Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array)

Ultrasonographic Evaluation of Sub-Clinical Synovitis in Juvenile Idiopathic Arthritis: The Disease Classification and Management

Background: Ultrasonography (USG) is a perfect device for analyzing more than one joint in rather brief intervals of time and is well accepted by children with no harmful ionizing radiation, usually does not require sedation, and can be carried out without difficulty in an outpatient setting. Purpose: To demonstrate the ability of ultrasonography (USG) in detecting clinical and subclinical synovitis in children with juvenile idiopathic arthritis (JIA) and compare the USG findings with clinical findings. Methods: 20 patients with JIA diagnosed according to the ILAR criteria were include. A total of 208 joints were examined both clinically and ultrasonographically for detection of synovitis. The presence of subclinical synovitis detected by USG was sought and its effect on the classification of JIA was assessed. USG assessment was done using the High-Resolution Linear probe including both grey scale and Power Doppler assessment. Results: The mean age of patients was 10.2 years with average disease duration of 5.9 months. A total of 49 joints (23.5%) had clinical synovitis and 59 joints (28.4%) had USG synovitis out of a total of 208 joints. A total of 14 joints had subclinical synovitis (8.8% out of the 159 clinically normal joints) upon USG. USG additionally brought about classifying three patients as having poly articular disorder who had been considered as oligo articular upon clinical examination. Conclusion: USG assessment of subclinical synovitis in JIA patients is an essential component of classifying the disease and detects more joints with synovitis than clinical examination; however, both are complimentary and should be used in combination in all patients with JIA.

Phenolic Compounds Impact on Rheumatoid Arthritis, Inflammatory Bowel Disease and Microbiota Modulation

Non-communicable chronic diseases (NCDs) are nowadays the principal cause of death, especially in most industrialized nations. These illnesses have increased exponentially with the consumption of diets very high in fat and sugar, not to mention stress and physical inactivity among other factors. The potential impact of suboptimal diets on NCDs’ morbidity and mortality rates brings to the forefront the necessity for a new way of improving dietary habits. The literature provides extensive scientific work that presents evidence that phenolic compounds from diets have antioxidant, anti-inflammatory and antiproliferative activities that impact human health. Gut microbiota modulation by some phenolic compounds leads to favorable changes in abundance, diversity, and in the immune system. However, polyphenol’s limited bioavailability needs to be overcome, highlighting their application in new delivery systems and providing their health benefits in well-established ways such as health maintenance, treatment or adjuvant to conventional pharmacological treatments. In this context, novel dietary approaches, including new food supplements, have emerged to prevent diseases and preserve health.

Value of contrast-enhanced ultrasound for detection of synovial vascularity in experimental rheumatoid arthritis: an exploratory study

Objective

This study aimed to examine the associations between contrast-enhanced ultrasound (CEUS) imaging and synovial hypervascularity and synovitis score in a rabbit model of antigen-induced arthritis (AIA), compared with power Doppler ultrasound (PDUS).

Methods

We investigated 50 knee joints in 25 AIA rabbits (AIA group), and 10 knee joints in five sham-injected rabbits (control group). PDUS and CEUS images were evaluated at the 8th week. Ultrasound-guided synovial biopsies were targeted in the area with hypervascularity, and synovial microvessel density (MVD) was evaluated by immunohistochemical staining of CD31.

Results

The PDUS score was significantly higher in the AIA group (2.61 ± 0.78) compared with the control group (0.50 ± 0.53). CEUS in the AIA group revealed a fast-in/slow-out pattern of contrast enhancement. MVD revealed by CD31+ vessel count and the synovitis score were significantly higher in the AIA group compared with the control group. In the AIA group, CEUS findings showed a better correlation with MVD revealed by CD31+ and synovitis score than PDUS findings.

Conclusion

CEUS is superior to PDUS for estimating synovial hypervascularity and hyperplasia in experimental rheumatoid arthritis.

Detection of Increased Vascular Signal in Arthritis-Prone Rats Without Joint Swelling Using Superb Microvascular Imaging Ultrasonography

This study aimed to determine whether ultrasonography (US) can detect increased vascular signal in the synovial tissue before overt synovitis in rheumatoid arthritis (RA). Env-pX rats that spontaneously develop RA-like synovitis were used. Ankle joints of 15 pre-morbid env-pX rats were observed with power Doppler and superb microvascular imaging (SMI) using an ultrahigh-frequency (8-24 MHz) probe. Signal values were counted as the number of pixels. The total number of vessels and vessel area in the synovial tissue were histologically evaluated. Dilated vessels were determined from the mean value of synovial vessels in three wild-type rats. In all env-pX rats, apparent synovial proliferation was not observed. However, vasodilation was evident. Only SMI values were significantly correlated with the number of dilated vessels (r = 0.585, p = 0.022) but not with the total number of vessels. US with SMI using ultrahigh-frequency probe can detect increased vascular signal in the synovial tissue of arthritis-prone rats.

Subclinical enthesitis in nail psoriasis patients: a case-control study

BACKGROUND

Patients with nail psoriasis have a higher prevalence of psoriatic arthritis; however, the pathogenetic relationship between these two disorders is as yet unclear. Entheses have been suggested as disease epicenter, which might explain the pathogenesis on an anatomical level.

OBJECTIVE

To contribute to the elucidation of the hypothesis as regards the anatomical link between nail psoriasis and psoriatic arthritis, with the extensor enthesis of the distal interphalangeal joint as the epicenter.

METHODS

We conducted a cross-sectional cohort study, visualizing the distal interphalangeal (DIP) joints entheses of patients with fingernail psoriasis (n = 54), psoriasis patients without nail involvement (n = 32), and healthy controls (n = 32) using three-dimensional ultrasound. Patients with nail psoriasis underwent repeat imaging studies after one year.

RESULTS

Individuals with nail psoriasis had significantly thicker radial entheses than psoriasis patients without nail involvement. However, there were no significant differences in entheseal thickness between adjacent nails that were affected and those that were not (1.297 mm vs. 1.253 mm, p = 0.13). Follow-up after one year showed no significant differences in entheseal thickness in correlation with nail psoriasis activity.

CONCLUSIONS

The present study provides evidence for subclinical enthesitis at the level of the DIP joint in patients with nail psoriasis. However, an anatomical correlation between nail psoriasis and psoriatic arthritis could not be confirmed.

What the Rheumatologist Is Looking for and What the Radiologist Should Know in Imaging for Rheumatoid Arthritis

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.

Ultrasound Color Doppler Image Segmentation and Feature Extraction in MCP and Wrist Region in Evaluation of Rheumatoid Arthritis

The present study focuses on automatically to segment the blood flow pattern of color Doppler ultrasound in hand region of rheumatoid arthritis patients and to correlate the extracted the statistical features and color Doppler parameters with standard parameters. Thirty patients with rheumatoid arthritis (RA) and their total of 300 joints of both the hands, i.e., 240 MCP and 60 wrists were examined in this study. Ultrasound color Doppler of both the hands of all the patients was obtained. Automated segmentation of color Doppler image was performed using color enhancement scaling based segmentation algorithm. The region of interest is fixed in the MCP joints and wrist of the hand. Features were extracted from the defined ROI of the segmented output image. The color fraction was measured using Mimics software. The standard parameters such as HAQ score, DAS 28 score, and ESR was obtained for all the patients. The color fraction tends to be increased in wrist and MCP3 joints which indicate the increased blood flow pattern and color Doppler activity as part of inflammation in hand joints of RA. The ESR correlated significantly with the feature extracted parameters such as mean, standard deviation and entropy in MCP3, MCP4 joint and the wrist region. The developed automated color image segmentation algorithm provides a quantitative analysis for diagnosis and assessment of RA. The correlation study between the color Doppler parameters with the standard parameters provides moral significance in quantitative analysis of RA in MCP3 joint and the wrist region.

Ultrasound Assessment of Synovial Thickness of Some of the Metacarpophalangeal Joints of Hand in Rheumatoid Arthritis Patients and the Normal Population

Objective. To compare ultrasound synovial thickness of the 2nd, 3rd and 4th metacarpophalangeal joints (MCPJ) in a group of patients with proven rheumatoid arthritis (RA) and a control group of normal individuals. Materials and Methods. This is a cross-sectional study comprising 30 rheumatoid arthritis patients and 30 healthy individuals. Ultrasound scans were performed at the dorsal side of 2nd, 3rd, and 4th MCPJ of both hands in RA patients and the healthy individuals. Synovial thickness was measured according to quantitative method. The synovial thickness of RA patients and healthy individuals was compared and statistical cut-off was identified. Results. Maximum synovial thickness was most often detected at the radial side of the 2nd MCPJ and 3rd MCPJ and ulnar side of the 4th MCPJ of both hands which is significantly higher (p < 0.05) in RA patients compared to healthy individuals. With high specificity (96%) and sensitivity (90%) the optimum cut-off value to distinguish RA patients and healthy individuals' synovial thickness differs for the radial side of the 2nd and 3rd MCPJ and ulnar side of the 4th MCPJ. Conclusion. Patients with early RA appear to exhibit a characteristic pattern of synovitis which shows radial side predominance in the 2nd and 3rd MCPJ and ulnar side in the 4th MCPJ.

Contrast-enhanced ultrasound in coxitis

OBJECTIVES

Hip involvement is common in rheumatological diseases but can be difficult to diagnose, especially in absence of MRI. B-mode ultrasound (US) detects joint capsule distention while distinguishing effusion from proliferative synovial tissue is strenuous since both appear hypoechoic. Power Doppler ultrasound (PDUS) often fails to detect vascularisation in the hip. We therefore evaluated contrast-enhanced ultrasound (CEUS) in the hip joint.

METHODS

We investigated 36 hip joints of patients with known rheumatological joint diseases presenting with hip pain and 5 hips of healthy controls using B-mode US, PDUS and CEUS. We assessed CEUS hypervascularisation semiquantitatively comparing to the periarticular tissue. In B-mode, we measured the distance between femoral neck and joint capsule (DNC) and compared the results to the avascular intraarticular margin (AIM) in CEUS using t-tests and crosstables.

RESULTS

PDUS signals were received in only 2/36 cases (5.6%). B-mode US established the diagnosis of coxitis in 64% of all symptomatic hip joints. In 4 cases (11%), the diagnosis was revised after the use of CEUS. In patients with definite coxitis, 14 hips (73.7%) showed CEUS hypervascularisation°2, five°1 (26.3%) and none°0 (χ²=3.277, P<0.001). The difference DNC/AIM was highly significant in patients with hip pain (P<0.001, 95% CI: 2.054-4.684) and those with definite coxitis (P<0.001, 95% CI: 3.268-7.258).

CONCLUSIONS

In most cases, clinical parameters together with B-mode US findings are sufficient to diagnose coxitis. However, CEUS is capable of visualizing and quantifying the degree of hypervascularisation and enables the discrimination between effusion and proliferative synovial tissue.

Ultrasound of the hand and wrist

There have been immense technical innovations and broadened clinical applications of ultrasound in the musculoskeletal system over the past 20 years. Specifically with regard to the hand and wrist, the advent of higher resolution transducers and postprocessing software applications have resulted in overall enhanced visualization of soft tissue structures (tendons/ligaments) as well as surface osseous lesions such as subclinical erosions in rheumatoid arthritis. Quantitative ultrasound, using either power Doppler or contrast-enhanced imaging, has become a central outcomes measure used to evaluate and document patient response to treatment in inflammatory arthropathies such as rheumatoid arthritis. This review will summarize the current state of clinical applications of ultrasound in the evaluation of the hand and wrist, with a summary of technical advances and specific applications in rheumatologic conditions.This review was exempt from institutional review board approval.

Sonographic cutoff values for detection of abnormalities in small, medium and large joints: a comparative study between patients with rheumatoid arthritis and healthy volunteers

To determine ultrasound measurements indicative of abnormalities in small, medium and large joints, we conducted a cross-sectional study comparing 60 patients with rheumatoid arthritis (RA) and 78 healthy volunteers. A MyLab 60 ultrasound machine (Esaote) and a linear multifrequency probe were used. Quantitative measurements of synovial recesses and semiquantitative measurements of synovial hyperplasia, power Doppler and bone erosion (scores = 0-3) were performed. The cutoff values for synovial recesses indicating RA (receiver operating characteristic curve, area under the curve >0.800) were found to be (radiocarpal) 3.78 mm and (ulnocarpal) 3.07 mm. Those measurements with the greatest chance of indicating RA (logistic regression analysis expressed as odds ratios [ORs]) were (p < 0.001) measurements of synovial hyperplasia (ulnocarpal, OR = 100, and radiocarpal, OR = 70); synovial power Doppler (radiocarpal, OR = 66); synovial bone erosion (radiocarpal, OR = 324); fifth metatarsophalangeal joint (OR = 100); and second metacarpophalangeal joint (OR = 92). We concluded that for both quantitative and semiquantitative ultrasound measurements, radiocarpal abnormalities increase the chance of detecting RA.

[The modified US7 score in the assessment of synovitis in early rheumatoid arthritis]

OBJECTIVE

To evaluate the modified US7 score (MUS7 score SYN) in the assessment of patients with early rheumatoid arthritis (ERA). In addition, dorsal and palmar recesses of the wrists as well as of small joints of the hands and feet were examined for the presence of synovitis by means of a global assessment of joints.

METHODS

The study sample comprised 32 patients treated for arthritis, with an average disease duration of 13 months. An ultrasound machine with high frequency transducer was used. Hands were also X-rayed and analysed by Larsen score.

RESULTS

Out of the 832 examined joints, synovitis was detected in 173 (20,79%), tenosynovitis in 22 (4,91%), and erosions in 3 (1,56%). Synovitis was predominantly detected in the dorsal recess (73,38%) of MCP and PIP joints, when compared with palmar recess (26%). The presence of synovitis in the joints evaluated correlated with clinical (HAQ-DI, DAS28), laboratory (ACPA, RF, CRP), and ultrasound results (r = 0,37 to r = 0,42; p = 0,04 to p = 0,003). We found correlation of the MUS7 score SYN of the gray scale US or of the power Doppler US with DAS28 (PCR) values (r = 0,38; p = 0,0332), and with CRP results (r = 0,39; p = 0,0280), respectively.

CONCLUSION

The dorsal recess, the wrist, and small joints can be considered as important sites to detect synovitis by the MUS7 score SYN in patients with ERA.

Serum YKL-40 in psoriasis with and without arthritis; correlation with disease activity and high-resolution power Doppler ultrasonographic joint findings

BACKGROUND

YKL-40 may be involved in angiogenesis in psoriasis and psoriatic arthritis (PsA). High-resolution power Doppler ultrasound (PDUS) can detect angiogenesis of synovium in PsA.

AIM

To assess serum YKL-40 in psoriasis patients with or without PsA, and to correlate its levels with disease activity and high-resolution PDUS findings.

METHODS

In this case-control study, 48 patients with psoriasis (26 of them also had PsA) and 30 controls were assessed by high-resolution PDUS, and assayed for serum levels of YKL-40 by ELISA. Patients were clinically assessed using Composite Psoriatic Disease Activity Index (CPDAI). Total joint score (TJS) was used to assess joint involvement in PsA.

RESULTS

A statistically significant elevation was found in YKL-40 levels in psoriatics with or without PsA compared with controls (P < 0.001), as well as in PsA (group II) compared to patients without arthritis (group I) (P = 0.002). CPDAI, synovial thickness score and colour Doppler ultrasound (CDUS) score were highly significantly higher in group II vs. group I (P < 0.001). In all patients, CPDAI, synovial thickness and CDUS score were positively correlated to each other, and each of them was positively correlated to serum YKL-40 levels (P < 0.05). In either group I or II, serum YKL-40 levels correlated positively with CPDAI (P < 0.05). In group II, TJS, synovial thickness and CDUS score were positively correlated to each other (P < 0.05).

CONCLUSIONS

Serum YKL-40 can be used as a new biological marker for angiogenesis and disease activity in psoriasis with or without PsA. High-resolution PDUS is a non-invasive tool for the evaluation of angiogenesis in PsA patients as well as for the detection of early synovial changes in psoriasis patients without arthritis.

Ultrasound Detection of Salmonella Septic Arthritis in a Rheumatoid Arthritis Patient on Anti-TNF Treatment

We report a case of Salmonella septic arthritis detected by ultrasound in a 40-year-old man with rheumatoid arthritis while he was on anti–tumor necrosis factor-α monoclonal antibody certolizumab. An aspirate of his left elbow joint showed Salmonella enteritidis infection that was sensitive to ceftraixone. This was preceded by a brief episode of loose stools following a visit to the Far East. He was treated with antibiotics and made a good recovery. There have only been a few case reports of Salmonella septic arthritis in a rheumatoid arthritis patient on anti–tumor necrosis factor treatment but none previously in association with certolizumab.

Evaluation of synovial inflammation in juvenile idiopathic arthritis by power color Doppler and Spectral Doppler ultrasonography

OBJECTIVES

To compare Power Color Doppler and Spectral Doppler ultrasonography indices (Resistive index and color fraction) in cases of Juvenile Idiopathic Arthritis (JIA) with healthy controls and evaluate their correlation with clinical and laboratory parameters.

METHODS

A cross sectional study was done over a period of 16 mo. Thirty patients of JIA and 30 age and sex matched healthy children were enrolled. Swelling and tenderness scores were evaluated and hemoglobin, total leukocyte count, erythrocyte sedimentation rate and C-reactive protein were done. A total of 112 diseased joints and 135 healthy joints were evaluated by USG by the same radiologist, and color fraction and RI were recorded.

RESULTS

Statistically significant higher color fraction and lower RI (Resistive Index) were found in diseased joints as compared to healthy joints. Also the value of color fraction increased significantly with increasing grade of tenderness and RI decreased significantly with increasing grade of swelling.

CONCLUSIONS

Power Color Doppler and Spectral Doppler ultrasonography (USG) indices (RI and color fraction) are significantly different in JIA patients. These might find a place in early diagnosis, monitoring of disease activity and response to therapy in JIA patients.

Factors influencing concordance between clinical and ultrasound findings in rheumatoid arthritis

OBJECTIVE

Clinical joint examination (CJE) is less time-consuming than ultrasound (US) in rheumatoid arthritis (RA). Low concordance between CJE and US would indicate that the 2 tests provide different types of information. Knowledge of factors associated with CJE/US concordance would help to select patients and joints for US. Our objective was to identify factors associated with CJE/US concordance.

METHODS

Seventy-six patients with RA requiring tumor necrosis factor-α (TNF-α) antagonist therapy were included in a prospective, multicenter cohort. In each patient, 38 joints were evaluated. Synovitis was scored using CJE, B-mode US (B-US), and power Doppler US (PDUS). Joints whose kappa coefficient (κ) for agreement CJE/US was < 0.1 were considered discordant. Multivariate analysis was performed to identify factors independently associated with CJE/US concordance, defined as factors yielding p < 0.05 and OR > 2.

RESULTS

Concordance before TNF-α antagonist therapy varied across joints for CJE/US (κ = -0.08 to 0.51) and B-US/PDUS (κ = 0.30 to 0.67). CJE/US concordance was low at the metatarsophalangeal joints and shoulders (κ < 0.1). Before TNF-α antagonist therapy, a low 28-joint Disease Activity Score (DAS28) was associated with good CJE/B-US concordance, and no factors were associated with CJE/PDUS concordance. After TNF-α antagonist therapy, only the joint site was associated with CJE/B-US concordance; joint site and short disease duration were associated with CJE/PDUS concordance.

CONCLUSION

Concordance between CJE and US is poor overall. US adds information to CJE, most notably at the metatarsophalangeal joints and shoulders. Usefulness is decreased for B-US when DAS28 is low and for PDUS when disease duration is short.

The evolution of ultrasound in rheumatology

Musculoskeletal ultrasound is a powerful tool not only for evaluating joint and related structures but also for assessing disease activity. Ultrasound in rheumatology has rapidly evolved and been incorporated into routine clinical practice over the past decade. Moreover, technological development of equipment has made it more accessible for rheumatologists. We present a review of advances in ultrasound in rheumatology, focusing on major chronological developments.

Relationship of ultrasonographic findings with synovial angiogenesis modulators in different forms of knee arthritides

Angiogenesis is controlled by a variety of angiogenesis stimulators and inhibitors. The increased power Doppler (PD) signals determined by ultrasonography is an indirect marker of synovial vascularity in arthritis. We aimed to investigate relationship between ultrasonographic findings and synovial angiogenesis modulators. Thirteen Behcet's disease (BD), 15 spondyloarthropathy, 21 rheumatoid arthritis (RA), and 15 osteoarthritis (OA) patients with knee arthritis were included. Cumulative effusion, synovial hypertrophy, and PD signal scores were calculated in arthritic joints. In synovial fluid samples, angiogenesis inhibitors (angiostatin, thrombospondin-1, and endostatin) and stimulators [bFGF (basic fibroblast growth factor), angiopoietin-1] were studied. The comparisons between groups were made by Kruskal-Wallis test, and correlation analysis was calculated with Pearson and Spearman tests. Effusion scores were significantly higher in inflammatory arthritis than in OA. Synovial hypertrophy scores were higher in RA and spondylarthritis than in OA and BD. PD scores were not different between the groups. Synovial angiostatin and bFGF levels were significantly higher in patients with inflammatory arthritis than in OA. Cumulative effusion scores were positively correlated with angiopoietin-1, angiostatin, and bFGF and negatively correlated with thrombospondin-1 levels. Synovial hypertrophy scores were positively correlated with angiostatin and bFGF levels and negatively correlated with thrombospondin-1. No correlation was found between PD scores and modulators of angiogenesis. In large joints like knee, detecting PD signals alone was not sufficient to assess the angiogenesis. However, cumulative activity scores were positively correlated with angiogenesis stimulators. Therefore, when investigating the angiogenesis, PD technique should be added to gray-scale examinations.

Evaluation of finger joint synovial vascularity in patients with rheumatoid arthritis using contrast-enhanced ultrasound with water immersion and a stabilized probe

PURPOSE.: To assess synovial microvascularity in finger joints with rheumatoid arthritis (RA) by contrast-enhanced ultrasound (CEUS), distinguishing between cases of active disease and those in remission; to standardize the technique for software analysis. METHODS.: Fifty-two finger joints of RA patients (26 with active disease and 26 in remission) were immersed in water and examined by CEUS using a fixed probe. Signal intensity curves were calculated with the software. RESULTS.: Contrast enhancement was detectable in all 26 patients with active RA (100%), but not in 25 of 26 patients in remission (96%); one of the latter patients (4%) showed minimal enhancement. The method's sensitivity and specificity in distinguishing active disease from remission were 100% and 96%. The grades of synovial enhancement correlated with clinical disease activity and software flow parameters. The peak contrast levels correlated with clinical activity, a peak of 9% representing the cutoff between remission and active disease. CONCLUSIONS.: CEUS with a fixed probe on finger joints immersed in water detected synovial vascularization in RA, producing results suitable for standardized software analysis and avoiding artifacts.

Musculoskeletal ultrasound in pediatric rheumatology

Although musculoskeletal ultrasound (MSUS) has emerged as an indispensible tool among physicians involved in musculoskeletal medicine in the last two decades, only recently has it become more attractive to pediatric rheumatologists. Thereafter, the use of MSUS in pediatric rheumatology has started to increase. Yet, an ever-growing body of literature shows parity and even superiority of MSUS when compared to physical examination and other imaging modalities.MSUS is suitable for examination of children of all ages and it has certain advantages over other imaging modalities; as it is cheaper, mobile, instantly accessible bedside, easy to combine with clinical assessment (interactivity) and non-invasive. It does not require sedation, which facilitates repetitive examinations. Assessment of multiple locations is possible during the same session. Agitation is rarely a problem and small children can be seated in their parents' lap or they can even play while being examined.

Musculoskeletal Ultrasonography in Healthy Subjects and Ultrasound Criteria for Early Arthritis (The ESPOIR Cohort)

Objective.

To confirm the occurrence of bone erosions and synovitis in healthy subjects detectable by ultrasound (US) and to establish US criteria for early arthritis.

Methods.

Our study involved 127 healthy subjects matched with a cohort of patients with early arthritis (the ESPOIR cohort). The second and fifth metacarpophalangeal (MCP) joints and the fifth metatarsophalangeal (MTP) joint of both hands and feet were assessed with US to detect bone erosion; and the second, third, fourth, and fifth MCP and the fifth MTP were evaluated for synovial thickening in B-mode US and synovial vascularity in power Doppler. Bone erosion and synovitis were defined according to the Outcome Measures in Rheumatology Clinical Trials consensus.

Results.

Bone erosion and grade 2–3 synovial thickening in B-mode were detected in 11% and 9% of healthy subjects. To consider the diagnosis of early arthritis, a cutoff at 1 case of synovial thickening in B-mode enabled discrimination between patients with early arthritis and healthy subjects, with a good sensitivity of 74.8% (95% CI 67.2%–82.3%) and a high specificity of 90.5% (95% CI 85.4%–95.6%). If higher specificity is required to confirm the diagnosis of early arthritis, cutoff at 2 cases of synovial thickening in B-mode or at 2 cases of bone erosion gave optimal results, with specificity of 98.4% (95% CI 96.2%–100%) and 100%, respectively, and lower sensitivity of 59.8% (95% CI 51.2%–68.3%) and 17% (95% CI 10.5%–23.5%) (area under the curve = 0.85 for synovitis and 0.63 for bone erosion). Neither the combination of power Doppler signal plus bone erosion, nor bone erosions plus synovial thickening on the same joint, were seen in healthy subjects.

Conclusion.

A single case of bone erosion or synovial thickening in B-mode is common in healthy subjects. However, more than 1 case of synovial thickening in B-mode or bone erosion is a strong argument for the diagnosis of early inflammatory arthritis.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study

BACKGROUND

The ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used for guidance of steroid injection and to assess treatment efficacy.

METHODS

Forty swollen ankles regions were studied in 30 patients (median age 6.5 years, range 1-16 years) with JIA. All patients were assessed clinically, by US (synovial hypertrophy, effusion) and by color Doppler (synovial hyperemia) before and 4 weeks after US-guided steroid injection.

RESULTS

US detected 121 compartments with active disease (joints, tendon sheaths and 1 ganglion cyst). Multiple compartments were involved in 80% of the ankle regions. The talo-crural joint, posterior subtalar joint, midfoot joints and tendon sheaths were affected in 78%, 65%, 30% and 55% respectively. Fifty active tendon sheaths were detected, and multiple tendons were involved in 12 of the ankles. US-guidance allowed accurate placement of the corticosteroid in all 85 injected compartments, with a low rate of subcutaneous atrophy (4,7%). Normalization or regression of synovial hypertrophy was obtained in 89%, and normalization of synovial hyperemia in 89%. Clinical resolution of active arthritis was noted in 72% of the ankles.

CONCLUSIONS

US enabled exact anatomical location of synovial inflammation in the ankle region of JIA patients. The talo-crural joint was not always involved. Disease was frequently found in compartments difficult to evaluate clinically. US enabled exact guidance of steroid injections, gave a low rate of subcutaneous atrophy and was proved valuable for follow-up examinations. Normalization or regression of synovial hypertrophy and hyperemia was achieved in most cases, which supports the notion that US is an important tool in the management of ankle involvement in JIA.

Quantitative Power Doppler Ultrasonography Is a Sensitive Measure of Metacarpophalangeal Joint Synovial Vascularity in Rheumatoid Arthritis and Declines Significantly Following a 2-week Course of Oral Low-dose Corticosteroids

Objective.

To investigate the stability over 2 weeks of ultrasonographic assessments of synovial thickness and vascularity in all 10 metacarpophalangeal joints of subjects with rheumatoid arthritis (RA) with a range of disease activities as measured by the validated Disease Activity Score-28 joint score (DAS28-ESR). And in subjects with severe disease activity, to compare the sensitivity of these measurements, acute-phase markers, and vascular endothelial growth factor to change in response to 2 weeks of oral prednisolone (7.5 mg daily).

Methods.

A group of 38 subjects with RA were enrolled, 13 (mean DAS28 2.1), 14 (mean DAS28 5.2), and 11 (mean DAS28 5.7) meriting oral corticosteroid treatment. Synovial thickness and vascularity were assessed by ultrasonography at 3 timepoints. Images were ranked by semiquantitative scale. Vascularity was also measured by quantitative determination of the power Doppler area (PDA).

Results.

In the whole RA cohort, baseline indices of synovial thickness and vascularity correlated with DAS28, as did PDA (r = 0.42, p < 0.05). In the RA groups on stable therapy, synovial thickness and vascularity showed little variation over 2 weeks. In the corticosteroid group, PDA had fold changes of −1.9-fold (p < 0.05) after 1 week and −2.2-fold (p < 0.05) after 2 weeks. These were the largest fold changes of all measured variables.

Conclusion.

Ultrasonographic measures can differentiate disease severity in RA correlating closely with DAS28. Quantitative power Doppler signal was significantly reduced within 1 week of oral prednisolone, a rapid kinetic suggesting that PDA may have value as a sensitive early marker of therapeutic response.

The thickness of the A1 pulleys reflects the disability of hand mobility in scleroderma. A pilot study using high-frequency ultrasound

BACKGROUND

Hand involvement in scleroderma is a serious concern. Clinical tests to asses hand dysfunction are based on the experience of the clinician.

OBJECTIVE

To asses if utrasonographic (US) measurement of A1 pulley thickness may be used as an indicator of hand mobility in scleroderma.

MATERIALS AND METHODS

Institutional review board approval and patient informed consent was obtained. Twenty-eight patients affected suffering from scleroderma and 40 healthy controls were prospectively evaluated by two blinded radiologists with US, with a transducer operating at 17MHz. A1 pulley thickness was measured and correlated with the Hand Mobility in Scleroderma Test (HAMIS) and disease duration.

RESULTS

The thickness of the A1 pulley was greater in sclerodermic patients than in controls (p < 0.05). Intra and inter-observer agreement were better for ultrasound (0.94;0.88) than for HAMIS tests (0.71;0.70). A good correlation between pulley thickness, hand mobility and disease duration was found (r = 0.78, p < 0.018; r = 0.54, p < 0.05).

CONCLUSION

A1 pulley thickness measured on ultrasound correlates with hand mobility and disease duration. Ultrasound is an useful tool to evaluate hand disability in scleroderma.

Reproducibility of Joint Swelling Assessment by Sonography in Patients with Long-lasting Rheumatoid Arthritis (SEA-Repro Study Part II)

Objective.

To evaluate the intraobserver and interobserver reproducibility of B-mode and power Doppler (PD) sonography in patients with active long-standing rheumatoid arthritis (RA) comparatively with clinical data.

Methods.

In each of 7 patients being considered for a change in their RA treatment regimen, 7 healthcare professionals examined the 28 joints used in the Disease Activity Score 28-joint count (DAS28). Then 7 sonographers examined each of the 7 patients twice, using previously published B-mode and PD grading systems. The clinical reference standard was presence of synovitis according to at least 4/7 examiners. The sonographic reference standard was at least grade 1 (ALG1) or 2 (ALG2) synovitis according to at least 4/7 sonographers. Interobserver reproducibility of sonography was assessed versus the sonographer having the best intraobserver reproducibility. Agreement was measured by Cohen’s kappa statistic.

Results.

Intraobserver and interobserver reproducibility of B-mode and PD used separately was fair to good. Agreement between clinicians and sonographers at all sites using B-mode, PD, and both was 0.46, 0.37, and 0.36, respectively, for grade 1 synovitis; and 0.58, 0.19, and 0.19 for grade 2 synovitis. The number of joints with synovitis was smaller by physical examination (36.7%) than by B-mode with ALG1 (58.6%; p < 0.001). The number of joints with synovitis was higher by physical examination than by PD with both ALG1 (17.8%; p < 0.0001) and ALG2 (6.6%; p < 0.0001).

Conclusion.

PD findings explain most of the difference between clinical and sonographic joint assessments for synovitis in patients with long-standing RA.

Using ultrasonography to facilitate best practice in diagnosis and management of RA

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Association of ultrasonographic findings of synovitis with anti-cyclic citrullinated Peptide antibodies and rheumatoid factor in patients with palindromic rheumatism during active episodes

OBJECTIVE

The purpose of this study was to investigate whether the presence of ultrasonographic findings of synovitis is associated with the presence of anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor (RF) in patients with palindromic rheumatism (PR) during active episodes.

METHODS

Clinically involved regions of 84 patients with PR during active episodes were examined with high-resolution ultrasonography. Serum levels of anti-CCP antibodies were determined by an enzyme-linked immunosorbent assay, and RF levels were measured by nephelometry.

RESULTS

Thirty patients (36%) had ultrasonographic findings of synovitis during active episodes. Significantly higher positive rates of anti-CCP antibodies and RF were observed in patients with PR who had ultrasonographic findings of synovitis compared with those who had no ultrasonographic findings of synovitis (26.7% versus 5.6%; odds ratio, 6.18; P < .05; and 30.0% versus 5.6%; odds ratio, 7.29; P < .01, respectively). The intraobserver and interobserver agreement for the detection of synovitis and Doppler signals by ultrasonographic assessment was excellent.

CONCLUSIONS

Ultrasonography is a reliable method for assessing the presence of synovitis in patients with PR during active episodes. The ultrasonographic findings of synovitis are associated with the presence of anti-CCP antibodies and RF in patients with PR.

Quantification of synovitis in rheumatoid arthritis: do we really need quantitative measurement of contrast-enhanced ultrasound?

OBJECTIVE

The quantification of synovitis is of great significance for adequate therapy management and follow-up in patients with Rheumatoid Arthritis (RA). The purpose of this study was to validate a semi-quantitative Power Doppler (PD) scoring system by comparing the PD scores to the objective measurement of the synovial inflammation using dynamic contrast-enhanced Pulse-Inversion Harmonic Imaging (PIHI).

MATERIALS AND METHODS

In 27 patients with RA, two radiologists performed semi-quantitative scoring of a PD examination, using a four-point scale from 0 to 3, in the metacarpophalangeal joints, proximal interphalangeal joints, and the wrists. The scores were compared to the area under the time-echo intensity curves obtained by contrast-enhanced PIHI examination. The interobserver agreement for PD scoring was evaluated using the Cohen's kappa test.

RESULTS

Preliminary results showed that the area under the curve of dynamic measurements of PIHI tended to correlate with PD scores. The interobserver agreement for PD scoring was good (kappa=0.768).

DISCUSSION

Based on comparisons with dynamic contrast-enhanced PIHI, semi-quantitative PD scoring might meet the criteria for a reliable, reproducible, and practical scoring system. Although further studies that would include a larger study population are required, our preliminary results show that PIHI may not provide a real benefit for quantification of synovitis in day-to-day practice.

Contrast-enhanced Coded Phase-inversion Harmonic Sonography of Knee Synovitis Correlates with Histological Vessel Density: 2 Automated Digital Quantifications

Objective.

To use contrast-enhanced coded phase-inversion harmonic B-mode sonography to assess the acoustic enhancement of the synovial area of the knee; and to compare the data with the histological vessel density.

Methods.

Eleven patients eligible for a knee arthroscopy were studied. Acoustic quantification was carried out by a digital image analysis program that detects the time-dependent increase [intensity (time) = k × time + C] of gray-level intensity in all the pixels of a specific region of interest (ROI) following intravenous injection of the microbubble contrast agent sulfur hexafluoride. Echo-guided synovial biopsies were carried out in the same ROI. Synovial vessel areas were quantified after Factor VIII immunostaining of synovial biopsies using an automated digital image analysis.

Results.

Significant (p < 0.05) correlations were observed between histological vessel density and percentage of the synovial area with a k value > 0.01 (r = 0.93) and kmaxvalues (r = 0.79), as well as between the 2 latter parameters (r = 0.72). The histological vessel density and the 2 acoustic parameters were also significantly correlated with the logarithm of erythrocyte sedimentation rate (r = 0.77, r = 0.87, r = 0.67, respectively) and with log C-reactive protein serum concentration (r = 0.69, r = 0.83, r = 0.62, respectively).

Conclusion.

Contrast-enhanced coded phase-inversion harmonic B-mode sonography coupled with an appropriate data analysis method is a new tool to identify and quantify vessel density in knee synovitis.

Imaging in rheumatoid arthritis--status and recent advances for magnetic resonance imaging, ultrasonography, computed tomography and conventional radiography

Sensitive and reproducible tools for diagnosis, monitoring of disease activity and damage, and prognostication are essential in the management of patients with rheumatoid arthritis (RA). Conventional radiography (X-ray), the traditional gold standard for imaging in RA, is not able to detect early disease manifestations such as inflammatory changes in the soft tissues (synovitis, tensynovitis, enthesitis etc.) and the earliest stages of bone erosion. In contrast, magnetic resonance imaging (MRI) and ultrasonography (US) allow direct visualization of early inflammatory and destructive joint changes, and have several documented and potential applications in RA patients. This chapter will review key aspects of the current status and recent important advances in imaging in RA, briefly discussing X-ray and computed tomography, and particularly focusing on MRI and US. Suggestions for use in clinical trials and practice are provided.

Ultrasound of the small joints of the hands and feet: current status

The aim of this article was to review the current status of ultrasound imaging of patients with rheumatological disorders of the hands and feet. Ultrasound machines with high-resolution surface probes are readily available in most radiology departments and can be used to address important clinical questions posed by the rheumatologist and sports and rehabilitation physician. There is increasing evidence that ultrasound detects synovitis that is silent to clinical examination. Detection and classification of synovitis and the early detection of bone erosions are important in clinical decision making. Ultrasound has many advantages over other imaging techniques with which it is compared, particularly magnetic resonance. The ability to carry out a rapid assessment of many widely spaced joints, coupled with clinical correlation, the ability to move and stress musculoskeletal structures and the use of ultrasound to guide therapy accurately are principal amongst these. The use of colour flow Doppler studies provides a measure of neovascularisation within the synovial lining of joints and tendons, and within tendons themselves, that is not available with other imaging techniques. Disadvantages compared to MRI include small field of view, poor image presentation, and difficulty in demonstrating cartilage and deep joints in their entirety. Contrast-enhanced magnetic resonance provides a better measure of capillary permeability and extracellular fluid than does ultrasound. The ability to image simultaneously multiple small joints in the hands and feet and their enhancement characteristics cannot be matched with ultrasound, though future developments in 3-D ultrasound may narrow this gap. Magnetic resonance provides a more uniform and reproducible image for long-term follow-up studies.