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How to perform ultrasound-guided injections.

Best Pract Res Clin Rheumatol. 2009 Apr;23(2):269-79

Authors: Bruyn GA, Schmidt WA

Among the most important reasons for the increased use of ultrasound by rheumatologists is its feasibility to guide injections. Correct positioning of the needle in the targeted structure occurs much more frequently with ultrasound guidance than with conventional positioning without imaging. The sonographer can mark the skin above the structure, using ultrasound to localize this point and to estimate the depth of the structure. Alternatively, the sonographer might introduce the needle under direct sonographic visualisation, holding the probe in one hand and the needle in the other. The needle can be longitudinally parallel to the probe, with an angle of about 45 degrees to the probe. It can be introduced close to the middle of the probe or opposite the probe; the needle can be also depicted transversely. Ultrasound allows needle guidance in nearly all important structures of shoulders, elbows, hand, hips, knees and feet. Education involves training to coordinate probe and needle in sponges, chicken, cheese and other objects. Knowledge of anatomy, probe positioning and the ability to coordinate probe and needle are necessary when injecting patients with sonographic guidance. The rheumatologist might start with easy approaches in which the needle is parallel to the probe.

PMID: 19393570 [PubMed - indexed for MEDLINE]

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How to perform local soft-tissue glucocorticoid injections.

Best Pract Res Clin Rheumatol. 2009 Apr;23(2):193-219

Authors: Jacobs JW

Inflammation of periarticular soft-tissue structures such as tendons, tendon sheaths, entheses, bursae, ligaments and fasciae are the hallmark of many inflammatory rheumatic diseases, but inflammation – or rather irritation – of these structures also occurs in the absence of an underlying rheumatic disease. In both these primary and secondary soft-tissue lesions, local glucocorticoid injection often is beneficial, although evidence in literature is limited. This chapter reviews local injection therapy for these lesions and for nerve compression syndromes.

PMID: 19393566 [PubMed - indexed for MEDLINE]

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The antiphospholipid syndrome.

Best Pract Res Clin Rheumatol. 2008 Oct;22(5):831-45

Authors: Pasquali JL, Poindron V, Korganow AS, Martin T

The antiphospholipid syndrome is an acquired autoimmune syndrome characterized by arterial and/or venous thrombosis and/or pregnancy morbidity in association with the prolonged presence of serum autoantibodies, including the so-called lupus anticoagulant and anticardiolipin antibodies, which are mainly directed against complexes of proteins and anionic phospholipids.

PMID: 19028366 [PubMed - indexed for MEDLINE]

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Behçet's syndrome.

Best Pract Res Clin Rheumatol. 2008 Oct;22(5):793-809

Authors: Yurdakul S, Yazici H

Recent epidemiological work suggests that genetic background overrides environmental factors in the pathogenesis of Behçet's syndrome (BS). There are at least two clusters of disease expression. The first is the cluster of superficial vein thrombosis, deep vein thrombosis and dural sinus thrombi; the second cluster is that of acne, arthritis and enthesitis. The association of antibodies to anti-Saccharomyces cerevisiae antibodies and the presence of inflammatory bowel disease is perhaps another such cluster. The presence of such clusters suggests that there might be more than one disease mechanism operative in this complex disorder. There is a recent trend to classify BS with the autoinflammatory disorders. However, practically all autoinflammatory conditions are recurrent fever syndromes of children, and are genetically linked to well-defined loci; none of this is true for BS. Recent guidelines from the European League Against Rheumatism are quite useful for the management of the disease in organ systems other than the vascular, neurological and gastrointestinal systems, because of the lack of controlled studies related to these latter pathologies.

PMID: 19028364 [PubMed - indexed for MEDLINE]

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The treatment of antiphospholipid syndrome: a harmonic contrast.

Best Pract Res Clin Rheumatol. 2007 Dec;21(6):1079-92

Authors: Ruiz-Irastorza G, Khamashta MA

The antiphospholipid syndrome (APS) is characterized by a wide variability in clinical manifestations. Recommendations for therapy are conditioned by the lack of appropriate studies, due either to methodological limitations or excessive selection of patients. There is consensus in treating patients with APS and first venous thrombosis with warfarin to a target international normalized ratio (INR) of 2.3-3.0. However, a recent systematic review including observational studies found patients with APS and stroke to be at a high risk of recurrent events. We thus recommend a target INR>3.0 in this group. Likewise, the optimal approach for women with obstetric manifestations of APS is not completely defined; some authors recommend universal aspirin plus heparin whereas others consider aspirin in monotherapy useful for women with recurrent early miscarriage only. Correction of vascular risk factors and a high-risk management of pregnancy, including Doppler studies of the uterine and umbilical vessels, are warranted. Hydroxychloroquine and statins are likely to become important in the future.

PMID: 18068863 [PubMed - indexed for MEDLINE]

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