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Garcia-Pompermayer MR, Ayton SG, Molina-Collada J, Tamborrini G, Sanchez MED, Luna KS, Elizondo MAG. The power of us: breaking barriers and bridging the gap of ultrasound in rheumatology to empower a new generation. Clin Rheumatol 2024; 43:2103-2116. [PMID: 38653847 DOI: 10.1007/s10067-024-06973-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 04/07/2024] [Accepted: 04/17/2024] [Indexed: 04/25/2024]
Abstract
OBJECTIVE This study assesses musculoskeletal ultrasound (MSUS) knowledge, attitudes, and practices among young rheumatologists in Mexico, aiming to identify barriers and facilitators to its clinical use. METHODS An online survey distributed to a network of young rheumatologists captured demographics, institutional, and personal MSUS information. Multivariable analysis identified factors associated with positive MSUS attitudes. RESULTS Ninety-six rheumatologists (39.18% national response rate) completed the survey. Of respondents (54.2% females, median age 35.1 years), 81.2% deemed MSUS necessary in clinical rheumatology. The main barriers included limited training access (56.2%) and required training time (54.1%). Lack of scientific evidence was not a major barrier (60.4%). Positive MSUS attitudes were associated with learning from conferences (p = 0.029) and colleagues (p = 0.005), formal (p = 0.043), and in-person training (p = 0.020), MSUS use in practice (p = 0.027), and use by radiologists in their institute (p < 0.001). Interest in learning MSUS (88.5%) was significantly higher in those with positive attitudes (94.4%, p < 0.001). Elastic net analysis identified key drivers, including learning MSUS from conferences, colleagues, and in residency; using MSUS in practice; respondent-performed MSUS; and MSUS use by radiologists. Statistically significant associations were found with using MSUS for synovitis/inflammatory joint disease (OR = 1.43, 95% CI 1.00-2.05) and MSUS use by radiologists in respondent's institutes (OR = 1.70, 95% CI 1.20-2.90). CONCLUSION Most young rheumatologists in Mexico recognize the necessity of MSUS in clinical practice. By addressing identified barriers, encouraging rheumatologist-radiologist collaboration, and establishing a regulatory body to certify rheumatologist's MSUS experience, there is an opportunity to empower them with the necessary skills for effective MSUS use, ultimately benefiting patient care.
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Affiliation(s)
| | - Sarah G Ayton
- Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Juan Molina-Collada
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain
| | | | | | - Karina Silva Luna
- Reumatología, Instituto de Medicina Interna, Hospital Zambrano-Hellion, Tecnologico de Monterrey, Monterrey, Mexico
| | - Mario Alberto Garza Elizondo
- Reumatología, Instituto de Medicina Interna, Hospital Zambrano-Hellion, Tecnologico de Monterrey, Monterrey, Mexico
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McCrum C, Furner R, Grainger S. Peri-procedural management and incidence of bleeding events following musculoskeletal injections or aspirations in people on oral anticoagulation and antiplatelet therapy. Musculoskeletal Care 2023; 21:702-712. [PMID: 36806477 DOI: 10.1002/msc.1743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 01/24/2023] [Accepted: 02/01/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Corticosteroid injections and aspirations are common interventions for managing musculoskeletal and inflammatory conditions. However, there remains limited safety evidence to support injection decisions and peri-procedural management in people on anti-thrombotics, particularly for direct oral anticoagulants (DOACs). OBJECTIVES To investigate peri-procedural management and bleeding complications following musculoskeletal injections or aspirations with anti-thrombotic medication use. DESIGN A prospective observational study was undertaken (October 2018-December 2020) in Orthopaedics, Rheumatology and Radiology specialities in two large UK healthcare providers. Data collection involved weekly identification of musculoskeletal procedures, emergency attendance or admission within 30 days and follow-up questionnaires sent within 2 weeks post-procedure. Descriptive statistics were used to analyse anticoagulant/anti-platelet use, peri-procedural management and bleeding complications. RESULTS Of 5080 procedures, 237 of 1338 responses reported antithrombotic use: warfarin (n = 36), DOACs (n = 75) and antiplatelets (n = 126). There were no self-report or electronic identification of clinically significant bleeding events/complications. Only local bruising was reported (8.6% vs. 0.2% with non-use), and only with medication continuation or international normalised ratio (INR) levels ≥3.8 or unknown. Only 3/72 DOAC use was interrupted. CONCLUSIONS In this study, no clinically significant bleeding events or complications were reported or identified following musculoskeletal injections or aspirations, with only localised bruising reported. It was not universal practice to check INR levels and DOAC interruption was uncommon. Findings add evidence that musculoskeletal procedures appear to be low risk procedures for bleeding complications with antithrombotic continuation and when INR levels within lower target range. Research on intra-articular or soft tissue iatrogenic consequences would add to risk/benefit evaluations.
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Affiliation(s)
- Carol McCrum
- Research Centre for Health Professions, University of Brighton, Eastbourne, UK
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
- Rheumatology Department, Canberra Health Service, Canberra, Australian Capital Territory, Australia
| | - Rosie Furner
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
| | - Sally Grainger
- East Sussex Healthcare NHS Trust, Saint Leonards-on-Sea, UK
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Elsawy NA, Ibrahiem AH, Younis GA, Meheissen MA, Abdel-Fattah YH. Clinical examination, ultrasound assessment and aspiration of knee effusion in primary knee osteoarthritis patients. J Orthop Surg Res 2023; 18:422. [PMID: 37301888 DOI: 10.1186/s13018-023-03891-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND To assess the diagnostic performance of clinical examination and ultrasound (US) assessment of knee effusion in primary knee osteoarthritis (KOA) patients. Furthermore, the success rate for effusion aspiration and the factors related to it were investigated. METHODS This cross-sectional study included patients diagnosed with primary KOA-induced knee effusion clinically or sonographically. The affected knee of each patient was subjected to clinical examination and US assessment using the ZAGAZIG effusion and synovitis ultrasonographic score. Patients with confirmed effusion and consented to aspiration were prepared for direct US-guided aspiration under complete aseptic techniques. RESULTS One hundred and nine knees were examined. During visual inspection, swelling was detected in 80.7% of knees and effusion was confirmed by US in 67.8% of knees. Visual inspection was the most sensitive at 90.54% while bulge sign was the most specific at 65.71%. Only 48 patients (61 knees) consented to aspiration procedure; 47.5% had grade III effusion, and 45.9% had grade III synovitis. Successful aspiration was achieved in 77% of knees. Two needle types were used; a 22 gauge / 3.5-inch spinal needle in 44 knees and an 18 gauge/ 1.5-inch needle in 17 knees, with a success rate of 90.9% and 41.2%, respectively. Aspirated amount of synovial fluid correlated positively with effusion grade (rs=0.455, p < 0.001) and negatively with synovitis grade on US (rs = - 0.329, p = 0.01). CONCLUSIONS The superiority of the US over clinical examination in detecting knee effusion suggests that US should be used routinely to confirm the presence of effusion. Long needles (spinal needle) may have a higher success rate of aspiration than shorter needles.
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Affiliation(s)
- Noha Abdelhalim Elsawy
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Aya Hanafy Ibrahiem
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt.
| | - Gihan Abdellatif Younis
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Marwa Ahmed Meheissen
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Yousra Hisham Abdel-Fattah
- Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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[Ultrasound-targeted joint puncture in rheumatology]. Z Rheumatol 2022; 81:858-867. [PMID: 36197588 DOI: 10.1007/s00393-022-01269-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2022] [Indexed: 12/13/2022]
Abstract
Joint punctures not only have a long tradition but are also an essential component in the diagnostic differentiation of various joint diseases. In addition, therapeutic injections are an essential component of an individual targeted treatment strategy in a disease-modifying antirheumatic drug (DMARD)-based treat-to-target concept. This article aims to convey to the reader the ultrasound-targeted joint puncture techniques in text and with many video clips that can be downloaded. This article therefore steps away from the conventional two-dimensional demonstration of anatomy-oriented puncture techniques and elucidates the diagnostic and therapeutic potency of ultrasound-targeted techniques in the daily routine. Furthermore, special importance is given to a sterile working technique, puncture material and synovial analysis.
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Gorelik N, Darwish Y, Walter WR, Burke CJ, Sarpel D, Chong J, Adler RS. Incidence of infectious complications following ultrasound-guided percutaneous musculoskeletal interventions with the use of an uncovered transducer footprint. Eur Radiol 2022; 32:6759-6768. [PMID: 35579710 DOI: 10.1007/s00330-022-08849-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine the incidence of infectious complications following ultrasound-guided musculoskeletal interventions performed with a disinfected uncovered ultrasound transducer footprint. METHODS Electronic medical records of all patients who underwent an ultrasound-guided musculoskeletal procedure (including injection, calcific lavage, or ganglion cyst aspiration) performed by any of the 14 interventional musculoskeletal radiologists at our institution between January 2013 and December 2018 were retrospectively reviewed to identify procedure site infections. Biopsies and joint aspirations were excluded. The procedures were performed using a disinfected uncovered transducer footprint. First, an automated chart review identified cases with (1) positive answers to the nurse's post-procedure call, (2) an International Classification of Diseases (ICD) diagnostic code related to a musculoskeletal infection, or (3) an antibiotic prescription within 30 days post-procedure. Then, these cases were manually reviewed for evidence of procedure site infection. RESULTS In total, 6511 procedures were included. The automated chart review identified 3 procedures (2 patients) in which post-procedural fever was reported during the nurse's post-procedure call, 33 procedures (28 patients) with an ICD code for a musculoskeletal infection, and 220 procedures (216 patients) with an antibiotic prescription within 30 post-procedural days. The manual chart review of these patients revealed no cases of confirmed infection and 1 case (0.015%) of possible site infection. CONCLUSIONS The incidence of infectious complications after an ultrasound-guided musculoskeletal procedure performed with an uncovered transducer footprint is extremely low. This information allows radiologists to counsel their patients more precisely when obtaining informed consent. KEY POINTS • Infectious complications after ultrasound-guided musculoskeletal procedures performed with a disinfected uncovered transducer footprint are extremely rare.
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Affiliation(s)
- Natalia Gorelik
- Department of Diagnostic Radiology, McGill University Health Center, 1001 Decarie Blvd., Montreal, Quebec, H4A 3J1, Canada. .,Department of Radiology, NYU Langone Medical Center, 333 E 38th St, 6th Floor, New York, NY, 10016, USA.
| | - Yousef Darwish
- , New York City, NY, USA.,Information Technology Department, NYU Langone Health, 550 First Avenue, New York, NY, 10016, USA
| | - William R Walter
- Department of Radiology, NYU Langone Medical Center, 333 E 38th St, 6th Floor, New York, NY, 10016, USA
| | - Christopher J Burke
- Department of Radiology, NYU Langone Medical Center, 333 E 38th St, 6th Floor, New York, NY, 10016, USA
| | - Dost Sarpel
- Division of Infectious Disease, Milford Regional Medical Center, 14 Prospect St, Milford, MA, 01757, USA
| | - Jaron Chong
- Department of Radiology, London Health Sciences Centre, Victoria Hospital, 800 Commissioners Rd E, C1-609, London, Ontario, N6A 5W9, Canada
| | - Ronald S Adler
- Department of Radiology, NYU Langone Medical Center, 333 E 38th St, 6th Floor, New York, NY, 10016, USA
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A critical review of the available evidence on the diagnosis and clinical features of CPPD: do we really need imaging? Clin Rheumatol 2020; 40:2581-2592. [PMID: 33231775 DOI: 10.1007/s10067-020-05516-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/14/2020] [Accepted: 11/16/2020] [Indexed: 02/08/2023]
Abstract
Imaging has been playing an important role in the pathogenetic and clinical characterisation of many rheumatic diseases, especially in the most recent years with the advent of many new, highly technological and promising techniques. Calcium pyrophosphate deposition disease (CPPD) benefited also from these new techniques, most of which can readily identify calcium crystals. Nowadays, imaging is used mainly to identify crystals in joints but given the complexity of CPPD, imaging should be used with an "holistic" approach in order to gain insights in the pathogenesis, spectrum of clinical manifestations and natural history of the disease. Furthermore, overlap or association of CPPD with other prevalent diseases of the elderly makes the differential diagnosis challenging. In this review, we provide a critical review of the current knowledge on the use of imaging both for the identification of crystals and for its application in clinical practice as an aid for determining the impact of the disease on patients.Key Points• CPPD is a complex disease with a wide spectrum of clinical manifestations and understanding of pathogenetic mechanisms and clinical phenotypes is essential for correct characterisation• Imaging has made important advances regarding identification of CPPD in recent years, and new, more sophisticated techniques are under investigation• Imaging has the potential to improve our knowledge on pathogenesis and clinical phenotypes of CPPD• Imaging techniques have to be tested thoroughly for reliability, discrimination and sensitivity to change before they can be implemented in clinical trials.
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Filippucci E, Reginato AM, Thiele RG. Imaging of crystalline arthropathy in 2020. Best Pract Res Clin Rheumatol 2020; 34:101595. [PMID: 33012644 DOI: 10.1016/j.berh.2020.101595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Crystal-related arthropathies are the result of crystal deposition in joint and periarticular soft tissues. Identification of urate crystals is mandatory to distinguish gout from other crystalline arthropathies, including calcium pyrophosphate dihydrate and basic calcium phosphate crystal deposition diseases. ACR/EULAR classification criteria for gout included dual-energy computed tomography and ultrasound with equal impact to the final score. Different diagnostic strengths of these imaging modalities depend on disease duration and scanned anatomic site. While ultrasound has been indicated as the first-choice imaging technique, especially in the early stages of the disease, dual-energy computed tomography has shown to be highly specific, allowing the detection of crystal deposits in anatomic sites not accessible by ultrasound, such as the spine. At the spinal level, MRI findings are usually nonspecific. Finally, there is preliminary evidence that at the knee, dual-energy computed tomography may discriminate calcium pyrophosphate dihydrate from basic calcium phosphate crystal deposits.
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Affiliation(s)
- Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, "Carlo Urbani" Hospital, Jesi, Ancona, Italy.
| | - Anthony M Reginato
- Division of Rheumatology, Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA.
| | - Ralf G Thiele
- Division of Allergy, Immunology and Rheumatology, Department of Medicine, University of Rochester, Rochester, NY, USA.
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