods: This study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection). Assessment: a “blinded” observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0-10 cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response. Results: We studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain = 6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: “elbow and metacarpophalangeal (MCP) IAI, and functional class II”. Under multivariate analysis, “males” and “non-whites” were the predictors with the best response to IAI at T4, while “elbow and MCP IAI”, “polyarticular injection”, “use of methotrexate” and “higher total dose of TH” obtained the best response at T24. Conclusion: Several predictors of good response to IAI in patients with RA were identified. The best-response predictors for TH IAI of long term were “inject elbow and MCP IAI” and “perform polyarticular injection”.

OBJECTIVE: This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis. METHODS: This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated. RESULTS: There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal. CONCLUSIONS: The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain.

OBJETIVOS: Comparar a curto prazo (04 semanas) a efetividade das infiltrações intra-articulares (IIA) guiadas por fluoroscopia (FC) e ultrassom (US) em pacientes com enfermidades reumáticas. MATERIAL E MÉTODOS: Foi realizado um estudo controlado e prospectivo em pacientes portadores de doenças reumáticas captados dos ambulatórios da Disciplina de Reumatologia da Universidade Federal de São Paulo (UNIFESP), Brasil. Critério de inclusão: adultos com indicação de IIA com corticosteróide por sinovite refratária. Todos os pacientes forma infiltrados com hexacetonide triancinolona (20 mg/mL) com doses variáveis, de acordo com a articulação estudada. RESULTADOS: Foram avaliados 71 pacientes (52 mulheres; 44 brancos), portadores de enfermidades reumáticas variadas. A média de idade era 51,9 ± 13 anos e 47 deles (66,2%) faziam uso de drogas modificadora do curso da doença (DMARD). Na análise global da amostra (71 pacientes) e na subanálise coxofemoral (23 pacientes), observou-se melhora estatística (p < 0,001) em ambos os grupos quanto à EVA de dor. Na análise global observou-se aumento significativo da flexão articular (p < 0,001) e um Δ de flexão maior a favor do grupo guiado por FC. A avaliação de melhora segundo Likert Scale mostrou diferença significativa (p < 0,05) entre os grupos na avaliação global, nas proporções inalterado e melhor, a favor do grupo guiado por US. Não foi observada diferença estatisticamente significante entre os grupos para qualquer outra variável. CONCLUSÃO: A IIA guiada por imagem melhorou a dor regional, a curto prazo, relacionada à sinovite de vários tipos de articulações. Para a grande maioria das variáveis avaliadas não houve diferença entre a efetividade da IIA guiada por US ou FC.

OBJECTIVE: Compare the effectiveness of ultrasound and fluoroscopy to guide intra-articular injections (IAI) in selected cases. MATERIAL AND METHODS: A prospective study in our outpatient clinics at the Rheumatology Division at Universidade Federal de São Paulo (UNIFESP), Brazil, was conducted to compare the short-term (4 weeks) effectiveness of ultrasound and fluoroscopy-guided IAI in patients with rheumatic diseases. Inclusion criteria were: adults with refractory synovitis undergoing IAI with glucocorticoid. All patients had IAI performed with triamcinolone hexacetonide (20mg/ml) with varying doses according to the joint injected. RESULTS: A total of 71 rheumatic patients were evaluated (52 women, 44 whites). Mean age was 51.9 ± 13 years and 47 of them (66.2%) were on regular DMARD use. Analysis of the whole sample (71 patients) and hip sub-analysis (23 patients) showed that significant improvement was observed for both groups in terms of pain (P < 0.001). Global analysis also demonstrated better outcomes for patients in the FCG in terms of joint flexion (P < 0.001) and percentage change in joint flexion as compared to the USG. Likert scale score analyses demonstrated better results for the patients in the USG as compared to the FCG at the end of the study (P < 0.05). No statistically significant difference between groups was observed for any other study variable. DISCUSSION AND CONCLUSION: Imaging-guided IAI improves regional pain in patients with various types of synovitis in the short term. For the vast majority of variables, no significant difference in terms of effectiveness was observed between fluoroscopy and ultrasoundguided IAI.

OBJECTIVES: The aim of the present study was to investigate the effectiveness of Samarium153-particulate hydroxyapatite radiation synovectomy in rheumatoid arthritis patients with chronic knee synovitis. METHODS: Fifty-eight rheumatoid arthritis patients (60 knees) with chronic knee synovitis participated in a controlled double-blinded trial. Patients were randomized to receive either an intra-articular injection with 40 mg triamcinolone hexacetonide alone (TH group) or 40 mg triamcinolone hexacetonide combined with 15 mCi Samarium153-particulate hydroxyapatite (Sm/TH group). Blinded examination at baseline (T0) and at 1 (T1), 4 (T4), 12 (T12), 32 (T32), and 48 (T48) weeks post-intervention were performed on all patients and included a visual analog scale for joint pain and swelling as well as data on morning stiffness, flexion, extension, knee circumference, Likert scale of improvement, percentage of improvement, SF-36 generic quality of life questionnaire, Stanford Health Assessment Questionnaire (HAQ), Lequesne index, use of non-steroidal anti-inflammatory drugs or oral corticosteroids, events and adverse effects, calls to the physician, and hospital visits. RESULTS: The sample was homogeneous at baseline, and there were no withdrawals. Improvement was observed in both groups in relation to T0, but no statistically significant differences between groups were observed regarding all variables at the time points studied. The Sm/TH group exhibited more adverse effects at T1 (p<0.05), but these were mild and transitory. No severe adverse effects were reported during follow-up. CONCLUSION: Intra-articular injection of Samarium153-particulate hydroxyapatite (15 mCi) with 40 mg of triamcinolone hexacetonide is not superior to triamcinolone hexacetonide alone for the treatment of knee synovitis in patients with rheumatoid arthritis at 1 y of follow-up.