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Seskute G, Jasionyte G, Rugiene R, Butrimiene I. The Use of Superb Microvascular Imaging in Evaluating Rheumatic Diseases: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1641. [PMID: 37763760 PMCID: PMC10537482 DOI: 10.3390/medicina59091641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 08/28/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023]
Abstract
Background and Objectives: Superb microvascular imaging is an advanced Doppler algorithm that seems to be useful in detecting low-velocity blood flow without using a contrast agent. Increasing evidence suggests that SMI is a more sensitive tool than conventional Doppler techniques for evaluating rheumatic diseases, especially inflammatory arthritis. We aimed to assess the use of SMI in evaluating joints and extraarticular structures. Materials and Methods: Two reviewers independently reviewed the literature to provide a global overview of the possibilities of SMI in rheumatology. Original English-language articles published between February 2014 and November 2022 were identified through database (PubMed, Medline, Ebsco, the Cochrane Library, and ScienceDirect) searching, and analysed to summarise existing evidence according to PRISMA methodology. Inclusion criteria covered original research articles reporting applications of SMI on rheumatic diseases and musculoskeletal disorders secondary to rheumatic conditions. Qualitative data synthesis was performed. Results: A total of 18 articles were included. No systematic reviews fulfilled our inclusion criteria. Most studies focused on characterising the synovial vascularity of rheumatoid arthritis. There have been several attempts to demonstrate SMI's value for evaluating extra-articular soft tissues (fat pads or salivary glands) and large-diameter vessels. The quantitative importance of SMI vascular indices could become a useful non-invasive diagnostic marker. Studies on therapeutic applications are still scarce, and the majority of studies have gaps in reporting the methodology (ultrasound performance technique and settings) of the research. Conclusions: SMI has proved to be useful in characterising low-flow vascularity, and growing evidence indicates that SMI is a non-invasive and lower-cost tool for prognostic assessment, especially in inflammatory arthritis. Preliminary findings also suggest potential interest in evaluating the effect of treatment.
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Affiliation(s)
- Goda Seskute
- Clinic of Rheumatology, Orthopaedics Traumatology, and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (G.J.); (R.R.); (I.B.)
| | - Gabija Jasionyte
- Clinic of Rheumatology, Orthopaedics Traumatology, and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (G.J.); (R.R.); (I.B.)
| | - Rita Rugiene
- Clinic of Rheumatology, Orthopaedics Traumatology, and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (G.J.); (R.R.); (I.B.)
- Department of Experimental, Preventive and Clinical Medicine, State Research Institute Centre for Innovative Medicine, LT-08406 Vilnius, Lithuania
| | - Irena Butrimiene
- Clinic of Rheumatology, Orthopaedics Traumatology, and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT-01513 Vilnius, Lithuania; (G.J.); (R.R.); (I.B.)
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Santos IA, Donizeti Ribeiro de Oliveira R, Couto Luna Almeida S, Vargas-Santos AB, Balbino Chaves Amorim R, Monteiro Gomides AP, de Albuquerque CP, Barros Bertolo M, Brandão Resende Guimarães MF, da Costa Pinto MR, Gomes Resende G, Dalva Neubarth Giorgi R, de Carvalho Saciloto N, Radominski SC, Borghi FM, Rossi Bonfiglioli K, Carrico da Silva H, de Fatima L. da Cunha Sauma M, Alves Pereira I, Werner de Castro GR, Viegas Brenol C, Machado Xavier R, Maria Henrique Mota L, Louzada-Junior P, da Rocha Castelar-Pinheiro G. Comparison of rheumatoid arthritis composite disease activity indices and residual activity in a Brazilian multicenter study- REAL study. PLoS One 2022; 17:e0273789. [PMID: 36174077 PMCID: PMC9521837 DOI: 10.1371/journal.pone.0273789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 08/16/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Rheumatoid arthritis (RA) composite disease activity indices have become handy tools in daily clinical practice and crucial in defining remission or low disease activity, the main target of the RA treatment. However, there is no definition of the best index to assess disease activity in clinical practice. OBJECTIVES To compare the residual activity among the indices with the ACR/EULAR remission criteria (Boolean method) to identify the most feasible for assessing remission in daily practice, also considering correlation and concordance, sensibility, and specificity. PATIENTS AND METHODS We selected 1116 patients with established RA from the real-life rheumatoid arthritis study database-REAL. The composite disease activity indices-DAS28-ESR, DAS28-CRP, SDAI, and CDAI-and their components were compared to the Boolean method to identify residual activity using binomial regression. The indices were analyzed for correlation and agreement using the Spearman index and weighted kappa. The chi-square test evaluated sensibility and specificity for remission based on the Boolean method. RESULTS DAS28-CRP overestimated remission and confirmed higher residual activity than SDAI and CDAI. The indices showed good correlation and agreement, with a better relationship between SDAI and CDAI (k:0,88). CDAI and SDAI showed higher sensitivity and specificity for remission based on the Boolean method. CDAI was performed in 99% of patients, while DAS28 and SDAI were completed in approximately 85%. CONCLUSIONS Although all composite indices of activity can be used in clinical practice and showed good agreement, CDAI and SDAI have better performance in evaluating remission based on the Boolean method, showing less residual activity and higher sensibility and specificity. In addition, CDAI seems to be more feasible for disease activity evaluation in daily clinical practice, especially in developing countries.
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Assessment of disease activity with simplified joint ultrasonography method in rheumatoid arthritis patients. JOURNAL OF SURGERY AND MEDICINE 2022. [DOI: 10.28982/josam.1014924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background/Aim: Ultrasound (US) is a highly useful tool for assessing the disease activity of rheumatoid arthritis (RA). On the other hand, examining all joints could be time-consuming and unfeasible. Defining the number of joints and which joints should be tested is essential to accurately measuring RA activity. Several simplified US methods are undergoing development for this purpose. The aim of this study was to assess the correlation between simplified 12-joint US findings and physical examination findings/disease activity in RA patients.
Methods: This cohort study included 62 RA patients who had been undergoing treatment for at least three months. Multiplanar grayscale images and power Doppler (PD) of the 12 joints (bilateral elbow, wrist, second and third metacarpophalangeal [MCP] joints, knee, and ankle) were acquired and compared with clinical assessments. Disease activity was assessed using the clinical disease activity and simplified disease activity indices and disease activity score-28 (CDAI, SDAI, and DAS28, respectively). Synovial effusion, synovial proliferation, and PD US scores were calculated for 12 joints. Correlations between US scores and disease activity, clinical examination, and acute phase reactants were assessed.
Results: The number of joints with PD activity and US total and US synovial proliferation scores showed weak correlations with clinical activity scores (r = 0.25, r = 0.26, and r = 0.28 for SDAI and r = 0.23, r = 0.26, and r = 0.28 for DAS28, respectively). The CDAI did not present any statistically significant correlations. The agreement between US findings and clinical joint examination was generally weak. PD activities of the second MCP joints (r = 0.84, P < 0.01) and knees (r = 0.42, P < 0.01) mostly correlated with clinical examination although it was weakly correlated at the third MCP (r = 0.152) and wrist (r = 0.148), and not correlated at the elbow (r = 0.125).
Conclusion: The weak correlation between US findings and clinical examination/disease activity suggests that clinical examination alone may not be sufficient to determine joint inflammation and disease activity. US could provide a more accurate assessment of RA patients and aid in medication selection.
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Sun C, Qi X, Yang Y, Lei L, Gao L, Guo H. Importance of baseline musculoskeletal ultrasound findings in the prognosis of rheumatoid arthritis. Clin Rheumatol 2022; 41:847-857. [PMID: 35041111 DOI: 10.1007/s10067-021-06017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 10/16/2021] [Accepted: 12/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate the prognostic value of baseline musculoskeletal ultrasound (MSUS) findings for rheumatoid arthritis (RA). METHOD We retrospectively analyzed 138 patients with RA. Patients' first MSUS record was considered as the baseline expression. The subsequent MSUS changes that showed alleviation or progression were regarded as the cutoff point. Grayscale ultrasound (GSUS) synovitis, power Doppler ultrasound (PDUS) synovitis, PDUS tenosynovitis (TS), and bone erosion were scored using a semi-quantitative scale. According to the ultrasound (US) results of the cutoff point, patients were divided into the alleviation group and the progression group. Laboratory results (erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], rheumatoid factor [RF], anticyclic citrullinated peptide [anti-CCP] antibody, and anti-keratin antibody [AKA]), disease activity score in 28 joints (DAS28)-ESR, and US scores were compared between the two groups to analyze the prognostic value of US findings in RA. RESULTS The alleviation group had higher levels of CRP, synovitis, TS, GSUS synovitis, PDUS synovitis, PDUS TS, and US total scores at baseline than the progression group (p < 0.05). The alleviation group received more aggressive treatment in their initial approach than the progression group (p < 0.05). The frequency of US examinations in the alleviation group was more than that in the progression group at follow-up (p < 0.05). Presence of baseline synovitis (OR 0.248, p = 0.006) and a higher GSUS synovitis score (OR 0.521, p = 0.006) were negatively correlated with RA progression. CONCLUSIONS Presence of baseline synovitis and higher GSUS synovitis score do not always indicate worse prognosis of RA, which can be improved with aggressive treatment. Regular MSUS follow-up may have positive influences on prognosis. Key Points • The presence of synovitis at baseline and higher GSUS synovitis score do not necessarily imply poor prognosis of RA. • Prompt and powerful therapy and regular ultrasound follow-up can slow down the progression of RA and improve its prognosis. • Patients with slight and less arthritis at baseline might be ignored and get worse prognosis due to mild treatment strategies and irregular MSUS examination.
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Affiliation(s)
- Chao Sun
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China
| | - Xuan Qi
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China
| | - Yushu Yang
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China
| | - Lingyan Lei
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China
| | - Lixia Gao
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China
| | - Huifang Guo
- Department of Rheumatology and Immunology, the Second Hospital of Hebei Medical University, No. 215, Heping West Road, Xinhua District, Shijiazhuang, 050000, Hebei Province, China.
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Hoque A, Gallagher K, McEntegart A, Porter D, Steultjens M, Woodburn J, Hendry GJ. Measuring Inflammatory Foot Disease in Rheumatoid Arthritis: Development and Validation of the Rheumatoid Arthritis Foot Disease Activity Index-5. Arthritis Care Res (Hoboken) 2021; 73:1290-1299. [PMID: 32433810 DOI: 10.1002/acr.24259] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 05/12/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Omission of foot joints from composite global disease activity indices may lead to underestimation of foot and overall disease in rheumatoid arthritis (RA) and under-treatment. The aim of this study was to evaluate the measurement properties of the Rheumatoid Arthritis Foot Disease Activity Index-5 (RADAI-F5), a newly developed patient-reported outcome measure for capturing foot disease activity in people with RA. METHODS Participants with RA self-completed the RADAI-F5, modified Rheumatoid Arthritis Disease Activity Index (mRADAI-5), Foot Function Index (FFI), and Foot Impact Scale (FIS) impairment/footwear and activity/participation subscales. The 28-joint Disease Activity Score using the erythrocyte sedimentation rate (DAS28-ESR) was also recorded. Subgroups completed the RADAI-F5 at 1 week and 6 months. Psychometric properties, including construct, content and longitudinal validity, internal consistency, 1-week reproducibility, and responsiveness over 6 months were evaluated. RESULTS Of 142 respondents, 103 were female, with a mean ± SD age of 55 ± 12.5 years and median RA disease duration of 10 (interquartile range 3.6-20.8) months. Theoretically consistent associations confirming construct validity were observed with mRADAI-5 (0.789 [95% confidence interval (95% CI) 0.73, 0.85]), FFI (0.713 [95% CI 0.62, 0.79]), FIS impairment/footwear (0.695 [95% CI 0.66, 0.82], P < 0.001), FIS activity/participation (0.478 [95% CI 0.37, 0.63], P < 0.001), and the DAS28-ESR (0.379 [95% CI 0.26, 0.57], P < 0.001). The RADAI-F5 demonstrated high internal consistency (Cronbach's α = 0.90) and good reproducibility (intraclass correlation coefficient = 0.868 [95% CI 0.80, 0.91], P < 0.001, smallest detectable change = 2.69). Content validity was confirmed, with 82% rating the instrument relevant and easy to understand. CONCLUSION The RADAI-F5 is a valid, reliable, responsive, clinically feasible patient-reported outcome measure for measuring foot disease activity in RA.
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Affiliation(s)
- Anika Hoque
- School of Health and Life Sciences, Glasgow Caledonian University and NHS Greater Glasgow and Clyde, Trust Headquarters, Glasgow, UK
| | | | | | | | - Martijn Steultjens
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - James Woodburn
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Gordon J Hendry
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
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Zhao C, Wang Q, Wang M, Tao X, Liu S, Qi Z, Lanxi X, Liu D, He X, Tian X, Zeng X, Jiang Y, Yang M. Ultra-microangiography in evaluating the disease activity of rheumatoid arthritis and enhancing the efficacy of ultrasonography: A preliminary study. Eur J Radiol 2021; 137:109567. [PMID: 33556758 DOI: 10.1016/j.ejrad.2021.109567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 12/12/2020] [Accepted: 01/19/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Ultra-microangiography (UMA) is a novel Doppler technique that has high sensitivity for low-velocity blood flows. In this study, a distinctive imaging feature, penetrating blood vessels on the surface of eroded bones within the inflamed joints, was observed on UMA. We aimed to investigate the feasibility of UMA in assessing disease activity and identify the clinical value of the UMA feature for evaluating rheumatoid arthritis (RA). METHODS AND MATERIALS Power-Doppler ultrasound (PDUS) and UMA were performed on small joints of RA patients. The semiquantitative scores of PDUS and UMA of the joints were assessed and compared. The UMA imaging feature of penetrating vessels on the surface of eroded bones was evaluated, and the patients were divided into three groups based on imaging features. (Group 1: no inflammatory signs; Group 2: inflammatory US features but no UMA features; and Group 3: detected UMA features). The correlations between the groups and clinical parameters were assessed. RESULTS A total of 52 patients with RA were recruited, with 364 joints (MCP, PIP, MTP and wrist) scanned. Synovial blood vessel signals were detected for 68 by PDUS and for 93 by UMA (display rate of blood vessel signals: 18.68 % VS 25.55 %). UMA presented better display capability of blood vessels within the inflamed regions than that of PDUS in overall. Significant differences were detected in clinical scores (P < 0.0001 for DAS28 [ESR], DAS28 [CRP], SDAI, CDAI, CRP P = 0.0303, SJC P = 0.0059, and TJC P = 0.0423) between Group 2 and 3. Significant correlations between the groups and clinical parameters were also observed (DAS28 [ESR] ρ=0.750; DAS28 [CRP] ρ=0.762; SDAI ρ=0.778; CDAI ρ=0.773; CRP ρ= 0.524; SJC ρ=0.742; TJC ρ=0.693, P < 0.0001), indicating that the UMA feature was related to high disease activity. CONCLUSIONS UMA can help enhance the detection rate of micro-vascularization. The UMA feature of the penetrating vessels on the surface of eroded bones is likely to be associated with severe disease activity.
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Affiliation(s)
- Chenyang Zhao
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID) and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Ming Wang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Xixi Tao
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Sirui Liu
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Zhenhong Qi
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China
| | - Xiang Lanxi
- Shenzhen Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China
| | - Donald Liu
- Mindray Innovation Center, San Jose, CA, USA
| | - Xujin He
- Shenzhen Mindray Bio-Medical Electronics Co., Ltd., Shenzhen, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID) and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China; National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID) and Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, China
| | - Yuxin Jiang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
| | - Meng Yang
- Department of Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, China.
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Molina Collada J, Castrejón I, Pérez M, Nieto-González JC, González T, Rivera J, González C, Álvaro-Gracia JM. Clinical impact of musculoskeletal ultrasound on rheumatoid arthritis in routine care. Int J Rheum Dis 2020; 24:341-346. [PMID: 33314707 DOI: 10.1111/1756-185x.14040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 11/12/2020] [Accepted: 11/14/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate the impact of musculoskeletal ultrasound (MSUS) in the management of rheumatoid arthritis (RA) patients and to investigate factors affecting treatment strategy by the referring rheumatologist. METHODS Prospective study of RA patients evaluated at a MSUS clinic over a 6-month period. Data extraction included demographics, current treatment and MSUS findings. Pre- and post-MSUS follow-up of 3 months data were analyzed. Patients were classified into 2 groups based on the decision of the referring rheumatologist to change the treatment after the MSUS examination. Comparisons between groups were performed in a univariate analysis. We used logistic regression models to investigate factors associated with changes in clinical management. RESULTS A total of 64 RA patients were included. Mean age was 61.9 years and 83.6% were female. Main referral indication was assessment of disease activity (89%). Overall, MSUS led to subsequent therapeutic actions by the referring rheumatologist in 41 (64.1%) patients, and to a change in the clinical impression of the complaint that generated the referral in 7 (11.5%) patients. The detection of power Doppler (PD), the 28 swollen joint count and the presence of radiographic erosions were significantly associated with a subsequent clinical action. In the multivariate analysis only PD remained significant (odds ratio = 3.29; 95% CI: 1.05-10.26). CONCLUSION Disease activity evaluation is the most common indication for MSUS examination, with the presence of PD the factor most frequently associated with changes in therapeutic management. This study highlights the impact of MSUS, especially the use of PD, to support treatment decisions in RA routine care.
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Affiliation(s)
- Juan Molina Collada
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain
| | - Isabel Castrejón
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain
| | - María Pérez
- Complutense University of Madrid, Madrid, Spain
| | | | - Teresa González
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain
| | - Javier Rivera
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain
| | - Carlos González
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain
| | - José María Álvaro-Gracia
- Department of Rheumatology, Gregorio Marañón University Hospital, Madrid, Spain.,Complutense University of Madrid, Madrid, Spain
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Lin M, Wang C. Superb microvascular imaging evaluating joint lesion scores in rheumatoid arthritis compared with power Doppler imaging: A meta-analysis. Medicine (Baltimore) 2020; 99:e22185. [PMID: 32925790 PMCID: PMC7489735 DOI: 10.1097/md.0000000000022185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND To compare superb microvascular imaging with power Doppler imaging for evaluating joint lesion scores in rheumatoid arthritis based on high quality clinical cohort or case control studies. METHODS We searched Medline (via PubMed), Web of Science, Cochrane Library, Embase, and Chinese Biomedical Literature Database without restrictions of language and publication status. Two investigators will identify relevant trials, extract data, and appraise risk of bias in each eligible trial. Data will be pooled by either a fixed-effects model or a random-effects model according to the results of heterogeneity identification. The primary outcomes include a semi-quantitative scoring system, through which synovial vascularity intensity was evaluated by means of both power Doppler imaging (PDI) and superb microvascular imaging (SMI). This study will only include high quality clinical cohort or case control studies. Statistical analyses were conducted by STATA version 15.1 software. RESULTS This meta-analysis included 11 studies. A total of 4342 joints were assessed through both SMI and PDI. The pooled summary odds ratio was 2.12 (95% confidence interval = 1.80-2.51) with statistical significance (z = 8.82, P < .01). In subgroup analyses, the results revealed also that SMI exhibited more sensitive performance in different subgroups. We found no evidence for publication bias (t = 0.55, P = .598). CONCLUSION Our meta-analysis indicates that SMI ultrasound is more sensitive than conventional PDI in detecting synovitis in RA patients. INPLASY REGISTRATION NUMBER INPLASY202060089.
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Kawashiri SY, Endo Y, Okamoto M, Tsuji S, Shimizu T, Sumiyoshi R, Koga T, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Kawakami A. Contributing factors of clinical outcomes at 1 year post-diagnosis in early rheumatoid arthritis patients with tightly controlled disease activity in clinical practice: a retrospective study. Mod Rheumatol 2020; 31:343-349. [PMID: 32654596 DOI: 10.1080/14397595.2020.1795392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To determine whether specific parameters contribute to clinical outcomes at 1 year post-diagnosis in early rheumatoid arthritis (RA) patients under the 'treat-to-target' strategy in clinical practice. METHODS We retrospectively analyzed 125 RA patients selected according to the following criteria; the patients' symptom duration was ≤6 months, and none had experience with DMARDs. We evaluated the patients' clinical disease activity at baseline and 1 year of treatment and the musculoskeletal ultrasound (MSUS)-detected synovitis activity at baseline. We performed an analysis to identify parameters that contribute to SDAI remission and the use of biologic/targeted synthetic (b/ts) DMARDs at 1 year post-diagnosis. RESULTS Forty-seven patients received b/tsDMARDs therapy, and 58 patients achieved SDAI remission at 1 year post-diagnosis. Rheumatoid factor positivity, low patient's/evaluator's global assessment at baseline, and methotrexate use at 1 year post-diagnosis were associated with SDAI remission. The baseline clinical disease activity and MSUS scores were not associated with SDAI remission. Anti-cyclic citrullinated peptide antibody positivity/high titer and high swollen joint counts or the presence of severe synovial hypertrophy at baseline were associated with the use of b/tsDMARDs therapy. CONCLUSION The value of the expected poor-prognosis factors may be diminished by intensive therapy within the 'windows of opportunity'.
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Affiliation(s)
- Shin-Ya Kawashiri
- Departments of Community Medicine, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan.,Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Yushiro Endo
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Momoko Okamoto
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Sosuke Tsuji
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Toshimasa Shimizu
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Remi Sumiyoshi
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Tomohiro Koga
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Naoki Iwamoto
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Kunihiro Ichinose
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Mami Tamai
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Hideki Nakamura
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Tomoki Origuchi
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
| | - Atsushi Kawakami
- Immunology and Rheumatology, Division of Advanced Preventive Medical Sciences, Nagasaki University Graduate School of Medical Sciences, Nagasaki, Japan
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Silva Chakr RMD, Santos JCDO, Alves LDS, de Andrade NPB, Ranzolin A, Brenol CV. Ultrasound Assessment of Disease Activity Prevents Disease-Modifying Antirheumatic Drug (DMARD) Escalation and May Reduce DMARD-Related Direct Costs in Rheumatoid Arthritis With Fibromyalgia: An Exploratory Study. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:1271-1278. [PMID: 31958164 DOI: 10.1002/jum.15215] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES as an objective measure, ultrasound (US) could prevent rheumatoid arthritis (RA) overtreatment induced by concomitant fibromyalgia (FM). Our goal was to study how patients with RA and FM who underwent a US examination differed from those without a US examination in terms of overall disease-modifying antirheumatic drug (DMARD) escalation and biologic DMARD-related direct costs. METHODS Patients with RA and FM were seen between 2011 and 2017. In cases of 28-joint Disease Activity Score (DAS28) overestimation, patients were referred to undergo a US examination. The US group underwent a US examination to confirm disease activity, and the DAS28 group had disease activity assessment based solely on the DAS28. RESULTS Of 230 patients with RA, 22 women with RA and FM (DAS28 group, n = 9; and US group, n = 13) were seen in 316 visits (115.68 patient-years). The DMARD treatment was escalated in 27.1% of visits in the DAS28 group versus 17.3% in the US group (P = .046). The relative risk of DMARD escalation in the DAS28 group compared to the US group was 1.57 (95% confidence interval, 1.01-2.43). In sum total, US$240,784.52 were spent on biologics throughout the entire study period. Basing biologic DMARD prescriptions on US results could save an average of US$405.66 per patient-year. CONCLUSIONS In this real-life study of patients with RA and FM, a US examination was associated with less DMARD escalation and could reduce biologic DMARD direct costs. Specifically, synovitis as scored by power Doppler US could be useful as a treatment target for RA in patients with DAS28 overestimation due to FM, but further studies are necessary.
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Affiliation(s)
- Rafael Mendonça da Silva Chakr
- Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - João Cláudio de Oliveira Santos
- Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Laura da Silva Alves
- Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Aline Ranzolin
- Hospital das Clínicas, Universidade Federal de Pernambuco, Recife, Brazil
| | - Claiton Viegas Brenol
- Serviço de Reumatologia, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
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11
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Daly R, Blackburn G, Best C, Goodyear CS, Mudaliar M, Burgess K, Stirling A, Porter D, McInnes IB, Barrett MP, Dale J. Changes in Plasma Itaconate Elevation in Early Rheumatoid Arthritis Patients Elucidates Disease Activity Associated Macrophage Activation. Metabolites 2020; 10:metabo10060241. [PMID: 32531990 PMCID: PMC7344783 DOI: 10.3390/metabo10060241] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/05/2020] [Accepted: 06/07/2020] [Indexed: 12/29/2022] Open
Abstract
Changes in the plasma metabolic profile were characterised in newly diagnosed rheumatoid arthritis (RA) patients upon commencement of conventional disease-modifying anti-rheumatic drug (cDMARD) therapy. Plasma samples collected in an early RA randomised strategy study (NCT00920478) that compared clinical (DAS) disease activity assessment with musculoskeletal ultrasound assessment (MSUS) to drive treatment decisions were subjected to untargeted metabolomic analysis. Metabolic profiles were collected at pre- and three months post-commencement of nonbiologic cDMARD. Metabolites that changed in association with changes in the DAS44 score were identified at the three-month timepoint. A total of nine metabolites exhibited a clear correlation with a reduction in DAS44 score following cDMARD commencement, particularly itaconate, its derived anhydride and a derivative of itaconate CoA. Increasing itaconate correlated with improved DAS44 score and decreasing levels of C-reactive protein (CRP). cDMARD treatment effects invoke consistent changes in plasma detectable metabolites, that in turn implicate clinical disease activity with macrophages. Such changes inform RA pathogenesis and reveal for the first time a link between itaconate production and resolution of inflammatory disease in humans. Quantitative metabolic biomarker-based tests of clinical change in state are feasible and should be developed around the itaconate pathway.
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Affiliation(s)
- Rónán Daly
- Glasgow Polyomics, University of Glasgow, Glasgow G61 1BD, UK; (R.D.); (G.B.); (M.M.); (K.B.); (M.P.B.)
| | - Gavin Blackburn
- Glasgow Polyomics, University of Glasgow, Glasgow G61 1BD, UK; (R.D.); (G.B.); (M.M.); (K.B.); (M.P.B.)
| | - Cameron Best
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
| | - Carl S. Goodyear
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
| | - Manikhandan Mudaliar
- Glasgow Polyomics, University of Glasgow, Glasgow G61 1BD, UK; (R.D.); (G.B.); (M.M.); (K.B.); (M.P.B.)
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
- Institute of Biodiversity Animal Health and Comparative Medicine, University of Glasgow, Bearsden Road, Glasgow G61 1QH, UK
| | - Karl Burgess
- Glasgow Polyomics, University of Glasgow, Glasgow G61 1BD, UK; (R.D.); (G.B.); (M.M.); (K.B.); (M.P.B.)
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
- Institute of Quantitative Biology, Biochemistry and Biotechnology, The University of Edinburgh, Edinburgh EH9 3FF, UK
| | - Anne Stirling
- Department of Rheumatology, Gartnavel General Hospital, Glasgow G12 0YN, UK;
| | - Duncan Porter
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
- Department of Rheumatology, Gartnavel General Hospital, Glasgow G12 0YN, UK;
| | - Iain B. McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
| | - Michael P. Barrett
- Glasgow Polyomics, University of Glasgow, Glasgow G61 1BD, UK; (R.D.); (G.B.); (M.M.); (K.B.); (M.P.B.)
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
| | - James Dale
- Institute of Infection, Immunity and Inflammation, University of Glasgow, 120 University Place, Glasgow G12 8TA, UK; (C.B.); (C.S.G.); (D.P.); (I.B.M.)
- Department of Rheumatology, Wishaw General Hospital, 50 Netherton Street, Wishaw, North Lanarkshire ML2 0DP, UK
- Correspondence:
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12
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Zayat AS, Mahmoud K, Md Yusof MY, Mukherjee S, D'Agostino MA, Hensor EMA, Wakefield RJ, Conaghan PG, Edwards CJ, Emery P, Vital EM. Defining inflammatory musculoskeletal manifestations in systemic lupus erythematosus. Rheumatology (Oxford) 2019; 58:304-312. [PMID: 30265343 DOI: 10.1093/rheumatology/key277] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Indexed: 01/25/2023] Open
Abstract
Objective To define the prevalence and clinical associations of clinical and imaging definitions of synovitis in unselected SLE patients with musculoskeletal (MSK) symptoms. Methods 112 patients with SLE (excluding RF and CCP positive patients); 88 consecutive with inflammatory MSK symptoms and 24 asymptomatic SLE controls were recruited. Patients had clinical assessment (BILAG, SLEDAI, joint counts, patient and physician visual analogue score), routine laboratory tests and US of two hands and wrists (synovitis and tenosynovitis, OMERACT definitions). Results Overall, 68% (60/88) of symptomatic patients had US inflammation (grey scale ⩾ 2 and/or PD ⩾ 1 or tenosynovitis) compared with 17% (4/23) of asymptomatic patients. In symptomatic patients, clinical inflammation was seen defined by BILAG A or B in 38% (34/88) or defined by the SLEDAI-MSK criterion in 32% (28/88). BILAG A/B had sensitivity (95% CI) of 56% (41, 69%) and specificity of 89% (72, 96%) for US-confirmed inflammation. SLEDAI-MSK criterion had sensitivity of 44% (31, 59%) and specificity of 89% (72, 96%). In patients with inflammatory symptoms, 27% (24/88) had subclinical inflammation (abnormal US but no clinically swollen joints) and 35% (31/88) had no clinical or US inflammation. Subclinical tenosynovitis and PD were associated with significantly higher IgG, physician visual analogue score, tender joint count. Conclusion In SLE patients with MSK symptoms, a large proportion of objective, clinically meaningful inflammation is only identifiable by US. The existing classification of MSK SLE using disease activity instruments based on joint swelling is inaccurate to guide patient selection for clinical trials, biologic therapy, or treat-to-target protocols.
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Affiliation(s)
- Ahmed S Zayat
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Khaled Mahmoud
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Md Yuzaiful Md Yusof
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Sandeep Mukherjee
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Maria-Antoinetta D'Agostino
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Elizabeth M A Hensor
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Christopher J Edwards
- NIHR Wellcome Trust Clinical Research Facility, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Edward M Vital
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Leeds Teaching Hospitals NHS Trust, NIHR Leeds Biomedical Research Centre, Leeds, UK
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Abstract
BACKGROUND Medication-based strategies to treat rheumatoid arthritis are crucial in terms of outcome. They aim at preventing joint destruction, loss of function and disability by early and consistent inhibition of inflammatory processes. OBJECTIVE Achieving consensus about evidence-based recommendations for the treatment of rheumatoid arthritis with disease-modifying anti-rheumatic drugs in Germany. METHODS Following a systematic literature research, a structured process among expert rheumatologists was used to reach consensus. RESULTS The results of the consensus process can be summed up in 6 overarching principles and 10 recommendations. There are several new issues compared to the version of 2012, such as differentiated adjustments to the therapeutic regime according to time point and extent of treatment response, the therapeutic goal of achieving remission as assessed by means of the simplified disease activity index (SDAI) as well as the potential use of targeted synthetic DMARDs (JAK inhibitors) and suggestions for a deescalating in case of achieving a sustained remission. Methotrexate still plays the central role at the beginning of the treatment and as a combination partner in the further treatment course. When treatment response to methotrexate is inadequate, either switching to or combining with another conventional synthetic DMARD is an option in the absence of unfavourable prognostic factors. Otherwise biologic or targeted synthetic DMARDs are recommended according to the algorithm. Rules for deescalating treatment with glucocorticoids and-where applicable-DMARDs give support for the management of patients who have reached a sustained remission. DISCUSSION The new guidelines set up recommendations for RA treatment in accordance with the treat-to-target principle. Modern disease-modifying drugs, now including also JAK inhibitors, are available in an algorithm.
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15
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Physician’s Experience and Disease Activity Affect the Impact of Ultrasound on the Treatment Decision in Rheumatoid Arthritis. ACTA ACUST UNITED AC 2019; 25:209-216. [DOI: 10.1097/rhu.0000000000001036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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do Prado AD, Staub HL, Bisi MC, da Silveira IG, Mendonça JA, Polido-Pereira J, Fonseca JE. Ultrasound and its clinical use in rheumatoid arthritis: where do we stand? Adv Rheumatol 2018; 58:19. [PMID: 30657086 DOI: 10.1186/s42358-018-0023-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 07/16/2018] [Indexed: 01/08/2023] Open
Abstract
High-resolution musculoskeletal ultrasound (MSUS) has been increasingly employed in daily rheumatological practice and in clinical research. In rheumatoid arthritis (RA), MSUS can be now considered a complement to physical examination. This method evaluates synovitis through gray-scale and power Doppler and it is also able to identify bone erosions. The utilization of MSUS as a marker of RA activity has received attention in recent literature. Current data account for good correlation of MSUS with classical measures of clinical activity; in some instances, MSUS appears to perform even better. Diagnosis of subclinical synovitis by MSUS might help the physician in RA management. With some variation, interobserver MSUS agreement seems excellent for erosion and good for synovitis. However, lack of MSUS score standardization is still an unmet need. In this review, we describe several MSUS scores, as well as their correlation with clinical RA activity and response to therapy. Finally, we look at the relationship of MSUS with synovial tissue inflammation and discuss future perspectives for a better interpretation and integration of this imaging method into clinical practice.
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Affiliation(s)
- Aline Defaveri do Prado
- Rheumatology Unit, Nossa Senhora da Conceição Hospital, Porto Alegre, RS, Brazil. .,Rheumatology Department, Sao Lucas Hospital, Faculty of Medicine of Pontifical Catholic University of Rio Grande do Sul (PUCRS), Av. Ipiranga, 6690/220, Porto Alegre, 90610-000, Brazil.
| | - Henrique Luiz Staub
- Rheumatology Department, Sao Lucas Hospital, Faculty of Medicine of Pontifical Catholic University of Rio Grande do Sul (PUCRS), Av. Ipiranga, 6690/220, Porto Alegre, 90610-000, Brazil
| | - Melissa Cláudia Bisi
- Rheumatology Department, Sao Lucas Hospital, Faculty of Medicine of Pontifical Catholic University of Rio Grande do Sul (PUCRS), Av. Ipiranga, 6690/220, Porto Alegre, 90610-000, Brazil
| | - Inês Guimarães da Silveira
- Rheumatology Department, Sao Lucas Hospital, Faculty of Medicine of Pontifical Catholic University of Rio Grande do Sul (PUCRS), Av. Ipiranga, 6690/220, Porto Alegre, 90610-000, Brazil
| | - José Alexandre Mendonça
- Rheumatology Unit, Pontifical Catholic University of Campinas (PUCCAMP), Campinas, SP, Brazil
| | - Joaquim Polido-Pereira
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - João Eurico Fonseca
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal.,Rheumatology Department, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal
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17
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Wailoo A, Hock ES, Stevenson M, Martyn-St James M, Rawdin A, Simpson E, Wong R, Dracup N, Scott DL, Young A. The clinical effectiveness and cost-effectiveness of treat-to-target strategies in rheumatoid arthritis: a systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 21:1-258. [PMID: 29206093 DOI: 10.3310/hta21710] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Treat to target (TTT) is a broad concept for treating patients with rheumatoid arthritis (RA). It involves setting a treatment target, usually remission or low disease activity (LDA). This is often combined with frequent patient assessment and intensive and rapidly adjusted drug treatment, sometimes based on a formal protocol. OBJECTIVE To investigate the clinical effectiveness and cost-effectiveness of TTT compared with routine care. DATA SOURCES Databases including EMBASE and MEDLINE were searched from 2008 to August 2016. REVIEW METHODS A systematic review of clinical effectiveness was conducted. Studies were grouped according to comparisons made: (1) TTT compared with usual care, (2) different targets and (3) different treatment protocols. Trials were subgrouped by early or established disease populations. Study heterogeneity precluded meta-analyses. Narrative synthesis was undertaken for the first two comparisons, but was not feasible for the third. A systematic review of cost-effectiveness was also undertaken. No model was constructed as a result of the heterogeneity among studies identified in the clinical effectiveness review. Instead, conclusions were drawn on the cost-effectiveness of TTT from papers relating to these studies. RESULTS Sixteen clinical effectiveness studies were included. They differed in terms of treatment target, treatment protocol (where one existed) and patient visit frequency. For several outcomes, mixed results or evidence of no difference between TTT and conventional care was found. In early disease, two studies found that TTT resulted in favourable remission rates, although the findings of one study were not statistically significant. In established disease, two studies showed that TTT may be beneficial in terms of LDA at 6 months, although, again, in one case the finding was not statistically significant. The TICORA (TIght COntrol for RA) trial found evidence of lower remission rates for TTT in a mixed population. Two studies reported cost-effectiveness: in one, TTT dominated usual care; in the other, step-up combination treatments were shown to be cost-effective. In 5 of the 16 studies included the clinical effectiveness review, no cost-effectiveness conclusion could be reached, and in one study no conclusion could be drawn in the case of patients denoted low risk. In the remaining 10 studies, and among patients denoted high risk in one study, cost-effectiveness was inferred. In most cases TTT is likely to be cost-effective, except where biological treatment in early disease is used initially. No conclusions could be drawn for established disease. LIMITATIONS TTT refers not to a single concept, but to a range of broad approaches. Evidence reflects this. Studies exhibit substantial heterogeneity, which hinders evidence synthesis. Many included studies are at risk of bias. FUTURE WORK Future studies comparing TTT with usual care must link to existing evidence. A consistent definition of remission in studies is required. There may be value in studies to establish the importance of different elements of TTT (the setting of a target, the intensive use of drug treatments and protocols pertaining to those drugs and the frequent assessment of patients). CONCLUSION In early RA and studies of mixed early and established RA populations, evidence suggests that TTT improves remission rates. In established disease, TTT may lead to improved rates of LDA. It remains unclear which element(s) of TTT (the target, treatment protocols or increased frequency of patient visits) drive these outcomes. Future trials comparing TTT with usual care and/or different TTT targets should use outcomes comparable with existing literature. Remission, defined in a consistent manner, should be the target of choice of future studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017336. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma S Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Andrew Rawdin
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David L Scott
- King's College Hospital NHS Foundation Trust, London, UK
| | - Adam Young
- West Hertfordshire Hospitals NHS Trust, Watford, UK
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18
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Torrente-Segarra V, Monte TCS, Corominas H. Musculoskeletal involvement and ultrasonography update in systemic lupus erythematosus: New insights and review. Eur J Rheumatol 2018; 5:127-130. [PMID: 30183613 DOI: 10.5152/eurjrheum.2017.17198] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/13/2018] [Indexed: 12/25/2022] Open
Abstract
Ultrasonography has been rarely used to measure musculoskeletal and joint activity in systemic lupus erythematosus (SLE). The aim of this review is to discuss the utility and reliability of this non-invasive diagnostic tool for the assessment of joint disease in SLE patients. In the last decade, several reports have highlighted the role of ultrasonography for a better evaluation of SLE-related musculoskeletal symptoms. The symptoms have also been associated with worse outcomes in SLE; therefore, it is essential to seek useful and accessible techniques for better understanding of such patients who are insufficiently assessed by standard physical examination.
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Affiliation(s)
- Vicenç Torrente-Segarra
- Department of Rheumatology, Hospital Sant Joan Despí Moisès Broggi/Hospital General de l' Hospitalet, Barcelona, Spain
| | | | - Hèctor Corominas
- Rheumatology Unit, Hospital Universitari de Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
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19
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Simpson E, Hock E, Stevenson M, Wong R, Dracup N, Wailoo A, Conaghan P, Estrach C, Edwards C, Wakefield R. What is the added value of ultrasound joint examination for monitoring synovitis in rheumatoid arthritis and can it be used to guide treatment decisions? A systematic review and cost-effectiveness analysis. Health Technol Assess 2018; 22:1-258. [PMID: 29712616 PMCID: PMC5949573 DOI: 10.3310/hta22200] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Synovitis (inflamed joint synovial lining) in rheumatoid arthritis (RA) can be assessed by clinical examination (CE) or ultrasound (US). OBJECTIVE To investigate the added value of US, compared with CE alone, in RA synovitis in terms of clinical effectiveness and cost-effectiveness. DATA SOURCES Electronic databases including MEDLINE, EMBASE and the Cochrane databases were searched from inception to October 2015. REVIEW METHODS A systematic review sought RA studies that compared additional US with CE. Heterogeneity of the studies with regard to interventions, comparators and outcomes precluded meta-analyses. Systematic searches for studies of cost-effectiveness and US and treatment-tapering studies (not necessarily including US) were undertaken. MATHEMATICAL MODEL A model was constructed that estimated, for patients in whom drug tapering was considered, the reduction in costs of disease-modifying anti-rheumatic drugs (DMARDs) and serious infections at which the addition of US had a cost per quality-adjusted life-year (QALY) gained of £20,000 and £30,000. Furthermore, the reduction in the costs of DMARDs at which US becomes cost neutral was also estimated. For patients in whom dose escalation was being considered, the reduction in number of patients escalating treatment and in serious infections at which the addition of US had a cost per QALY gained of £20,000 and £30,000 was estimated. The reduction in number of patients escalating treatment for US to become cost neutral was also estimated. RESULTS Fifty-eight studies were included. Two randomised controlled trials compared adding US to a Disease Activity Score (DAS)-based treat-to-target strategy for early RA patients. The addition of power Doppler ultrasound (PDUS) to a Disease Activity Score 28 joints-based treat-to-target strategy in the Targeting Synovitis in Early Rheumatoid Arthritis (TaSER) trial resulted in no significant between-group difference for change in Disease Activity Score 44 joints (DAS44). This study found that significantly more patients in the PDUS group attained DAS44 remission (p = 0.03). The Aiming for Remission in Rheumatoid Arthritis (ARCTIC) trial found that the addition of PDUS and grey-scale ultrasound (GSUS) to a DAS-based strategy did not produce a significant between-group difference in the primary end point: composite DAS of < 1.6, no swollen joints and no progression in van der Heijde-modified total Sharp score (vdHSS). The ARCTIC trial did find that the erosion score of the vdHS had a significant advantage for the US group (p = 0.04). In the TaSER trial there was no significant group difference for erosion. Other studies suggested that PDUS was significantly associated with radiographic progression and that US had added value for wrist and hand joints rather than foot and ankle joints. Heterogeneity between trials made conclusions uncertain. No studies were identified that reported the cost-effectiveness of US in monitoring synovitis. The model estimated that an average reduction of 2.5% in the costs of biological DMARDs would be sufficient to offset the costs of 3-monthly US. The money could not be recouped if oral methotrexate was the only drug used. LIMITATIONS Heterogeneity of the trials precluded meta-analysis. Therefore, no summary estimates of effect were available. Additional costs and health-related quality of life decrements, relating to a flare following tapering or disease progression, have not been included. The feasibility of increased US monitoring has not been assessed. CONCLUSION Limited evidence suggests that US monitoring of synovitis could provide a cost-effective approach to selecting RA patients for treatment tapering or escalation avoidance. Considerable uncertainty exists for all conclusions. Future research priorities include evaluating US monitoring of RA synovitis in longitudinal clinical studies. STUDY REGISTRATION This study is registered as PROSPERO CRD42015017216. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Emma Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Hock
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Ruth Wong
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Naila Dracup
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Allan Wailoo
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Philip Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
| | - Cristina Estrach
- Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Christopher Edwards
- National Institute for Health Research (NIHR) Wellcome Trust Clinical Research Facility, University of Southampton, Southampton, UK
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research (NIHR) Leeds Biomedical Research Centre, Leeds, UK
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Chiu WC, Lai HM, Ko CH, Chen JF, Hsu CY, Chen YC. Ultrasound is more reliable than inflammatory parameters to evaluate disease activity in patients with RA receiving tocilizumab therapy. J Investig Med 2018; 66:1015-1018. [PMID: 29581384 PMCID: PMC6073910 DOI: 10.1136/jim-2017-000705] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/20/2022]
Abstract
The target of treatment for rheumatoid arthritis (RA) is to keep low disease activity or remission. Tocilizumab can fully inhibit interleukin-6 and C reactive protein (CRP) production. The goal of the study is to search whether tocilizumab treatment compared with adalimumab treatment had the similar effect on sonography and inflammatory parameters in patients with RA. We compared ultrasound scores and inflammatory parameters between patients with RA receiving tocilizumab therapy and those receiving adalimumab therapy. Power Doppler (PD) ultrasound and grayscale synovial hypertrophy on bilateral radiocarpal joints were performed. Inflammatory mediators and ultrasound scores were compared by independent t-test between the adalimumab and tocilizumab groups. 65 patients with RA (32 tocilizumab and 33 adalimumab) were included. Between the two groups, there were no significant differences in age, gender, rheumatoid factors and anticyclic citrullinated peptide antibody. Following biological therapy, the ultrasound score was 2.33 in the tocilizumab group and 2.08 in the adalimumab group (p=0.570), while the erythrocyte sedimentation rate, CRP and Disease Activity Score in 28 joints (DAS28) were lower in the tocilizumab group. So ultrasound scores between the two groups were not significantly different, but the laboratory parameters and DAS28 were lower in the tocilizumab group than in the adalimumab group. Hence, to assess disease activity cannot be based only on clinical evaluations, so we suggest PD ultrasound to be used for all patients on tocilizumab therapy and reflect the true disease activity in these patients.
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Affiliation(s)
- Wen-Chan Chiu
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Han-Ming Lai
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chi-Hua Ko
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jia-Feng Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chung-Yuan Hsu
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ying-Chou Chen
- Department of Rheumatology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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21
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Ten Cate DF, Jacobs JWG, Swen WAA, Hazes JMW, de Jager MH, Basoski NM, Haagsma CJ, Luime JJ, Gerards AH. Can baseline ultrasound results help to predict failure to achieve DAS28 remission after 1 year of tight control treatment in early RA patients? Arthritis Res Ther 2018; 20:15. [PMID: 29382379 PMCID: PMC5791342 DOI: 10.1186/s13075-018-1514-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 01/03/2018] [Indexed: 12/21/2022] Open
Abstract
Background At present, there are no prognostic parameters unequivocally predicting treatment failure in early rheumatoid arthritis (RA) patients. We investigated whether baseline ultrasonography (US) findings of joints, when added to baseline clinical, laboratory, and radiographical data, could improve prediction of failure to achieve Disease Activity Score assessing 28 joints (DAS28) remission (<2.6) at 1 year in newly diagnosed RA patients. Methods A multicentre cohort of newly diagnosed RA patients was followed prospectively for 1 year. US of the hands, wrists, and feet was performed at baseline. Clinical, laboratory, and radiographical parameters were recorded. Primary analysis was the prediction by logistic regression of the absence of DAS28 remission 12 months after diagnosis and start of therapy. Results Of 194 patients included, 174 were used for the analysis, with complete data available for 159. In a multivariate model with baseline DAS28 (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.2–2.2), the presence of rheumatoid factor (OR 2.3, 95% CI 1.1–5.1), and type of monitoring strategy (OR 0.2, 95% CI 0.05–0.85), the addition of baseline US results for joints (OR 0.96, 95% CI 0.89–1.04) did not significantly improve the prediction of failure to achieve DAS28 remission (likelihood ratio test, 1.04; p = 0.31). Conclusion In an early RA population, adding baseline ultrasonography of the hands, wrists, and feet to commonly available baseline characteristics did not improve prediction of failure to achieve DAS28 remission at 12 months. Trial registration Clinicaltrials.gov, NCT01752309. Registered on 19 December 2012. Electronic supplementary material The online version of this article (10.1186/s13075-018-1514-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- D F Ten Cate
- Department of Rheumatology, Erasmus University Medical Center, Room Na-609; 0031-10-7038251, PO Box 2040, 3000, CA, Rotterdam, The Netherlands.
| | - J W G Jacobs
- Department of Rheumatology and Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - W A A Swen
- Rheumatology, Medical Center Alkmaar, Alkmaar, The Netherlands
| | - J M W Hazes
- Department of Rheumatology, Erasmus University Medical Center, Room Na-609; 0031-10-7038251, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - M H de Jager
- Rheumatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - N M Basoski
- Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - C J Haagsma
- Rheumatology, Hospital Group Twente, Almelo, The Netherlands
| | - J J Luime
- Department of Rheumatology, Erasmus University Medical Center, Room Na-609; 0031-10-7038251, PO Box 2040, 3000, CA, Rotterdam, The Netherlands
| | - A H Gerards
- Rheumatology, Vlietland Hospital Schiedam, Schiedam, The Netherlands
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22
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Sifuentes-Cantú C, Contreras-Yáñez I, Saldarriaga L, Lozada A, Gutiérrez M, Pascual-Ramos V. The added value of musculoskeletal ultrasound to clinical evaluation in the treatment decision of rheumatoid arthritis outpatients: physician experience matters. BMC Musculoskelet Disord 2017; 18:390. [PMID: 28893220 PMCID: PMC5594469 DOI: 10.1186/s12891-017-1747-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/30/2017] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Musculoskeletal ultrasound improves the accuracy of detecting the level of disease activity (DA) in RA patients, although its impact on the final treatment decision in a real clinical setting is uncertain. The objectives were to define the percentage of clinical scenarios from an ongoing cohort of RA outpatients in which the German Ultrasound Score on 7 joints (GUS-7) impacted the treatment and to explore if the impact differed between a senior rheumatologist (SR) vs. a trainee (TR). METHODS Eighty-five consecutive and randomly selected RA outpatients underwent 170 assessments, 85 each by the SR and the TR. Initially, both physicians (blinded to each other) performed a rheumatic assessment and recommended a preliminary treatment. Then, the patients underwent the GUS-7 evaluation by an experienced rheumatologist blinded to clinical evaluations; selected joints of the clinically dominant hand were assessed by gray-scale and power Doppler (PD). In the final step, the TR and the SR integrated the GUS-7 findings with their previous evaluation and reviewed their recommendations. The patients received the final recommendation from the SR to avoid patient confusion. The study was approved by the Internal Review Board and all the patients signed informed consent. GUS-7 usefulness was separately evaluated by the SR and the TR according to a visual analogue scale (0 = not useful at all, 10 = very useful). Descriptive statistics were used. RESULTS The patients were primarily middle-aged females (91.4%) with (mean ± SD) disease duration of 7.5 ± 3.9 years. The majority of them (69.2% according to TR and 71.8% to SR) were in DAS28-ESR-remission. In 34 of 170 clinical scenarios (20%), the GUS-7 findings modified the final treatment proposal; 24 of these scenarios were determined by the TR vs. 10 by the SR: 70.5% vs. 29.5%, p = 0.01. Treatment changes (increase, decrease and joint injection) were similar between both specialists. As expected, the TR rated the GUS-7 usefulness higher than the SR, particularly in the clinical scenarios where the GUS-7 findings impacted treatment. CONCLUSIONS Musculoskeletal ultrasound added to standard rheumatic assessments impacted the treatment proposal in a limited number of patients; the impact was greater in the TR.
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Affiliation(s)
- C. Sifuentes-Cantú
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia sección XVI, Tlalpan, 14000 México City, Mexico
| | - I. Contreras-Yáñez
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia sección XVI, Tlalpan, 14000 México City, Mexico
| | - L. Saldarriaga
- Division of Musculoskeletal Ultrasound. Instituto Nacional de Rehabilitación y Ortopedia, Calzada México-Xochimilco 289, Arenal de Guadalupe, 14389 México City, Mexico
| | - A.C. Lozada
- Division of Musculoskeletal Ultrasound. Instituto Nacional de Rehabilitación y Ortopedia, Calzada México-Xochimilco 289, Arenal de Guadalupe, 14389 México City, Mexico
| | - M. Gutiérrez
- Division of Musculoskeletal Ultrasound. Instituto Nacional de Rehabilitación y Ortopedia, Calzada México-Xochimilco 289, Arenal de Guadalupe, 14389 México City, Mexico
| | - V. Pascual-Ramos
- Department of Immunology and Rheumatology. Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, colonia sección XVI, Tlalpan, 14000 México City, Mexico
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Lins CF, Lima de Sá Ribeiro D, Dourado Santos WG, Rosa G, Machicado V, Pedreira AL, Pimenta da Fonseca E, Mota Duque Sousa AP, Rodrigues Silva CB, Matos MAA, Santiago MB. Ultrasound Findings on Hands and Wrists of Patients with Systemic Lupus Erythematosus: Relationship with Physical Examination. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1764-1768. [PMID: 28602490 DOI: 10.1016/j.ultrasmedbio.2017.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Revised: 04/11/2017] [Accepted: 04/19/2017] [Indexed: 06/07/2023]
Abstract
Diagnosis of synovitis/tenosynovitis by physical examination can be difficult. Ultrasound (US) can be an effective tool for the evaluation of joint involvement in systemic lupus erythematosus (SLE). This study will describe musculoskeletal findings by US in SLE patients and the evaluation of their correlation with physical examination. SLE patients underwent clinical/sonographic evaluation of hand/wrists. In total, 896 joints were evaluated: at least 1 change on physical examination was found in 136 joints and at least 1 US abnormality was found in 65 of 896 joints. Out of the 65 joints with US changes, only 13 had findings on physical examination. Conversely, 111 joints had tenderness on physical examination with no sonographic abnormalities. Tenosynovitis was statistically significant more frequently with joint edema (41%) (p = 0.0003). US can detect musculoskeletal changes in only a minority of symptomatic SLE patients. Clinical findings may be related to some reasons that cannot be explained using US.
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Affiliation(s)
| | | | | | - Genevievi Rosa
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil
| | | | | | | | | | | | | | - Mittermayer Barreto Santiago
- Escola Bahiana de Medicina e Saúde Pública, Salvador, Bahia, Brazil; Serviços Especializados em Reumatologia da Bahia, Salvador, Bahia, Brazil
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24
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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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25
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Burmester GR, Pope JE. Novel treatment strategies in rheumatoid arthritis. Lancet 2017; 389:2338-2348. [PMID: 28612748 DOI: 10.1016/s0140-6736(17)31491-5] [Citation(s) in RCA: 609] [Impact Index Per Article: 87.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/27/2017] [Accepted: 05/03/2017] [Indexed: 02/06/2023]
Abstract
New treatment strategies have substantially changed the course of rheumatoid arthritis. Many patients can achieve remission if the disease is recognised early and is treated promptly and continuously; however, some individuals do not respond adequately to treatment. Rapid diagnosis and a treat-to-target approach with tight monitoring and control, can increase the likelihood of remission in patients with rheumatoid arthritis. In this Series paper, we describe new insights into the management of rheumatoid arthritis with targeted therapy approaches using classic and novel medications, and outline the potential effects of precision medicine in this challenging disease. Articles are included that investigate the treat-to-target approach, which includes adding or de-escalating treatment. Rheumatoid arthritis treatment is impeded by delayed diagnosis, problematic access to specialists, and difficulties adhering to treat-to-target principles. Clinical management goals in rheumatoid arthritis include enabling rapid access to optimum diagnosis and care and the well informed use of multiple treatments approved for this disease.
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Affiliation(s)
- Gerd R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-University Medicine Berlin, Berlin, Germany.
| | - Janet E Pope
- Division of Rheumatology, St Joseph's Hospital, Western University, London, ON, Canada
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26
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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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27
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Impact of ultrasonography on treatment decision in rheumatoid arthritis: the IMPULSAR study. Rheumatol Int 2017; 37:891-896. [DOI: 10.1007/s00296-017-3689-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Accepted: 02/22/2017] [Indexed: 12/12/2022]
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28
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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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29
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Ultrasound Techniques in Rheumatoid Arthritis. CURRENT RADIOLOGY REPORTS 2016. [DOI: 10.1007/s40134-016-0175-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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30
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D'Agostino MA, Terslev L, Wakefield R, Østergaard M, Balint P, Naredo E, Iagnocco A, Backhaus M, Grassi W, Emery P. Novel algorithms for the pragmatic use of ultrasound in the management of patients with rheumatoid arthritis: from diagnosis to remission. Ann Rheum Dis 2016; 75:1902-1908. [PMID: 27553213 DOI: 10.1136/annrheumdis-2016-209646] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/31/2016] [Indexed: 12/25/2022]
Abstract
The absence of specific guidance on how to use ultrasound (US) to diagnose and manage patients with inflammatory arthritis, especially with rheumatoid arthritis (RA) has hindered the optimal utilisation of US in clinical practice, potentially limiting its benefits for patient outcomes. In view of this, a group of musculoskeletal US experts formed a working group to consider how this unmet need could be satisfied and to produce guidance (additional to European League against Rheumatism (EULAR) imaging recommendations) to support clinicians in their daily clinical work. This paper describes this process and its outcome, namely five novel algorithms, which identify when US could be used. They are designed to aid diagnosis, to inform assessment of treatment response/disease monitoring and to evaluate stable disease state or remission in patients with suspected or established RA, by providing a pragmatic template for using US at certain time points of the RA management. A research agenda has also been defined for answering unmet clinical needs.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt, France INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Saint-Quentin en Yvelines, France Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Richard Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Balint
- Third Rheumatology Department, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Esperanza Naredo
- Department of Rheumatology, Hospital General Universitario Gregorio Marañón and Universidad Complutense, Madrid, Spain
| | - Annamaria Iagnocco
- Ultrasound Unit, Rheumatology Department, Sapienza Università di Roma, Rome, Italy
| | - Marina Backhaus
- Department of Internal Medicine, Rheumatology and Clinical Immunology Academic Hospital of the Charité Berlin, Park-Klinik Weissensee Berlin, Berlin, Germany
| | - Walter Grassi
- Clinica Reumatologica-Scuola di Specializzazione in Reumatologia Università Politecnica delle Marche, Ancona, Italy
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Chapel Allerton Hospital, Leeds, UK NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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31
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Ciurtin C, Wyszynski K, Clarke R, Mouyis M, Manson J, Marra G. Ultrasound-detected subclinical inflammation was better reflected by the disease activity score (DAS-28) in patients with suspicion of inflammatory arthritis compared to established rheumatoid arthritis. Clin Rheumatol 2016; 35:2411-9. [PMID: 27325125 PMCID: PMC5031733 DOI: 10.1007/s10067-016-3326-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/01/2016] [Accepted: 06/05/2016] [Indexed: 02/08/2023]
Abstract
Limited data are available about the ultrasound (US)-detected inflammatory features in patients with suspicion of inflammatory arthritis (S-IA) vs. established rheumatoid arthritis (RA). Our study aimed to assess if the presence of power Doppler (PD) can be predicted by a combination of clinical, laboratory and US parameters. We conducted a real-life, retrospective cohort study comparing clinical, laboratory and US parameters of 108 patients with established RA and 93 patients with S-IA. We propose a PD signal prediction model based on a beta-binomial distribution for PD variable using a mix of outcome measures. Patients with RA in clinical remission had significantly more active inflammation and erosions on US when compared with patients with S-IA with similar disease scores (p = 0.03 and p = 0.01, respectively); however, RA patients with different disease activity score (DAS-28) scores had similar PD scores (p = 0.058). The PD scores did not correlate with erosions (p = 0.38) or DAS-28 scores (p = 0.28) in RA patients, but they correlated with high disease activity in S-IA patients (p = 0.048). Subclinical inflammation is more common in patients with RA in clinical remission or with low disease activity than in patients with S-IA; therefore, US was more useful in assessing for true remission in RA rather than diagnosing IA in patients with low disease activity scores. This is the first study to propose a PD prediction model integrating several outcome measures in the two different groups of patients. Further research into validating this model can minimise the risk of underdiagnosing subclinical inflammation.
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Affiliation(s)
- Coziana Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Trust, 3rd Floor Central, 250 Euston Road, London, NW1 2PG, UK.
| | - Karol Wyszynski
- Department of Statistics, University College London, London, UK
| | - Robert Clarke
- Medical School, University College London, London, UK
| | - Maria Mouyis
- Department of Rheumatology, Northwick Park Hospital, Harrow, UK
| | - Jessica Manson
- Department of Rheumatology, University College London Hospitals NHS Trust, 3rd Floor Central, 250 Euston Road, London, NW1 2PG, UK
| | - Giampiero Marra
- Department of Statistics, University College London, London, UK
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Dale J, Stirling A, Zhang R, Purves D, Foley J, Sambrook M, Conaghan PG, van der Heijde D, McConnachie A, McInnes IB, Porter D. Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial. Ann Rheum Dis 2016; 75:1043-50. [DOI: 10.1136/annrheumdis-2015-208941] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 03/03/2016] [Indexed: 11/04/2022]
Abstract
ObjectiveTo investigate whether an intensive early rheumatoid arthritis (RA) treat-to-target (T2T) strategy could be improved through the use of musculoskeletal ultrasound (MSUS) assessment of disease activity.Methods111 newly diagnosed patients with RA or undifferentiated arthritis (symptom duration <1 year) were randomised to strategies that aimed to attain either DAS28-erythrocyte sedimentation rate (ESR)<3.2 (control) or a total power Doppler joint count≤1 during a combined DAS28-ESR/MSUS assessment (intervention). MSUS examination was indicated if: DAS28-ESR<3.2 or DAS28-ESR≥3.2 with two swollen joints. Step-up disease-modifying antirheumatic drug (DMARD) escalation was standardised: methotrexate monotherapy, triple therapy and then etanercept/triple therapy. American College of Rheumatology (ACR) core-set variables were assessed 3 monthly by a metrologist blinded to group allocation. MRI of dominant hand and wrist, and plain radiographs of hands and feet were undertaken at baseline and 18 months for grading by two readers using the Outcome Measures in Rheumatology (OMERACT) Rheumatoid Arthritis MRI Scoring System (RAMRIS) and van der Heijde/Sharp Score, respectively. The coprimary outcomes were mean change from baseline of DAS44 and RAMRIS erosion score.ResultsGroups were matched for baseline clinical, demographic and radiographic features. The intervention group received more intensive DMARD therapy. Both groups demonstrated significant improvements in DAS44 (mean change: control −2.58, intervention −2.69; 95% CI difference between groups −0.70 to 0.48; p=0.72). There were no significant between-group differences for any ACR core-set variables, except DAS44 remission after 18 months (control 43%, intervention 66%; p=0.03). There was minimal progression of MRI and radiographic erosions and no difference in imaging outcomes or serious adverse event rates.ConclusionsIn early RA, a MSUS-driven T2T strategy led to more intensive treatment, but was not associated with significantly better clinical or imaging outcomes than a DAS28-driven strategy.Trial registration numberNCT00920478.
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Stoffer MA, Schoels MM, Smolen JS, Aletaha D, Breedveld FC, Burmester G, Bykerk V, Dougados M, Emery P, Haraoui B, Gomez-Reino J, Kvien TK, Nash P, Navarro-Compán V, Scholte-Voshaar M, van Vollenhoven R, van der Heijde D, Stamm TA. Evidence for treating rheumatoid arthritis to target: results of a systematic literature search update. Ann Rheum Dis 2016; 75:16-22. [PMID: 25990290 PMCID: PMC4717391 DOI: 10.1136/annrheumdis-2015-207526] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 04/20/2015] [Accepted: 04/30/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE A systematic literature review (SLR; 2009-2014) to compare a target-oriented approach with routine management in the treatment of rheumatoid arthritis (RA) to allow an update of the treat-to-target recommendations. METHODS Two SLRs focused on clinical trials employing a treatment approach targeting a specific clinical outcome were performed. In addition to testing clinical, functional and/or structural changes as endpoints, comorbidities, cardiovascular risk, work productivity and education as well as patient self-assessment were investigated. The searches covered MEDLINE, EMBASE, Cochrane databases and Clinicaltrial.gov for the period between 2009 and 2012 and separately for the period of 2012 to May of 2014. RESULTS Of 8442 citations retrieved in the two SLRs, 176 articles underwent full-text review. According to predefined inclusion/exclusion criteria, six articles were included of which five showed superiority of a targeted treatment approach aiming at least at low-disease activity versus routine care; in addition, publications providing supportive evidence were also incorporated that aside from expanding the evidence provided by the above six publications allowed concluding that a target-oriented approach leads to less comorbidities and cardiovascular risk and better work productivity than conventional care. CONCLUSIONS The current study expands the evidence that targeting low-disease activity or remission in the management of RA conveys better outcomes than routine care.
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Affiliation(s)
- Michaela A Stoffer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- University of Applied Sciences for Health Professions Upper Austria, Linz, Austria
| | - Monika M Schoels
- Department of Internal Medicine, Centre for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
- Department of Internal Medicine, Centre for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Ferdinand C Breedveld
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité—University Medicine Berlin, Free University and Humboldt University Berlin, Berlin, Germany
| | - Vivian Bykerk
- Division of Rheumatology, Weill Cornell Medical College, Cornell University, Hospital for Special Surgery, New York, USA
| | - Maxime Dougados
- Department of Rheumatology,Hôpital Cochin, Paris Descartes University, Assistance Publique—Hôpitaux de Paris; INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Paul Emery
- Academic Unit of Musculoskeletal Disease, University of Leeds, Leeds, UK
| | - Boulos Haraoui
- Rheumatic Disease Unit, University of Montreal, Montreal, Canada
| | - Juan Gomez-Reino
- Rheumatology Service and Department of Medicine, Hospital Clinico Universitario, Universidad de Santiago, Spain
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Peter Nash
- Department of Medicine, University of Queensland, Brisbane, Australia
| | - Victoria Navarro-Compán
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, University Hospital La Paz, Madrid, Spain
| | - Marieke Scholte-Voshaar
- Department of Psychology, Health and Technology, University of Twente, Enschede, The Netherlands
| | | | | | - Tanja A Stamm
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
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Aletaha D. Management of rheumatoid arthritis: what happens and what does not happen in real life. Rheumatol Int 2015; 36:167-8. [PMID: 26687684 DOI: 10.1007/s00296-015-3402-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 11/20/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine 3, Medical University of Vienna, Vienna, Austria.
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Yamagata T, Skepner J, Yang J. Targeting Th17 Effector Cytokines for the Treatment of Autoimmune Diseases. Arch Immunol Ther Exp (Warsz) 2015; 63:405-14. [PMID: 26358867 DOI: 10.1007/s00005-015-0362-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/28/2015] [Indexed: 12/14/2022]
Abstract
Interleukin (IL)-17-producing T cells, especially T helper (Th)17 cells, play a critical role in the pathogenesis of a variety of autoimmune inflammatory diseases. The pathogenic function of Th17 cells results from their production of Th17 effector cytokines, namely IL-17 (or IL-17A), IL-17F, IL-22 and IL-26. The importance of IL-17 has been demonstrated by antibody neutralization studies in both animal models of autoimmune diseases as well as in human clinical trials. This review highlights the current knowledge of the clinical aspects of the Th17 cytokines as well as therapeutic antibodies against IL-17, IL-17F, IL-17 receptor, IL-22, IL-26 and granulocyte macrophage colony-stimulating factor for the future treatment of autoimmune inflammatory diseases.
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Affiliation(s)
| | - Jill Skepner
- Tempero, GlaxoSmithKline, Cambridge, MA, 02139, USA
| | - Jianfei Yang
- Tempero, GlaxoSmithKline, Cambridge, MA, 02139, USA.
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Zayat AS, Md Yusof MY, Wakefield RJ, Conaghan PG, Emery P, Vital EM. The role of ultrasound in assessing musculoskeletal symptoms of systemic lupus erythematosus: a systematic literature review. Rheumatology (Oxford) 2015; 55:485-94. [PMID: 26447163 DOI: 10.1093/rheumatology/kev343] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Musculoskeletal symptoms are common in SLE and are associated with significant morbidity. However, assessing their nature can be challenging, with implications for treatment decisions and measuring response. US has been shown to be valid and reliable for the assessment of other inflammatory arthritides, but data in SLE are more limited. The objectives of this systematic literature review were to determine the characteristics of musculoskeletal US abnormalities in SLE and to evaluate the metric properties of US in the detection and quantification of musculoskeletal symptoms. METHODS We systematically searched the literature using the PubMed, Embase and Cochrane Library databases for studies using musculoskeletal US for assessing SLE. Studies were assessed for quality using the Quality Assessment of Diagnostic Accuracy Studies tool and for their metric qualities, including reliability and validity. RESULTS Nine studies were identified. Most studies investigated construct validity. Rates of abnormality were highly variable: synovitis and tenosynovitis were reported in 25-94% and 28-65% of patients, respectively; power Doppler and erosions were reported in 10-82% and 2-41% of patients, respectively. There was poor to moderate association between US abnormalities and disease activity indices and immunological findings. There was moderate to high risk of bias and there were concerns about applicability in most studies. CONCLUSION US has potential value in the assessment of musculoskeletal symptoms in SLE. However, there is methodological variation between studies that may account for lack of consensus on US abnormalities. Studies that address these problems are required before US can used as an outcome measure in SLE.
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Affiliation(s)
- Ahmed S Zayat
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Md Yuzaiful Md Yusof
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Richard J Wakefield
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Philip G Conaghan
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Paul Emery
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Edward M Vital
- NIHR Leeds Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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A comparative study between ultrasonographic hand features in systemic sclerosis and rheumatoid arthritis patients: Relation to disease activity, clinical and radiological findings. EGYPTIAN RHEUMATOLOGIST 2015. [DOI: 10.1016/j.ejr.2014.12.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Naranjo A, Cáceres L, Hernández-Beriaín JÁ, Francisco F, Ojeda S, Talaverano S, Nóvoa-Medina J, Martín JA, Delgado E, Trujillo E, Álvarez F, Magdalena L, Rodríguez-Lozano C. Factors associated with the intensification of treatment in rheumatoid arthritis in clinical practice. Rheumatol Int 2015; 35:1851-5. [PMID: 26238094 DOI: 10.1007/s00296-015-3332-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 07/22/2015] [Indexed: 11/28/2022]
Abstract
The aim of the present study was to analyse the patterns of treatment adjustment in rheumatoid arthritis (RA) patients with active disease in routine clinical care. This was a cross-sectional study of consecutive patients with RA conducted in five hospitals. Activity scales (DAS28-ESR) and function (HAQ) were measured, as well as whether ultrasound was performed as part of the assessment. Treatment decision (no changes/reduction/intensification) and time to the next scheduled visit were the outcomes variables. Associated factors were analysed by multilevel regression models. A total of 343 patients were included (77 % women, mean age 57 years, mean RA duration 10 years), of whom 44 % were in remission by DAS28. Treatment was continued in 202 (59 %) patients, reduced in 57 (16 %), and intensified in 83 (24 %). In the 117 patients with active RA (DAS28 ≥ 3.2), treatment was intensified in 61 (52 %). Factors associated with treatment intensification were physician and patient VAS, and DAS28, but not the centre. In the multilevel regression analysis with intensification of treatment as dependent variable, the following factors were significantly associated: DAS28 [OR 3.67 (95 % CI 2.43-5.52)], patient VAS [OR 1.04 (95 % CI 1.01-1.08)], and have performed an ultrasound [OR 3.36 (95 % CI 1.47-7.68)]. Factors associated with time to the next scheduled visit (an average of 4.3 months) were patient and physician VAS, DAS28, and centre. In clinical practice, half of the patients with active RA maintain or reduce the treatment. The decision to intensify treatment in active RA as recommended by a treat-to-target strategy is complex in practice.
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Affiliation(s)
- Antonio Naranjo
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Calle Barranco de La Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain.
| | - Laura Cáceres
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Calle Barranco de La Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | | | - Félix Francisco
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Calle Barranco de La Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Soledad Ojeda
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Calle Barranco de La Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | | | - Javier Nóvoa-Medina
- Complejo Hospitalario Universitario Materno Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | | | | | | | | | | | - Carlos Rodríguez-Lozano
- Department of Rheumatology, Hospital Universitario de Gran Canaria Dr. Negrín, Universidad de Las Palmas de Gran Canaria, Calle Barranco de La Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
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Marks JL, Holroyd CR, Dimitrov BD, Armstrong RD, Calogeras A, Cooper C, Davidson BK, Dennison EM, Harvey NC, Edwards CJ. Does combined clinical and ultrasound assessment allow selection of individuals with rheumatoid arthritis for sustained reduction of anti-tumor necrosis factor therapy? Arthritis Care Res (Hoboken) 2015; 67:746-53. [PMID: 25605045 DOI: 10.1002/acr.22552] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 12/03/2014] [Accepted: 01/13/2015] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate whether a strategy combining clinical and ultrasound (US) assessment can select individuals with rheumatoid arthritis (RA) for sustained dose reduction of anti-tumor necrosis factor (anti-TNF) therapies. METHODS As part of a real-world approach, patients with RA receiving anti-TNF therapies were reviewed in a dedicated biologic therapy clinic. Patients not taking oral corticosteroids with both Disease Activity Score in 28 joints (DAS28) remission (≤2.6) and absent synovitis on power Doppler US (PDUS 0) for >6 months were invited to reduce their anti-TNF therapy dose by one-third. RESULTS Between January 2012 and February 2014, a total of 70 patients underwent anti-TNF dose reduction. Combined DAS28 and PDUS remission was maintained by 96% of patients at 3 months followup, 63% at 6 months, 37% at 9 months, and 34% at 18 months followup. However, 88% of patients maintained at least low disease activity (LDA) with DAS28 <3.2 and PDUS ≤1 at 6 months. The addition of PDUS identified 8 patients (25% of those that flared) in DAS28 remission, with subclinically active disease. Those who maintained dose reduction were more likely to be rheumatoid factor (RF) negative (46% versus 17%; P = 0.03) and have lower DAS28 scores at biologic therapy initiation (5.58 versus 5.96; P = 0.038). CONCLUSION Combined clinical and US assessment identifies individuals in remission who may be suitable for anti-TNF dose reduction and enhances safe monitoring for subclinical disease flares. Despite longstanding severe RA, a subset of our cohort sustained prolonged DAS28 and PDUS remission. LDA at biologic therapy initiation and RF status appeared predictive of sustained remission.
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Affiliation(s)
| | | | | | | | | | - Cyrus Cooper
- University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK, and University of Oxford, Oxford, UK
| | | | - Elaine M Dennison
- University Hospital Southampton and University of Southampton, Southampton, UK
| | - Nicholas C Harvey
- University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Christopher J Edwards
- University of Southampton and University Hospital Southampton, Southampton, UK, and University of Oxford, Oxford, UK
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Baker JF, Tan YK, Conaghan PG. Monitoring in established RA: Role of imaging and soluble biomarkers. Best Pract Res Clin Rheumatol 2015; 29:566-79. [DOI: 10.1016/j.berh.2015.09.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Schmidt WA, Schönau V, Reiche BE, Oberdorfer PD, Ohrndorf S, Backhaus M. Grading of ultrasound Doppler signals in synovitis: does it need an update? Rheumatology (Oxford) 2015; 54:1897-903. [DOI: 10.1093/rheumatology/kev205] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Indexed: 11/14/2022] Open
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New insights into the measurement of disease activity in rheumatoid arthritis. Curr Opin Rheumatol 2015; 27:268-72. [DOI: 10.1097/bor.0000000000000167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Brenol CV, da Chakr RMS, Andrade NPB, Toni M, Laurindo IMM, Brenol JCT, Xavier RM. Daily practice feasibility and effectiveness of treating long-standing rheumatoid arthritis to target with synthetic disease-modifying antirheumatic drugs: a prospective cohort study. Clin Rheumatol 2015; 34:1781-5. [PMID: 25771853 DOI: 10.1007/s10067-015-2915-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 02/19/2015] [Accepted: 03/01/2015] [Indexed: 12/25/2022]
Abstract
To prospectively study the daily practice feasibility and effectiveness of treat-to-target (T2T) strategy with synthetic drugs aiming to maintain and achieve disease remission or low activity based on DAS28 and CDAI in long-standing rheumatoid (RA) patients. Two hundred and forty-one consecutive RA patients from Hospital de Clínicas de Porto Alegre were followed for 14 (±5.3) months. At follow-up, patients were evaluated by a rheumatologist at least once every 3 to 4 months. Treatment was adjusted following a step-up strategy, based on the disease activity scores (DAS28 and CDAI), aiming at remission (<2.6 or <2.8, respectively) or at least low disease activity (<3.2 or <10). Patients were predominantly women (84.7 %), mean age 54.9 (±11.9) years with 11.1 (±7.4) years of disease duration. At visit 4, T2T intervention significantly reduced DAS28 (4.6 ± 1.6 vs. 4.0 ± 1.5; p < 0.005), CDAI [17.8 (8.2-28.7) vs. 12.6 (5.1-22.5); p < 0.001], and HAQ (1.5 ± 0.9 vs. 1.3 ± 0.8; p = 0.002). At the end of the study, compared to the baseline scores, more patients achieved remission by DAS28 (11.6 vs. 18.6 %; p < 0.001) and CDAI (8.1 vs. 13.6 %; p < 0.001) and also low disease activity by DAS28 (9.8 vs. 13.0 %; p < 0.001) and CDAI (23.9 vs. 28.4 %; p < 0.001). Both average doses of sulfasalazine and methotrexate at visit 4 were higher (1375 vs. 1621 mg, p = 0.024; and 14.5 vs. 16.5 mg, p < 0.001, respectively). More patients were on combination therapy at the end of the follow-up (48.2 vs. 52.3 %; p < 0.001). The implementation of T2T strategy in the treatment of RA was feasible and effective in this outpatient population. The optimization of synthetic DMARDs use with dose adjustments and combinations of drugs seemed to improve disease outcome regarding disease activity and functional status.
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Affiliation(s)
- Claiton Viegas Brenol
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
| | - Rafael Mendonça Silva da Chakr
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
| | - Nicole Pamplona Bueno Andrade
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
| | - Mariana Toni
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
| | | | - João Carlos Tavares Brenol
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
| | - Ricardo Machado Xavier
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2350, sala 645, Porto Alegre, RS, 90035-903, Brazil.
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da Silva Chakr RM, Brenol JCT, Behar M, Mendonça JA, Kohem CL, Monticielo OA, Brenol CV, Xavier RM. Is ultrasound a better target than clinical disease activity scores in rheumatoid arthritis with fibromyalgia? A case-control study. PLoS One 2015; 10:e0118620. [PMID: 25738587 PMCID: PMC4349702 DOI: 10.1371/journal.pone.0118620] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 01/21/2015] [Indexed: 12/11/2022] Open
Abstract
Objectives Our goal is to study the correlations among gray-scale seven-joint ultrasound score (GS-US7), power Doppler seven-joint ultrasound score (PD-US7), disease activity score-28 joints (DAS28), simplified disease activity index (SDAI) and clinical disease activity index (CDAI) in patients with and without fibromyalgia (FM). Methods A matched case-control study included all patients consecutively seen in the Rheumatoid Arthritis (RA) Clinic. Participants were allocated into one of two groups: RA with FM and RA without FM. Ultrasound (US) and clinical scoring were blinded for the presence of FM. Medians and proportions were compared by Mann-Whitney’s test and McNemar’s test, respectively. Spearman’s rank correlation coefficients (rs) were calculated among clinical and US scores and differences were tested by r-to-z transformation test. Results Seventy-two women were included, out of 247 RA patients, mostly white, with median (IQR) age of 57.5 (49.3–66.8) years, with RA symptoms for 13.0 (6.0–19.0) years and FM symptoms for 6.0 (2.0–15.0) years. Disease-modifying antirheumatic drugs, non-steroidal anti-inflammatory drugs and prednisone use was comparable between groups. Objective activity parameters were not different between groups. RA patients with FM had greater DAS28, SDAI and CDAI but similar GS-US7 and PD-US7. GS-US7 correlated with DAS28, SDAI and CDAI in patients with and without FM (rs = 0.36–0.57), while PD-US7 correlated with clinical scores only in patients without FM (rs = 0.35–0.38). Conclusion To our knowledge, this is the first study to demonstrate that ultrasound synovitis scores are not affected by FM in RA patients. PD-US7 performed better than GS-US7 in long-standing RA patients with DAS28, SDAI or CDAI allegedly overestimated due to FM. Since sonographic synovitis predicts erosion better than swollen joint count, C-reactive protein and erythrocyte sedimentation rate, US should be considered a promising treatment target in RA patients with FM.
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Affiliation(s)
- Rafael Mendonça da Silva Chakr
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- * E-mail:
| | - João Carlos Tavares Brenol
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Marina Behar
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | | | - Charles Lubianca Kohem
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Odirlei André Monticielo
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Claiton Viegas Brenol
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ricardo Machado Xavier
- Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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Wang H, Chen W, Wang L, Li F, Zhang C, Xu L. Tumor necrosis factor receptor-associated factor 6 promotes migration of rheumatoid arthritis fibroblast-like synoviocytes. Mol Med Rep 2014; 11:2761-6. [PMID: 25522907 DOI: 10.3892/mmr.2014.3104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 11/03/2014] [Indexed: 11/06/2022] Open
Abstract
Fibroblast‑like synoviocytes (FLSs) have a pivotal role in the destruction of joints in rheumatoid arthritis (RA). Tumor necrosis factor receptor‑associated factor 6 (TRAF6) is a critical mediator in the inflammatory pathway and of the activity of osteoclasts. The aim of the present study was to investigate whether TRAF6 is involved in the progression of RA in mouse collagen‑induced arthritis (CIA) and human RA FLSs in vitro. In vivo mouse models were transfected with TRAF6 small interfering (si)RNA (siTRAF6) and TRAF6 inhibition was achieved in FLSs using an anti‑TRAF6 monoclonal antibody in vitro in order to assess the effects of TRAF6 inhibition on the migration and invasion of FLSs. Inhibition of TRAF6 using mouse specific siTRAF6 reduced the severity of arthritis and joint inflammation. Serum anti‑collagen II antibodies, matrix metalloproteinase (MMP)‑1, MMP‑3 and MMP‑9 were also inhibited in CIA mice by siTRAF6. The levels of MMPs produced by IL‑1β‑stimulated human RA‑FLSs were reduced by anti‑TRAF6 monoclonal antibody. TRAF6 blockade significantly suppressed the IL‑1β‑stimulated migration and invasion of human RA‑FLSs. These results support a role for TRAF6 in the pathogenesis of RA, and suggest that the TRAF6 blockade may be a potential strategy in the management of RA.
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Affiliation(s)
- Huiqin Wang
- Department of Clinical Laboratory, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277102, P.R. China
| | - Weixia Chen
- Department of Clinical Laboratory, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277102, P.R. China
| | - Ling Wang
- Department of Rheumatology, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277102, P.R. China
| | - Faxin Li
- Department of Rheumatology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong 250204, P.R. China
| | - Chunling Zhang
- Department of Rheumatology, Jinan Central Hospital Affiliated to Shandong University, Jinan, Shandong 250204, P.R. China
| | - Li Xu
- Department of Clinical Laboratory, Zaozhuang Municipal Hospital, Zaozhuang, Shandong 277102, P.R. China
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