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Biomedical subjects

Richard J Wakefield

Publications and source records attributed to Richard J Wakefield.

15 recordsLinked to original sources
PubMed2006

Response to intramuscular methyl prednisolone in inflammatory hand pain: evidence for a targeted clinical, ultrasonographic and therapeutic approach.

BACKGROUND: Hand pain with stiffness is a common clinical presentation to early arthritis clinics, with outcome varying from resolution to the development of rheumatoid arthritis. OBJECTIVE: To assess the response and predictors of response to intramuscular methylprednisolone (MP) and hydroxychloroquine (HCQ) using a standardised treatment protocol. METHODS: Patients with inflammatory hand pain (IHP), defined as predominantly hand pain and morning stiffness of at least 30 min duration, received a standardised assessment prior to receiving intramuscular MP. Response (primary outcome) at 4 weeks was a 50% improvement in symptoms as perceived by the patient; responders who relapsed received repeat intramuscular MP and HCQ. RESULTS: 102 patients were recruited, of which 21% were rheumatoid factor (RF) positive, 23% had clinical synovitis, 25% had raised C-reactive protein level and 55% had ultrasound-detected synovitis. 73% responded, with associated significant reductions in morning stiffness, Health Assessment Questionnaire, painful and tender joint counts, and visual analogue scores (p < or = 0.006 for all). Ultrasound-detected synovitis (p<0.001) and RF (p = 0.04), but not clinical synovitis (p = 0.74), were significantly associated with response to intramuscular MP. 86% who remained on HCQ long term reported a benefit. CONCLUSIONS: Patients with IHP have significant improvement in symptoms and function following intramuscular MP. Further placebo-controlled trials are required to assess the role of intramuscular MP and ultrasonography in managing this patient group.

Adult↗
PubMed2005

Recommendations for musculoskeletal ultrasonography by rheumatologists: setting global standards for best practice by expert consensus.

OBJECTIVE: To establish an expert consensus of best practice for rheumatologists performing musculoskeletal ultrasonography (MUS). METHODS: A panel of worldwide experts in MUS was identified by literature review, membership of teaching faculty, and peer recommendation. They were invited to take part in a 4-stage Delphi process employing 2 iterative rounds to establish a consensus of specific indications, anatomic areas, and knowledge and skills required by rheumatologists performing MUS. RESULTS: Experts in MUS were identified (n = 57; 37 radiologists, 20 rheumatologists). Successive rounds of this rigorous Delphi exercise enabled group consensus to be achieved in 30 of the proposed 37 categories comprising 8 of 13 indications (inflammatory arthritis, tendon pathology, effusion, bursitis, monitoring disease activity, monitoring disease progression, guided aspiration, and injection), 8 of 10 anatomic areas (hand, wrist, elbow, shoulder, hip, knee, ankle and heel, and forefoot), and 14 categories of knowledge and skills (physics, anatomy, pathology, equipment, clinical application and relevance, indications and limitations, artifact, machine function and operation, patient and probe position, planes and system of examination, image optimization, dynamic assessment, color Doppler, and power Doppler). CONCLUSION: We have produced the first expert-derived, interdisciplinary consensus of recommendations for rheumatologists performing MUS. This represents a significant advance that will not only direct future rheumatology MUS practice, but will facilitate informed educational development. This is an important step towards the introduction of a specific training curriculum and assessment process to ensure competent rheumatologist ultrasonographers.

Benchmarking↗
PubMed2005

MRI and musculoskeletal ultrasonography as diagnostic tools in early arthritis.

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium and is characterized by destruction of bone and cartilage. Early diagnosis and treatment of RA can improve disease outcomes substantially. Magnetic resonance imaging and musculoskeletal ultrasonography may facilitate early diagnosis and aid the targeting of intensive therapy. Magnetic resonance imaging and musculoskeletal ultrasonography also are able to monitor temporal changes in disease activity (ie, synovitis) and damage (ie, erosions). These imaging modalities are likely to be increasingly used in the management of early rheumatoid arthritis to ensure the best patient outcomes, although more work is required to determine their optimal roles.

Arthritis↗
PubMed2005

Musculoskeletal ultrasound including definitions for ultrasonographic pathology.

Ultrasound (US) has great potential as an outcome in rheumatoid arthritis trials for detecting bone erosions, synovitis, tendon disease, and enthesopathy. It has a number of distinct advantages over magnetic resonance imaging, including good patient tolerability and ability to scan multiple joints in a short period of time. However, there are scarce data regarding its validity, reproducibility, and responsiveness to change, making interpretation and comparison of studies difficult. In particular, there are limited data describing standardized scanning methodology and standardized definitions of US pathologies. This article presents the first report from the OMERACT ultrasound special interest group, which has compared US against the criteria of the OMERACT filter. Also proposed for the first time are consensus US definitions for common pathological lesions seen in patients with inflammatory arthritis.

Arthritis, Rheumatoid↗
PubMed2004

Practice, training, and assessment among experts performing musculoskeletal ultrasonography: toward the development of an international consensus of educational standards for ultrasonography for rheumatologists.

OBJECTIVE: To evaluate the training and practice of specialist practitioners in musculoskeletal ultrasonography (MUS) with the aim of developing an expert-derived consensus of educational standards for rheumatologists performing MUS. METHODS: A panel of worldwide experts in MUS was identified by literature review, consultation with members of training committees, and peer recommendation. Using a postal questionnaire, information was obtained about personal experience, current practice, training regimen, and participation in competency assessment. RESULTS: International experts in MUS were identified (57 in total: 37 radiologists, 20 rheumatologists). Response rate was 70%. Radiologists had been performing MUS for longer than rheumatologists. Both rheumatologists and radiologists conducted the same number of MUS sessions per week, although radiologists examined more patients. More radiologists performed MUS for muscle and ligament injury, nerve lesions, soft tissue masses, and of the groin (P <0.01). The number of training hours was similar. Approaches to training varied, although attending a training course and scanning with an expert was more common among rheumatologists (P <0.001). More than two-thirds of the group had not undergone any form of competency assessment. CONCLUSION: This study highlights differences in training and practice between individual expert ultrasonographers and between specialty backgrounds. In particular, there appears to be no formal training regimen and competency assessment is uncommon. The establishment of a core set of internationally applicable educational standards for MUS training for rheumatologists is required.

Internationality↗
PubMed2004

Noninvasive techniques for assessing skeletal changes in inflammatory arthritis: imaging technique.

New imaging techniques such as ultrasound and MRI are likely to play increasing roles in the future management of patients with inflammatory arthritis, particularly those with rheumatoid arthritis and spondyloarthropathies. Ultrasound has a number of distinct advantages including its ability to scan multiple joints, safety, and immediately availability in clinic. MRI, however, is more sensitive and has a greater field of view because of its tomographic nature. Both modalities have the added advantage over radiography in that they can image soft tissue as well as bone. Dual X-ray absorptiometry already has an established role to play in the assessment of osteoporosis, but new techniques such as digital radiogrametry, quantitative CT, and ultrasound potentially will have a more important role to play in the future.

Absorptiometry, Photon↗
PubMed2003

Elucidation of the relationship between synovitis and bone damage: a randomized magnetic resonance imaging study of individual joints in patients with early rheumatoid arthritis.

OBJECTIVE: To simultaneously image bone and synovium in the individual joints characteristically involved in early rheumatoid arthritis (RA). METHODS: Forty patients with early, untreated RA underwent gadolinium-enhanced magnetic resonance imaging (MRI) of the second through fifth metacarpophalangeal joints of the dominant hand at presentation, 3 months, and 12 months. In the first phase (0-3 months), patients were randomized to receive either methotrexate alone (MTX) or MTX and intraarticular corticosteroids (MTX + IAST) into all joints with clinically active RA. The MTX-alone group received no further corticosteroids until the second phase (3-12 months), when both groups received standard therapy. RESULTS: In the first phase, MTX + IAST reduced synovitis scores more than MTX alone. There were significantly fewer joints with new erosions on MRI in the former group compared with the latter. During the second phase, the synovitis scores were equivalent and a similar number of joints in each group showed new erosions on MRI. In both phases, there was a close correlation between the degree of synovitis and the number of new erosions, with the area under the curve for MRI synovitis the only significant predictor of bone damage progression. In individual joints, there was a threshold effect on new bone damage related to the level of synovitis; no erosions occurred in joints without synovitis. CONCLUSION: In early RA, synovitis appears to be the primary abnormality, and bone damage occurs in proportion to the level of synovitis but not in its absence. In the treatment of patients with RA, outcome measures and therapies should focus on synovitis.

Adrenal Cortex Hormones↗
PubMed2003

Prognostic factors in a large cohort of patients with early undifferentiated inflammatory arthritis after application of a structured management protocol.

OBJECTIVE: Inflammatory arthritis of the hands is a frequent clinical presentation with a variable outcome. Patients not satisfying the classification criteria for recognized arthritides are described as having undifferentiated inflammatory arthritis, for which there are no accepted therapeutic algorithms. This study assessed the clinical outcome of patients with undifferentiated arthritis of the hands after use of a treatment algorithm, and evaluated the prognostic features in these patients. METHODS: One hundred consecutive patients with undifferentiated arthritis of the hands were assessed following use of a pragmatic treatment algorithm that was based on clinical presentation and response to treatment. The following standard step-up treatment protocol was used: 1) nonsteroidal antiinflammatory drugs (NSAIDs), 2) a single dose of corticosteroid administered by either intramuscular or intraarticular injection, and 3) disease-modifying antirheumatic drugs (DMARDs). Patients with specific rheumatologic diagnoses were excluded. The primary outcome was persistence of synovitis at 12 months. RESULTS: Seventy-eight percent of patients received NSAIDs, 72% received corticosteroids, and 30% received DMARD therapy. Among patients who had synovitis at 12 months, the prevalence of rheumatoid factor (RF) seropositivity, swollen joints, and synovitis at baseline was greater than in those without persistent synovitis. Logistic regression analysis showed baseline investigations to be poor predictors of subsequent DMARD use, with the best predictor being persistence of synovitis at 12 weeks. Rheumatoid arthritis (RA) developed in 14 patients. Logistic regression analysis showed that significant predictors of RA were RF seropositivity and the painful joint count at baseline. No patient who experienced resolution of synovitis by 12 weeks had persistent synovitis that subsequently required DMARD therapy. Only 13% of patients entered remission. Early resolution of synovitis was associated with an excellent prognosis. CONCLUSION: Undifferentiated arthritis of the hands is not a benign condition, with 30% of patients receiving DMARD therapy by 12 months and low remission rates. Results of the clinical assessment at 12 weeks is the single best predictor of future therapy. This study provides background data for use in determining future therapeutic interventions.

Adolescent↗
PubMed2003

Imaging of the musculoskeletal system: magnetic resonance imaging, ultrasonography and computed tomography.

In the last decade, musculoskeletal imaging has rapidly expanded largely due to the imaging capabilities of magnetic resonance imaging and ultrasound. These modalities have increased the clinical understanding and mechanisms of arthritis and are assuming increasing importance in the diagnosis of arthritis; more recently, they have been used to monitor therapy. This chapter reviews recent imaging studies relevant to rheumatic diseases.

Humans↗
PubMed2002

The geometric architecture of the subtalar and midtarsal joints in rheumatoid arthritis based on magnetic resonance imaging.

OBJECTIVE: To compare in vivo the 3-dimensional (3-D) geometric architecture of the subtalar and midtarsal joints in normal and rheumatoid arthritic (RA) feet, using magnetic resonance imaging (MRI) analysis. METHODS: MRI was performed on 23 patients with RA, all of whom had disease activity in the subtalar and/or midtarsal joints. Image processing techniques were used to create 3-D reconstructions of the calcaneus (C), cuboid (c), navicular (N), and talus (T) bones. Twenty-four standard architectural parameters were measured from the reconstructions and were compared with data from 10 normal subjects. These parameters defined both 3-D distance and angular relationships among the 4 bones studied. Pattern classification techniques were used to establish a geometric architecture foot profile for the RA patients. The degree of individual patient fit to the new RA foot profile and to profiles for normal, pes planus, and pes cavus foot types was derived. Logistic regression was used to examine the relationship of foot architecture to inflammatory disease characteristics and physical examination variables. RESULTS: Subtalar or midtarsal pain was reported by all 23 patients, and 22 of the 23 patients presented with >/=1 clinical feature of pes planovalgus deformity. In 21 patients, ultrasonography revealed synovitis at >/=1 tarsal joint or surrounding tendon. In the RA group, the normalized distances between the geometric centroids were significantly closer for bone pairs Cc and cT and significantly distracted for bone pair CN compared with the distances in normal subjects. In RA patients (versus normal subjects), the angles subtended at the bone centroids were significantly decreased in 3 bone groups (CNc, TCN, and TNc) and significantly increased in 3 bone groups (CcN, CcT, NTc). The angles formed between the major principal axes of bone pairs CT and cT were significantly increased in RA patients compared with those in normal subjects. Pattern classification defined 11 RA feet as having normal structure and 12 as having abnormal structure. However, the abnormal feet did not fit consistently with structures defined for RA, pes planus, or pes cavus foot types. Logistic regression demonstrated that subtalar joint synovitis was the only predictive factor for abnormal subtalar and midtarsal architecture (odds ratio 19.2, 95% confidence interval 1.77-200.0). CONCLUSION: This unique 3-D MRI-based technique successfully quantified the effects of RA on the geometric architecture of the foot and the patient-specific nature of these changes. This technique can be used to provide logical therapy for correction.

Adult↗