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Ranganath VK, Hammer HB, McQueen FM. Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI. Best Pract Res Clin Rheumatol 2020; 34:101593. [PMID: 32988757 DOI: 10.1016/j.berh.2020.101593] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.
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Affiliation(s)
- Veena K Ranganath
- University of California, David Geffen School of Medicine, Los Angeles, USA.
| | - Hilde B Hammer
- Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
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Mandl P, Studenic P, Supp G, Durechova M, Haider S, Lehner M, Stamm T, Smolen JS, Aletaha D. Doubtful swelling on clinical examination reflects synovitis in rheumatoid arthritis. Ther Adv Musculoskelet Dis 2020; 12:1759720X20933489. [PMID: 32612711 PMCID: PMC7309376 DOI: 10.1177/1759720x20933489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022] Open
Abstract
Aims The aim of this study was to evaluate the implication of doubtful joint swelling on clinical examination with respect to objective markers of synovitis by ultrasound (US) in patients with rheumatoid arthritis (RA). Methods Two independent observers performed a modified 28 swollen joint assessment (28SJC), in which joints could be graded as either definitely swollen, non-swollen, or doubtfully swollen. Two examiners blinded to clinical information performed US assessment of the hands. We performed descriptive statistics and models to analyse the links between clinical assessment and objective markers of inflammation. Results A total of 1204 joints were evaluated in 43 RA patients; 93% (40/43) of patients had ⩾1 joint with doubtful swelling (range: 0-4/patient). Inter-reader reliability for the modified 28SJC was good (0.74). Generally, both grey scale (GS) and power Doppler (PD) discriminated across not swollen, doubtful, and swollen joints. GS signals discriminated better than PD between doubtful swelling and no swelling [odds ratio (OR) for GS: 5.2; 95% confidence interval (CI) 1.2-23.3 versus OR for PD 1.7; 95% CI 0.2-13.0], whereas PD discriminated better than GS between swelling and doubtful swelling (OR for PD: 28.7; 95% CI 3.6-228.2 versus GS: 1.7; 95% CI 0.3-8.4). Joint osteophytes did not increase the degree of doubtfulness. Conclusion Clinical doubt in the assessment of joint swelling constitutes an intermediate state between unequivocal swelling and the lack thereof also regarding the objectively quantified level of inflammation. In order to increase sensitivity for joint inflammation, the historical clinical approach of considering doubtful swelling the absence of swelling should be revisited to interpret clinical doubtfulness as an indication of swelling.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, Department of Rheumatology, Medical University of Vienna, 18-20, Währinger Gürtel, Vienna, 1180, Austria
| | - Paul Studenic
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Gabriela Supp
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Martina Durechova
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Stefanie Haider
- Orthopedic Hospital Speising, Institute of Physical Medicine und Orthopaedic Rehabilitation, Vienna, Austria
| | - Michaela Lehner
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Tanja Stamm
- Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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Terslev L, Hammer HB. Ultrasound may improve patient care. Clin Rheumatol 2020; 39:1715-1717. [PMID: 32358662 DOI: 10.1007/s10067-020-05071-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 03/19/2020] [Accepted: 03/23/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Lene Terslev
- Copenhagen Center for Arthritis Research and Center for Rheumatology, Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark. .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark. .,Center for Rheumatology and Spinal Diseases, Copenhagen University Hospital, Rigshsopitalet, Nordre Ringvej 57, 2600, Glostrup, Copenhagen, Denmark.
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Mandl P, Aletaha D. The role of ultrasound and magnetic resonance imaging for treat to target in rheumatoid arthritis and psoriatic arthritis. Rheumatology (Oxford) 2020; 58:2091-2098. [PMID: 31518423 DOI: 10.1093/rheumatology/kez397] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 01/04/2023] Open
Abstract
The treat-to-target (T2T) approach has revolutionized the way we treat patients with rheumatic and musculoskeletal diseases. Recent attention has focused on imaging techniques, in particular musculoskeletal ultrasound and MRI as a focus for T2T strategies. Recently, a number of randomized clinical trials have been performed that compared tight clinical control vs control augmented by imaging techniques. While the three published trials have concluded that imaging does not add to tight clinical care, implementing imaging into the T2T strategy has actual advantages, such as the detection of subclinical involvement, and information on joint involvement/pathology and may possess potential advantages as evidenced by certain secondary endpoints. This review examines the findings of these studies and discusses the advantages and disadvantages of incorporating imaging into the T2T strategy.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
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Rubin DA. MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value. Skeletal Radiol 2019; 48:837-857. [PMID: 30806723 DOI: 10.1007/s00256-019-03180-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/03/2019] [Accepted: 02/03/2019] [Indexed: 02/02/2023]
Abstract
Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.
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Affiliation(s)
- David A Rubin
- Department of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd., St. Louis, MO, 63110, USA.
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Sivakumaran P, Hussain S, Attipoe L, Ciurtin C. Diagnostic accuracy of simplified ultrasound hand examination protocols for detection of inflammation and disease burden in patients with rheumatoid arthritis. Acta Radiol 2019; 60:92-99. [PMID: 29742922 DOI: 10.1177/0284185118773507] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND There is no consensus regarding the minimum number of joints that should be included in an ultrasound (US) scoring system to reliably assess for disease activity in rheumatoid arthritis (RA). PURPOSE To assess whether simplified US protocols for hand examination are as informative as the examination of 22 joints in patients with RA, and to correlate the US parameters with disease activity (DAS-28). MATERIAL AND METHODS This is a cross-sectional study of 224 RA patients stratified based on their DAS-28 scores and assessed using eight preselected US examination protocols, including 22, 18, 16, 14, ten, eight, and two different combinations of four joints, respectively. RESULTS We found a significant difference between US hand scores regarding their ability to detect active inflammation and erosions. DAS-28 scores correlated very well with the power Doppler (PD) scores generated by all eight US examination protocols (r = 0.89-1, P < 0.05), irrespective of patients' disease activity. Simplified US scores missed information on presence of PD in 20.6-40.2% patients ( P < 0.05) and misdiagnosed non-erosive hand RA in 12-38.4% patients ( P < 0.05), depending on the number of joints excluded from US hand examination. CONCLUSION Preselected simplified US scores are less reliable in appreciating the disease burden when compared with an extended protocol for 22 joint US examination, raising clinicians' awareness regarding the need to comprehensively assess multiple hand joints to reliably rule out subclinical inflammation.
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Affiliation(s)
- Priyanka Sivakumaran
- University College London Medical School, London, UK
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Sidra Hussain
- University College London Medical School, London, UK
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Laura Attipoe
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Coziana Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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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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Najm A, Orr C, Gallagher L, Biniecka M, Gaigneux E, Le Goff B, Fearon U, Veale DJ. Knee joint synovitis: study of correlations and diagnostic performances of ultrasonography compared with histopathology. RMD Open 2018. [PMID: 29531789 PMCID: PMC5845411 DOI: 10.1136/rmdopen-2017-000616] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objectives Ultrasonography (US) is a fast, available and low-cost imaging tool used for detecting knee synovitis. Our aims were to assess the relationship between US and histology findings in appraising levels of inflammation and vascularity in the knee joint in subjects with inflammatory arthropathies; to determine whether differences exist in the appraisal between varying knee compartments and to compare US performances compared with gold standard histology for knee synovitis detection. Methods Subjects with actively inflamed knee joint having crystal arthropathies, rheumatoid arthritis, psoriatic arthritis or ostoearthritis were prospectively recruited from rheumatology clinics after giving their written consent between May and October 2015. Study was approved by the institutional ethics committee. The knee was divided into three compartments (medial, lateral, superior). Patients had a knee US followed by a knee arthroscopy with biopsies retrieval from each compartment. Biopsies were blindly scored for lining layer hyperplasia, inflammation, vascularity, CD68 and factor VIII staining. Correlation was determined using the Spearman’s correlation test. Results 26 patients with active arthritis in a knee joint and recent onset of disease were prospectively included. Strong correlations were observed between US synovitis grade and histological inflammation score (r=0.63; P=0.002), US Doppler grade and histological score for vascularity (r=0.68; P<0.001); US measured synovial thickness and lining layer hyperplasia (r=0.61; P=0.002). Moderate correlation was found between US synovitis grade and CD68 score (r=0.49; P=0.02). Conclusion US findings correlate with histological inflammation and vascularity scores in actively inflamed knee joints. US accurately describes knee synovitis.
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Affiliation(s)
- Aurélie Najm
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, Pays de la Loire, France.,The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Dublin, Ireland
| | - Carl Orr
- The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Dublin, Ireland
| | - Lorna Gallagher
- Department of Molecular Rheumatology, Trinity College Dublin, Dublin, Ireland
| | - Monika Biniecka
- The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Dublin, Ireland
| | - Emeline Gaigneux
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, Pays de la Loire, France
| | - Benoit Le Goff
- Rheumatology Department, Centre Hospitalier Universitaire de Nantes, Nantes, Pays de la Loire, France
| | - Ursula Fearon
- Department of Molecular Rheumatology, Trinity College Dublin, Dublin, Ireland
| | - Douglas J Veale
- The Centre for Arthritis and Rheumatic Diseases, Saint Vincent's University Hospital and Dublin Academic Medical Centre, University College Dublin, Dublin, Ireland
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Carotti M, Galeazzi V, Catucci F, Zappia M, Arrigoni F, Barile A, Giovagnoni A. Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:48-77. [PMID: 29350637 PMCID: PMC6179068 DOI: 10.23750/abm.v89i1-s.7010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.
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Zufferey P, Scherer A, Nissen MJ, Ciurea A, Tamborrini G, Brulhart L, Blumhardt S, Toniolo M, Möller B, Ziswiler HR. Can Ultrasound Be Used to Predict Loss of Remission in Patients with RA in a Real-life Setting? A Multicenter Cohort Study. J Rheumatol 2018; 45:887-894. [PMID: 29335344 DOI: 10.3899/jrheum.161193] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Several studies have suggested that patients with rheumatoid arthritis (RA) presenting with ultrasound (US) synovitis despite clinical remission have more subsequent flares than those who show both clinical and sonographic remission. The objective of our study was to investigate whether these results could be translated to a real-life setting. METHODS We compared the time from the first US performed in clinical remission to loss of remission (defined by a DAS28 > 2.6 or the need for stepping up treatment with disease-modifying antirheumatic drugs) within the Swiss Clinical Quality Management cohort of patients with RA, and we adjusted for relevant confounders. Analyses were repeated for different definitions of US-detected synovitis (US+) using greyscale, Doppler, and combined modes based on previously validated scores, and they were adjusted for relevant confounders. RESULTS There were 318 RA patients with 378 remission phases included. Loss of clinical remission was observed in 60% of remission phases. Residual US synovitis was associated with a shorter duration of clinical remission (median 2-5 mos) and a moderately increased hazard ratio (HR) for loss of remission (HR 1.2-1.5), with the highest HR for the combined US score. The association between US+ and loss of remission was strongest when the US measurement had taken place early in remission (shorter median duration of 6-20 mos) and when followup time was limited to the first 3 or 6 months (most HR between 2-4). CONCLUSION US-detected synovitis, particularly when US is performed early in clinical remission, has a moderate predictive power for loss of remission in a real-life setting.
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Affiliation(s)
- Pascal Zufferey
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland. .,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma.
| | - Almut Scherer
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Michael J Nissen
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Adrian Ciurea
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Giorgio Tamborrini
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Laure Brulhart
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Sandra Blumhardt
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Martin Toniolo
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
| | - Burkhard Möller
- From the Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital, Lausanne; Service of Rheumatology, Geneva University Hospital, Geneva; Department of Rheumatology, Zurich University Hospital; Swiss Clinical Quality Management (SCQM) Foundation, Zurich; Ultrasound Centre Rheumatology (UZR), Basel; Department of Rheumatology, Immunology and Allergology, Inselspital; Osteo Rheuma, Bern; Service of Rheumatology, Hôpital neuchâtelois, Neuchâtel, Switzerland.,P. Zufferey, MD, Service of Rheumatology, Musculoskeletal Department, Lausanne University Hospital; A. Scherer, PhD, SCQM Foundation; M.J. Nissen, MBBS, FRACP, Service of Rheumatology, Geneva University Hospital; A. Ciurea, MD, Department of Rheumatology, Zurich University Hospital; G. Tamborrini, MD, Ultrasound Centre Rheumatology (UZR); B. Möller, Prof, Department of Rheumatology, Immunology and Allergology, Inselspital; L. Brulhart, MD, Service of Rheumatology, Hôpital neuchâtelois; M. Toniolo, MD, Department of Rheumatology, Zurich University Hospital; S. Blumhardt, MD, Department of Rheumatology, Zurich University Hospital; H.R. Ziswiler, MD, Osteo Rheuma
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11
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Allen JC, Thumboo J, Lye WK, Conaghan PG, Chew LC, Tan YK. Novel joint selection methods can reduce sample size for rheumatoid arthritis clinical trials with ultrasound endpoints. Int J Rheum Dis 2017; 21:693-698. [PMID: 28971583 DOI: 10.1111/1756-185x.13185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To determine whether novel methods of selecting joints through (i) ultrasonography (individualized-ultrasound [IUS] method), or (ii) ultrasonography and clinical examination (individualized-composite-ultrasound [ICUS] method) translate into smaller rheumatoid arthritis (RA) clinical trial sample sizes when compared to existing methods utilizing predetermined joint sites for ultrasonography. METHODS Cohen's effect size (ES) was estimated (ES^) and a 95% CI (ES^L, ES^U) calculated on a mean change in 3-month total inflammatory score for each method. Corresponding 95% CIs [nL(ES^U), nU(ES^L)] were obtained on a post hoc sample size reflecting the uncertainty in ES^. Sample size calculations were based on a one-sample t-test as the patient numbers needed to provide 80% power at α = 0.05 to reject a null hypothesis H0 : ES = 0 versus alternative hypotheses H1 : ES = ES^, ES = ES^L and ES = ES^U. We aimed to provide point and interval estimates on projected sample sizes for future studies reflecting the uncertainty in our study ES^S. RESULTS Twenty-four treated RA patients were followed up for 3 months. Utilizing the 12-joint approach and existing methods, the post hoc sample size (95% CI) was 22 (10-245). Corresponding sample sizes using ICUS and IUS were 11 (7-40) and 11 (6-38), respectively. Utilizing a seven-joint approach, the corresponding sample sizes using ICUS and IUS methods were nine (6-24) and 11 (6-35), respectively. CONCLUSIONS Our pilot study suggests that sample size for RA clinical trials with ultrasound endpoints may be reduced using the novel methods, providing justification for larger studies to confirm these observations.
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Affiliation(s)
- John C Allen
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Weng Kit Lye
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Biomedical Research Centre, Leeds, UK
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - York Kiat Tan
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
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12
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Orlandi D, Gitto S, Perugin Bernardi S, Corazza A, De Flaviis L, Silvestri E, Cimmino MA, Sconfienza LM. Advanced Power Doppler Technique Increases Synovial Vascularity Detection in Patients with Rheumatoid Arthritis. ULTRASOUND IN MEDICINE & BIOLOGY 2017; 43:1880-1887. [DOI: 10.1016/j.ultrasmedbio.2017.05.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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13
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Reliability of ultrasound grading traditional score and new global OMERACT-EULAR score system (GLOESS): results from an inter- and intra-reading exercise by rheumatologists. Clin Rheumatol 2017; 36:2799-2804. [DOI: 10.1007/s10067-017-3662-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/07/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
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14
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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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15
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D'Agostino MA, Haavardsholm EA, van der Laken CJ. Diagnosis and management of rheumatoid arthritis; What is the current role of established and new imaging techniques in clinical practice? Best Pract Res Clin Rheumatol 2016; 30:586-607. [PMID: 27931956 DOI: 10.1016/j.berh.2016.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/19/2016] [Indexed: 01/05/2023]
Abstract
Ultrasound and magnetic resonance imaging (MRI) have become established imaging techniques for the management of rheumatoid arthritis. Several publications have pointed out the advantages of these techniques for a more complete evaluation of the inflammation and structural damage at joint level. Recently new imaging techniques as the positron emission tomography (PET) associated with computed tomography (CT) or MRI scan, and the optical imaging have been introduced in the panorama. This article presents the advantages and limitations of each imaging techniques in light with the recent publications.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France; INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vindern, 0319, Oslo, Norway
| | - Conny J van der Laken
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center - Location VU University Medical Center, Amsterdam, The Netherlands
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16
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Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2016; 14:9-19. [PMID: 28029551 DOI: 10.1016/j.reuma.2016.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). METHODS Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and MRI in RA patients.
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17
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Abstract
Rheumatoid arthritis is a chronic inflammatory joint disease, which can cause cartilage and bone damage as well as disability. Early diagnosis is key to optimal therapeutic success, particularly in patients with well-characterised risk factors for poor outcomes such as high disease activity, presence of autoantibodies, and early joint damage. Treatment algorithms involve measuring disease activity with composite indices, applying a treatment-to-target strategy, and use of conventional, biological, and newz non-biological disease-modifying antirheumatic drugs. After the treatment target of stringent remission (or at least low disease activity) is maintained, dose reduction should be attempted. Although the prospects for most patients are now favourable, many still do not respond to current therapies. Accordingly, new therapies are urgently required. In this Seminar, we describe current insights into genetics and aetiology, pathophysiology, epidemiology, assessment, therapeutic agents, and treatment strategies together with unmet needs of patients with rheumatoid arthritis.
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Affiliation(s)
- Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria; 2nd Department of Medicine, Hietzing Hospital Vienna, Vienna, Austria.
| | - Daniel Aletaha
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK
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18
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Abstract
Background Local treatments to alleviate symptoms in hand osteoarthritis (OA) are preferred, especially in elderly patients with comorbidities. Therefore, we have summarized the benefits and harms of intra-articular (IA) therapies. Methods We conducted a systematic literature review until May 2015, including all controlled trials investigating efficacy or safety of any IA therapy in carpometacarpal (CMC) and interphalangeal (IP) OA compared with placebo
or other treatments. Two authors independently selected trials and assessed risk of bias using the Cochrane tool. The main efficacy outcome was pain. We performed meta-analysis where appropriate. Results A total of 13 trials (864 patients) studying CMC (n = 11) and IP OA (n = 2) were included, comparing corticosteroids or hyaluronic acid (HA) versus placebo (n = 4 and n = 3), and corticosteroids versus HA (n = 6). Single studies investigated infliximab, dextrose, and different HAs. The overall risk of bias was unclear or high in most trials. Meta-analysis of two trials comparing corticosteroids with placebo in CMC OA showed no improvement in pain [mean difference −3.56, 95 % confidence interval (CI) −13.87 to 6.75, scale 0–100). HA also appeared not efficacious compared with placebo in CMC OA. One trial comparing corticosteroids with placebo in IP OA demonstrated significantly improved pain during movement. No convincing evidence for efficacy of corticosteroids or HA over the other or alternative therapies was found. Only local adverse events were reported. No specific IA therapy appeared more harmful than another. Conclusion Despite a beneficial short-term safety profile, IA corticosteroids or HA do not appear more effective than placebo in CMC OA. The suggestion that IA corticosteroids might be efficacious in IP OA requires confirmation. Electronic supplementary material The online version of this article (doi:10.1007/s40266-015-0330-5) contains supplementary material, which is available to authorized users.
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19
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Tan YK, Allen JC, Lye WK, Conaghan PG, Chew LC, Thumboo J. Dichotomous versus semi-quantitative scoring of ultrasound joint inflammation in rheumatoid arthritis using novel individualized joint selection methods. Clin Rheumatol 2016; 36:1137-1141. [PMID: 27699656 DOI: 10.1007/s10067-016-3432-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/10/2016] [Accepted: 09/21/2016] [Indexed: 01/01/2023]
Abstract
The aim of the study is to compare the responsiveness of two joint inflammation scoring systems (dichotomous scoring (DS) versus semi-quantitative scoring (SQS)) using novel individualized ultrasound joint selection methods and existing ultrasound joint selection methods. Responsiveness measured by the standardized response means (SRMs) using the DS and the SQS system (for both the novel and existing ultrasound joint selection methods) was derived using the baseline and the 3-month total inflammatory scores from 20 rheumatoid arthritis patients. The relative SRM gain ratios (SRM-Gains) for both scoring system (DS and SQS) comparing the novel to the existing methods were computed. Both scoring systems (DS and SQS) demonstrated substantial SRM-Gains (ranged from 3.31 to 5.67 for the DS system and ranged from 1.82 to 3.26 for the SQS system). The SRMs using the novel methods ranged from 0.94 to 1.36 for the DS system and ranged from 0.89 to 1.11 for the SQS system. The SRMs using the existing methods ranged from 0.24 to 0.32 for the DS system and ranged from 0.34 to 0.49 for the SQS system. The DS system appears to achieve high responsiveness comparable to SQS for the novel individualized ultrasound joint selection methods.
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Affiliation(s)
- York Kiat Tan
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore. .,Duke-NUS Graduate Medical School, Singapore, Singapore. .,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - John C Allen
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Weng Kit Lye
- Office of Clinical Sciences, Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, & NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Li-Ching Chew
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore.,Duke-NUS Graduate Medical School, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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20
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Kaeley GS, Nishio MJ, Goyal JR, MacCarter DK, Wells AF, Chen S, Kupper H, Kalabic J. Changes in Ultrasonographic Vascularity Upon Initiation of Adalimumab Combination Therapy in Rheumatoid Arthritis Patients With an Inadequate Response to Methotrexate. Arthritis Rheumatol 2016; 68:2584-2592. [PMID: 27214046 PMCID: PMC5129587 DOI: 10.1002/art.39751] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 05/05/2016] [Indexed: 11/30/2022]
Abstract
Objective To assess joint disease activity by ultrasound (US) in patients with rheumatoid arthritis (RA) initiating treatment with adalimumab (ADA) plus methotrexate (MTX). Methods Data for this post hoc analysis originated from the MUSICA trial (ClinicalTrials.gov identifier: NCT01185288), which evaluated the efficacy of initiating ADA (40 mg every other week) plus 7.5 or 20 mg/week MTX in 309 patients with RA with an inadequate response to MTX. Synovial vascularization over 24 weeks was assessed bilaterally at metacarpophalangeal joint 2 (MCP2), MCP3, MCP5, metatarsophalangeal joint 5, and the wrists by power Doppler US (PDUS). A semiquantitative 4‐grade scale was used. Disease activity was assessed using the Disease Activity Score in 28 joints using the C‐reactive protein level (DAS28‐CRP) and Simplified Disease Activity Index (SDAI). The correlation between continuous variables was assessed using Pearson's correlation coefficient. Results After 24 weeks of treatment with ADA plus MTX, rapid improvements in the mean synovial vascularity score were observed; the greatest improvements were in MCP2 (−0.5), MCP3 (−0.4), and the wrist (−0.4). At week 24, patients with the lowest DAS28‐CRP (<2.6) had the lowest mean 5‐joint and 3‐joint composite synovial vascularity scores. The 5‐joint and 3‐joint scores were strongly correlated (ρ > 0.9). Synovial vascularity scores correlated poorly with DAS28, swollen joint count in 66 joints (SJC66), SJC28, tender joint count in 68 joints (TJC68), TJC28, Clinical Disease Activity Index (CDAI), SDAI, physician's global assessment, patient's global assessment of pain, and disease duration (ρ < 0.2). Thirty‐two (70%) of 46 patients with a DAS28‐CRP of <2.6, and 11 (58%) of 19 patients with an SDAI indicating remission had at least 1 joint with a synovial vascularity score of ≥1. Conclusion PDUS detects changes in synovial vascularity in RA patients treated with ADA plus MTX, and residual synovial vascularity in patients in whom clinical disease control has been achieved.
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Affiliation(s)
| | | | | | | | - Alvin F Wells
- Rheumatology and Immunotherapy Center, Franklin, Wisconsin
| | - Su Chen
- AbbVie, North Chicago, Illinois
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21
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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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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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Mandl P, Baranauskaite A, Damjanov N, Hojnik M, Kurucz R, Nagy O, Nemec P, Niedermayer D, Perić P, Petranova T, Pille A, Rednic S, Vlad V, Zlnay M, Balint PV. Musculoskeletal ultrasonography in routine rheumatology practice: data from Central and Eastern European countries. Rheumatol Int 2016; 36:845-54. [PMID: 26923691 PMCID: PMC4873522 DOI: 10.1007/s00296-016-3442-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 02/10/2016] [Indexed: 12/01/2022]
Abstract
The main aim was to gain structured insight into the use of musculoskeletal ultrasonography (MSUS) in routine rheumatology practices in Central and Eastern European (CEE) countries. In a cross-sectional, observational, international, multicenter survey, a questionnaire was sent to investigational sites in CEE countries. Data on all subsequent routine MSUS examinations, site characteristics, MSUS equipment, and investigators were collected over 6 months or up to 100 examinations per center. A total of 95 physicians at 44 sites in 9 countries provided information on a total of 2810 MSUS examinations. The most frequent diagnoses were rheumatoid arthritis (RA) and spondyloarthritis (34.8 and 14.9 % of cases, respectively). Mean number of joints examined was 6.8. MSUS was most frequently performed for diagnostic purposes (58 %), particularly in patients with undifferentiated arthritis, suspected soft tissue disorders, or osteoarthritis (73.0–85.3 %). In RA patients, 56.3 % of examinations were conducted to monitor disease activity. Nearly all investigations (99 %) had clinical implications, while the results of 78.6 % of examinations (51.6–99.0 %) were deemed useful for patient education. This first standardized multicountry survey performed in CEEs provided a structured documentation of the routine MSUS use in participating countries. The majority of MSUS examinations were performed for diagnostic purposes, whereas one-third was conducted to monitor disease activity in RA. A majority of examinations had an impact on clinical decision making and were also found to be useful for patient education.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, 3rd Department of Internal Medicine, Medical University of Vienna, 18-20 Währinger Gürtel, Vienna, Austria. .,3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary.
| | - Asta Baranauskaite
- Department of Rheumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Nemanja Damjanov
- Institute of Rheumatology, University of Belgrade School of Medicine, Belgrade, Serbia
| | - Maja Hojnik
- Global Medical Affairs Rheumatology, AbbVie, Ljubljana, Slovenia
| | - Reka Kurucz
- 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | | | - Petr Nemec
- Department of Rheumatology, St. Anne's University Hospital, Brno, Czech Republic
| | - Dora Niedermayer
- 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Porin Perić
- Department of Rheumatology, Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Tzvetanka Petranova
- Department of Rheumatology, UMHAT St.Iv.Rilsky, Medical University, Sofia, Bulgaria
| | | | - Simona Rednic
- Department of Rheumatology, Clinical County Emergency Hospital, Cluj-Napoca, Romania
| | - Violeta Vlad
- Department of Rheumatology, Sf. Maria Clinical Hospital, Bucharest, Romania
| | - Martin Zlnay
- Department of Rheumatology, National Institute of Rheumatic Diseases, Piestany, Slovak Republic
| | - Peter V Balint
- 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
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Ultrasound Findings in Hand Joints Involvement in Patients with Psoriatic Arthritis and Its Correlation with Clinical DAS28 Score. Radiol Res Pract 2015; 2015:353657. [PMID: 26858846 PMCID: PMC4700862 DOI: 10.1155/2015/353657] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 11/04/2015] [Accepted: 11/08/2015] [Indexed: 01/08/2023] Open
Abstract
Objective. To determine the frequency of the various ultrasound findings in hand joints in patients with psoriatic arthritis and correlate grayscale and Power Doppler ultrasonography findings with Disease Activity Score 28. Methods. This prospective study was performed in 30 patients. Ultrasound evaluation of 28 joints of both hands was undertaken and various findings were recorded including synovial hypertrophy, Power Doppler abnormality, soft tissue thickening, tendonitis, joint effusion, periosteal reaction, and erosions. Composite ultrasound scores and Disease Activity Score 28 were calculated and compared. Spearman correlation was used to see relationship between the ultrasound and DAS28 scores. Results. Ultrasound detected more abnormalities in the hand joints than did clinical examination. The frequency of various ultrasound abnormalities was as follows: Synovial hypertrophy was seen in 100%, Power Doppler abnormality suggesting hypervascularity was seen in 36.7%, soft tissue thickening was seen in 66.7%, periosteal reaction was seen in 33.3%, erosions were seen in 30% (mostly in DIP and PIP joints), and flexor tendonitis was seen in 6.7% of patients. Significant correlation was found between Disease Activity Score 28 and grayscale joint score (GSJS) (Spearman's ρ: 0.499; P: 0.005), grayscale joint count (GSJC) (ρ: 0.398; P: 0.029), and Power Doppler joint score (PDJS) (ρ: 0.367; P: 0.046). There was a statistically significant difference between remission and low disease activity group and moderate disease activity group in terms of GSJC, GSJS, PDJC, and PDJS (P < 0.05). These ultrasound measures were higher in moderate disease activity zone patients. Conclusion. Ultrasound is a useful modality for the objective assessment of psoriatic arthritis. Ultrasound including Power Doppler can be used as a modality for assessment of severity of psoriatic arthritis as it correlates with the clinical scoring.
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Aga AB, Hammer HB, Olsen IC, Uhlig T, Kvien TK, van der Heijde D, Fremstad H, Madland TM, Lexberg ÅS, Haukeland H, Rødevand E, Høili C, Stray H, Bendvold AN, Soldal DM, Bakland G, Lie E, Haavardsholm EA. First step in the development of an ultrasound joint inflammation score for rheumatoid arthritis using a data-driven approach. Ann Rheum Dis 2015; 75:1444-51. [PMID: 26085490 DOI: 10.1136/annrheumdis-2015-207572] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/24/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To develop and validate candidate sets of joints and tendons for assessment of ultrasound (US) joint inflammation in rheumatoid arthritis (RA). METHODS Patients were included in one of two cohorts from 2010 to June 2013: disease-modifying antirheumatic drug naïve early RA or established RA starting/switching biologics. An extensive US examination was performed by experienced sonographers using a validated grey-scale (GSUS) and power Doppler (PDUS) semiquantitative scoring system with scores 0-3 for both GSUS and PDUS in 36 joints and four tendons. We performed factor analysis in the early RA US data and selected candidate joint/tendon sets based on these results. The proportion of information in the total US scores retained in these candidate sets was assessed by R(2) from linear regression analysis. Finally, the candidate sets and previously proposed joint scores were tested in the established RA cohort, and we also evaluated the sensitivity to change with standardised response means. RESULTS 227 patients with early RA and 212 patients with established RA were included. We identified two candidate sets of joints/tendons: candidate set A consisted of seven joints/two tendons (meatacarpophalangeal 1 (MCP1), MCP2, proximal interphalangeal 3, radiocarpal, elbow, metatarsophalangeal 1 (MTP1), MTP2, tibialis posterior tendon, extensor carpi ulnaris tendon) and set B of nine joints/two tendons (MCP5 and MTP5 added to set A). Unilateral reduced scores retained 78%-85% of the information in total score, while bilateral reduced scores retained 89%-93%, and both sets performed better than previously proposed reduced joint scores, and similar or slightly better regarding sensitivity to change. CONCLUSIONS The reduced GSUS and PDUS scores retained most of the information from the total score and performed well in a validation cohort of established RA. TRIAL REGISTATION NUMBER NCT01205854, ACTRN12610000284066.
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Affiliation(s)
| | | | | | - Till Uhlig
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Tore K Kvien
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Désirée van der Heijde
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hallvard Fremstad
- Department of Rheumatology, Ålesund Hospital, Helse Møre og Romsdal HF, Ålesund, Norway
| | - Tor Magne Madland
- Department of Rheumatology, Haukeland University Hospital, Helse Bergen HF, Bergen, Norway
| | | | - Hilde Haukeland
- Department of Rheumatology, Martina Hansens Hospital AS, Bærum, Norway
| | - Erik Rødevand
- Department of Rheumatology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Christian Høili
- Department of Rheumatology, Hospital Østfold HF, Moss, Norway
| | - Hilde Stray
- Haugesund Rheumatism HospitalAS, Haugesund, Norway
| | | | - Dag Magnar Soldal
- Department of Rheumatology, Sørlandet Hospital HF, Kristiansand, Norway
| | - Gunnstein Bakland
- Department of Rheumatology, University Hospital of North Norway, Tromsø, Norway Institute of Clinical Medicine, University of Tromsø, Tromsø, Norway
| | - Elisabeth Lie
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
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Mandl P, Kurucz R, Niedermayer D, Balint PV, Smolen JS. Contributions of ultrasound beyond clinical data in assessing inflammatory disease activity in rheumatoid arthritis: current insights and future prospects. Rheumatology (Oxford) 2014; 53:2136-42. [PMID: 24836013 DOI: 10.1093/rheumatology/keu211] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Appropriate measures of disease activity need to be valid, reliable and sensitive to change for use in clinical studies while remaining at the same time feasible and practicable for utilization in daily clinical practice. Ultrasonography was shown to be a valid, sensitive and reliable imaging modality for the detection of synovitis in RA, however, it has so far failed to demonstrate superior sensitivity to change as compared with clinical examination. This review examines the current evidence for the use of established measures and/or US, either as an alternative or as a supplementary measure to clinical examination, as tools for monitoring synovitis in RA. It also includes a summary of results of recent studies evaluating clinical examination-based as well as clinical- and US-based multimodal disease activity indices. We review the rationale and limitations of incorporating US into composite disease activity indices and suggest a research roadmap for further studies in this field.
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Affiliation(s)
- Peter Mandl
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria.
| | - Reka Kurucz
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Dora Niedermayer
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Peter V Balint
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
| | - Josef S Smolen
- Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria. Division of Rheumatology, Department of Medicine 3, Medical University of Vienna, Vienna, Austria, 3rd Department of Rheumatology, National Institute of Rheumatology and Physiotherapy, Budapest, Hungary and 2nd Department of Medicine, Center for Rheumatic Diseases, Hietzing Hospital, Vienna, Austria
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Ikeda K, Seto Y, Ohno S, Sakamoto F, Henmi M, Fukae J, Narita A, Nakagomi D, Nakajima H, Tanimura K, Koike T. Analysis of the factors which influence the measurement of synovial power Doppler signals with semi-quantitative and quantitative measures – a pilot multicenter exercise in Japan. Mod Rheumatol 2013; 24:419-25. [DOI: 10.3109/14397595.2013.843763] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Ultrasound evaluation of synovitis in RA: correlation with clinical disease activity and sensitivity to change in an observational cohort study. Joint Bone Spine 2013; 81:222-7. [PMID: 24210684 DOI: 10.1016/j.jbspin.2013.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/30/2013] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the correlation between clinical measures of disease activity and a ultrasound (US) scoring system for synovitis applied by many different ultrasonographers in a daily routine care setting within the Swiss registry for RA (SCQM) and further to determine the sensitivity to change of this US Score. METHODS One hundred and eight Swiss rheumatologists were trained in performing the Swiss Sonography in Arthritis and Rheumatism (SONAR) score. US B-mode and Power Doppler (PwD) scores were correlated with DAS28 and compared between the clinical categories in a cross-sectional cohort of patients. In patients with a second US (longitudinal cohort), we investigated if change in US score correlated with change in DAS and evaluated the responsiveness of both methods. RESULTS In the cross-sectional cohort with 536 patients, correlation between the B-mode score and DAS28 was significant but modest (Pearson coefficient r = 0.41, P < 0.0001). The same was true for the PwD score (r = 0.41, P < 0.0001). In the longitudinal cohort with 183 patients we also found a significant correlation between change in B-mode and in PwD score with change in DAS28 (r = 0.54, P < 0.0001 and r = 0.46, P < 0.0001, respectively). Both methods of evaluation (DAS and US) showed similar responsiveness according to standardized response mean (SRM). CONCLUSIONS The SONAR Score is practicable and was applied by many rheumatologists in daily routine care after initial training. It demonstrates significant correlations with the degree of as well as change in disease activity as measured by DAS. On the level of the individual, the US score shows many discrepancies and overlapping results exist.
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Duftner C, Schüller-Weidekamm C, Mandl P, Nothnagl T, Schirmer M, Kainberger F, Machold K, Dejaco C. Clinical implementation of musculoskeletal ultrasound in rheumatology in Austria. Rheumatol Int 2013; 34:1111-5. [PMID: 24071934 DOI: 10.1007/s00296-013-2863-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 09/02/2013] [Indexed: 10/26/2022]
Abstract
The aim of the study is to assess the clinical implementation of musculoskeletal ultrasound (MSUS) in rheumatology in Austria. A survey was conducted among Austrian rheumatologists and physicians of other specialties with a focus on rheumatology. The questionnaire was designed by the members of the Austrian Radiology-Rheumatology Initiative for Musculoskeletal UltraSound including the following items: demographics, access to MSUS and MSUS training, application of MSUS to support diagnosis, monitoring and treatment decisions, and obstacles for the routine performance of MSUS. Eighty-eight (21.9 %) out of the 402 surveyed physicians responded. No access to MSUS and/or inadequate training in the technique was more commonly reported by senior (>50 years; 64.3 and 67.7 %, respectively) than by younger physicians (16.7 %, p = 0.01 and 18.5 %, p < 0.001, respectively). The lowest availability of sonography was found among senior rheumatologists (25.0 %, p = 0.001 compared to the total group). MSUS is routinely used for diagnosis and/or monitoring purposes by 12.5 % of physicians and 20.5 % perform sonography in clinically unclear cases. A limited number of physicians apply the method to support treatment decisions and/or to evaluate treatment success. The most important obstacles for routine application of MSUS in rheumatology are limited access to ultrasound machines, lack of training/education in the technique, and time constraints in daily routine. Low access to high-end ultrasound devices, lack of training, and time constraints may explain the low appreciation of MSUS among Austrian physicians evaluating patients with rheumatic diseases.
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Affiliation(s)
- Christina Duftner
- Department of Internal Medicine, General Hospital of Kufstein, Endach 27, 6330, Kufstein, Austria
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Gärtner M, Mandl P, Radner H, Supp G, Machold KP, Aletaha D, Smolen JS. Sonographic Joint Assessment in Rheumatoid Arthritis: Associations With Clinical Joint Assessment During a State of Remission. ACTA ACUST UNITED AC 2013; 65:2005-14. [DOI: 10.1002/art.38016] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Accepted: 05/07/2013] [Indexed: 11/11/2022]
Affiliation(s)
| | - Peter Mandl
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary, and Medical University of Vienna; Vienna Austria
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Mandl P, Balint PV, Brault Y, Backhaus M, D'Agostino MA, Grassi W, van der Heijde D, de Miguel E, Wakefield RJ, Logeart I, Dougados M. Clinical and Ultrasound-Based Composite Disease Activity Indices in Rheumatoid Arthritis: Results From a Multicenter, Randomized Study. Arthritis Care Res (Hoboken) 2013; 65:879-87. [DOI: 10.1002/acr.21913] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 11/06/2012] [Indexed: 01/01/2023]
Affiliation(s)
- P. Mandl
- Medical University of Vienna, Vienna, Austria, and National Institute of Rheumatology and Physiotherapy; Budapest; Hungary
| | - P. V. Balint
- National Institute of Rheumatology and Physiotherapy; Budapest; Hungary
| | | | - M. Backhaus
- University Hospital Charité; Berlin; Germany
| | - M. A. D'Agostino
- Versailles-Saint Quentin en Yvelines University; AP-HP, Ambroise-Paré Hospital; Boulogne-Billancourt; France
| | - W. Grassi
- Università Politecnica delle Marche; Jesi; Ancona; Italy
| | | | | | | | | | - M. Dougados
- Paris-Descartes University; UPRES-EA 4058; AP-HP; Cochin Hospital; Paris; France
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Ohrndorf S, Backhaus M. Musculoskeletal ultrasonography in patients with rheumatoid arthritis. Nat Rev Rheumatol 2013; 9:433-7. [DOI: 10.1038/nrrheum.2013.73] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Markers of treatment response to methotrexate in rheumatoid arthritis: where do we stand? Int J Rheumatol 2012; 2012:978396. [PMID: 22844292 PMCID: PMC3400362 DOI: 10.1155/2012/978396] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 05/21/2012] [Accepted: 05/29/2012] [Indexed: 02/08/2023] Open
Abstract
Methotrexate (MTX) is the most commonly used disease-modifying antirheumatic drug (DMARD) for the treatment of rheumatoid arthritis (RA). However, despite its efficacy and affordability, additional DMARDs or biologic agents are often required in order to achieve the recommended goals of low disease activity or remission. Although well tolerated by most, some patients develop important side effects such as cytopenias, gastrointestinal adverse events (stomatitis, nausea), or abnormal liver function tests, which may limit its use and may result in additional health care costs. Given the clinical implications of widespread use of MTX in RA, various studies have evaluated the role of potential biomarkers in predicting treatment effectiveness of MTX. These biomarkers include RBC MTX polyglutamate (PG) levels; genetic variation in genes from relevant biological and metabolic pathways; gene expression profiles; serum proteins. This paper provides an update on the current data regarding biomarkers of treatment response to MTX.
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Ultrasonography Applications in Diagnosis and Management of Early Rheumatoid Arthritis. Rheum Dis Clin North Am 2012; 38:259-75. [DOI: 10.1016/j.rdc.2012.05.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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