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Jonsson MK, Sundlisæter NP, Nordal HH, Hammer HB, Aga AB, Olsen IC, Brokstad KA, van der Heijde D, Kvien TK, Fevang BTS, Lillegraven S, Haavardsholm EA. Calprotectin as a marker of inflammation in patients with early rheumatoid arthritis. Ann Rheum Dis 2017; 76:2031-2037. [DOI: 10.1136/annrheumdis-2017-211695] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 07/03/2017] [Accepted: 07/24/2017] [Indexed: 11/04/2022]
Abstract
ObjectivesCalprotectin is an inflammatory marker of interest in rheumatoid arthritis (RA). We evaluated whether the level of calprotectin was associated with disease activity, and if it was predictive of treatment response and radiographic progression in patients with early RA.MethodsPlasma from disease-modifying antirheumatic drug (DMARD)-naïve patients with RA fulfilling 2010 American College of Rheumatology/European League Against Rheumatism classification criteria with symptom duration <2 years was analysed for calprotectin at baseline, and after 1, 3 and 12 months. All patients received treat-to-target therapy, as part of a randomised controlled strategy trial (ARCTIC). The association between calprotectin, erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) and measures of disease activity were assessed by correlations. We used likelihood ratios and logistic regression models to assess the predictive value of the baseline inflammatory markers for treatment response and radiographic damage.Results215 patients were included: 61% female, 82% anti-citrullinated peptide antibody positive, mean (SD) age 50.9 (13.7) years and median (25, 75 percentile) symptom duration 5.8 (2.8, 10.5) months. Calprotectin was significantly correlated with Clinical Disease Activity Index (r=0.32), ESR (r=0.50) and ultrasonography power Doppler (r=0.42) before treatment onset. After 12 months of treatment, calprotectin, but not ESR and CRP, was significantly correlated with power Doppler (r=0.27). Baseline levels of calprotectin, ESR and CRP were not predictive of treatment response, but high levels of calprotectin were associated with radiographic progression in multivariate models.ConclusionsCalprotectin was correlated with inflammation assessed by ultrasound before and during DMARD treatment, and was also associated with radiographic progression. The data support that calprotectin may be of interest as an inflammatory marker when assessing disease activity in different stages of RA.Trial registration numberNCT01205854; Post-results.
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202
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Choi IY, Karpus ON, Turner JD, Hardie D, Marshall JL, de Hair MJH, Maijer KI, Tak PP, Raza K, Hamann J, Buckley CD, Gerlag DM, Filer A. Stromal cell markers are differentially expressed in the synovial tissue of patients with early arthritis. PLoS One 2017; 12:e0182751. [PMID: 28793332 PMCID: PMC5549962 DOI: 10.1371/journal.pone.0182751] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 07/23/2017] [Indexed: 12/28/2022] Open
Abstract
Introduction Previous studies have shown increased expression of stromal markers in synovial tissue (ST) of patients with established rheumatoid arthritis (RA). Here, ST expression of stromal markers in early arthritis in relationship to diagnosis and prognostic outcome was studied. Methods ST from 56 patients included in two different early arthritis cohorts and 7 non-inflammatory controls was analysed using immunofluorescence to detect stromal markers CD55, CD248, fibroblast activation protein (FAP) and podoplanin. Diagnostic classification (gout, psoriatic arthritis, unclassified arthritis (UA), parvovirus associated arthritis, reactive arthritis and RA), disease outcome (resolving vs persistent) and clinical variables were determined at baseline and after follow-up, and related to the expression of stromal markers. Results We observed expression of all stromal markers in ST of early arthritis patients, independent of diagnosis or prognostic outcome. Synovial expression of FAP was significantly higher in patients developing early RA compared to other diagnostic groups and non-inflammatory controls. In RA FAP protein was expressed in both lining and sublining layers. Podoplanin expression was higher in all early inflammatory arthritis patients than controls, but did not differentiate diagnostic outcomes. Stromal marker expression was not associated with prognostic outcomes of disease persistence or resolution. There was no association with clinical or sonographic variables. Conclusions Stromal cell markers CD55, CD248, FAP and podoplanin are expressed in ST in the earliest stage of arthritis. Baseline expression of FAP is higher in early synovitis patients who fulfil classification criteria for RA over time. These results suggest that significant fibroblast activation occurs in RA in the early window of disease.
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Affiliation(s)
- Ivy Y. Choi
- Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Olga N. Karpus
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Jason D. Turner
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
| | - Debbie Hardie
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
| | - Jennifer L. Marshall
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
| | - Maria J. H. de Hair
- Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karen I. Maijer
- Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul P. Tak
- Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - Jörg Hamann
- Department of Experimental Immunology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Christopher D. Buckley
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
| | - Danielle M. Gerlag
- Division of Clinical Immunology and Rheumatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
- * E-mail: (DMG); (AF)
| | - Andrew Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, The University of Birmingham, United Kingdom
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
- * E-mail: (DMG); (AF)
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203
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Caporali R, Smolen JS. Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management. Ann Rheum Dis 2017; 77:18-20. [PMID: 28768630 DOI: 10.1136/annrheumdis-2017-211458] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/03/2022]
Abstract
Ultrasound (US) unquestionably improves many aspects of rheumatoid arthritis (RA) diagnosis and management, but no consensus has been reached regarding the optimal US methodology that should be used, and high levels of standardisation have not yet been attained. Current evidence from two randomised controlled trials does not support the US in directing treatment decisions. A return to the endorsement of clinical assessment and the adoption of T2T strategies aiming at ACR/EULAR remission still represent the standard of care for RA and should be pursued through appropriate educational programmes. Thus, for now, the major application of sonography in arthritis should have a focus on diagnostic and especially differential diagnostic aspects.
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Affiliation(s)
- Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS Policlinico San Matteo Foundation, Pavia, Italy
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
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204
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Patterns of circulatory and peripheral blood mononuclear cytokines in rheumatoid arthritis. Rheumatol Int 2017; 37:1727-1734. [DOI: 10.1007/s00296-017-3774-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
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205
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Inciarte-Mundo J, Victoria Hernández M, Ruiz-Esquide V, Raquel Cabrera-Villalba S, Ramirez J, Cuervo A, Pascal M, Yagüe J, Cañete JD, Sanmarti R. Serum Calprotectin Versus Acute-Phase Reactants in the Discrimination of Inflammatory Disease Activity in Rheumatoid Arthritis Patients Receiving Tumor Necrosis Factor Inhibitors. Arthritis Care Res (Hoboken) 2017; 68:899-906. [PMID: 26841119 DOI: 10.1002/acr.22795] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 10/26/2015] [Accepted: 11/17/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the accuracy of serum calprotectin and acute-phase reactants (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) in stratifying disease activity in rheumatoid arthritis (RA) patients receiving tumor necrosis factor inhibitors (TNFi), and to correlate calprotectin levels with TNFi trough serum levels. METHODS We conducted a cross-sectional study of 87 RA patients receiving adalimumab, etanercept (ETN), or infliximab (IFX); 56 psoriatic arthritis (PsA) patients and 40 healthy blood donors were included as controls. Associations between calprotectin, CRP, and ESR and composite articular indices (Disease Activity Score in 28 joints [DAS28], Simplified Disease Activity Index [SDAI], and Clinical Disease Activity Index) were analyzed by correlation and linear regression and the accuracy and discriminatory capacity of calprotectin by receiver operator characteristic curves (area under the curve [AUC]). RESULTS Calprotectin levels correlated better with all composite activity indices than CRP and ESR (all r coefficients >0.70). Calprotectin levels were significantly lower in RA and PsA patients in clinical remission compared with those with low disease activity for all articular indices. In RA, ESR discriminated between remission and low disease activity only when using DAS28, and CRP only with SDAI. In RA patients in remission/low disease activity, calprotectin but not CRP or ESR distinguished between patients with no swollen joints and those with ≥1 swollen joint (1.74 μg/ml versus 3.04 μg/ml; P = 0.010). Using DAS28 ≥2.6 as the reference variable, calprotectin showed an AUC of 0.92; the best cutoff was ≥2.47 μg/ml with a likelihood ratio of 6.3 (95% confidence interval 2.5-15.8). Calprotectin serum levels inversely correlated with trough serum drug levels of ETN (ρ = -0.671, P < 0.001) and IFX (ρ = -0.729, P = 0.017). CONCLUSION Calprotectin may more accurately discriminate disease activity in RA patients receiving TNFi than acute-phase reactants, even in patients with low inflammatory activity.
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Affiliation(s)
| | | | | | | | - Julio Ramirez
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Andrea Cuervo
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Mariona Pascal
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jordi Yagüe
- Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Juan D Cañete
- Hospital Clinic, University of Barcelona, Barcelona, Spain
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206
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De Marco G, Helliwell P, McGonagle D, Emery P, Coates LC, Hensor EMA, Marzo-Ortega H. The GOLMePsA study protocol: an investigator-initiated, double-blind, parallel-group, randomised, controlled trial of GOLimumab and methotrexate versus methotrexate in early diagnosed psoriatic arthritis using clinical and whole body MRI outcomes. BMC Musculoskelet Disord 2017; 18:303. [PMID: 28720139 PMCID: PMC5516354 DOI: 10.1186/s12891-017-1659-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 07/05/2017] [Indexed: 01/02/2023] Open
Abstract
Background Psoriatic arthritis (PsA) is a chronic inflammatory arthritis which impacts significantly on the quality of life and work capacity of affected individuals. Recent evidence has shown that early control of inflammation in PsA leads to improved long-term outcomes. It is postulated that prompt intervention after diagnosis using a remission-induction treatment strategy will lead to improved outcomes and optimal disease control of PsA. The aim of the present study was to compare the clinical efficacy of a treatment strategy in newly diagnosed, treatment naïve PsA subjects, using the combination of golimumab (GOL), methotrexate (MTX) and steroids versus standard care (MTX monotherapy plus steroids). Methods/design GOLMePsA is an investigator initiated, phase IIIb, single-centre, randomised, double-blind, placebo-controlled, two-armed, parallel-group, imaging-supplemented study. Eighty-eight PsA patients, diagnosed within 24 months prior to screening and treatment naïve, will be randomised at baseline to receive: (arm 1) the combination of intramuscular/intra-articular prednisolone, MTX and GOL or (arm 2) the combination of intramuscular/intra-articular prednisolone, MTX and placebo for 24 weeks (interventional period). Primary outcome measure is clinical improvement (at least 1 unit difference) in the Psoriatic ArthritiS Disease Activity Score (PASDAS) composite index. Reflecting a “step down” therapeutic approach, all participants successfully completing the interventional period will be followed up for a further 28 weeks. During this observational period, stable maintenance MTX monotherapy will continue for both arms, unless in case of intolerance or PsA relapse. In the latter case, additional treatment will be provided. Overall, the GOLMePsA study length is planned to be 52 weeks. Discussion The hypothesis underlining this study is that very early treatment with first-line GOL reduces disease activity in PsA, in comparison to conventional therapy. Trial registration EudraCT 2013–004122-28. 24/09/2013.
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Affiliation(s)
- Gabriele De Marco
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Philip Helliwell
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Dennis McGonagle
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Paul Emery
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Laura C Coates
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Elizabeth M A Hensor
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, West Yorkshire, UK.,Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK
| | - Helena Marzo-Ortega
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, 2nd Floor Chapeltown Road, Leeds, West Yorkshire, LS7 4SA, UK.
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207
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Solomon DH, Kay J, Duryea J, Lu B, Bolster MB, Yood RA, Han R, Ball S, Coleman C, Lo E, Wohlfahrt A, Sury M, Yin M, Yu Z, Zak A, Gravallese EM. Effects of Teriparatide on Joint Erosions in Rheumatoid Arthritis: A Randomized Controlled Trial. Arthritis Rheumatol 2017; 69:1741-1750. [PMID: 28544807 DOI: 10.1002/art.40156] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/16/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Articular erosions correlate with disability in rheumatoid arthritis (RA). Biologic agents reduce erosion progression in RA, but erosion healing occurs infrequently. This study was undertaken to assess the effects of the anabolic agent teriparatide on joint erosion volume in RA patients treated with a tumor necrosis factor inhibitor (TNFi). METHODS We conducted a randomized controlled trial in 24 patients with erosive RA, osteopenia, and disease activity controlled by TNFi treatment for at least 3 months. Half were randomized to receive teriparatide for 1 year and the others constituted a wait-list control group. Subjects and primary rheumatologists were not blinded with regard to treatment assignment, but all outcomes were assessed in a blinded manner. The primary outcome measure was change in erosion volume determined by computed tomography at 6 anatomic sites. Significance within each hand and anatomic site was based on a 2-tailed test, with P values less than 0.05 considered significant. RESULTS Baseline characteristics of the treatment groups were well balanced. After 52 weeks, the median change in erosion volume in the teriparatide group was -0.4 mm3 (interquartile range [IQR] -34.5, 29.6) and did not differ significantly from that in controls (median change +9.1 mm3 [IQR -29.6, 26.4]) (P = 0.28). No significant difference in change in erosion volume was noted at the radius, ulna, or metacarpophalangeal joints. Bone mineral density improved at the femoral neck and lumbar spine in the teriparatide group. CONCLUSION Our findings indicate that teriparatide treatment for 1 year does not significantly reduce erosion volume in the hands or wrists of patients with established RA with disease activity controlled by TNFi treatment.
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Affiliation(s)
- D H Solomon
- Brigham and Women's Hospital, Boston, Massachusetts
| | - J Kay
- University of Massachusetts Memorial Medical Center, Worcester
| | - J Duryea
- Brigham and Women's Hospital, Boston, Massachusetts
| | - B Lu
- Brigham and Women's Hospital, Boston, Massachusetts
| | | | - R A Yood
- Reliant Medical Group, Worcester, Massachusetts
| | - R Han
- Brigham and Women's Hospital, Boston, Massachusetts
| | - S Ball
- University of Massachusetts Memorial Medical Center, Worcester
| | - C Coleman
- Brigham and Women's Hospital, Boston, Massachusetts
| | - E Lo
- Brigham and Women's Hospital, Boston, Massachusetts
| | - A Wohlfahrt
- Brigham and Women's Hospital, Boston, Massachusetts
| | - M Sury
- Brigham and Women's Hospital, Boston, Massachusetts
| | - M Yin
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Z Yu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - A Zak
- Brigham and Women's Hospital, Boston, Massachusetts
| | - E M Gravallese
- University of Massachusetts Memorial Medical Center, Worcester
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208
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Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus M, Balint P, Bruyn GAW, Iagnocco A, Jousse-Joulin S, Schmidt WA, Szkudlarek M, Conaghan PG, Filippucci E, D'Agostino MA. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open 2017; 3:e000427. [PMID: 28948984 PMCID: PMC5597800 DOI: 10.1136/rmdopen-2016-000427] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 12/14/2022] Open
Abstract
Objectives To test the reliability of new ultrasound (US) definitions and quantification of synovial hypertrophy (SH) and power Doppler (PD) signal, separately and in combination, in a range of joints in patients with rheumatoid arthritis (RA) using the European League Against Rheumatisms–Outcomes Measures in Rheumatology (EULAR-OMERACT) combined score for PD and SH. Methods A stepwise approach was used: (1) scoring static images of metacarpophalangeal (MCP) joints in a web-based exercise and subsequently when scanning patients; (2) scoring static images of wrist, proximal interphalangeal joints, knee and metatarsophalangeal joints in a web-based exercise and subsequently when scanning patients using different acquisitions (standardised vs usual practice). For reliability, kappa coefficients (κ) were used. Results Scoring MCP joints in static images showed substantial intraobserver variability but good to excellent interobserver reliability. In patients, intraobserver reliability was the same for the two acquisition methods. Interobserver reliability for SH (κ=0.87) and PD (κ=0.79) and the EULAR-OMERACT combined score (κ=0.86) were better when using a ‘standardised’ scan. For the other joints, the intraobserver reliability was excellent in static images for all scores (κ=0.8–0.97) and the interobserver reliability marginally lower. When using standardised scanning in patients, the intraobserver was good (κ=0.64 for SH and the EULAR-OMERACT combined score, 0.66 for PD) and the interobserver reliability was also good especially for PD (κ range=0.41–0.92). Conclusion The EULAR-OMERACT score demonstrated moderate-good reliability in MCP joints using a standardised scan and is equally applicable in non-MCP joints. This scoring system should underpin improved reliability and consequently the responsiveness of US in RA clinical trials.
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Affiliation(s)
- Lene Terslev
- Rheumatology department, Centre for Rheumatology and Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Esperanza Naredo
- Rheumatology and Joint and Bone Research Unit, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain
| | - Philippe Aegerter
- Public Health Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt; INSERM U1173, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Marina Backhaus
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Park-Klinik Weissensee, Berlin, Germany
| | - Peter Balint
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - George A W Bruyn
- Department of Rheumatology, MC Groep Hospitals, Lelystad, the Netherlands
| | | | | | - Wolfgang A Schmidt
- Medical Centre for Rheumatology, Immanuel Krankenhaus, Buch, Berlin, Germany
| | - Marcin Szkudlarek
- Department of Rheumatology, Zealand's University Hospital at Kàge, Copenaghen, Denmark
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Emilio Filippucci
- Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Ancona, Italy
| | - Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Ambroise Paré Hospital, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
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209
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Klein A, Just GW, Werner SG, Oommen PT, Minden K, Becker I, Langer HE, Klee D, Horneff G. Fluorescence optical imaging and musculoskeletal ultrasonography in juvenile idiopathic polyarticular disease before and during antirheumatic treatment - a multicenter non-interventional diagnostic evaluation. Arthritis Res Ther 2017; 19:147. [PMID: 28666454 PMCID: PMC5493121 DOI: 10.1186/s13075-017-1355-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Accepted: 05/30/2017] [Indexed: 11/10/2022] Open
Abstract
Background Valid detection of inflamed joints is essential for correct classification, therapeutic decisions, prognosis and assessment of treatment efficacy in juvenile idiopathic arthritis (JIA). Fluorescence optical imaging (FOI) enables visualization of inflammation in arthritis of finger and hand joints and might be used for monitoring. Methods A 24-week observational study in polyarticular JIA patients newly starting treatment with methotrexate or an approved biologic was performed in three centers. Patients were evaluated clinically, by gray-scale ultrasonography (GSUS), power-Doppler ultrasonography (PDUS) and FOI at baseline, week 12 and week 24. Results Of 37 patients enrolled, 24 patients started methotrexate and 13 patients a biologic for the first time (etanercept n = 11, adalimumab and tocilizumab n = 1 each). Mean JADAS 10 decreased significantly from 17.7 at baseline to 12.2 and 7.2 at week 12 and 24 respectively. PedACR 30/50/70/100 response rates at week 24 were 85%/73%/50%/27%. The total number of clinically active joints in hand and fingers at baseline/week 12/week 24 was 262 (23.6%)/162 (16.4%)/162 (9.0%). By GSUS, at baseline/week 12/week 24, 192 (19.4%)/135 (16.1%)/83 (11.5%) joints showed effusions and 186 (18.8%)/107 (12.7%)/69 (9.6%) showed synovial thickening, and by PDUS 68 (6.9%)/15 (1.8%)/36 (5%) joints showed hyperperfusion. Any sign of arthritis was detected by US in a total of 243 joints (24.5%) at baseline, 161 joints (19.2%) at week 12 and 123 joints (17%) at week 24. By FOI at baseline/week 12/week 24, 430 (38.7%)/280 (29.2%)/215 (27.6%) showed a signal enhancement in at least one phase. Summarizing all three points of time, the highest numbers of signals were detected by FOI with 32% of joints, especially in phase 2, while by US 20.7% and by clinical examination 17.5% of joints were active. A high number of joints (21.1%) had FOI signals but were inactive by clinical examination. A total 20.1% of joints with signals in FOI did not show effusion, synovial thickening or hyperperfusion by US. Because of the high number of negative results, specificity of FOI compared with clinical examination/US/PD was high (84–95%), and sensitivity was only moderate. Conclusion FOI and US could detect clinical but also subclinical inflammation. FOI detected subclinical inflammation to a higher extent than US. Improvement upon treatment with either methotrexate or a biologic can be visualized by FOI and US. Trial registration Deutsches Register Klinischer Studien DRKS00011579. Registered 10 January 2017.
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Affiliation(s)
- Ariane Klein
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Arnold-Janssen-Strasse 29, 53757, Sankt Augustin, Germany.
| | - Georg Werner Just
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Arnold-Janssen-Strasse 29, 53757, Sankt Augustin, Germany
| | | | - Prasad T Oommen
- Department of Pediatric Oncology, Hematology and Clinical Immunology, University Children's Hospital, Medical Faculty, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kirsten Minden
- Charité University Medicine and Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Ingrid Becker
- Institute of Medical Statistics, University of Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Hans-Eckhard Langer
- RHIO (Rheumatologie, Immunologie, Osteologie) Düsseldorf, Düsseldorf, Germany
| | - Dirk Klee
- Department of Diagnostic and Interventional Radiology, University Düsseldorf, Medical Faculty, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Gerd Horneff
- Centre for Paediatric Rheumatology, Department of Paediatrics, Asklepios Clinic Sankt Augustin, Arnold-Janssen-Strasse 29, 53757, Sankt Augustin, Germany
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Yoshikawa A, Yoshida S, Kimura Y, Tokai N, Fujiki Y, Kotani T, Matsumura Y, Takeuchi T, Makino S. Add-on iguratimod as a therapeutic strategy to achieve remission in patients with rheumatoid arthritis inadequately responding to biological DMARDs: A retrospective study. Mod Rheumatol 2017. [DOI: 10.1080/14397595.2017.1336865] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Ayaka Yoshikawa
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Shuzo Yoshida
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Yuko Kimura
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Nao Tokai
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Yohei Fujiki
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Takuya Kotani
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Yoko Matsumura
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Tohru Takeuchi
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
| | - Shigeki Makino
- Department of Internal Medicine IV, Osaka Medical College, Osaka, Japan
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Teh J, Østergaard M. What the Rheumatologist Is Looking for and What the Radiologist Should Know in Imaging for Rheumatoid Arthritis. Radiol Clin North Am 2017; 55:905-916. [PMID: 28774454 DOI: 10.1016/j.rcl.2017.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This article outlines what the rheumatologist is looking for and wants to know in the clinical diagnosis and imaging of rheumatoid arthritis, and what the radiologist should know to facilitate this.
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Affiliation(s)
- James Teh
- Department of Radiology, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7LD, UK.
| | - Mikkel Østergaard
- Department of Rheumatology, Copenhagen University Hospital at Hvidovre, Kettegaard alle 30, Hvidovre 2650, Denmark
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Ultrasound-detected bone erosion is a relapse risk factor after discontinuation of biologic disease-modifying antirheumatic drugs in patients with rheumatoid arthritis whose ultrasound power Doppler synovitis activity and clinical disease activity are well controlled. Arthritis Res Ther 2017; 19:108. [PMID: 28545509 PMCID: PMC5445491 DOI: 10.1186/s13075-017-1320-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 05/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the present study, we explored the risk factors for relapse after discontinuation of biologic disease-modifying antirheumatic drug (bDMARD) therapy in patients with rheumatoid arthritis (RA) whose ultrasound power Doppler (PD) synovitis activity and clinical disease activity were well controlled. METHODS In this observational study in clinical practice, the inclusion criteria were based on ultrasound disease activity and clinical disease activity, set as low or remission (Disease Activity Score in 28 joints based on erythrocyte sedimentation rate <3.2). Ultrasound was performed in 22 joints of bilateral hands at discontinuation for evaluating synovitis severity and presence of bone erosion. Patients with a maximum PD score ≤1 in each joint were enrolled. Forty patients with RA were consecutively recruited (November 2010-March 2015) and discontinued bDMARD therapy. Variables at the initiation and discontinuation of bDMARD therapy that were predictive of relapse during the 12 months after discontinuation were assessed. RESULTS The median patient age was 54.5 years, and the median disease duration was 3.5 years. Nineteen (47.5%) patients relapsed during the 12 months after the discontinuation of bDMARD therapy. Logistic regression analysis revealed that only the presence of bone erosion detected by ultrasound at discontinuation was predictive of relapse (OR 8.35, 95% CI 1.78-53.2, p = 0.006). No clinical characteristics or serologic biomarkers were significantly different between the relapse and nonrelapse patients. The ultrasound synovitis scores did not differ significantly between the groups. CONCLUSIONS Our findings are the first evidence that ultrasound bone erosion may be a relapse risk factor after the discontinuation of bDMARD therapy in patients with RA whose PD synovitis activity and clinical disease activity are well controlled.
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Stewart S, Dalbeth N, Vandal AC, Allen B, Miranda R, Rome K. Are ultrasound features at the first metatarsophalangeal joint associated with clinically-assessed pain and function? A study of people with gout, asymptomatic hyperuricaemia and normouricaemia. J Foot Ankle Res 2017; 10:22. [PMID: 28539973 PMCID: PMC5441079 DOI: 10.1186/s13047-017-0203-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 05/15/2017] [Indexed: 01/05/2023] Open
Abstract
Background The first metatatarsophalangeal joint (1st MTP joint) is a common location for sonographic evidence of urate deposition in people with gout and asymptomatic hyperuricaemia. However, it is unclear whether these are related to clinically-assessed pain and function. This study aimed to determine the association between ultrasound features and clinical characteristics of the 1st MTP joint in people with gout, asymptomatic hyperuricaemia and age- and sex-matched normouricaemic individuals. Methods Twenty-three people with gout, 29 with asymptomatic hyperuricaemia and 34 with normouricaemia participated in a cross-sectional study. No participant had clinical evidence of acute inflammatory arthritis at the time of assessment. Four sonographic features at the 1st MTP joint were analysed: double contour sign, tophus, bone erosion and synovitis. Clinical characteristics included in the analysis were 1st MTP joint pain, overall foot pain and disability, 1st MTP joint temperature, 1st MTP joint range of motion and gait velocity. Statistical analyses adjusted for the diagnostic group of the participant. Results After accounting for the diagnostic group, double contour sign was associated with higher foot pain and disability scores (P < 0.001). Ultrasound tophus was associated with higher foot pain and disability scores (P < 0.001), increased temperature (P = 0.005), and reduced walking velocity (P = 0.001). No associations were observed between ultrasound synovitis or erosion and the clinical characteristics. Conclusions Ultrasound features of urate crystal deposition, rather than soft tissue inflammation or bone erosion, are associated with clinical measures of foot-related functional impairment and disability even in the absence of clinical evidence of current acute inflammatory arthritis. This association persisted regardless of the diagnosis of the participant as having gout or asymptomatic hyperuricaemia.
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Affiliation(s)
- Sarah Stewart
- Department of Podiatry, Health & Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland, 1142 New Zealand
| | - Nicola Dalbeth
- Faculty of Medical and Health Sciences, The University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand.,Department of Rheumatology, Auckland District Health Board, P.O. Box 92189, Auckland, New Zealand
| | - Alain C Vandal
- Department of Biostatistics & Epidemiology, Faculty of Health and Environmental Sciences, Auckland University of Technology, Private Bag 92006, Auckland, 1142 New Zealand.,Health Intelligence & Informatics, Ko Awatea, Counties Manukau Health, Private Bag 93311, Auckland, 1640 New Zealand
| | - Bruce Allen
- Horizon Radiology, Auckland University of Technology North Shore Campus, AA Building, 90 Akoranga Drive, Northcote, Auckland, New Zealand
| | - Rhian Miranda
- Auckland City Hospital Radiology, Auckland District Health Board, P.O Box 92189, Auckland, New Zealand
| | - Keith Rome
- Department of Podiatry, Health & Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland, 1142 New Zealand
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Koga T, Okada A, Fukuda T, Hidaka T, Ishii T, Ueki Y, Kodera T, Nakashima M, Takahashi Y, Honda S, Horai Y, Watanabe R, Okuno H, Aramaki T, Izumiyama T, Takai O, Miyashita T, Sato S, Kawashiri SY, Iwamoto N, Ichinose K, Tamai M, Origuchi T, Nakamura H, Aoyagi K, Eguchi K, Kawakami A. Anti-citrullinated peptide antibodies are the strongest predictor of clinically relevant radiographic progression in rheumatoid arthritis patients achieving remission or low disease activity: A post hoc analysis of a nationwide cohort in Japan. PLoS One 2017; 12:e0175281. [PMID: 28505163 PMCID: PMC5432072 DOI: 10.1371/journal.pone.0175281] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/23/2017] [Indexed: 11/18/2022] Open
Abstract
Objectives To determine prognostic factors of clinically relevant radiographic progression (CRRP) in patients with rheumatoid arthritis (RA) achieving remission or low disease activity (LDA) in clinical practice. Methods Using data from a nationwide, multicenter, prospective study in Japan, we evaluated 198 biological disease-modifying antirheumatic drug (bDMARD)-naïve RA patients who were in remission or had LDA at study entry after being treated with conventional synthetic DMARDs (csDMARDs). CRRP was defined as the yearly progression of modified total Sharp score (mTSS) >3.0 U. We performed a multiple logistic regression analysis to explore the factors to predict CRRP at 1 year. We used receiver operating characteristic (ROC) curve to estimate the performance of relevant variables for predicting CRRP. Results The mean Disease Activity Score in 28 joints-erythrocyte sedimentation rate (DAS28-ESR) was 2.32 ± 0.58 at study entry. During the 1-year observation, remission or LDA persisted in 72% of the patients. CRRP was observed in 7.6% of the patients. The multiple logistic regression analysis revealed that the independent variables to predict the development of CRRP were: anti-citrullinated peptide antibodies (ACPA) positivity at baseline (OR = 15.2, 95%CI 2.64–299), time-integrated DAS28-ESR during the 1 year post-baseline (7.85-unit increase, OR = 1.83, 95%CI 1.03–3.45), and the mTSS at baseline (13-unit increase, OR = 1.22, 95%CI 1.06–1.42). Conclusions ACPA positivity was the strongest independent predictor of CRRP in patients with RA in remission or LDA. Physicians should recognize ACPA as a poor-prognosis factor regarding the radiographic outcome of RA, even among patients showing a clinically favorable response to DMARDs.
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Affiliation(s)
- Tomohiro Koga
- Center for Bioinformatics and Molecular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
- * E-mail:
| | - Akitomo Okada
- Japanese Red Cross Nagasaki Genbaku Hospital, Department of Rheumatology, Mori-machi 3–15, Nagasaki, Japan
| | - Takaaki Fukuda
- Kurume University Medical Center, Department of Rheumatology, Kokubun 155–1, Kurume, Japan
| | - Toshihiko Hidaka
- Zenjinkai Shimin-no-Mori Hospital, Shioji 2783–37, Miyazaki, Japan
| | - Tomonori Ishii
- Tohoku University Hospital, Department of Hematology and Rheumatology, Aoba-ku, seiryo 1–1, Sendai, Japan
| | - Yukitaka Ueki
- Sasebo Chuo Hospital, Rheumatic and Collagen Disease Center, Yamato 15, Sasebo, Japan
| | - Takao Kodera
- Tohoku Medical and Pharmaceutical University Hospital, Aoba-ku, komatsujima 4-4-1, Sendai, Japan
| | - Munetoshi Nakashima
- Japanese Red Cross Nagasaki Genbaku Hospital, Department of Rheumatology, Mori-machi 3–15, Nagasaki, Japan
- Kurume University Medical Center, Department of Rheumatology, Kokubun 155–1, Kurume, Japan
| | | | - Seiyo Honda
- Kurume University School of Medicine, asahi-machi 67, Kurume, Japan
| | - Yoshiro Horai
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
| | - Ryu Watanabe
- Tohoku University Hospital, Department of Hematology and Rheumatology, Aoba-ku, seiryo 1–1, Sendai, Japan
| | - Hiroshi Okuno
- Tohoku University Hospital, Department of Orthopaedic Surgery, Hirase 9–3, Sasebo, Japan
| | - Toshiyuki Aramaki
- Japanese Red Cross Nagasaki Genbaku Hospital, Department of Rheumatology, Mori-machi 3–15, Nagasaki, Japan
- Sasebo Chuo Hospital, Rheumatic and Collagen Disease Center, Yamato 15, Sasebo, Japan
| | - Tomomasa Izumiyama
- East Sendai Rheumatism and internal medicine Clinic, Miyagino, Nittahigashi 1-17-5, Sendai, Japan
| | - Osamu Takai
- Osaki Citizen Hospital, Furukawa-honami 3-8-1, Osaki, Japan
| | | | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Sakamoto 1-7-1, Nagasaki, Japan
| | - Shin-ya Kawashiri
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-12-4, Nagasaki, Japan
| | - Naoki Iwamoto
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
| | - Kunihiro Ichinose
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
| | - Mami Tamai
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
| | - Tomoki Origuchi
- Department of Rehabilitation Sciences, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-12-4, Nagasaki, Japan
| | - Hideki Nakamura
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
| | - Kiyoshi Aoyagi
- Department of Public Health, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-12-4, Nagasaki, Japan
| | | | - Atsushi Kawakami
- Unit of Translational Medicine, Department of Immunology and Rheumatology, Nagasaki University Graduate School of Biomedical Sciences, Sakamoto 1-7-1, Nagasaki, Japan
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Hirata A, Ogura T, Hayashi N, Takenaka S, Ito H, Mizushina K, Fujisawa Y, Yamashita N, Nakahashi S, Imamura M, Kujime R, Kameda H. Concordance of Patient-Reported Joint Symptoms, Physician-Examined Arthritic Signs, and Ultrasound-Detected Synovitis in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:801-806. [PMID: 27564121 DOI: 10.1002/acr.23006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/07/2016] [Accepted: 08/09/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Ultrasonography has been prevalently used as a valid and objective modality for joint examination in patients with rheumatoid arthritis (RA). This study aimed to examine and compare the concordance between ultrasound, clinical assessment, and patient-reported assessment of joint synovitis in RA. METHODS Fifty patients with RA (84% female, median age 69 years, median disease duration 31 months, and median Disease Activity Score in 28 joints 3.8) completed the self-evaluation of joint symptoms, including pain and considerable stiffness in the (proximal) interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, knee, and ankle joints. These joints were also examined by a physician in order to assess the presence of tenderness or swelling; the presence of imaging synovitis was assessed by ultrasonography. RESULTS In a total of 1,492 evaluated joints, symptoms (pain and stiffness), tenderness, and swelling were noted in 288 (19.3%), 182 (12.2%), and 220 (14.7%) joints, respectively, while ultrasound indicated synovitis in 317 (21.2%) joints. Overall concordance with ultrasound findings was lowest for joint tenderness (κ = 0.30), followed by symptoms (κ = 0.39), and by swelling (κ = 0.43), irrespective of the evaluated joint, except for the elbow. Moreover, the percentages of inflamed joints detected only on the basis of symptoms, tenderness, or swelling were 18.6%, 2.2%, and 8.5%, respectively, of all joints with signs of synovitis on ultrasonography. CONCLUSION Joint swelling showed the best concordance with ultrasonography, followed by patient-reported joint symptoms, and joint tenderness. Joint symptoms, rather than tenderness evaluation, may be a better clinical indicator of synovitis in RA patients.
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Ruta S, Marin J, Acosta Felquer ML, Ferreyra-Garrot L, Rosa J, García-Monaco R, Soriano ER. Utility of Power Doppler Ultrasound–detected Synovitis for the Prediction of Short-term Flare in Psoriatic Patients with Arthritis in Clinical Remission. J Rheumatol 2017; 44:1018-1023. [DOI: 10.3899/jrheum.161347] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2017] [Indexed: 11/22/2022]
Abstract
Objective.Power Doppler ultrasound (PDUS) has been shown to detect subclinical synovitis in psoriatic arthritis (PsA), but its value is not yet fully understood. The aim of this study was to evaluate PDUS features at joint level in patients with PsA in clinical remission and to investigate its value for predicting short-term flares.Methods.Consecutive patients with PsA in clinical remission according to the attending rheumatologist and who fulfill minimal disease activity criteria and/or 28-joint Disease Activity Score in remission criteria underwent PDUS examination of 18 joints. All patients were followed up for 6 months. Disease flare was defined as any increase of disease activity generating the need of any of the following changes in therapy with disease-modifying antirheumatic drugs (DMARD) by the attending rheumatologist: dose increase, switch or addition of a different DMARD, and/or switch or addition of biological therapies.Results.Among 54 patients with PsA in clinical remission, 15 (27.8%) experienced a flare within the next 6 months. Twenty patients had at least 1 joint with PDUS synovitis at baseline, and 13 (65%) of these had a disease flare during the followup period compared with only 2 of the 34 patients (5.9%) without baseline PDUS synovitis (relative risk = 11, 95% CI 2.8–44, p < 0.001). On logistic regression analysis, the only variables associated with short-term flares were baseline PDUS synovitis and the use of nonbiologic DMARD.Conclusion.Among patients with PsA in clinical remission, PDUS-detected synovitis was a strong predictor of short-term flare of the disease.
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Fluorescence optical imaging and 3T-MRI for detection of synovitis in patients with rheumatoid arthritis in comparison to a composite standard of reference. Eur J Radiol 2017; 90:6-13. [DOI: 10.1016/j.ejrad.2017.02.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 01/16/2017] [Accepted: 02/12/2017] [Indexed: 11/22/2022]
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Raffeiner B, Grisan E, Botsios C, Stramare R, Rizzo G, Bernardi L, Punzi L, Ometto F, Doria A. Grade and location of power Doppler are predictive of damage progression in rheumatoid arthritis patients in clinical remission by anti-tumour necrosis factor α. Rheumatology (Oxford) 2017; 56:1320-1325. [DOI: 10.1093/rheumatology/kex084] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Indexed: 11/13/2022] Open
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Sewerin P, Vordenbaeumen S, Hoyer A, Brinks R, Buchbender C, Miese F, Schleich C, Klein S, Schneider M, Ostendorf B. Silent progression in patients with rheumatoid arthritis: is DAS28 remission an insufficient goal in RA? Results from the German Remission-plus cohort. BMC Musculoskelet Disord 2017; 18:163. [PMID: 28420375 PMCID: PMC5395882 DOI: 10.1186/s12891-017-1528-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Accepted: 04/07/2017] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Remission is arguably the ultimate therapeutic goal in rheumatoid arthritis (RA). Applying modern strategies, clinical remission can be achieved in a substantial number of patients with early RA (ERA). Even in those patients, the number and scope of erosions can increase. We, therefore, investigated the value of MRI for the detection of radiological progression in patients with DAS28 improvement and/or clinical remission of the German Remission-plus cohort. METHODS Data-sets of 80 RA patients (according to 2010 ACR/EULAR criteria) from the Remission-plus study cohort, who fulfilled the following criteria, were retrospectively analysed: availability of two consecutive MRI scans (low-field MRI, follow-up interval 1 year) of the clinically dominant hand and wrist, and the presence of DAS28 (CRP) scores at both time points, which was used to assess disease activity. RESULTS Seventy-one of the 80 investigated patients presented a numerical improvement of the DAS28 (CRP) after 12 months (DAS28(CRP) T0 average (Ø) 4.96, SD 1.2; DAS28 T4 (12 month) Ø 2.6, SD 1.0), 73% of them also improved in the RAMRIS-Score, while 24% demonstrated an increase despite DAS28 improvement and 3% showed equal values. 48% of patients who improved in the DAS28 reached EULAR remission. 41% of these patients had an increase in the RAMRIS Erosion-subscore after 12 months. When considering EULAR response criteria (non-response (n = 7), moderate response (n = 19), good response (n = 45)), an increase of erosions was found in 71.4% of non-responders, 52.6% of moderate responders, and 31.1% of good responders after 12 months, all compared to baseline. CONCLUSION Up to 40% of patients in this study demonstrated a progressive erosive disease detected by MRI despite DAS28 improvement or EULAR remission. Future studies are needed to determine the prognostic clinical impact of disease progression in MRI despite clinical remission, and to investigate if DAS28 remission may be an insufficient therapeutic goal and should be accompanied by MRI remission criteria.
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Affiliation(s)
- Philipp Sewerin
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany.
| | - Stefan Vordenbaeumen
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Annika Hoyer
- German Diabetes Centre, Institute for Biometry and Epidemiology, Auf'm Hennekamp 65, Duesseldorf, 40225, Germany
| | - Ralph Brinks
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Christian Buchbender
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Falk Miese
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Christoph Schleich
- Department of Diagnostic and Interventional Radiology, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Sabine Klein
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Matthias Schneider
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
| | - Benedikt Ostendorf
- Department of Rheumatology & Hiller Research Unit, University Hospital Düsseldorf, Moorenstreet 5, Duesseldorf, 40225, Germany
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de Miguel E, Pecondón-Español A, Castaño-Sánchez M, Corrales A, Gutierrez-Polo R, Rodriguez-Gomez M, Pinto-Tasende JA, Rivas JL, Ivorra-Cortés J. A reduced 12-joint ultrasound examination predicts lack of X-ray progression better than clinical remission criteria in patients with rheumatoid arthritis. Rheumatol Int 2017; 37:1347-1356. [PMID: 28389854 DOI: 10.1007/s00296-017-3714-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 03/30/2017] [Indexed: 11/30/2022]
Abstract
To study the predictive value of clinical remission definitions and ultrasound (US) examination on X-ray progression in rheumatoid arthritis (RA). This was an observational prospective multicenter 1-year follow-up cohort of RA patients with moderate disease activity (3.2 < DAS28 ≤ 5.1) who started anti-TNF therapy. DAS28ESR, DAS28CRP, SDAI, CDAI, and ACR/EULAR remission criteria were applied and reduced 12-joint US examination was performed at baseline and at 6 and 12 months. At baseline and month 12, radiographs of hands and feet were obtained in a subset of patients. A blind independent reader scored radiographs. X-ray progression was defined as Sharp van der Heijde change score >1 and no progression was defined as ≤0. 319 of 357 patients completed the study; patients had a mean (SD) age of 53.5 (13.1) years, with a disease duration of 7.5 (7.1) years. Laboratory, clinical, and US values significantly improved at month 6, except CRP, with additional improvement at month 12. Remission and low disease activity rates increased at follow-up. In the subset of 115 patients with radiological studies, clinical remission by any definition was not significantly associated with X-ray progression. Patients without PD signal at baseline and month 6 were a lower risk of X-ray progression than patients with PD signal, OR 0.197 (95% CI 0.046-0.861) and 0.134 (95% CI 0.047-0.378), respectively. Absence of PD signal, but not clinical remission predicts lack of X-ray progression. A feasible 12-joint US examination may add relevant information to RA remission criteria.
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Affiliation(s)
- Eugenio de Miguel
- Rheumatology Department, Hospital Universitario La Paz, Pº de la Castellana 261, 28046, Madrid, Spain.
| | | | - Manuel Castaño-Sánchez
- Rheumatology Department, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Alfonso Corrales
- Rheumatology Department, Hospital Marqués de Valdecilla, Santander, Spain
| | | | | | - Jose A Pinto-Tasende
- Rheumatology Department, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain
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Basra HAS, Humphries PD. Juvenile idiopathic arthritis: what is the utility of ultrasound? Br J Radiol 2017; 90:20160920. [PMID: 28291375 DOI: 10.1259/bjr.20160920] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is a heterogeneous condition and an important cause of acquired disability in children. Evidence supports early treatment to prevent future complications. This relies on prompt diagnosis, achieved by a high index of clinical suspicion and supportive evidence, including the detection of joint and or tendon inflammation. Ultrasound is a readily accessible, well-tolerated, safe and accurate modality for assessing joints and the surrounding soft tissues. It can also be used to guide therapy into those joints and tendon sheaths resistant to systemic treatments. Ultrasound imaging is highly operator dependent, and the developing skeleton poses unique challenges in interpretation with sonographic findings that can mimic pathology and vice versa. Ultrasound technology has been rapidly improving and is more accessible than ever before. In this article, we review the normal appearances, highlight potential pitfalls and present the key pathological findings commonly seen in JIA.
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Affiliation(s)
- Hershernpal A S Basra
- 1 Department of Radiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Paul D Humphries
- 2 Department of Radiology, Great Ormond Street Hospital for Children, University College London Hospital NHS Foundation Trust, London, UK
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Allen PB, Olivera P, Emery P, Moulin D, Jouzeau JY, Netter P, Danese S, Feagan B, Sandborn WJ, Peyrin-Biroulet L. Review article: moving towards common therapeutic goals in Crohn's disease and rheumatoid arthritis. Aliment Pharmacol Ther 2017; 45:1058-1072. [PMID: 28247573 DOI: 10.1111/apt.13995] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 08/01/2016] [Accepted: 01/28/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Crohn's disease (CD) and rheumatoid arthritis are chronic, progressive and disabling conditions that frequently lead to structural tissue damage. Based on strategies originally developed for rheumatoid arthritis, the treatment goal for CD has recently moved from exclusively controlling symptoms to both clinical remission and complete mucosal healing (deep remission), with the final aim of preventing bowel damage and disability. AIM To review the similarities and differences in treatment goals between CD and rheumatoid arthritis. METHODS This review examined manuscripts from 1982 to 2016 that discussed and/or proposed therapeutic goals with their supportive evidence in CD and rheumatoid arthritis. RESULTS Proposed therapeutic strategies to improve outcomes in both rheumatoid arthritis and CD include: (i) evaluation of musculoskeletal or organ damage and disability, (ii) tight control, (iii) treat-to-target, (iv) early intervention and (v) disease modification. In contrast to rheumatoid arthritis, there is a paucity of disease-modification trials in CD. CONCLUSIONS Novel therapeutic strategies in CD based on tight control of objective signs of inflammation are expected to change disease course and patients' lives by halting progression or, ideally, preventing the occurrence of bowel damage. Most of these strategies require validation in prospective studies, whereas several disease-modification trials have addressed these issues in rheumatoid arthritis over the last decade. The recent approval of new drugs in CD such as vedolizumab and ustekinumab should facilitate initiation of disease-modification trials in CD in the near future.
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Affiliation(s)
- P B Allen
- Division of Gastroenterology, Ulster Hospital, Belfast, UK
| | - P Olivera
- Gastroenterology Section, Department of Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas (CEMIC), Buenos Aires, Argentina
| | - P Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - D Moulin
- UMR 7365 IMoPA CNRS-Université de Lorraine, Biopôle de l'Université de Lorraine, Campus Biologie-Santé, Vandœuvre-lès-Nancy Cedex, France
| | - J-Y Jouzeau
- UMR 7365 IMoPA CNRS-Université de Lorraine, Biopôle de l'Université de Lorraine, Campus Biologie-Santé, Vandœuvre-lès-Nancy Cedex, France
| | - P Netter
- UMR 7365 IMoPA CNRS-Université de Lorraine, Biopôle de l'Université de Lorraine, Campus Biologie-Santé, Vandœuvre-lès-Nancy Cedex, France
| | - S Danese
- Department of Gastroenterology, IBD Center, Istituto Clinico Humanitas, Humanitas University, Milan, Italy
| | - B Feagan
- Western University, London, ON, Canada
| | - W J Sandborn
- Division of Gastroenterology, University of California San Diego, La Jolla, CA, USA
| | - L Peyrin-Biroulet
- Inserm U954 and Department of Hepato-Gastroenterology, University Hospital of Nancy, Lorraine University, Vandoeuvre-les-Nancy, France
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Vergara F, Ruta S, Rosa J, Marín J, García-Mónaco R, Soriano ER. The value of power Doppler ultrasound in patients with rheumatoid arthritis in clinical remission: Reclassifying disease activity? ACTA ACUST UNITED AC 2017; 14:202-206. [PMID: 28330716 DOI: 10.1016/j.reuma.2017.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 01/06/2017] [Accepted: 01/18/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of the present study was to describe the ultrasound (US) findings in patients with rheumatoid arthritis (RA) in clinical remission, and to evaluate the ability of power Doppler (PD) US to reclassify disease activity in these patients. MATERIAL AND METHODS We included consecutive patients with RA according to 2010 American College of Rheumatology/European League Against Rheumatism criteria, who were in clinical remission by the Disease Activity Score (DAS28<2.6). Twenty joints of both hands were assessed by US. PD signal was evaluated on a semi-quantitative scale from 0 to 3. Three different US-modified DAS28 (US-DAS28) were constructed, replacing the clinical swollen joint count by the PD US joint count using PD score ≥1, ≥2 or ≥3, respectively. RESULTS Eighty-six patients were included. Twenty-three (26.7%) patients had at least one joint with abnormal US-positive PD signal. Thirteen percent of patients were reclassified to low disease activity by applying the US-DAS28 when joints were considered active with a PD signal ≥1; 12%, when a PD signal ≥2 was considered, and 2% of the patients were reclassified when a PD score of 3 was considered. No patients were reclassified to a level of moderate or high activity applying US-DAS28. CONCLUSIONS Although around a quarter of patients with RA in clinical remission showed PD US features indicating residual activity, only a small percentage were reclassified to a state of low activity and none to a level of moderate or high activity, applying the proposed US-DAS28.
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Affiliation(s)
- Facundo Vergara
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Ruta
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Javier Rosa
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Josefina Marín
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Ricardo García-Mónaco
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Enrique R Soriano
- Sección de Reumatología, Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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"To be or not to be" for PET in rheumatology. A marriage of love or of convenience? Reumatologia 2017; 55:1-3. [PMID: 28386135 PMCID: PMC5380765 DOI: 10.5114/reum.2017.66679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 02/27/2017] [Indexed: 11/17/2022] Open
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Harman H, Tekeoğlu İ. Ankle pathologies in patients with inflammatory rheumatic diseases: a clinical and ultrasonographic study. Int J Rheum Dis 2017; 20:675-684. [DOI: 10.1111/1756-185x.13007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Halil Harman
- Department of Pysical Medicine and Rehabilitation, Rheumatology; Sakarya University Faculty of Medicine; Sakarya Turkey
| | - İbrahim Tekeoğlu
- Department of Pysical Medicine and Rehabilitation, Rheumatology; Sakarya University Faculty of Medicine; Sakarya Turkey
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Baker JF, Østergaard M, Conaghan PG. Is MRI a predictive biomarker for clinical response to biologics in rheumatoid arthritis? Ann Rheum Dis 2017; 76:e45. [DOI: 10.1136/annrheumdis-2017-211265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 11/03/2022]
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Nikiphorou E, Carpenter L, Norton S, Morris S, MacGregor A, Dixey J, Williams P, Kiely P, Walsh DA, Young A. Can Rheumatologists Predict Eventual Need for Orthopaedic Intervention in Patients with Rheumatoid Arthritis? Results of a Systematic Review and Analysis of Two UK Inception Cohorts. Curr Rheumatol Rep 2017; 19:12. [DOI: 10.1007/s11926-017-0636-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lazaar H, Lhoste-Trouilloud A, Pereira B, Couderc M, Mathieu S, Soubrier M. Does rheumatoid synovitis activity vary during the day? Evaluation with color doppler sonography. BMC Musculoskelet Disord 2017; 18:98. [PMID: 28257635 PMCID: PMC5336684 DOI: 10.1186/s12891-017-1450-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/13/2017] [Indexed: 11/26/2022] Open
Abstract
Background Clinical symptoms of rheumatoid arthritis (RA) improve in the course of the day, as can synovitis activity, reported via doppler ultrasound (US). The aim of the study was to establish whether the Color Doppler (CD) scores of synovitis in RA changes throughout the day. Methods In total, 27 patients with active RA, including 14 patients receiving corticosteroids were studied. US evaluation was performed twice in each patient, at 9 a.m. (T0) and after 4 p.m. (T1) on the same day by a single radiologist and using the same instrument. Overall, 30 joints were assessed, including grey scale and CD (S0 = no flow [no detectable CD)]; S1 = mild [CD <1/3 of the synovium]; S2 = moderate [CD <2/3]; S3 = pronounced [CD >2/3]). Results In the total population, synovitis was detected more often in the evening than in the morning (39% vs. 33%, p = 0.02). The difference remained significant only in patients without corticosteroid administration (44% vs. 37%, p = 0.04). Moreover, a greater number of CD-positive joints were likewise found (S0 vs. S1 + S2 + S3) in the evening (57% vs. 51%, p = 0.04) in patients not receiving corticosteroids (67% vs. 41%, p = 0.002). More moderate (S2) and pronounced (S3) than mild (S1) synovitis was observed at T1 vs. T0 (39% vs. 24%, p = 0.03) in patients not receiving corticosteroids. More synovitis (40% vs 36% p = 0.02) in the dominant hand were found in the evening than in the morning. Conclusion Synovitis and CD activity increase during the day in RA patients, especially in joints of the dominant hands and in patients without corticosteroids.
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Affiliation(s)
- Hakim Lazaar
- Clermont-Ferrand Teaching Hospital, Radiology A Department, Place H. DUNANT, Clermont-Ferrand, 63000, France.
| | - Agnes Lhoste-Trouilloud
- Clermont-Ferrand Teaching Hospital, Radiology A Department, Place H. DUNANT, Clermont-Ferrand, 63000, France
| | - Bruno Pereira
- Clermont-Ferrand Teaching Hospital, Biostatistics Unit, Clermont-Ferrand, 63003, France
| | - Marion Couderc
- Clermont-Ferrand Teaching Hospital, Rheumatology Department, Place H. DUNANT, Clermont-Ferrand, 63000, France
| | - Sylvain Mathieu
- Clermont-Ferrand Teaching Hospital, Rheumatology Department, Place H. DUNANT, Clermont-Ferrand, 63000, France
| | - Martin Soubrier
- Clermont-Ferrand Teaching Hospital, Rheumatology Department, Place H. DUNANT, Clermont-Ferrand, 63000, France.
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Takase-Minegishi K, Horita N, Kobayashi K, Yoshimi R, Kirino Y, Ohno S, Kaneko T, Nakajima H, Wakefield RJ, Emery P. Diagnostic test accuracy of ultrasound for synovitis in rheumatoid arthritis: systematic review and meta-analysis. Rheumatology (Oxford) 2017; 57:49-58. [DOI: 10.1093/rheumatology/kex036] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Indexed: 11/14/2022] Open
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Joshua F, Bailey C, Marabani M, Romas E, White R, Wong P. Perceptions of Doppler ultrasound for rheumatoid arthritis disease activity assessment and education. Int J Rheum Dis 2017; 22:55-61. [PMID: 28205411 DOI: 10.1111/1756-185x.13034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIM The aim of this qualitative study was to report the findings of the Defining rheumatoid arthritis progression using Doppler Ultrasound in Clinical practice (DEDUCE) Medical Practice Activity, which was developed to facilitate the utilization of Doppler ultrasound (DUS) by Australian rheumatologists in the treatment of patients with rheumatoid arthritis (RA). METHOD Twenty-one rheumatologists recruited a total of 80 patients with RA in Disease Activity Score of 28 joints (DAS28) remission for DUS assessment and completed a pre- and post-activity questionnaire assessing their experience with DUS, as well as a 6-month follow-up questionnaire. Rheumatologists discussed DUS results with patients using visual aids. Patients completed a pre- and post-DUS assessment questionnaire. Data were summarized using descriptive statistics. RESULTS Following completion of the activity, 95% of rheumatologists (20/21) believed DUS was a useful assessment tool for patients with RA. The majority found the DUS results useful and more than half thought the DUS assessment fit well into their consultation. A majority of rheumatologists indicated they would use DUS imaging in patients with low disease activity and remission, and for disease activity assessment to inform in therapeutic decision-making. All patients who responded found the visual aids useful and most felt that discussing DUS results improved understanding of their disease and would help with medication adherence. CONCLUSION Incorporation of DUS imaging into routine clinical practice is feasible, encourages rheumatologists to utilize and expand their clinical application of DUS imaging in patients with RA, and may improve patient understanding of their disease and adherence to medication.
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Affiliation(s)
- Fredrick Joshua
- Combined Rheumatology Practice and Macquarie University, Sydney, New South Wales, Australia
| | | | - Mona Marabani
- Private Rheumatology Practice, Campsie, New South Wales, Australia
| | - Evange Romas
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Raymond White
- Private Rheumatology Practice, Campbelltown, New South Wales, Australia
| | - Peter Wong
- Mid-North Coast Arthritis Clinic and Univeristy of New South Wales Rural Clinical School, Coffs Harbour, New South Wales, Australia
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Cerqueira M, Teixeira F, Sousa Neves J, Peixoto D, Afonso MC, Costa JA. Relationship between clinical evaluation and ultrasound assessment of rheumatoid arthritis patients using a 12 joint score. Int J Rheum Dis 2017; 20:852-858. [DOI: 10.1111/1756-185x.13005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Marcos Cerqueira
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
| | - Filipa Teixeira
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
| | - Joana Sousa Neves
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
| | - Daniela Peixoto
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
| | - Maria Carmo Afonso
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
| | - José A. Costa
- Rheumatology department; Hospital Conde de Bertiandos; ULSAM; Ponte de Lima Portugal
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Mendonça JA. Ultrasound color histogram assessment allows better view of echotexture damage. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:88-91. [PMID: 28137409 DOI: 10.1016/j.rbre.2015.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Accepted: 12/07/2014] [Indexed: 10/22/2022] Open
Affiliation(s)
- José Alexandre Mendonça
- Pontifícia Universidade Católica de Campinas (PUC-Campinas), Departamento de Reumatologia, Campinas, SP, Brazil.
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233
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Závada J, Hánová P, Hurňáková J, Szczuková L, Uher M, Forejtová Š, Klein M, Mann H, Olejárová M, Růžičková O, Šléglová O, Hejduk K, Pavelka K. The relationship between synovitis quantified by an ultrasound 7-joint inflammation score and physical disability in rheumatoid arthritis - a cohort study. Arthritis Res Ther 2017; 19:5. [PMID: 28086960 PMCID: PMC5237153 DOI: 10.1186/s13075-016-1208-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 12/09/2016] [Indexed: 12/30/2022] Open
Abstract
Background Restoring normal physical functioning is a major therapeutic aim in the management of rheumatoid arthritis (RA). It is unknown, whether the extent of synovial inflammation quantified by musculoskeletal ultrasound (US) can predict current or future capacity for physical functioning. To answer this question we investigated the longitudinal relationship between physical function assessed by the health assessment questionnaire (HAQ) and the German 7-joint ultrasound score (US7S) in a prospective cohort of patients with RA. Methods Patients with RA (n = 185 (46 with incident and 139 with prevalent disease) were followed for 30.9 ± 9.1 months. Baseline and annual assessments comprised the disease activity score in 28 joints (DAS28), HAQ and US7S. The US7S includes semiquantitative measurements of synovitis assessed by greyscale (GS) and power Doppler (PD) in seven joints of the clinically dominant hand and foot, which are then aggregated in PD and GS synovitis sum-scores (PDsynSS and GSsynSS). A linear mixed-effect model was used to assess the longitudinal relationship between GSsynSS, PDsynSS and HAQ. We used standard and time-lag models to explore the association between HAQ, and GSsynSS, PDsynSS and DAS28 measured at the same time or at the previous visit 12 months ago, respectively. Results When the standard model was applied, in univariate analyses HAQ score was positively associated with GSsynSS and PDsynSS with β coefficients significantly higher in incident than in prevalent disease. In multivariate analysis both synSSs were individually no longer significant predictors of HAQ score. When using the time-lag model, after adjustment for the previous DAS28 or HAQ score, both PDsynSS and GSsynSS were significantly and negatively associated with the current HAQ. Conclusions US7 PD and GS synovitis sum-scores alone were positively associated with current functional status reflected by the HAQ in patients with RA, and this relationship was stronger in patients with early disease. When combined with the DAS28 or HAQ, US7 PD and GS synovitis sum-scores were predictive of the change in HAQ score over one year. Electronic supplementary material The online version of this article (doi:10.1186/s13075-016-1208-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jakub Závada
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic.
| | - Petra Hánová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Jana Hurňáková
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Lenka Szczuková
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Michal Uher
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Šárka Forejtová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Martin Klein
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Herman Mann
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Marta Olejárová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Olga Růžičková
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Olga Šléglová
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
| | - Karel Hejduk
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, Prague, and Department of Rheumatology, First Faculty of Medicine, Charles University, Na Slupi 4, 12850, Prague, Czech Republic
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GRAVALLESE ELLENM. Bone Wasn't Built in a Day: Destruction and Formation of Bone in the Rheumatic Diseases. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2017; 128:24-43. [PMID: 28790485 PMCID: PMC5525397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
The hallmark of rheumatoid arthritis is synovitis, or inflammation of synovial tissues lining joints. Synovitis in rheumatoid arthritis promotes destruction of articular bone by inducing the differentiation and function of osteoclasts, leading to significant patient morbidity. The cell types and pathways mediating articular bone destruction have now been elucidated and the critical role of receptor activator of nuclear factor-kappa B ligand has been recognized, leading to the identification of new targets for the protection of articular bone. Synovitis not only promotes bone destruction, but also inhibits the ability of bone-forming osteoblasts to repair bone. In stark contrast, inflammation in spondyloarthritis, including ankylosing spondylitis, promotes bone formation at periosteal sites, resulting in pain and decreased motion of the spine and joints. Local anatomic factors contribute to these distinct outcomes for bone and anabolic pathways regulating bone formation are now being investigated to identify novel targets for prevention of abnormal bone formation.
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Affiliation(s)
- ELLEN M. GRAVALLESE
- Correspondence and reprint requests: Ellen M. Gravallese, MD, University of Massachusetts Medical School, Lazare Research Building, Suite 223, 364 Plantation Street, Worcester, MA 01605
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Effect of Osteoprotegerin and Dickkopf-Related Protein 1 on Radiological Progression in Tightly Controlled Rheumatoid Arthritis. PLoS One 2016; 11:e0166691. [PMID: 27911913 PMCID: PMC5135438 DOI: 10.1371/journal.pone.0166691] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 11/02/2016] [Indexed: 11/19/2022] Open
Abstract
Objective To analyze the association between circulating osteoprotegerin (OPG) and Dickkopf-related protein 1 (DKK-1) and radiological progression in patients with tightly controlled rheumatoid arthritis (RA). Methods Serum levels of OPG and DKK-1 were measured in 97 RA patients who were treated according to a treat-to-target strategy (T2T) aimed at remission (DAS28<2.6). Radiologic joint damage progression was assessed by changes in the total Sharp-van der Heijde score (SHS) on serial radiographs of the hands and feet. The independent association between these biomarker levels and the structural damage endpoint was examined using regression analysis Results The mean age of the 97 RA patients (68 women) at the time of the study was 54 ± 14 years, and the median disease duration was 1.6 ± 1.5 years. Most patients were seropositive for either RF or ACPA, and the large majority (76%) were in remission or had low disease activity. After a median follow-up time of 3.3 ± 1.5 years (range, 1–7.5 yrs.), the mean total SHS annual progression was 0.88 ± 2.20 units. Fifty-two percent of the patients had no progression (defined as a total SHS of zero). The mean serum OPG level did not change significantly over the study period (from 3.9 ± 1.8 to 4.07 ± 2.23 pmol/L), whereas the mean serum DKK-1 level decreased, although not significantly (from 29.9 ± 10.9 to 23.6 ± 18.8 pmol/L). In the multivariate analysis, the predictive factors increasing the likelihood of total SHS progression were age (OR per year = 1.10; p = 0.003) and a high mean C-reactive protein level over the study period (OR = 1.29; p = 0.005). Circulating OPG showed a protective effect reducing the likelihood of joint space narrowing by 60% (95% CI: 0.38–0.94) and the total SHS progression by 48% (95% CI: 0.28–0.83). The DKK-1 levels were not associated with radiological progression. Conclusion In patients with tightly controlled RA, serum OPG was inversely associated with progression of joint destruction. This biomarker may be useful in combination with other risk factors to improve prediction in patients in clinical remission or low disease activity state.
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Absence of Association of Joint Tenderness and High-Resolution Ultrasound Findings in Established Rheumatoid Arthritis. J Clin Rheumatol 2016; 22:449-450. [DOI: 10.1097/rhu.0000000000000443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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D'Agostino MA, Haavardsholm EA, van der Laken CJ. Diagnosis and management of rheumatoid arthritis; What is the current role of established and new imaging techniques in clinical practice? Best Pract Res Clin Rheumatol 2016; 30:586-607. [PMID: 27931956 DOI: 10.1016/j.berh.2016.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/19/2016] [Indexed: 01/05/2023]
Abstract
Ultrasound and magnetic resonance imaging (MRI) have become established imaging techniques for the management of rheumatoid arthritis. Several publications have pointed out the advantages of these techniques for a more complete evaluation of the inflammation and structural damage at joint level. Recently new imaging techniques as the positron emission tomography (PET) associated with computed tomography (CT) or MRI scan, and the optical imaging have been introduced in the panorama. This article presents the advantages and limitations of each imaging techniques in light with the recent publications.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France; INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vindern, 0319, Oslo, Norway
| | - Conny J van der Laken
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center - Location VU University Medical Center, Amsterdam, The Netherlands
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Rezaei H, Af Klint E, Hammer HB, Terslev L, D'Agostino MA, Kisten Y, Arnaud L. Analysis of correlation and causes for discrepancy between quantitative and semi-quantitative Doppler scores in synovitis in rheumatoid arthritis. Rheumatology (Oxford) 2016; 56:255-262. [PMID: 28123118 PMCID: PMC5410929 DOI: 10.1093/rheumatology/kew385] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/19/2016] [Indexed: 01/09/2023] Open
Abstract
Objectives. The aim of this study was to evaluate the association between two semi-quantitative Doppler US scoring systems (SQS), and the quantitative scoring (QS) of Doppler pixel count. Methods. Adult patients with RA and inadequate clinical response to anti-rheumatic therapy were examined with musculoskeletal US (MSUS). Dorsal MSUS of the wrists, MCP and MTP 2–5 were performed. MSUS images with sign of synovitis were collected and the QS was measured. Five assessors blinded to the QS evaluated the images independently, according to either SQS method. Association between QS and SQS was studied using correlations and multilevel models taking into account the clustering of ratings at the rater, patient and joint levels. Results. Analysis of the 1190 ratings revealed a strong correlation (ρ = 0.89, P < 0.0001) and significant associations (P < 0.0001) between QS and SQS. Correlations between QS and SQS according to Szkudlarek et al. (ρ = 0.87, P < 0.0001) or Hammer et al. (ρ = 0.91, P < 0.0001) were similar. A total of 239 (20.1%) images were given a SQS grade that did not match that expected based on initial QS, using pre-defined cut-offs. Main explanations for discrepancies were different perceived region of interest (40.7%) and Doppler pixel count near cut-offs between SQS grades (32.3%). Conclusion. We showed that both SQS methods correlated well with QS to assess synovitis, but SQS methods are intrinsically limited when the Doppler pixel count is close to the cut-offs between the SQS grades. Analysis discrepancies between these methods may help further revision of criteria used to assess disease activity with MSUS in RA.
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Affiliation(s)
- Hamed Rezaei
- Department of Rheumatology, institute of medicine, Karolinska University Hospital .,Unit of Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institutet, Stockholm, Sweden
| | - Erik Af Klint
- Unit of Clinical Therapy Research, Inflammatory Diseases (ClinTRID), Karolinska Institutet, Stockholm, Sweden
| | | | - Lene Terslev
- Center for Rheumatology and Spine Disease, Copenhagen, Denmark, Rigshospitalet
| | - Maria Antonietta D'Agostino
- APHP, Hôpital Ambroise Paré, Rheumatology Department, Boulogne-Billancourt, INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines
| | - Yogan Kisten
- Department of Rheumatology, institute of medicine, Karolinska University Hospital
| | - Laurent Arnaud
- Department of Rheumatology, institute of medicine, Karolinska University Hospital
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Nishino A, Kawashiri SY, Shimizu T, Umeda M, Fukui S, Koga T, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Nagata Y, Maeda T, Aoyagi K, Kawakami A. Assessment of both articular synovitis and tenosynovitis by ultrasound is useful for evaluations of hand dysfunction in early rheumatoid arthritis patients. Mod Rheumatol 2016; 27:605-608. [PMID: 27830970 DOI: 10.1080/14397595.2016.1253813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES We investigated the association between hand dysfunction and ultrasound (US)-detected articular synovitis and tenosynovitis in patients with rheumatoid arthritis (RA). METHODS Thirty RA patients were examined. In both hands of all subjects, articular synovitis and tenosynovitis were assessed by US at 22 joints and 12 tendons. Each joint and tendon was scored by gray-scale (GS) and power Doppler (PD) on a scale from 0 to 3. The sums of the GS or PD scores were used as the articular synovitis score and the tenosynovitis score. The sum of the articular synovitis and tenosynovitis scores was used as the combined US score. Hand dysfunction was evaluated by a grip-Health Assessment Questionnaire (HAQ) and visual analog scale of morning stiffness (MS-VAS). We used Spearman's correlation coefficient to determine the relationships among the US scores, the two hand dysfunction indices, and the DAS28-ESR. RESULTS The articular synovitis scores were significantly correlated with grip-HAQ (GS: rs = 0.47, p = 0.009, PD: rs = 0.48, p = 0.006), but not with MS-VAS. The tenosynovitis scores were correlated with MS-VAS (GS: rs = 0.38, p = 0.039, PD: rs = 0.36, p = 0.053), but not with grip-HAQ. Both grip-HAQ (GS: rs = 0.53, p = 0.002, PD: rs = 0.55, p = 0.001) and the MS-VAS (GS: rs = 0.39, p = 0.031, PD: rs = 0.47, p = 0.008) were correlated with the combined US scores. CONCLUSIONS The US scores combined with articular synovitis and tenosynovitis scores well reflect the severity of hand dysfunction in early-stage RA patients.
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Affiliation(s)
- Ayako Nishino
- a Department of Immunology and Rheumatology.,b Department of Center for Comprehensive Community Care Education
| | - Shin-Ya Kawashiri
- a Department of Immunology and Rheumatology.,c Department of Public Health.,d Department of Community Medicine , and
| | | | | | | | | | | | | | - Mami Tamai
- a Department of Immunology and Rheumatology
| | | | - Tomoki Origuchi
- e Department of Health Sciences , Nagasaki University Graduate School of Biomedical Sciences , Nagasaki , Japan
| | - Yasuhiro Nagata
- b Department of Center for Comprehensive Community Care Education
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Serum Calprotectin Discriminates Subclinical Disease Activity from Ultrasound-Defined Remission in Patients with Rheumatoid Arthritis in Clinical Remission. PLoS One 2016; 11:e0165498. [PMID: 27832086 PMCID: PMC5104448 DOI: 10.1371/journal.pone.0165498] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/12/2016] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Clinical remission in some patients with rheumatoid arthritis (RA) may be associated with ongoing synovial inflammation that is not always detectable on clinical examination or reflected by laboratory tests but can be visualized by musculoskeletal ultrasound. The goal of our study was to determine the levels of serum calprotectin, a major leukocyte protein, in patients with RA in clinical remission and to investigate the ability of serum calprotectin levels to distinguish patients in ultrasound-defined remission from those with residual ultrasound subclinical inflammation. METHODS Seventy RA patients in clinical remission underwent clinical and ultrasound examination. Ultrasound examination was performed according to the German US7 score. Ultrasound remission was defined as grey scale (GS) range 0-1 and power Doppler (PD) range 0. The levels of serum calprotectin and C-reactive protein (CRP) were determined. The discriminatory capacity of calprotectin and CRP in detecting residual ultrasound inflammation was assessed using ROC curves. RESULTS The total number of patients fulfilling the DAS28-ESR, DAS28-CRP, SDAI and CDAI remission criteria was 58, 67, 32 and 31, respectively. Residual synovial inflammation was found in 58-67% of the patients who fulfilled at least one set of clinical remission criteria. Calprotectin levels were significantly higher in patients with residual synovial inflammation than in those with ultrasound-defined remission (mean 2.5±1.3 vs. 1.7±0.8 μg/mL, p<0.005). Using ultrasound-defined remission criteria, calprotectin had an AUC of 0.692, p<0.05 using DAS28-ESR remission criteria and an AUC of 0.712, p<0.005 using DAS28-CRP remission criteria. Calprotectin correctly distinguished ultrasound remission from subclinical activity in 70% of patients. CRP (AUC DAS28-ESR = 0.494, p = NS; AUC DAS28-CRP = 0.498, p = NS) had lower and insignificant discriminatory capacity. CONCLUSION The present study demonstrates the potential of calprotectin to distinguish RA patients in both clinical and ultrasound-defined remission from patients in clinical remission but with residual subclinical disease activity.
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Lage-Hansen PR, Lindegaard H, Chrysidis S, Terslev L. The role of ultrasound in diagnosing rheumatoid arthritis, what do we know? An updated review. Rheumatol Int 2016; 37:179-187. [DOI: 10.1007/s00296-016-3587-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
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Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2016; 14:9-19. [PMID: 28029551 DOI: 10.1016/j.reuma.2016.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). METHODS Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and MRI in RA patients.
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Møller-Bisgaard S, Ejbjerg BJ, Eshed I, Hørslev-Petersen K, Hetland ML, Jurik AG, Thomsen H, Torfing T, Stengaard-Pedersen K, Junker P, Krogh NS, Lottenburger T, Ellingsen T, Andersen LS, Skjødt H, Svendsen AJ, Tarp U, Hansen IT, Pødenphant J, Pedersen JK, Lindegaard H, Hanson LG, Vestergaard A, Glinatsi D, Østergaard M. Effect of a treat-to-target strategy based on methotrexate and intra-articular betamethasone with or without additional cyclosporin on MRI-assessed synovitis, osteitis, tenosynovitis, bone erosion, and joint space narrowing in early rheumatoid arthritis: results from a 2-year randomized double-blind placebo-controlled trial (CIMESTRA). Scand J Rheumatol 2016; 46:335-345. [PMID: 27775461 DOI: 10.1080/03009742.2016.1209550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES To investigate whether a treat-to-target strategy based on methotrexate (MTX) and intra-articular (IA) betamethasone suppresses magnetic resonance imaging (MRI)-determined measures of disease activity and reduces joint destruction in early rheumatoid arthritis (eRA) patients, and to investigate whether concomitant cyclosporin A (CyA) provides an additional effect. METHOD In the 2-year randomized, double-blind, treat-to-target trial CIMESTRA, 160 patients with eRA (< 6 months) were randomized to MTX, intra-articular betamethasone and CyA, or placebo CyA. A total of 129 patients participated in the MRI substudy, and had contrast-enhanced MR images of the non-dominant hand at months 0, 6, 12, and 24. MR images were evaluated for osteitis, synovitis, tenosynovitis, bone erosion, and joint space narrowing (JSN), using validated scoring methods. RESULTS Significant reductions were seen at 6 months in all inflammatory parameters [synovitis, mean change -1.6 (p < 0.001, Wilcoxon), tenosynovitis, -3.5 (p < 0.001), and osteitis, -1.3 (p < 0.05)] and at 12/24 months in synovitis and tenosynovitis [-1.6/-2.2 and -3.6/-3.8, respectively; all p < 0.001]. MRI signs of inflammation were not fully eliminated, and increases in erosion and JSN scores were observed at 6 months [0.4 (p < 0.01)/0.1 (p < 0.05)], 12 months [0.8 (p < 0.001)/0.3 (p < 0.01)], and 24 months [1.0 (p < 0.001)/0.4 (p < 0.001)]. Clinical measures decreased significantly (p < 0.001) at all time points. There were no consistent statistically significant differences between treatment groups. CONCLUSIONS In this eRA treat-to-target trial, MTX and intra-articular glucocorticoids markedly reduced, but did not eliminate, MRI osteitis, synovitis, and tenosynovitis. Accordingly, minimal but statistically significant increases in bone erosion and JSN were observed. No additional effect of CyA was demonstrated.
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Affiliation(s)
- S Møller-Bisgaard
- a Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark.,b Department of Rheumatology , Slagelse Hospital , Slagelse , Denmark
| | - B J Ejbjerg
- b Department of Rheumatology , Slagelse Hospital , Slagelse , Denmark
| | - I Eshed
- c Department of Radiology , Sheba Medical Centre , Tel Hashomer , Israel
| | - K Hørslev-Petersen
- d King Christian X's Hospital for Rheumatic Diseases , Graasten , Denmark
| | - M L Hetland
- a Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark.,e The DANBIO Registry, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark
| | - A G Jurik
- f Department of Radiology , Aarhus University Hospital , Aarhus , Denmark
| | - H Thomsen
- g Department of Radiology , Herlev-Gentofte University Hospital , Herlev , Denmark
| | - T Torfing
- h Department of Radiology , Odense University Hospital , Odense , Denmark
| | | | - P Junker
- j Department of Rheumatology , Odense University Hospital , Odense , Denmark
| | - N S Krogh
- k Zitelab ApS , Copenhagen , Denmark
| | - T Lottenburger
- l Department of Rheumatology , Vejle Hospital , Vejle , Denmark
| | - T Ellingsen
- j Department of Rheumatology , Odense University Hospital , Odense , Denmark
| | - L S Andersen
- m Department of Rheumatology , Herlev-Gentofte University Hospital , Gentofte , Denmark
| | - H Skjødt
- a Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark
| | - A J Svendsen
- n Department of Epidemiology , Institute of Public Health, University of Southern Denmark , Odense , Denmark
| | - U Tarp
- i Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - I T Hansen
- i Department of Rheumatology , Aarhus University Hospital , Aarhus , Denmark
| | - J Pødenphant
- m Department of Rheumatology , Herlev-Gentofte University Hospital , Gentofte , Denmark
| | - J K Pedersen
- j Department of Rheumatology , Odense University Hospital , Odense , Denmark
| | - H Lindegaard
- j Department of Rheumatology , Odense University Hospital , Odense , Denmark
| | - L G Hanson
- o Centre for Functional and Diagnostic Imaging and Research , Danish Research Centre for Magnetic Resonance (DRCMR), Copenhagen University Hospital Hvidovre , Hvidovre , Denmark.,p Biomedical Engineering, Elektro , Technical University of Denmark (DTU) , Lyngby , Denmark
| | - A Vestergaard
- q Department of Radiology , Copenhagen University Hospita Hvidovrel , Hvidovre , Denmark
| | - D Glinatsi
- a Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark
| | - M Østergaard
- a Copenhagen Centre for Arthritis Research, Centre for Rheumatology and Spine Diseases , Rigshospitalet , Glostrup , Denmark
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Forien M, Ottaviani S. Ultrasound and follow-up of rheumatoid arthritis. Joint Bone Spine 2016; 84:531-536. [PMID: 27777169 DOI: 10.1016/j.jbspin.2016.08.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/31/2016] [Indexed: 01/09/2023]
Abstract
Rheumatoid arthritis (RA) is chronic rheumatic disorder leading to joint inflammation and potential structural damages. This destruction occurs early in the disease outcome leading to the concept of window of opportunity. New diagnosis RA criteria have been proposed to allow an earlier diagnosis and subsequently a better management of the disease. Moreover, tight control of the disease was able to improve the prognosis of RA. For this, rheumatologists need routinely feasible tools and ultrasound (US) appears as the ideal imaging modality. US is superior to clinical exam for the detection of subclinical synovitis. US has a good correlation with clinical findings and markers of inflammation. US persistence of synovitis is associated with higher rate of relapse and more radiographic progression. However, standardization of scoring and settings procedures is necessary before being universally accepted as a marker of disease activity. Finally, US did not improve the tight control strategy and did not replace clinical exam for RA management.
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Affiliation(s)
- Marine Forien
- Service de Rhumatologie, Hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France
| | - Sébastien Ottaviani
- Service de Rhumatologie, Hôpital Bichat, AP-HP, 46, rue Henri-Huchard, 75018 Paris, France.
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High prevalence of tenosynovial inflammation before onset of rheumatoid arthritis and its link to progression to RA—A combined MRI/CT study. Semin Arthritis Rheum 2016; 46:143-150. [DOI: 10.1016/j.semarthrit.2016.05.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 04/08/2016] [Accepted: 05/12/2016] [Indexed: 01/05/2023]
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246
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Chen S, Zheng Q, Liu H, Zeng J, Ye Z, Su Y, Lv G. Sonography Is Superior to Serum-Based Biomarkers for Measuring Disease Status in Experimental Rheumatoid Arthritis. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2223-2230. [PMID: 27573797 DOI: 10.7863/ultra.15.10044] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 05/05/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Progress in developing novel rational treatments for rheumatoid arthritis (RA) critically depends on preclinical work in experimental animals. However, there is lack of insight into the most appropriate mode of noninvasive measurement of disease status in experimental RA. This study compared sonography with serum biomarkers in a rabbit model of RA. METHODS Six-month-old male New Zealand White rabbits were randomized into 2 groups: antigen-induced arthritis group (n = 25), which was subjected to ovalbumin immunization and intra-articular injection; and control group (n = 5). Pathologic changes in the knee joints were evaluated by sonography, and serum C-reactive protein, tumor necrosis factor TNF-α, and interleukin 1 were measured by enzyme-linked immunosorbent assay. Synovial pathologic scores were obtained by ultrasound-guided biopsy. RESULTS A total of 23 rabbits (2 rabbits died before the end of the study) in the antigen-induced arthritis group and 5 rabbits in the control group completed the study. Sonographic scores for all rabbits were graded from 0 to 3, according to grayscale sonography, synovitis, and blood flow. Synovial lesions were evident on sonography before week 4; however, serum biomarkers slowly increased until weeks 5 and 6 (P < .05). Although both sonography and serum biomarkers correlated significantly with synovitis scoring, the correlations for the sonographically derived parameters were better. The correlation indices between pathologic scores and synovial membranes thickness, blood flow, and resistive index were 0.798, 0.557, and -0.320, respectively, whereas the correlation indices between pathologic scores and tumor necrosis factor α, interleukin 1, and C-reactive protein levels were 0.451, 0.503, and 0.529. CONCLUSIONS Sonographic findings had better correlations with histologic scoring than serologic biomarkers of disease activity in the RA rabbit model, especially at early stages. Local pathologic assessment of disease status by sonography is possible.
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Affiliation(s)
- Shuqiang Chen
- Ultrasound Department, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Qing Zheng
- Rheumatology Department, Fujian Medical University, Fuzhou, China
| | - Hui Liu
- Ultrasound Department, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jinshu Zeng
- Ultrasound Department, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zhen Ye
- Ultrasound Department, First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yiming Su
- Ultrasound Department, First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Guorong Lv
- Ultrasound Department, Second Affiliated Hospital of Fujian Medical University, Department of Clinical Medicine, Quanzhou Medical College, after University, Quanzhou, China
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Han J, Geng Y, Deng X, Zhang Z. Subclinical Synovitis Assessed by Ultrasound Predicts Flare and Progressive Bone Erosion in Rheumatoid Arthritis Patients with Clinical Remission: A Systematic Review and Metaanalysis. J Rheumatol 2016; 43:2010-2018. [PMID: 27803342 DOI: 10.3899/jrheum.160193] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Subclinical synovitis can be detected by ultrasound in patients with rheumatoid arthritis (RA) who are in clinical remission. We aimed to confirm its predictive value for flare and progressive bone erosion. METHODS A systematic literature search was performed in Pubmed, Web of Science, Embase, and Cochrane Library on September 7, 2014. Baseline clinical and ultrasonographic characteristics were collected. Methodological quality was assessed. Pooled OR were calculated using Mantel-Haenszel model. We explored the source of heterogeneity through subgroup analysis and completed a cumulative metaanalysis. RESULTS Thirteen articles were included (8 with flare, 4 with bone erosion, 1 with both flare and bone erosion). Metaanalysis revealed an association between power Doppler (PD) positivity and the risk of flare (OR 4.52, 95% CI 2.61-7.84, p < 0.00001, I2 = 21%), the risk of progressive bone erosion on patient level (OR 12.80, 95% CI 1.29-126.81, p = 0.03, I2 = 52%) and the risk of progressive bone erosion on joint level (OR 11.85, 95% CI 5.01-28.03, p < 0.00001, I2 = 0%). Further subgroup analysis showed a higher risk of flare in patients with a study period < 1 year (OR 19.98 vs 3.41). No significant differences were observed in the subgroup analysis in duration of remission, disease duration, and medications. Moreover, cumulative metaanalysis indicated the validation and an increasing accuracy of PD positivity in predicting flare since 2012. CONCLUSION Ultrasound-detected subclinical synovitis can predict the risk of flare and progressive bone erosion in RA patients with clinical remission. Additionally, the flare of RA tends to occur within a followup of 1 year.
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Affiliation(s)
- Jingjing Han
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Yan Geng
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Xuerong Deng
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China.,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital
| | - Zhuoli Zhang
- From the Department of Geriatrics, and the Department of Rheumatology and Clinical Immunology, Peking University First Hospital, Beijing, China. .,J. Han, MD, Department of Geriatrics, Peking University First Hospital; Y. Geng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; X. Deng, MD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital; Z. Zhang, MD, PhD, Department of Rheumatology and Clinical Immunology, Peking University First Hospital.
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Kaeley GS, Nishio MJ, Goyal JR, MacCarter DK, Wells AF, Chen S, Kupper H, Kalabic J. Changes in Ultrasonographic Vascularity Upon Initiation of Adalimumab Combination Therapy in Rheumatoid Arthritis Patients With an Inadequate Response to Methotrexate. Arthritis Rheumatol 2016; 68:2584-2592. [PMID: 27214046 PMCID: PMC5129587 DOI: 10.1002/art.39751] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 05/05/2016] [Indexed: 11/30/2022]
Abstract
Objective To assess joint disease activity by ultrasound (US) in patients with rheumatoid arthritis (RA) initiating treatment with adalimumab (ADA) plus methotrexate (MTX). Methods Data for this post hoc analysis originated from the MUSICA trial (ClinicalTrials.gov identifier: NCT01185288), which evaluated the efficacy of initiating ADA (40 mg every other week) plus 7.5 or 20 mg/week MTX in 309 patients with RA with an inadequate response to MTX. Synovial vascularization over 24 weeks was assessed bilaterally at metacarpophalangeal joint 2 (MCP2), MCP3, MCP5, metatarsophalangeal joint 5, and the wrists by power Doppler US (PDUS). A semiquantitative 4‐grade scale was used. Disease activity was assessed using the Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP) and Simplified Disease Activity Index (SDAI). The correlation between continuous variables was assessed using Pearson's correlation coefficient. Results After 24 weeks of treatment with ADA plus MTX, rapid improvements in the mean synovial vascularity score were observed; the greatest improvements were in MCP2 (−0.5), MCP3 (−0.4), and the wrist (−0.4). At week 24, patients with the lowest DAS28‐CRP (<2.6) had the lowest mean 5‐joint and 3‐joint composite synovial vascularity scores. The 5‐joint and 3‐joint scores were strongly correlated (ρ > 0.9). Synovial vascularity scores correlated poorly with DAS28, swollen joint count in 66 joints (SJC66), SJC28, tender joint count in 68 joints (TJC68), TJC28, Clinical Disease Activity Index (CDAI), SDAI, physician's global assessment, patient's global assessment of pain, and disease duration (ρ < 0.2). Thirty‐two (70%) of 46 patients with a DAS28‐CRP of <2.6, and 11 (58%) of 19 patients with an SDAI indicating remission had at least 1 joint with a synovial vascularity score of ≥1. Conclusion PDUS detects changes in synovial vascularity in RA patients treated with ADA plus MTX, and residual synovial vascularity in patients in whom clinical disease control has been achieved.
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Affiliation(s)
| | | | | | | | - Alvin F Wells
- Rheumatology and Immunotherapy Center, Franklin, Wisconsin
| | - Su Chen
- AbbVie, North Chicago, Illinois
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El Miedany Y, El Gaafary M, Youssef S, Ahmed I, Bahlas S, Hegazi M, Nasr A. Optimizing therapy in inflammatory arthritis: prediction of relapse after tapering or stopping treatment for rheumatoid arthritis patients achieving clinical and radiological remission. Clin Rheumatol 2016; 35:2915-2923. [DOI: 10.1007/s10067-016-3413-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/10/2016] [Accepted: 09/10/2016] [Indexed: 12/22/2022]
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Taljanovic MS, Melville DM, Gimber LH, Scalcione LR, Miller MD, Kwoh CK, Klauser AS. High-Resolution US of Rheumatologic Diseases. Radiographics 2016; 35:2026-48. [PMID: 26562235 DOI: 10.1148/rg.2015140250] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
For the past 15 years, high-resolution ultrasonography (US) is being routinely and increasingly used for initial evaluation and treatment follow-up of rheumatologic diseases. This imaging technique is performed by using high-frequency linear transducers and has proved to be a powerful diagnostic tool in evaluation of articular erosions, simple and complex joint and bursal effusions, tendon sheath effusions, and synovitis, with results comparable to those of magnetic resonance imaging, excluding detection of bone marrow edema. Crystal deposition diseases including gouty arthropathy and calcium pyrophosphate deposition disease (CPPD) have characteristic appearances at US, enabling differentiation between these two diseases and from inflammatory arthropathies. Enthesopathy, which frequently accompanies psoriatic and reactive arthritis, also has a characteristic appearance at high-resolution US, distinguishing these two entities from other inflammatory and metabolic arthropathies. The presence of Doppler signal in examined joints, bursae, and tendon sheaths indicates active synovitis. Microbubble echo contrast agents augment detection of tissue vascularity and may act in the future as a drug delivery vehicle. Frequently, joint, tendon sheath, and bursal fluid aspirations and therapeutic injections are performed under US guidance. The authors describe the high-resolution US technique including gray-scale, color or power Doppler, and contrast agent-enhanced US that is used in evaluation of rheumatologic diseases of the wrist and hand and the ankle and foot in their routine clinical practice. This article demonstrates imaging findings of normal joints, rheumatoid arthritis, gouty arthritis, CPPD, psoriatic and reactive arthritis, and osteoarthritis.
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Affiliation(s)
- Mihra S Taljanovic
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - David M Melville
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - Lana H Gimber
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - Luke R Scalcione
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - Margaret D Miller
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - C Kent Kwoh
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
| | - Andrea S Klauser
- From the Department of Medical Imaging (M.S.T., D.M.M., L.H.G., L.R.S.), Department of Medicine (M.D.M.), and Division of Rheumatology (C.K.K.), University of Arizona, Banner-University Medical Center, 1501 N Campbell Ave, PO Box 245067, Tucson, AZ 85724; and Department of Radiology, Medical University Innsbruck, Innsbruck, Austria (A.S.K.)
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