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Introduction and Objectives Intra-articular corticosteroid injections are standard of care for managing joint pain secondary to osteoarthritis or rheumatoid arthritis but are rarely used in haemophilic arthropathy. We have introduced and evaluated the efficacy and safety of ultrasound-guided corticosteroid injections for pain relief in patients with haemophilic arthropathy. Patients and methods Ultrasound-guided intra-articular injections performed on haemophilia patients at UCSD between March 2012 and January 2016 were analysed. Needle placement and injection (40 mg triamcinolone; 3–5 mL lidocaine) were performed with musculoskeletal ultrasound and Power Doppler. Analysis included patient demographics, joint-specific parameters such as tissue hypervascularity and effusions, pain relief, and procedure-associated complications. Results Forty-five injections (14 ankles, 13 elbows, 18 knees) were administered in 25 patients. Advanced arthropathy with hypervascularity and/or effusions was present in 91% and 61% of joints, respectively. Ninety-one per cent of injections resulted in pain relief which was significant in 84% (>30% reduction). Median pain score was reduced from 7 of 10 to 1 of 10 (P < 0.001), usually within 24 h. Median duration of pain relief was 8 weeks (range 1–16 weeks). Haemophilia B patients experienced longer periods of relief, and high Pettersson scores were associated with shorter duration of relief. There were no procedure-associated complications. Repeat ultrasound of eight joints within 4 weeks of injection demonstrated nearly complete resolution of hypervascularity. Conclusions Point-of-care ultrasound enabled intra-articular corticosteroid injections that provided highly effective, safe, and relatively long-lasting pain relief in haemophilic arthropathy. This approach should be used to improve pain management in haemophilic arthropathy.

Objective It is unclear if vascular remodeling in hemophilic joints perpetuates bleeding because it is difficult to gauge leakiness in the setting of low clotting factor levels. Two patients provided the unique opportunity to demonstrate that vascular changes directly contribute to joint bleeding. Approach and Results Two patients had severe hemophilic arthropathies; joint vascularity and bleeding were studied during periods of normalized plasma clotting factor activities with MSKUS and PD. One patient was “cured” of hemophilia with liver transplantation. Abnormal elbow vascularization persisted despite normalization of coagulation status and was associated with severe bleeding years after transplant. Dynamic vascular changes were detected prior to and during bleeding; angiography revealed enlarged, thickened vessels consistent with remodeling, and required arterial embolization. The second patient had continued knee bleeding and fluctuating vascular changes for months following knee replacement, unresponsive to intense daily factor treatment. Subsequently, new bleeds developed in other joints associated with similar vascular changes despite continued factor replacement. Conclusions Vascular remodeling contributes to perpetuated hemophilic joint bleeding and therefore contributes to progressive arthropathy. Intra-articular or systemic administration of anti-angiogenic drugs, such as vascular endothelial growth factor antagonists, might be of benefit in such patients, but requires study.

The objective of this study was to determine rates of blood pressure (BP) screening at well-child visits as recommended by the Task Force on Blood Pressure Control in Children. The 1985 and 1996 National Ambulatory Medical Care Surveys were analyzed for changes in proportion of well visits for children aged 3-18 years at which BP was checked. Patient and physician demo-graphics are described. BP screening increased from 50% in 1985 to 61 % in 1996. For pediatricians, the estimates were 50% (95% CI, 43-57) and 60% (95% CI, 53-68). For family/general medicine the estimates were 51% (95% CI, 34-69) and 58% (95% CI, 43-74). Age, geographic location, and length of a visit were significant in predicting BP screening. Gender, race, ethnicity, or urban location were not. A stepwise logistic regression confirmed these results. Rates of screening BP at well-child visits have increased but fall short of current recommendations. High-risk children are not screened at a rate different from their lower risk peers. Clin Pediatr. 2003;42:627-634

Background. There is widespread agreement among pediatric educators that continuity (following a panel of patients on a first contact basis for all their health care) is an important part of the education of pediatricians.Objective. To measure continuity in a pediatric residency practice and to compare this continuity with 2 nearby private general pediatric group practices. We also examined measures of continuity suggested in the literature.Design. Visit data were obtained from the practice billing system for a resident continuity practice and 2 nearby private practices for the 3-year period from July 1, 1992, to June 30, 1995. Visit data used were restricted to patients seen in the office of the practices during regular office hours. Continuity was measured using 5 different indices: 1) the usual provider of care index, visits by the usual clinician/total visits, 2) continuity for patient, the average proportion of visits that an individual patient was seen by his or her own physician, 3) continuity for physician (PHY), the average proportion of visits that an individual physician saw his or her own patients, 4) Continuity of Care Index (COC), and 5) the Modified, Modified Continuity Index. During the period examined, pediatric residents were present in the continuity practice for 1 half-day each week. The resident continuity practice (RCP) had 57 residents and saw 3386 patients for 18 955 visits. Private practice 1 (PP1) had 4 pediatricians who saw 4968 patients for 33 537 visits. Private practice 2 (PP2) had 5 pediatricians who saw 11 953 patients for 75 778 visits.Results. For all visit types, continuity in the RCP was not as high as in the private practices, PHY-RCP versus PP1, PP2; 53% versus 70%, 77%. However, continuity in RCP was greater than 50% for all measures except the COC index, which precipitously decreases as the number of clinicians seen increases. Examining continuity for health maintenance visits (PHY-RCP, PP2 vs PP1; 96%, 96% vs 82%) RCP was equal to the best of the private practices. The percentage of patients not seen for a health maintenance visit during the study period was lowest in the resident practice (RCP/PP1/PP2, 15/22/30).Conclusion. Although continuity for all visits in this RCP was less than in private practice, it was surprisingly high, considering the limited time residents spend in clinic. In a particularly important area for continuity, health maintenance visits, continuity was identical to one and superior to the other private practice.