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Sepriano A, Ramiro S, Landewé R, van der Heijde D, Ohrndorf S, FitzGerald O, Backhaus M, Larché M, Homik J, Saraux A, Hammer HB, Terslev L, Østergaard M, Burmester G, Combe B, Dougados M, Hitchon C, Boire G, Lambert RG, Dadashova R, Paschke J, Hutchings EJ, Maksymowych WP. Adding ultrasound to treat-to-target shows no benefit in achieving clinical remission nor in slowing radiographic progression in rheumatoid arthritis: results from a multicenter prospective cohort. Clin Rheumatol 2024; 43:1833-1844. [PMID: 38684600 DOI: 10.1007/s10067-024-06978-5] [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: 02/14/2024] [Revised: 04/11/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
OBJECTIVE To assess whether using ultrasound (US) in addition to clinical information versus only clinical information in a treat-to-target (T2T) strategy leads to more clinical remission and to less radiographic progression in RA. METHODS Patients with RA from the 2-year prospective BIODAM cohort were included. Clinical and US data (US7-score) were collected every 3 months and hands and feet radiographs every 6 months. At each visit, it was decided whether patients were treated according to the clinical definition of T2T with DAS44 remission as benchmark (T2T-DAS44). T2T-DAS44 was correctly applied if: (i) DAS44 remission had been achieved or (ii) if not, treatment was intensified. A T2T strategy also considering US data (T2T-DAS44-US) was correctly applied if: (i) both DAS44 and US remission (synovitis-score < 2, Doppler-score = 0) were present; or (ii) if not, treatment was intensified. The effect of T2T-DAS44-US on attaining clinical remission and on change in Sharp-van der Heijde score compared to T2T-DAS44 was analysed. RESULTS A total of 1016 visits of 128 patients were included. T2T-DAS44 was correctly followed in 24% of visits and T2T-DAS44-US in 41%. DAS44 < 1.6 was achieved in 39% of visits. Compared to T2T-DAS44, using the T2T-DAS44-US strategy resulted in a 41% lower likelihood of DAS44 remission [OR (95% CI): 0.59 (0.40;0.87)] and had no effect on radiographic progression [β(95% CI): 0.11 (- 0.16;0.39)] assessed at various intervals up to 12 months later. CONCLUSION Our results do not suggest a benefit of using the US7-score in addition to clinical information as a T2T benchmark compared to clinical information alone. Key Points • Ultrasound has a valuable role in diagnostic evaluation of rheumatoid arthritis, but it is unclear whether adding ultrasound to the clinical assessment in a treat-to-target (T2T) strategy leads to more patients achieving remission and reduction in radiographic progression. • Our data from a real-world study demonstrated that adding information from ultrasound to the clinical assessment in a T2T strategy led to a lower rather than a higher likelihood of obtaining clinical remission as compared to using only clinical assessment. • Our data demonstrated that adding ultrasound data to a T2T strategy based only on clinical assessment did not offer additional protection against radiographic progression in patients with RA. • Adding US to a T2T strategy based on clinical assessment led to far more treatment intensifications (with consequences for costs and exposure to adverse events) without yielding a meaningful clinical benefit.
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Affiliation(s)
- Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- NOVA Medical School, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Zuyderland Medical Center, Heerlen, The Netherlands
| | - Robert Landewé
- Zuyderland Medical Center, Heerlen, The Netherlands
- Amsterdam University Medical Center (ARC), Amsterdam, The Netherlands
| | | | - Sarah Ohrndorf
- Department of Internal Medicine - Rheumatology and Clinical Immunology, Academic Hospital of Charité - Universitätsmedizin Berlin, Parkklinik Weissensee, Berlin, Germany
| | - Olivier FitzGerald
- Department of Rheumatology, St. Vincent's University Hospital, Dublin, Ireland
- Conway Institute for Biomolecular Research, University College Dublin, Dublin, Ireland
| | - Marina Backhaus
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Maggie Larché
- Divisions of Rheumatology and Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Joanne Homik
- Department of Medicine, University of Alberta, 568 Heritage Medical Research Building, Edmonton, T6G 2S2, Canada
| | - Alain Saraux
- LBAI, U1227, University of Brest, Inserm; CHRU Brest, F-29200, Brest, France
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel Østergaard
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, University of Copenhagen, Copenhagen, Denmark
| | - Gerd Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Bernard Combe
- Departement de Rhumatologie, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Maxime Dougados
- Rheumatology Department, Paris Descartes University, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, INSERM (U1153): Clinical Epidemiology and Biostatistics, PRES Sorbonne Paris-Cité, Paris, France
| | - Carol Hitchon
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Gilles Boire
- Division of Rheumatology, Department of Medicine, Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (CIUSSS de l'Estrie - CHUS), Université de Sherbrooke, Québec, Canada
| | - Robert G Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
- Medical Imaging Consultants, Edmonton, Canada
| | | | | | | | - Walter P Maksymowych
- Department of Medicine, University of Alberta, 568 Heritage Medical Research Building, Edmonton, T6G 2S2, Canada.
- CARE ARTHRITIS LTD, Edmonton, Canada.
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Tan YK, Lim GH. Subclinical joint inflammation in rheumatoid arthritis: comparing thermal and ultrasound imaging at the metacarpophalangeal joint. Adv Rheumatol 2024; 64:36. [PMID: 38702760 DOI: 10.1186/s42358-024-00377-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 04/22/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND While ultrasound and MRI are both superior to clinical examination in the detection of joint inflammation, there is presently a lack of data whether thermography may be similarly useful in the assessment of joint inflammation in patients with RA. Our study aims to evaluate the use of thermography in detecting subclinical joint inflammation at clinically quiescent (non-tender and non-swollen) metacarpophalangeal joints (MCPJs) in patients with rheumatoid arthritis (RA). The outcomes from thermography in our study will be compared with ultrasonography (which is a more established imaging tool used for joint inflammation assessment in RA). METHODS The minimum (Tmin), average (Tavg) and maximum (Tmax) temperatures at the 10 MCPJs of each patient were summed to obtain the Total Tmin, Total Tavg and Total Tmax, respectively. Ultrasound grey-scale (GS) and power Doppler (PD) joint inflammation (scored semi-quantitatively, 0-3) at the 10 MCPJs were summed up to derive the respective TGS and TPD scores per patient. Pearson's correlation and simple linear regression were respectively used to assess correlation and characterize relationships between thermographic parameters (Total Tmin, Total Tavg and Total Tmax) and ultrasound imaging parameters (TGS, TPD and the number of joint(s) with PD ≥ 1 or GS ≥ 2). RESULTS In this cross-sectional study, 420 clinically non-swollen and non-tender MCPJs from 42 RA patients were examined. All thermographic parameters (Total Tmin, Total Tavg and Total Tmax) correlated significantly (P-values ranging from 0.001 to 0.0012) with TGS score (correlation coefficient ranging from 0.421 to 0.430), TPD score (correlation coefficient ranging from 0.383 to 0.424), and the number of joint(s) with PD ≥ 1 or GS ≥ 2 (correlation coefficient ranging from 0.447 to 0.465). Similarly, simple linear regression demonstrated a statistically significant relationship (P-values ranging from 0.001 to 0.005) between all thermographic parameters (Total Tmin, Total Tavg and Total Tmax) and ultrasound imaging parameters (TPD and TGS). CONCLUSION For the first time, thermographic temperatures were shown to correlate with ultrasound-detected joint inflammation at clinically quiescent MCPJs. The use of thermography in the detection of subclinical joint inflammation in RA appears promising and warrants further investigation.
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Affiliation(s)
- York Kiat Tan
- Department of Rheumatology and Immunology, Singapore General Hospital, Outram Road, Bukit Merah, Central Region, 169608, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, Queenstown, Singapore.
| | - Gek Hsiang Lim
- Health Services Research Unit, Singapore General Hospital, Bukit Merah, Central Region, Singapore
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Garcia-Montoya L, Kang J, Duquenne L, Di Matteo A, Nam JL, Harnden K, Chowdhury R, Mankia K, Emery P. Factors associated with resolution of ultrasound subclinical synovitis in anti-CCP-positive individuals with musculoskeletal symptoms: a UK prospective cohort study. THE LANCET. RHEUMATOLOGY 2024; 6:e72-e80. [PMID: 38267105 DOI: 10.1016/s2665-9913(23)00305-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Subclinical synovitis occurs in a third of individuals at risk of rheumatoid arthritis. The objective of this study was to assess the reversibility of subclinical synovitis in individuals at risk of rheumatoid arthritis who are positive for anti-cyclic citrullinated peptide (CCP) antibody with musculoskeletal symptoms and investigate factors associated with its resolution within 12 months. METHODS We conducted a single-centre, prospective, cohort study in the UK, recruiting individuals aged 18 years or older who were anti-CCP-positive with a new non-specific musculoskeletal symptom but no clinical synovitis. Referrals were made through primary or secondary care. Participants attended a baseline visit, which included a clinical assessment, blood tests, patient questionnaires, and a musculoskeletal ultrasound scan (ie, of wrists and metacarpophalangeal, proximal interphalangeal, and metatarsophalangeal joints), and then follow-up visits every 3 months for the first year, with a repeat ultrasound scan every 12 months. Participants with subclinical synovitis (ie, grey scale ≥1 and power Doppler ≥1) in at least one joint at baseline were selected for this analysis. Investigation of good prognostic factors by 12 months was done first using univariable analysis to identify significant factors in participants with no missing data. Then receiver operating characteristic (ROC) curves were used to establish the optimal cutoffs for significant continuous variables. Finally, a modified Poisson regression approach was performed to identify the best prediction model and was adjusted for confounders, using data from all participants, with missing values imputed. This study is registered with ClinicalTrials.gov, NCT02012764. FINDINGS Between June 30, 2008, and Feb 24, 2020, 451 participants consented to participate in the CCP study and 122 (27%) individuals had subclinical synovitis at baseline, of whom 90 (74%) had data available at 12 months. Mean age was 54·1 years (SD 12·5), and 63 (70%) of 90 participants were women and 27 (30%) were men. Subclinical synovitis resolved in 43 (48%) of 90 participants, whereas subclinical synovitis persisted in 47 (52%) participants, 27 (57%) of whom developed clinical synovitis within 12 months. In the multivariable analysis, low anti-CCP titre (relative risk [RR] 1·52, 95% CI 1·04-2·22), negative rheumatoid factor (1·54, 0·92-2·58), subclinical synovitis in only one joint (1·62, 1·04-2·50), and an erythrocyte sedimentation rate of 15 mm/h or lower (1·82, 1·15-2·87) were predictors of subclinical synovitis resolution within 12 months (ie, good prognostic factors). ROC curve showed an area under the curve of 0·84 (95% CI 0·76-0·92; p<0·0001). Resolution occurred in seven (100%) of seven participants with all four factors present, and in only one (7%) of 14 participants with none of the factors present. INTERPRETATION In individuals who were anti-CCP-positive, subclinical synovitis disappeared in approximately half of the participants by 12 months and was associated with the presence of good prognostic factors. Subclinical synovitis should be interpreted in the context of these additional factors. FUNDING National Institute for Health Research Leeds Biomedical Research Centre.
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Affiliation(s)
- Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Rotherham General Hospital, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jing Kang
- School of Dentistry, University of Leeds, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Harnden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Overgaard J, Thilagar BP, Bhuiyan MN. A Clinician's Guide to the Implementation of Point-of-Care Ultrasound (POCUS) in the Outpatient Practice. J Prim Care Community Health 2024; 15:21501319241255576. [PMID: 38773821 PMCID: PMC11113028 DOI: 10.1177/21501319241255576] [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: 02/22/2024] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/24/2024] Open
Abstract
Point-of-care ultrasound (POCUS) is a valuable clinical tool used at the patient bedside to rapidly assess a wide variety of symptoms and problems which would otherwise take hours or even days. Though it has become the standard of care in Emergency Medicine and is becoming so in hospital internal medicine, less uptake has been appreciated in the outpatient setting despite reported interest from clinicians practicing there. A number of common barriers have been cited to explain this gap in use, which usually include access to equipment, mentorship, and time. In this review we present a proposed framework for clinicians who have an interest in implementing POCUS in their outpatient practice which we hope can mitigate some of these barriers and provide a more streamlined pathway to their desired goals.
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Ishizaki J. Assessment of Musculoskeletal Ultrasound of Rheumatoid Arthritis. Methods Mol Biol 2024; 2766:335-342. [PMID: 38270893 DOI: 10.1007/978-1-0716-3682-4_34] [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] [Indexed: 01/26/2024]
Abstract
Musculoskeletal ultrasound (MSUS) is a valuable tool that is used in outpatient clinics or at the bedside to assess multiple joint sites, including small joints. It provides detailed images of structures commonly observed in rheumatoid arthritis (RA), such as synovitis, tenosynovitis, bone erosions, cartilage damage, and synovial fluid accumulation. MSUS is frequently used in the management of RA and provides more objective information for an early diagnosis and disease activity assessment through imaging findings.
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Affiliation(s)
- Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Toon, Ehime, Japan.
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Abe T, Tamura M, Azuma N, Matsui K. The role of pain catastrophizing in pain perception among patients with rheumatoid arthritis without clinical signs of inflammation. Musculoskeletal Care 2023; 21:694-701. [PMID: 36748978 DOI: 10.1002/msc.1740] [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: 01/12/2023] [Revised: 01/20/2023] [Accepted: 01/25/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Pain in rheumatoid arthritis (RA) is considered to be associated with non-inflammatory factors, including physical disabilities, psychiatric disorders, and pain catastrophizing (PC). PC is reportedly a key driver in the development of pain in patients with RA without clinical signs of inflammation; however, previous studies enroled patients with RA who were potentially in an inflammatory state. Hence, our aim was to investigate the role of PC as the possible link between pain, physical disabilities, and psychiatric disorders in patients with RA without clinical signs of inflammation. MATERIALS AND METHODS In this cross-sectional study, 81 patients with RA without clinical signs of inflammation were included; all patients had serum C-reactive protein levels <0.5 mg/dL, without any inflammatory joints. We examined the demographic and clinical data and administered the pain visual analogue scale (VAS), pain catastrophizing scale (PCS), Health Assessment Questionnaire Disability Index (HAQ-DI), and patient version of the Brief Scale for Psychiatric Problems in Orthopaedic Patients (pBS-POP). A series of multivariate-adjusted multiple regression analyses were performed to examine the associations between PC and pain intensity, physical disabilities, and psychiatric disorders. RESULTS We found associations between all the above-mentioned variables in separate models with HAQ-DI, pBS-POP, and PCS scores. However, in the model associated with pain VAS, the PCS score (β = 0.34, p = 0.0073) emerged as the only variable showing a statistically significant association. CONCLUSIONS PC is associated with pain in patients with RA without clinical signs of inflammation, and this association may be mediated through pathways involving physical disabilities and psychiatric disorders.
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Affiliation(s)
- Takeo Abe
- Division of Diabetes, Endocrinology and Clinical Immunology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
- Department of Rheumatology Medicine, Kobe City Medical Center West Hospital, Kobe-shi, Hyogo, Japan
| | - Masao Tamura
- Division of Diabetes, Endocrinology and Clinical Immunology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
- Department of Rheumatology Medicine, Kobe City Medical Center West Hospital, Kobe-shi, Hyogo, Japan
| | - Naoto Azuma
- Division of Diabetes, Endocrinology and Clinical Immunology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
| | - Kiyoshi Matsui
- Division of Diabetes, Endocrinology and Clinical Immunology, Department of Internal Medicine, Hyogo Medical University, Nishinomiya, Hyogo, Japan
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ÇAPKIN E. Musculoskeletal ultrasonography in rheumatic diseases. Turk J Med Sci 2023; 53:1537-1551. [PMID: 38813491 PMCID: PMC10760546 DOI: 10.55730/1300-0144.5723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 12/12/2023] [Accepted: 07/20/2023] [Indexed: 05/31/2024] Open
Abstract
Ultrasonography is an imaging technique based on sound waves used for the evaluation of soft tissues. Sound waves have been used for a long time in nonmedical fields, including military defense systems, radar systems, and detection of icebergs. Technological advances resulted in new techniques becoming available for medical imaging, including ultrasonography, magnetic resonance imaging, and computed tomography. Nowadays, the use of imaging has become a gold standard protocol in the diagnosis of many diseases, and recently developed diagnosis and therapy options provide more efficient treatment of rheumatic diseases. Thus, it has become possible to prevent structural damage and disability in patients with rheumatic disease. Musculoskeletal ultrasonography is becoming a preferred imaging technique for rheumatic diseases, as it has many advantages. Among its advantages are being inexpensive, being radiation-free, having a dynamic image capacity, helping to detect disease activity, and helping with early detection and diagnosis of structural damage. This review summarizes the use of ultrasonography in rheumatic diseases.
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Affiliation(s)
- Erhan ÇAPKIN
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Karadeniz Technical University, Farabi Hospital, Trabzon,
Turkiye
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Koppikar S, Diaz P, Kaeley GS, Eder L. Seeing is believing: Smart use of musculoskeletal ultrasound in rheumatology practice. Best Pract Res Clin Rheumatol 2023; 37:101850. [PMID: 37481369 DOI: 10.1016/j.berh.2023.101850] [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: 05/10/2023] [Accepted: 06/19/2023] [Indexed: 07/24/2023]
Abstract
Musculoskeletal ultrasonography has become an increasingly valuable tool as a complement to the physical exam in rheumatology practice. Its point-of-care access, low cost, safety, portability, and reliability in trained hands, make this technique especially useful in patients with inflammatory arthritis. Growing evidence has demonstrated the value of musculoskeletal ultrasound in the detection of inflammatory and structural changes in patients with joint pain without obvious joint swelling, in differentiating various inflammatory diagnoses, in the monitoring of inflammatory arthritis, and interventional procedures. The potential role of ultrasound guiding treat-to-target strategies or tapering treatment in inflammatory arthritis requires further research. However, musculoskeletal ultrasound can also have pitfalls and limitations that a clinician should be aware of.
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Affiliation(s)
- Sahil Koppikar
- Division of Rheumatology, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pamela Diaz
- Departamento de Inmunologia Clinica y Reumatologia, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Gurjit S Kaeley
- Division of Rheumatology and Clinical Immunology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Lihi Eder
- Division of Rheumatology, Women's College Hospital, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada.
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Parisi S, Zanetti A, Carrara G, Scirè CA, Iagnocco A, Filippou G. Relationship between the prevalence of subclinical tenosynovitis and treatment in patients with RA in clinical remission: STARTER study. Rheumatology (Oxford) 2022; 62:1485-1492. [PMID: 36066434 DOI: 10.1093/rheumatology/keac518] [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: 05/31/2022] [Revised: 08/04/2022] [Accepted: 08/30/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This study is a sub-analysis from the patient cohort of the STARTER (Sonographic Tenosynovitis Assessment in RheumaToid arthritis patiEnts in Remission) study. The aim was to evaluate differences in ultrasound-detected joint and/or tendon involvement between patients receiving therapies based on a combination of csDMARDs and bDMARDs and those who were treated with either csDMARDs or bDMARDs in monotherapy. METHODS 427 consecutive patients with a diagnosis of rheumatoid arthritis were recruited between October 2013 and June 2014.They were divided into 3 subgroups based on their therapy at baseline: patients with bDMARDs in monotherapy, patients with csDMARDs in monotherapy, patients in combination therapy (csDMARD+bDMARD). At baseline, 6 months and 12 months, a clinical examination (28 joint count), an ultrasound evaluation were performed in each patient. A score of Grey Scale (GS) and Power Doppler (PD)-synovitis and -tenosynovitis, was calculated based on the OMERACT scoring systems. RESULTS 256 patients completed the observation period: 48 patients from the bDMARDs group (19.7%), 152 patients from the csDMARDs group (59.1%) and 56 pts from csDMARD+bDMARD group (21.8%).The analysis has shown that GS-tenosynovitis and PD-tenosynovitis are better controlled in combination therapy than they are with csDMARDs alone (p:0.025 and p:0.047, respectively); for PD synovitis, there was a better response in those who were treated with the combination therapy when compared to the patients in csDMARD (p:0.01) and those in bDMARD (p:0.02). CONCLUSION The analysis showed a lower prevalence of subclinical inflammatory manifestations detected with ultrasound imaging in those patients treated with the combination therapy than in those in monotherapy.
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Affiliation(s)
- Simone Parisi
- Rheumatology Unit, AOU Città Della Salute e della Scienza di Torino, Turin, Italy
| | - Anna Zanetti
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy
| | - Carlo Alberto Scirè
- Epidemiology Unit, Italian Society for Rheumatology, Milan, Italy.,School of Medicine, University of Milano Bicocca, Milan, Italy, Milan, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Georgios Filippou
- IRCCS Istituto Ortopedico Galeazzi, Department of Rheumatology, Milan, Italy
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VEGF Profile in Early Undifferentiated Arthritis Cohort. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58060833. [PMID: 35744097 PMCID: PMC9230586 DOI: 10.3390/medicina58060833] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 05/29/2022] [Accepted: 06/15/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Early undifferentiated arthritis (UA) is a group of inflammatory joint diseases that are not classified under any specific rheumatic or connective tissue disorder and might evolve into chronic inflammatory arthritis or may be a self-limiting condition. Early recognition and treatment are crucial for the future course of the disease. Vascular endothelial growth factor (VEGF) is an angiogenic regulator that induces the growth of new capillary blood vessels, which are important in joint invasion and destruction during the progression of chronic inflammatory arthritis. The aim of this study was to assess VEGF levels associated with sociodemographic, clinical, laboratory, and ultrasound findings in the early UA patient cohort as well as to evaluate VEGF as a potential prognostic marker for arthritis outcomes. Materials and Methods: Seventy-six patients with inflammatory arthritis in at least one joint, with a duration of arthritis <12 months at the study entry that did not meet any rheumatic disease classification criteria, were enrolled after informed consent was obtained. Patient’s sociodemographic, laboratory data, and clinical disease characteristics were recorded, VEGF levels were measured, and ultrasound (US) of tender and swollen joints was performed. Results: VEGF levels had positive correlation with conventional rheumatic disease activity and diagnostic markers: erythrocyte sedimentation rate (ESR), C−reactive protein (CRP), and rheumatoid factor (RF) (p < 0.05). RF-positive patients had higher VEGF values (p = 0.024). A statistically higher number of patients whose VEGF levels were below the median value presented with active infection (p = 0.046). In patients with a higher number of swollen joints, and a higher score of synovitis and power doppler (PD) seen on US, VEGF levels were statistically significantly higher. Patients who after 12-month follow-up developed rheumatoid arthritis (RA) had statistically higher VEGF levels at baseline compared with those who developed spondyloarthropathies (p = 0.028). Conclusions: This study demonstrated that VEGF levels significantly represented inflammatory processes that were present in the joints (number of swollen joints, synovitis, and PD changes) of the early UA cohort.
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Kondo Y, Kaneko Y, Takeuchi T. Differential Diagnosis of Inflammatory Arthritis from Musculoskeletal Ultrasound View. RHEUMATOLOGY AND IMMUNOLOGY RESEARCH 2022; 3:54-60. [PMID: 36465322 PMCID: PMC9524817 DOI: 10.2478/rir-2022-0010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 03/05/2022] [Indexed: 06/17/2023]
Abstract
Diagnostic imaging in rheumatology has evolved over the centuries, and novel imaging modalities, including musculoskeletal ultrasonography (MSUS) and magnetic resonance imaging (MRI), are being widely used in the 21st century. With the increase in availability of molecular target-specific therapies, including biologic agents and Janus kinase (JAK) inhibitors, the therapeutic outcome of inflammatory arthritis has changed, and early and accurate diagnosis of inflammatory rheumatic diseases has become more important. Given this situation, MSUS, which is a portable, convenient, noninvasive, and cost-effective imaging technique, plays an important role in the diagnosis of rheumatic diseases. MSUS can be used to detect subclinical inflammation and to accurately determine the distribution of joint involvement and inflammation sites in each joint. Definitive diagnosis for patients with early arthritis should be made after noting their history and performing clinical examination, laboratory testing, and additional procedures. However, MSUS is an extension of physical examination and it can provide a further opportunity and motivation to consider differential diagnoses rather than a conclusive diagnosis. This review aims to describe the usefulness of MSUS in differential diagnoses of the phenotype of early inflammatory arthritis.
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Affiliation(s)
- Yasushi Kondo
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Shinjuku, Tokyo160-8582, Japan
| | - Yuko Kaneko
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Shinjuku, Tokyo160-8582, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Shinjuku, Tokyo160-8582, Japan
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12
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de Pablo P, Dinnes J, Berhane S, Osman A, Lim Z, Coombe A, Raza K, Filer A, Deeks JJ. Systematic review of imaging tests to predict the development of rheumatoid arthritis in people with unclassified arthritis. Semin Arthritis Rheum 2021; 52:151919. [PMID: 34782180 DOI: 10.1016/j.semarthrit.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/16/2021] [Accepted: 10/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To estimate and compare the diagnostic accuracy of magnetic resonance imaging (MRI) and ultrasound, for the prediction of rheumatoid arthritis (RA) in unclassified arthritis (UA). METHODS MEDLINE, Embase and BIOSIS were searched from 1987 to May 2019. Studies evaluating any imaging test in participants with UA were eligible. Reference standards were RA classification criteria or methotrexate initiation. Two authors independently extracted data and assessed validity using QUADAS-2. Sensitivities and specificities were calculated for each imaging characteristic and joint area. Summary estimates with 95% confidence intervals (CI) were estimated where possible. RESULTS Nineteen studies were included; 13 evaluated MRI (n=1,143; 454 with RA) and 6 evaluated ultrasound (n=531; 205 with RA). Studies were limited by unclear recruitment procedures, inclusion of patients with RA at baseline, differential verification, lack of blinding and consensus grading. Study heterogeneity largely precluded meta-analysis, however summary sensitivity and specificity for MRI synovitis in at least one joint were 93% (95% CI 88%, 96%) and 25% (95% CI 13%, 41%) (3 studies). Specificities may be higher for other MRI characteristics but data are limited. Ultrasound results were difficult to synthesise due to different diagnostic thresholds and reference standards. CONCLUSION The evidence for MRI or ultrasound as single tests for predicting RA in people with UA is heterogeneous and of variable methodological quality. Larger studies using consensus grading and consistently defined RA diagnosis are needed to identify whether combinations of imaging characteristics, either alone or in combination with other clinical findings, can better predict RA in this population.
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Affiliation(s)
- Paola de Pablo
- Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jacqueline Dinnes
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK.
| | - Sarah Berhane
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Aya Osman
- Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - Zhia Lim
- Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK
| | - April Coombe
- Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Karim Raza
- Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK; Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Andrew Filer
- Institute of Inflammation and Ageing, College of Medical & Dental Sciences, University of Birmingham, Birmingham, UK; NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK
| | - Jonathan J Deeks
- NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, UK; Test Evaluation Research Group, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
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13
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Rogier C, Wouters F, van Boheemen L, van Schaardenburg D, de Jong PHP, van der Helm-van Mil AHM. Subclinical synovitis in arthralgia: how often does it result in clinical arthritis? Reflecting on starting points for disease-modifying anti-rheumatic drug treatment. Rheumatology (Oxford) 2021; 60:3872-3878. [PMID: 33331633 PMCID: PMC8328495 DOI: 10.1093/rheumatology/keaa774] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/07/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives According to guidelines, clinical arthritis is mandatory for diagnosing RA. However, in the absence of clinical synovitis, imaging-detected subclinical synovitis is increasingly used instead and is considered as a starting point for DMARD therapy. To search for evidence we studied the natural course of arthralgia patients with subclinical synovitis from three longitudinal cohorts and determined the frequencies of non-progression to clinically apparent inflammatory arthritis (IA) (i.e. ‘false positives’). Methods Subclinical synovitis in the hands or feet of arthralgia patients was visualized with US (two cohorts; definition: greyscale ≥2 and/or power Doppler ≥1) or MRI (one cohort; definition: synovitis score ≥1 by two readers). Patients were followed for 1 year on for IA development; two cohorts also had 3 year data. Analyses were stratified for ACPA. Results Subclinical synovitis at presentation was present in 36%, 41% and 31% in the three cohorts. Of the ACPA-positive arthralgia patients with subclinical synovitis, 54%, 44% and 68%, respectively, did not develop IA. These percentages were even higher in the ACPA-negative arthralgia patients: 66%, 85% and 89%, respectively. Similar results were seen after 3 years of follow-up. Conclusion Replacing clinical arthritis with subclinical synovitis to identify RA introduces a high false-positive rate (44–89%). These data suggest an overestimation regarding the value of ACPA positivity in combination with the presence of subclinical synovitis in patients with arthralgia, which harbours the risk of overtreatment if DMARDs are initiated in the absence of clinical arthritis.
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Affiliation(s)
- Cleo Rogier
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fenne Wouters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Pascal H P de Jong
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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14
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Kobayashi K, Nakagomi D, Kobayashi Y, Ajima C, Hanai S, Koyama K, Ikeda K. Ultrasound of shoulder and knee improves the accuracy of the 2012 EULAR/ACR provisional classification criteria for polymyalgia rheumatica. Rheumatology (Oxford) 2021; 61:1185-1194. [PMID: 34164671 PMCID: PMC8889301 DOI: 10.1093/rheumatology/keab506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 06/11/2021] [Indexed: 11/24/2022] Open
Abstract
Objective Recent studies suggest that the knee is frequently involved in PMR. In this study, we aimed to determine whether the US assessment of the shoulder and knee discriminates between PMR and other differential diagnoses and improves the accuracy of the 2012 EULAR/ACR provisional classification criteria for PMR. Methods We consecutively enrolled 81 untreated patients who received a diagnosis of PMR. These patients were divided into two groups based on the final diagnosis made at 1-year follow-up: PMR-definite group (n = 60) and PMR-mimic group (n = 21). We also enrolled age/sex-matched untreated RA patients with shoulder pain from an independent cohort (RA group, n = 60). All patients underwent comprehensive US assessment of the shoulder and knee for synovitis, bursitis, tenosynovitis, tendinitis and ligament inflammation at baseline. Results US scores for tenosynovitis, tendinitis and ligament inflammation better discriminated the PMR-definite group from the PMR-mimic and RA groups than do those for synovitis or bursitis. Among logistic regression models to identify US variables that were associated with the PMR-definite group, the best fitted model included two US variables: the bilateral involvement of the shoulder (long head of biceps, supraspinatus or subscapularis tendon) and the bilateral involvement of the knee (popliteus tendon or medial or lateral collateral ligament). Incorporating these two items into the 2012 EULAR/ACR provisional classification criteria numerically increased the accuracy to classify the PMR-definite group. Conclusion US assessment of the tendon/ligament-related lesions in the shoulder and knee may improve the accuracy of the 2012 EULAR/ACR provisional classification criteria for PMR.
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Affiliation(s)
- Kei Kobayashi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Third Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Daiki Nakagomi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Third Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Yoshiaki Kobayashi
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Third Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Chisaki Ajima
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Third Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Shunichiro Hanai
- Department of Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Third Department of Internal Medicine, University of Yamanashi, Yamanashi, Japan.,Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan
| | - Kensuke Koyama
- Center for Clinical Immunology and Rheumatology, University of Yamanashi Hospital, Yamanashi, Japan.,Department of Orthopaedic Surgery, University of Yamanashi, Yamanashi, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
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15
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Kato M, Ikeda K, Sugiyama T, Tanaka S, Iida K, Suga K, Nishimura N, Mimura N, Kasuya T, Kumagai T, Furuya H, Iwamoto T, Iwata A, Furuta S, Suto A, Suzuki K, Kawakami E, Nakajima H. Associations of ultrasound-based inflammation patterns with peripheral innate lymphoid cell populations, serum cytokines/chemokines, and treatment response to methotrexate in rheumatoid arthritis and spondyloarthritis. PLoS One 2021; 16:e0252116. [PMID: 34019595 PMCID: PMC8139502 DOI: 10.1371/journal.pone.0252116] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/10/2021] [Indexed: 01/22/2023] Open
Abstract
Objectives We aimed to explore the associations of musculoskeletal inflammation patterns with peripheral blood innate lymphoid cell (ILC) populations, serum cytokines/chemokines, and treatment response to methotrexate in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods We enrolled 100 patients with either RA or SpA and performed ultrasound to evaluate power Doppler signals for synovitis (52 joint regions), tenosynovitis (20 tendons), and enthesitis (44 sites). We performed clustering analysis using unsupervised random forest based on the multi-axis ultrasound information and classified the patients into groups. We identified and counted ILC1-3 populations in the peripheral blood by flow cytometry and also measured the serum levels of 20 cytokines/chemokines. We also determined ACR20 response at 3 months in 38 patients who began treatment with methotrexate after study assessment. Results Synovitis was more prevalent and severe in RA than in SpA, whereas tenosynovitis and enthesitis were comparable between RA and SpA. Patients were classified into two groups which represented synovitis-dominant and synovitis-nondominant inflammation patterns. While peripheral ILC counts were not significantly different between RA and SpA, they were significantly higher in the synovitis-nondominant group than in the synovitis-dominant group (ILC1-3: p = 0.0007, p = 0.0061, and p = 0.0002, respectively). On the other hand, clustering of patients based on serum cytokines/chemokines did not clearly correspond either to clinical diagnoses or to synovitis-dominant/nondominant patterns. The synovitis-dominant pattern was the most significant factor that predicted clinical response to methotrexate (p = 0.0065). Conclusions Musculoskeletal inflammation patterns determined by ultrasound are associated with peripheral ILC counts and could predict treatment response to methotrexate.
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Affiliation(s)
- Manami Kato
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
- * E-mail:
| | - Takahiro Sugiyama
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Shigeru Tanaka
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kazuma Iida
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kensuke Suga
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Nozomi Nishimura
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Norihiro Mimura
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Tadamichi Kasuya
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Takashi Kumagai
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Hiroki Furuya
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Taro Iwamoto
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Arifumi Iwata
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Akira Suto
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kotaro Suzuki
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Eiryo Kawakami
- Artificial Intelligence Medicine, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
- Medical Sciences Innovation Hub Program, RIKEN, Wako, Saitama, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
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16
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Recommendations for the pragmatic use of ultrasound in rheumatoid arthritis by the GEISPER French group. Joint Bone Spine 2021; 88:105187. [PMID: 33892194 DOI: 10.1016/j.jbspin.2021.105187] [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: 12/03/2020] [Accepted: 03/30/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To develop recommendations for the appropriate use of ultrasound in the management of rheumatoid arthritis (RA) in routine practice based on data from the literature and of experts opinion. METHODS Based on a systematic literature review, a scientific committee decided on themes and relevant questions to draw up an initial draft of recommendations. These recommendations were submitted to a group of experts in ultrasound in rheumatic and musculoskeletal diseases using a Delphi method, which produced preliminary recommendations. These were submitted to an expanded group of ultrasound experts for relevance, comprehensibility and comprehensiveness. The level of agreement of the experts were recorded during a face-to-face meeting. RESULTS Following two rounds of the Delphi, a consensus was reached on three overarching principles, including definitions of joints, tendons and articular sites to be examined, and 10 recommendations. These recommendations underline the benefit of ultrasound for the diagnosis of RA in cases of inflammatory arthralgia or undifferentiated arthritis as well as in assessing the extent of initial structural and inflammatory damage. They also define the role of ultrasound during follow-up or when considering treatment reduction once clinical remission has been achieved. Lastly, they illustrate the utility of ultrasound in facilitating technical procedures. CONCLUSION These 10 consensus-based recommendations should harmonize and optimize clinical practice and thus improve the management of RA patients.
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17
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Ziegelasch M, Eloff E, Hammer HB, Cedergren J, Martinsson K, Reckner Å, Skogh T, Magnusson M, Kastbom A. Bone Erosions Detected by Ultrasound Are Prognostic for Clinical Arthritis Development in Patients With ACPA and Musculoskeletal Pain. Front Med (Lausanne) 2021; 8:653994. [PMID: 33834034 PMCID: PMC8021704 DOI: 10.3389/fmed.2021.653994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
Anti-citrullinated protein antibodies (ACPA) often precede onset of rheumatoid arthritis (RA) by years, and there is an urgent clinical need for predictors of arthritis development among such at-risk patients. This study assesses the prognostic value of ultrasound for arthritis development among ACPA-positive patients with musculoskeletal pain. We prospectively followed 82 ACPA-positive patients without clinical signs of arthritis at baseline. Ultrasound at baseline assessed synovial hypertrophy, inflammatory activity by power Doppler, and erosions in small joints of hands and feet. We applied Cox regression analyses to examine associations with clinical arthritis development during follow-up (median, 69 months; range, 24–90 months). We also compared the ultrasound findings among the patients to a control group of 100 blood donors without musculoskeletal pain. Clinical arthritis developed in 39/82 patients (48%) after a median of 6 months (range, 1–71 months). One or more ultrasound erosions occurred in 13/82 patients (16%), with none in control subjects (p < 0.001). Clinical arthritis development was more common among patients with baseline ultrasound erosions than those without (77 vs. 42%, p = 0.032), and remained significant in a multivariable Cox regression analysis that included previously described prognostic factors (HR 3.9, 95% CI 1.6–9.4, p = 0.003). Ultrasound-detected tenosynovitis was more frequent among the patients and associated with clinical arthritis development in a univariable analysis (HR 2.5, 95% CI 1.1–5.7, p = 0.031), but did not remain statistically significant in multivariable analysis. Thus, bone erosions detected by ultrasound are independent predictors of clinical arthritis development in an ACPA-positive at-risk population. Trial Registration: Regional Ethics Committee in Linköping, Sweden, Dnr M220-09. Registered 16 December 2009, https://etikprovningsmyndigheten.se/.
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Affiliation(s)
- Michael Ziegelasch
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Emma Eloff
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Jan Cedergren
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Klara Martinsson
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Åsa Reckner
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Thomas Skogh
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mattias Magnusson
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Alf Kastbom
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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18
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Stein M, Vaillancourt J, Rampakakis E, Sampalis JS. Prospective observational study to evaluate the use of musculoskeletal ultrasonography in rheumatoid arthritis management: the ECHO study. Rheumatology (Oxford) 2021; 59:2746-2753. [PMID: 32011706 DOI: 10.1093/rheumatology/keaa004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/25/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Since the creation of the Canadian Rheumatology Ultrasonography Society, an increasing number of rheumatologists has been trained in the use of musculoskeletal US (MSUS). We compared the effectiveness of MSUS to routine care (RC) as a disease management tool in patients with moderate-to-severe RA requiring a treatment change due to lack of efficacy. The predictive value of MSUS was also assessed. METHODS This was a prospective, two-cohort, quasi-experimental study. Patients were managed either with MSUS (within the Canadian Rheumatology Ultrasonography Society) or as per RC for up to 1 year. Main outcomes included Clinical Disease Activity Index low disease activity/remission, DAS28 low disease activity/remission, MSUS scores, patient satisfaction and perception of participation in disease management. RESULTS A total of 383 patients were enrolled (MSUS: n = 171; RC: n = 212). At baseline, a greater proportion of MSUS patients were treated with a biologic DMARD (50.3 vs 36.8%; P = 0.008) while more patients treated per RC received a non-biologic DMARD (84.2 vs 91.5%; P = 0.027). During follow-up, a greater number of RA treatment modifications was applied in the MSUS group compared with RC [adjusted incidence rate ratio (95% CI): 1.4 (1.1, 1.8)], including steroids, non-biologic DMARDs and biologic DMARDs. Regarding clinical and patient-reported outcomes, no remarkable differences were observed between groups. However, throughout the study, 50-80% of MSUS patients in clinical remission has a MSUS synovitis score of ≥1, and 37-73% an erosion score of ≥1. Significant associations were observed between baseline synovitis and joint erosion during follow-up. CONCLUSION MSUS assessments can be useful in detecting subclinical levels of inflammation and predicting future joint deterioration, thus allowing optimization of RA treatment and patient care.
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Affiliation(s)
- Michael Stein
- Division of Rheumatology, McGill University.,Canadian Rheumatology Ultrasonography Society (CRUS)
| | | | | | - John S Sampalis
- Medical Affairs, JSS Medical Research.,Division of Surgical Research, McGill University, Montreal, QC, Canada
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19
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Duquenne L, Chowdhury R, Mankia K, Emery P. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on "At-Risk" Individuals. Front Med (Lausanne) 2020; 7:587827. [PMID: 33195348 PMCID: PMC7662561 DOI: 10.3389/fmed.2020.587827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023] Open
Abstract
In individuals at-risk of developing inflammatory arthritis, the value of an ultrasound (US) scan assessment to predict progression has been demonstrated repeatedly. However, depending on recruitment criteria, these individuals may be at different stages in the arthritis development continuum, therefore representing a heterogeneous population. As a consequence, the predictive value of ultrasound results may differ between cohorts. As other reviews have focused on the challenges in population recruitment or have combined biomarkers predicting value according to one recruitment pathway, we wanted to focus on the sole use of ultrasound assessment and its variation according to population recruitment criteria. In this review, we discuss the use of ultrasound in the different at-risk populations across the inflammatory arthritis disease continuum. This review demonstrates that although some sub-population data is scarce, ultrasound is best predictive in three at-risk populations: those with a positive ACPA test in the context of non-specific MSK symptoms, those with clinically suspect arthralgia and those with palindromic rheumatism. We consider that ultrasound assessment will be a cornerstone in prediction risk modeling and prevention studies of the preclinical phases of IA in the future.
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Affiliation(s)
- Laurence Duquenne
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Kulveer Mankia
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Paul Emery
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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20
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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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21
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Sakellariou G, Scirè CA, Adinolfi A, Batticciotto A, Bortoluzzi A, Delle Sedie A, De Lucia O, Dejaco C, Epis OM, Filippucci E, Idolazzi L, Picchianti Diamanti A, Zabotti A, Iagnocco A, Filippou G. Differential Diagnosis of Inflammatory Arthropathies by Musculoskeletal Ultrasonography: A Systematic Literature Review. Front Med (Lausanne) 2020; 7:141. [PMID: 32457913 PMCID: PMC7221062 DOI: 10.3389/fmed.2020.00141] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 03/31/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Differential diagnosis in early arthritis is challenging, especially early after symptom onset. Several studies applied musculoskeletal ultrasound in this setting, however, its role in helping diagnosis has yet to be clearly defined. The purpose of this work is to systematically assess the diagnostic applications of ultrasonography in early arthritis in order to summarize the available evidence and highlight possible gaps in knowledge. Methods: In December 2017, existing systematic literature reviews (SLR) on rheumatoid arthritis (RA), osteoarthritis (OA), psoriatic arthritis (PsA), polymyalgia rheumatica (PMR), calcium pyrophosphate deposition disease (CPPD), and gout were retrieved. Studies on ultrasound to diagnose the target conditions and detecting elementary lesions (such as synovitis, tenosynovitis, enthesitis, bone erosions, osteophytes) were extracted from the SLRs. The searches of the previous reviews were updated and data from new studies fulfilling the inclusion criteria extracted. Groups of reviewers worked separately for each disease, when possible diagnostic accuracy (sensitivities, specificities) was calculated from primary studies. When available, the reliability of ultrasound to detect elementary lesions was extracted. Results: For all the examined disease, recent SLRs were available. The new searches identified 27 eligible articles, with 87 articles included from the previous SLRs. The diagnostic performance of ultrasound in identifying diseases was addressed by 75 studies; in most of them, a single elementary lesion was used to define diagnosis, except for PMR. Only studies on RA included consecutive patients with new onset of arthritis, while studies on gout and CPPD often focused on subjects with mono-arthritis. Most of the remaining studies enrolled patients with a defined diagnosis. Synovitis was the most frequently detected lesion; clinical diagnosis was the most common reference standard. The diagnostic performance of ultrasound across different conditions was extremely variable. Ultrasound to identify elementary lesions was assessed in 38 studies in OA, gout and CPPD. Its performance in OA was very variable, with better results in CPPD and gout. The reliability of ultrasound was moderate to good for most lesions. Conclusions: Although a consistent amount of literature investigated the diagnostic application of ultrasound, in only a minority of cases its additional value over clinical diagnosis was tested. This SLR underlines the need for studies with a pragmatic design to identify the placement of ultrasound in the diagnostic pathway of new-onset arthritis.
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Affiliation(s)
- Garifallia Sakellariou
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Carlo Alberto Scirè
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy.,Società Italiana di Reumatologia, Unità Epidemiologica, Milan, Italy
| | | | - Alberto Batticciotto
- Rheumatology Unit, Department of Internal Medicine, ASST-Settelaghi, "Ospedale di Circolo - Fondazione Macchi", Varese, Italy
| | - Alessandra Bortoluzzi
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
| | | | - Orazio De Lucia
- Unit of Clinical Rheumatology, Department of Rheumatology and Clinical Sciences, ASST Centro Traumatologico Ortopedico G. Pini - CTO, Milan, Italy
| | - Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Austria.,Department of Rheumatology, Hospital of Bruneck, Bruneck, Italy
| | | | - Emilio Filippucci
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Carlo Urbani Hospital, Polytechnic University of Marche, Ancona, Italy
| | - Luca Idolazzi
- Rheumatology Unit, Ospedale Civile Maggiore, University of Verona, Verona, Italy
| | - Andrea Picchianti Diamanti
- Department of Clinical and Molecular Medicine, S. Andrea University Hospital, "Sapienza" University, Rome, Italy
| | - Alen Zabotti
- Department of Medical and Biological Science, Rheumatology Clinic, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Annamaria Iagnocco
- Academic Rheumatology Centre, Università degli Studi di Torino, Turin, Italy
| | - Georgios Filippou
- UOC e Sezione di Reumatologia - Dipartimento di Scienze Mediche, Università degli Studi di Ferrara, Ferrara, Italy
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Gitto S, Messina C, Chianca V, Tuscano B, Lazzara A, Corazza A, Pedone L, Albano D, Sconfienza LM. Superb microvascular imaging (SMI) in the evaluation of musculoskeletal disorders: a systematic review. Radiol Med 2020; 125:481-490. [DOI: 10.1007/s11547-020-01141-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 01/16/2020] [Indexed: 12/12/2022]
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Saku A, Furuta S, Kato M, Furuya H, Suzuki K, Fukuta M, Suehiro K, Makita S, Tamachi T, Ikeda K, Takatori H, Maezawa Y, Suto A, Suzuki K, Hirose K, Nakajima H. Experience of musculoskeletal ultrasound scanning improves physicians' physical examination skills in assessment of synovitis. Clin Rheumatol 2020; 39:1091-1099. [PMID: 32008154 DOI: 10.1007/s10067-020-04960-5] [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: 09/10/2019] [Revised: 12/18/2019] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Musculoskeletal ultrasound (US) is more sensitive than physical examination in detecting synovitis and helps physicians to understand its pathophysiology. In this study, we aimed to determine if the experience in musculoskeletal US scanning is independently associated with improved physical examination skills to detect synovitis. METHOD Seventy patients with rheumatoid arthritis and twenty-three physicians were enrolled. Patients were first assessed by multiple physicians with a range of clinical/sonographic experience for the swelling of the wrist, metacarpophalangeal and proximal interphalangeal (PIP) joints and next underwent US assessment performed by another physician experienced in musculoskeletal US. We then calculated the positive/negative predictive values (PPV/NPV) of joint swelling to identify US-detected synovial hypertrophy. Finally, the factors independently associated with the accuracy of clinical assessment were identified by using multivariate analyses. RESULTS One thousand five hundred forty joints were assessed 6116 times in total for swelling. Overall, PPV and NPV of joint swelling were 51.7% and 88.3%, respectively. Multivariate analyses identified wrist joint, tenderness, male and greater patients' age as the factors significantly associated with higher PPV. In addition, there was a trend that longer experience in rheumatology clinical practice was associated with higher PPV (p = 0.058). On the other hand, longer experience in musculoskeletal US, PIP joint and positive rheumatoid factor were identified as the significant factors for higher NPV, while wrist joint, tenderness, presence of osteophyte and obesity as those for lower NPV. CONCLUSION Our data suggest that the experience in musculoskeletal US improves physical examination skills particularly to avoid overestimation.Key Points• Physicians with longer US experience are less likely to overestimate synovitis by physical examination.• Musculoskeletal US is a useful tool for rheumatologists to improve their physical examination skill.• Presence of osteophytes, joint tenderness and obesity influence the accuracy of physical examination of joints.
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Affiliation(s)
- Aiko Saku
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan.
| | - Manami Kato
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hiroki Furuya
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Kazumasa Suzuki
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Masashi Fukuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Kenichi Suehiro
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Sohei Makita
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Tomohiro Tamachi
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hiroaki Takatori
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Yuko Maezawa
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Akira Suto
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Kotaro Suzuki
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Koichi Hirose
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8670, Japan
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Boylan M. Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis? Ir J Med Sci 2019; 189:735-748. [PMID: 31646431 DOI: 10.1007/s11845-019-02096-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 09/04/2019] [Indexed: 12/29/2022]
Abstract
INTRODUCTION A growing body of evidence indicates the benefits of early diagnosis of rheumatoid arthritis (RA) and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDS) in terms of relieving symptoms, improving prognosis, and reducing long-term complications. There is however some controversy over the most beneficial method of imaging in providing accurate early diagnosis. Though current practice favours clinical and radiological assessment, this is increasingly supplemented by ultrasound techniques (and, to a lesser extent, CT and MRI scanning). While EULAR and ESSR favour the use of ultrasonography (US) as the first-line investigation in cases of suspected RA, a recent NICE review upholds the traditional place of plain film radiographs of hands and feet to detect erosions as early signs of synovitis. This review considers the evidence for US in the early diagnosis of RA and the case for it becoming the primary assessment modality in rheumatology clinics. AIMS This paper aims to assess the current literature on the efficacy of ultrasonography in diagnosing early RA, by comparing US with alternative imaging modalities. The goal is to propose the most appropriate method of diagnosis to improve early initiation of DMARD treatment for optimum disease outcomes. METHODS Searches for related studies and review articles were carried out using electronic databases and hand searches. Additional references were gleaned from the bibliographies of included papers. Related articles and pop-outs from PubMed were also used. The search was refined in PubMed, by only using reviews which were written in English and published in past 10 years and had full free text available. RESULTS This review confirms that US has a high level of sensitivity in diagnosing RA (and hence a low risk of missing cases of RA which might benefit from early treatment with DMARDs). It also has a high level of specificity (and hence a low risk of falsely diagnosing somebody with RA who may suffer adverse effects of DMARD therapy). US is already widely available and well accepted by clinicians and patients. It does not involve exposure to radiation and can be readily delivered by appropriately trained staff. CONCLUSION This review of relevant studies indicates that US should become accepted as the investigation with the most favourable balance of benefits to risks in the early diagnosis of RA. Given the continuing controversy surrounding studies of different imaging techniques in RA, further research into the diagnostic role of US in RA is indicated.
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Affiliation(s)
- Maria Boylan
- Graduate Entry Medical School, University of Limerick - Faculty of Education & Health Services, Limerick, V94 T9PX, Ireland.
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25
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Boesen M, Roemer FW, Østergaard M, Maas M, Terslev L, Guermazi A. Imaging of Common Rheumatic Joint Diseases Affecting the Upper Limbs. Radiol Clin North Am 2019; 57:1001-1034. [DOI: 10.1016/j.rcl.2019.03.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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26
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Horie T, Nishida M, Tanimura S, Kamishima T, Tamai E, Morimura Y, Nishibata Y, Masuda S, Nakazawa D, Tomaru U, Atsumi T, Ishizu A. Detection of Increased Vascular Signal in Arthritis-Prone Rats Without Joint Swelling Using Superb Microvascular Imaging Ultrasonography. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:2086-2093. [PMID: 31085028 DOI: 10.1016/j.ultrasmedbio.2019.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/10/2019] [Accepted: 04/01/2019] [Indexed: 06/09/2023]
Abstract
This study aimed to determine whether ultrasonography (US) can detect increased vascular signal in the synovial tissue before overt synovitis in rheumatoid arthritis (RA). Env-pX rats that spontaneously develop RA-like synovitis were used. Ankle joints of 15 pre-morbid env-pX rats were observed with power Doppler and superb microvascular imaging (SMI) using an ultrahigh-frequency (8-24 MHz) probe. Signal values were counted as the number of pixels. The total number of vessels and vessel area in the synovial tissue were histologically evaluated. Dilated vessels were determined from the mean value of synovial vessels in three wild-type rats. In all env-pX rats, apparent synovial proliferation was not observed. However, vasodilation was evident. Only SMI values were significantly correlated with the number of dilated vessels (r = 0.585, p = 0.022) but not with the total number of vessels. US with SMI using ultrahigh-frequency probe can detect increased vascular signal in the synovial tissue of arthritis-prone rats.
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Affiliation(s)
- Tatsunori Horie
- Diagnostic Center for Sonography, Hokkaido University Hospital, Kita-ku, Sapporo, Japan; Department of Radiological Technology, Hokkaido University Hospital, Kita-ku, Sapporo, Japan
| | - Mutsumi Nishida
- Diagnostic Center for Sonography, Hokkaido University Hospital, Kita-ku, Sapporo, Japan; Division of Laboratory and Transfusion Medicine, Hokkaido University Hospital, Kita-ku, Sapporo, Japan
| | - Shun Tanimura
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Tamotsu Kamishima
- Department of Biomedical Science and Engineering, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Erika Tamai
- Department of Biomedical Science and Engineering, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Yutaka Morimura
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Yuka Nishibata
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Sakiko Masuda
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Daigo Nakazawa
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Utano Tomaru
- Department of Pathology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita-ku, Sapporo, Japan
| | - Akihiro Ishizu
- Department of Medical Laboratory Science, Faculty of Health Sciences, Hokkaido University, Kita-ku, Sapporo, Japan.
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Ultrasound as a Useful Tool in the Diagnosis of Rheumatoid Arthritis in Patients With Undifferentiated Arthritis. ACTA ACUST UNITED AC 2019; 25:203-208. [DOI: 10.1097/rhu.0000000000001034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Kawashiri S, Fujikawa K, Nishino A, Takatani A, Shimizu T, Umeda M, Fukui S, Igawa T, Koga T, Iwamoto N, Ichinose K, Tamai M, Nakamura H, Origuchi T, Mizokami A, Maeda T, Kawakami A. Combination of ultrasound power Doppler‐verified synovitis and seropositivity accurately identifies patients with early‐stage rheumatoid arthritis. Int J Rheum Dis 2019; 22:842-851. [DOI: 10.1111/1756-185x.13543] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 02/14/2019] [Accepted: 02/16/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Shin‐ya Kawashiri
- Department of Community Medicine Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Keita Fujikawa
- Department of Rheumatology Isahaya General Hospital Isahaya Japan
| | - Ayako Nishino
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Ayuko Takatani
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Toshimasa Shimizu
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Masataka Umeda
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Shoichi Fukui
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Takeshi Igawa
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Tomohiro Koga
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Naoki Iwamoto
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Kunihiro Ichinose
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Mami Tamai
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Hideki Nakamura
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Tomoki Origuchi
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Akinari Mizokami
- Department of Rheumatology Isahaya General Hospital Isahaya Japan
| | - Takahiro Maeda
- Department of Community Medicine Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
| | - Atsushi Kawakami
- Department of Immunology and Rheumatology Nagasaki University Graduate School of Biomedical Sciences Nagasaki Japan
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29
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Ultrasound imaging in rheumatoid arthritis. Radiol Med 2019; 124:1087-1100. [DOI: 10.1007/s11547-019-01002-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/04/2019] [Indexed: 12/13/2022]
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Inamo J, Kaneko Y, Sakata K, Takeuchi T. Impact of subclinical synovitis in ankles and feet detected by ultrasonography in patients with rheumatoid arthritis. Int J Rheum Dis 2018; 22:62-67. [PMID: 30338640 DOI: 10.1111/1756-185x.13399] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Revised: 08/01/2018] [Accepted: 08/28/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the impact of subclinical synovitis detected by ultrasonography (US) on the ankles and feet of patients with rheumatoid arthritis. METHODS We retrospectively reviewed the data of patients (n = 59) who underwent US. RESULTS The functional ability and quality of life (QoL) of patients in the subclinical group were impaired. While the physician visual analog scale (VAS) scores significantly decreased in the subclinical group, patient and pain VAS scores significantly decreased only in patients without synovitis. CONCLUSION US-detected subclinical foot and ankle synovitis considerably affected patient functional status and QoL; however, it was often unnoticed by physicians.
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Affiliation(s)
- Jun Inamo
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Komei Sakata
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
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Ehrenstein B, Pongratz G, Fleck M, Hartung W. The ability of rheumatologists blinded to prior workup to diagnose rheumatoid arthritis only by clinical assessment: a cross-sectional study. Rheumatology (Oxford) 2018; 57:1592-1601. [PMID: 29850885 DOI: 10.1093/rheumatology/key127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives We aimed to study the ability of board-certified rheumatologists, blinded to all prior diagnostic test results, to establish the presence/absence of an inflammatory rheumatic disease (IRD) or RA among polyarthralgia or arthritis patients, solely relying on clinical assessment. Methods We performed a prospective, examiner-blinded, cross-sectional study documenting the diagnostic work in four sequential steps (medical history, physical examination, musculoskeletal ultrasonography and laboratory tests) of board-certified rheumatologists in a convenience cohort of 100 patients referred for inpatient diagnostic workup to a tertiary care rheumatology centre. Results The ability to correctly identify patients with or without an IRD (diagnostic accuracy) increased from 27% after the clinical assessment to 53% after the ultrasonography and to 70% after taking laboratory test results into account. The corresponding values for correctly identifying patients with or without RA were 19, 42 and 60%, respectively. Therefore the diagnostic accuracy of solely clinical assessment for determining the diagnosis of IRD or RA compared with the diagnosis established by a consecutive thorough in-patient workup was only 27 and 19% in our cohort, respectively. Pretreatment with corticosteroids (in the prior 7 days) vs none did not alter these results substantially (20 vs 29% for IRD, 15% vs 20% for RA). Conclusion Experienced rheumatologists, if deprived of information on prior external imaging and laboratory workup by blinding, were not able to correctly classify the majority of patients presenting with polyarthralgia or arthritis symptoms for inpatient workup, relying only on a brief symptom-focused medical history and physical examination.
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Affiliation(s)
- Boris Ehrenstein
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Internal Medicine I, University Medical Center Regensburg, Düsseldorf, Germany
| | - Georg Pongratz
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Rheumatology & Hiller Research Center for Rheumatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Fleck
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Internal Medicine I, University Medical Center Regensburg, Düsseldorf, Germany
| | - Wolfgang Hartung
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany
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Gutierrez M, Rodriguez S, Soto-Fajardo C, Santos-Moreno P, Sandoval H, Bertolazzi C, Pineda C. Ultrasound of sacroiliac joints in spondyloarthritis: a systematic review. Rheumatol Int 2018; 38:1791-1805. [PMID: 30099591 DOI: 10.1007/s00296-018-4126-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/05/2018] [Indexed: 12/25/2022]
Abstract
Ultrasound (US) is an accessible imaging technique with a possible role to diagnose active sacroiliitis, so this technique is projected as a promising diagnostic tool for the diagnosis of SpA. We analyse the available evidence about the use of US as a diagnostic tool in sacroiliitis in patients with SpA, by a systemic review of the literature fulfilling OMERACT criteria. A systematic literature search for original articles was carried out using four databases (Medline, Embase, Scopus and Web of Science). Data from studies were included only if participants had SpA and a US examination of sacroiliac joint (SIJ) was performed. The methodological quality of the studies was assessed using QUADAS-2 tool. Thirteen studies were included. All studies were observational, prospective and cross-sectional. In most articles (76.9%), the main US finding compatible with sacroiliitis evaluated was the presence of vascularisation (Doppler signals) with measurements of the resistive index (RI). The sensitivity and specificity analysis were performed in seven studies (58.8%) and were good, with a median of 90 and 89.2%, respectively. The studies showed a positive to moderate a strong correlation between the US and the gold standard but this was optimal only in four studies. In general, the agreement was good in all studies (≥ 0.80). The methods of evaluation of sacroiliitis vary between the studies included. To date, there is not enough evidence to support the use of ultrasound as a diagnostic method for sacroiliitis but it has potential to identify structural lesions at SIJ's level.
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Affiliation(s)
- Marwin Gutierrez
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion, Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Colonia Arenal de Guadalupe, CP 143898, Mexico City, Mexico.,Rheumatology Center of Excellence, Mexico City, Mexico
| | - Sheila Rodriguez
- Hospital de Alta Complejidad Virgen de la Puerta, Trujillo, Peru
| | - Carina Soto-Fajardo
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion, Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Colonia Arenal de Guadalupe, CP 143898, Mexico City, Mexico
| | | | - Hugo Sandoval
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion, Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Colonia Arenal de Guadalupe, CP 143898, Mexico City, Mexico
| | - Chiara Bertolazzi
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion, Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Colonia Arenal de Guadalupe, CP 143898, Mexico City, Mexico
| | - Carlos Pineda
- Division of Musculoskeletal and Rheumatic Disorders, Instituto Nacional de Rehabilitacion, Luis Guillermo Ibarra Ibarra, Calzada Mexico-Xochimilco 289, Colonia Arenal de Guadalupe, CP 143898, Mexico City, Mexico.
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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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Thietart S, Louati K, Gatfosse M, Sornay-Rendu E, Gaigneux E, Lemeunier L, Delmaire P, Riviere S, Mahevas T, Sellam J, Berenbaum F, Fain O, Roland C, Mekinian A. Overview of osteo-articular involvement in systemic sclerosis: Specific risk factors, clinico-sonographic evaluation, and comparison with healthy women from the French OFELY cohort. Best Pract Res Clin Rheumatol 2018; 32:591-604. [DOI: 10.1016/j.berh.2019.01.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Sahbudin I, Pickup L, Nightingale P, Allen G, Cader Z, Singh R, de Pablo P, Buckley CD, Raza K, Filer A. The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development. Rheumatology (Oxford) 2018; 57:1243-1252. [PMID: 29618136 PMCID: PMC6037116 DOI: 10.1093/rheumatology/key025] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 01/24/2018] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES Tenosynovitis (TS) is common in early arthritis. However, the value of US-defined TS in predicting RA development is unclear. We assessed the predictive utility of US-defined TS alongside US-defined synovitis and clinical and serological variables in a prospective cohort of early arthritis patients. METHODS One hundred and seven patients with clinically apparent synovitis of one or more joint and symptom duration ⩽3 months underwent baseline clinical, laboratory and US assessment of 19 bilateral joint sites and 16 bilateral tendon compartments. Diagnostic outcome was determined after 18 months, applying the 2010 ACR/EULAR classification criteria for RA. The predictive values of US-defined TS for persistent RA were compared with those of US-defined synovitis, clinical and serological variables. RESULTS A total of 4066 US joint sites and 3424 US tendon compartments were included in the analysis. Forty-six patients developed persistent RA, 17 patients developed non-RA persistent disease and 44 patients had resolving disease at follow-up. US-defined TS in at least one tendon compartment at baseline was common in all groups (RA 85%, non-RA persistent disease 71% and resolving 70%). On multi-variate analysis, US-defined digit flexor TS provided independent predictive data over and above the presence of ACPA and US-defined joint synovitis. CONCLUSION US-defined digit flexor TS provided independent predictive data for persistent RA development in patients with early arthritis. The predictive utility of this tendon site should be further assessed in a larger cohort; investigators designing imaging-based predictive algorithms for RA development should include this tendon component as a candidate variable.
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Affiliation(s)
- Ilfita Sahbudin
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Luke Pickup
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter Nightingale
- Rheumatology Department, Wolfson Computer Laboratory, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
| | - Gina Allen
- Green Templeton College, University of Oxford, Oxford, UK
| | - Zaeem Cader
- Division of Gastroenterology and Hepatology, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Ruchir Singh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Paola de Pablo
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Christopher D Buckley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Karim Raza
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK.,MRC-ARUK Centre for Musculoskeletal Ageing Research, University of Birmingham, Birmingham, UK
| | - Andrew Filer
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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Boer AC, Boeters DM, van der Helm-van Mil AHM. The use of MRI-detected synovitis to determine the number of involved joints for the 2010 ACR/EULAR classification criteria for Rheumatoid Arthritis - is it of additional benefit? Ann Rheum Dis 2018; 77:1125-1129. [PMID: 29678939 DOI: 10.1136/annrheumdis-2018-213143] [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: 01/31/2018] [Revised: 03/27/2018] [Accepted: 04/14/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the value of MRI-detected synovitis to determine the number of involved joints on the performance of the 2010-ACR/EULAR classification criteria for rheumatoid arthritis (RA). METHODS 277 patients with a clinical suspicion of RA consecutively included in the Leiden Early Arthritis Clinic (EAC)-cohort underwent 1.5T MRI of MCP-, wrist- and MTP-joints. Test characteristics of the 2010-criteria were calculated when the number of involved joints was determined with and without including MRI-detected synovitis. Two outcomes were studied: disease modifying anti-rheumatic drug (DMARD)-initiation and 1987-criteria fulfilment during the first year. RESULTS At baseline, 143 patients were classified as RA. When MRI-detected synovitis was considered, 14 patients additionally fulfilled the 2010-criteria. Of these, 64% (9/14) started DMARDs. When MRI-detected synovitis was also used to determine the number of involved joints the sensitivity changed from 62% to 67%, the specificity from 90% to 84% and the AUC from 0.76 to 0.75. The net reclassification index was -2.4%. When fulfilling the 1987-criteria was used as outcome, results were similar. CONCLUSION We found no scientific support that the use of MRI-detected synovitis is of additional benefit for the performance of the 2010 classification criteria.
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Affiliation(s)
- Aleid C Boer
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Debbie M Boeters
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leids Universitair Medisch Centrum, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Leiden, The Netherlands
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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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Hussain S, Sivakumaran P, Gill A, Dhas D, Ciurtin C. Ultrasonography-detected subclinical inflammation in patients with hand osteoarthritis and established rheumatoid arthritis: a comparison between two different pathologies using the same ultrasound examination protocol. Musculoskeletal Care 2018; 16:26-31. [PMID: 28471034 DOI: 10.1002/msc.1197] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES A recent review of ultrasound (US) studies in osteoarthritis (OA) showed very limited data about hand OA. Previous US studies in patients with OA described a degree of overlap between the US appearance of rheumatoid arthritis (RA) and OA joints. The present study aimed to assess the US features of subclinical inflammation in RA and hand OA, using the same US examination protocol. METHODS A retrospective, cohort study compared patients with established RA (n = 224) and hand OA (n = 73), with respect to several demographic, clinical, laboratory and US parameters. We used a 22-hand joint US examination protocol (wrists, metacarpophalangeal and proximal interphalangeal joints bilaterally - Outcome Measures in Rheumatology Clinical Trials [OMERACT] scoring system) for all patients. RESULTS Subclinical joint inflammation in the context of equivocal clinical examination was found in 9.6% of OA patients compared with 46.4% of RA patients (p = 0.0001), despite the fact that there was no significant difference between the degree of chronic joint swelling (synovial hypertrophy grades 2 and 3; p = 0.75 and p = 0.11, respectively). The presence of osteophytes was more common in patients with hand OA, as expected (p = 0.0001). CONCLUSIONS Our study findings reflected differences between the incidence and characteristics of subclinical inflammation in patients with RA and OA, which could be helpful in patients with an equivocal clinical examination or history of both diseases. Almost one in 10 patients with hand OA had active synovitis, while almost one in two patients with RA had uncontrolled inflammation in at least one joint.
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Affiliation(s)
- Sidra Hussain
- University College London Medical School, London, UK
| | | | - Anna Gill
- Department of Rheumatology, North Middlesex University Hospital NHS Trust, London, UK
| | - Delfin Dhas
- Department of Biomedical Sciences, Royal Holloway University, London, UK
| | - Coziana Ciurtin
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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40
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Role of ultrasound imaging in individuals at risk of RA. Best Pract Res Clin Rheumatol 2017; 31:71-79. [PMID: 29221600 DOI: 10.1016/j.berh.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/06/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
Early diagnosis and treatment improves outcomes for patients with rheumatoid arthritis (RA). Studies have shown that musculoskeletal ultrasound is more sensitive than clinical examination in identifying synovitis. This review aims to address the role of ultrasound in identifying (1) patients with early inflammatory arthritis (IA) at risk of progression to RA and (2) those without clinical synovitis at risk of progression to early IA and therefore early RA.
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41
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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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Terslev L, Naredo E, Aegerter P, Wakefield RJ, Backhaus M, Balint P, Bruyn GAW, Iagnocco A, Jousse-Joulin S, Schmidt WA, Szkudlarek M, Conaghan PG, Filippucci E, D'Agostino MA. Scoring ultrasound synovitis in rheumatoid arthritis: a EULAR-OMERACT ultrasound taskforce-Part 2: reliability and application to multiple joints of a standardised consensus-based scoring system. RMD Open 2017; 3:e000427. [PMID: 28948984 PMCID: PMC5597800 DOI: 10.1136/rmdopen-2016-000427] [Citation(s) in RCA: 132] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 05/09/2017] [Accepted: 05/16/2017] [Indexed: 12/14/2022] Open
Abstract
Objectives To test the reliability of new ultrasound (US) definitions and quantification of synovial hypertrophy (SH) and power Doppler (PD) signal, separately and in combination, in a range of joints in patients with rheumatoid arthritis (RA) using the European League Against Rheumatisms–Outcomes Measures in Rheumatology (EULAR-OMERACT) combined score for PD and SH. Methods A stepwise approach was used: (1) scoring static images of metacarpophalangeal (MCP) joints in a web-based exercise and subsequently when scanning patients; (2) scoring static images of wrist, proximal interphalangeal joints, knee and metatarsophalangeal joints in a web-based exercise and subsequently when scanning patients using different acquisitions (standardised vs usual practice). For reliability, kappa coefficients (κ) were used. Results Scoring MCP joints in static images showed substantial intraobserver variability but good to excellent interobserver reliability. In patients, intraobserver reliability was the same for the two acquisition methods. Interobserver reliability for SH (κ=0.87) and PD (κ=0.79) and the EULAR-OMERACT combined score (κ=0.86) were better when using a ‘standardised’ scan. For the other joints, the intraobserver reliability was excellent in static images for all scores (κ=0.8–0.97) and the interobserver reliability marginally lower. When using standardised scanning in patients, the intraobserver was good (κ=0.64 for SH and the EULAR-OMERACT combined score, 0.66 for PD) and the interobserver reliability was also good especially for PD (κ range=0.41–0.92). Conclusion The EULAR-OMERACT score demonstrated moderate-good reliability in MCP joints using a standardised scan and is equally applicable in non-MCP joints. This scoring system should underpin improved reliability and consequently the responsiveness of US in RA clinical trials.
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Affiliation(s)
- Lene Terslev
- Rheumatology department, Centre for Rheumatology and Spine Diseases, Rigshospitalet-Glostrup, Copenhagen, Denmark
| | - Esperanza Naredo
- Rheumatology and Joint and Bone Research Unit, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain
| | - Philippe Aegerter
- Public Health Department, APHP, Hôpital Ambroise Paré, Boulogne-Billancourt; INSERM U1173, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Marina Backhaus
- Department of Internal Medicine, Rheumatology and Clinical Immunology, Park-Klinik Weissensee, Berlin, Germany
| | - Peter Balint
- National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - George A W Bruyn
- Department of Rheumatology, MC Groep Hospitals, Lelystad, the Netherlands
| | | | | | - Wolfgang A Schmidt
- Medical Centre for Rheumatology, Immanuel Krankenhaus, Buch, Berlin, Germany
| | - Marcin Szkudlarek
- Department of Rheumatology, Zealand's University Hospital at Kàge, Copenaghen, Denmark
| | - Philip G Conaghan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds and NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Emilio Filippucci
- Clinica Reumatologica, Università Politecnica delle Marche, Jesi, Ancona, Italy
| | - Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Ambroise Paré Hospital, Boulogne-Billancourt, France.,INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, Montigny le Bretonneaux, France
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Yokota K, Tsuzuki Wada T, Akiyama Y, Mimura T. Detection of synovial inflammation in rheumatic diseases using superb microvascular imaging: Comparison with conventional power Doppler imaging. Mod Rheumatol 2017; 28:327-333. [DOI: 10.1080/14397595.2017.1337288] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Kazuhiro Yokota
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Takuma Tsuzuki Wada
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Yuji Akiyama
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
- Ogawa Red Cross Hospital, Saitama, Japan
| | - Toshihide Mimura
- Department of Rheumatology and Applied Immunology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
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Hirata A, Ogura T, Hayashi N, Takenaka S, Ito H, Mizushina K, Fujisawa Y, Yamashita N, Nakahashi S, Imamura M, Kujime R, Kameda H. Concordance of Patient-Reported Joint Symptoms, Physician-Examined Arthritic Signs, and Ultrasound-Detected Synovitis in Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2017; 69:801-806. [PMID: 27564121 DOI: 10.1002/acr.23006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 07/07/2016] [Accepted: 08/09/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Ultrasonography has been prevalently used as a valid and objective modality for joint examination in patients with rheumatoid arthritis (RA). This study aimed to examine and compare the concordance between ultrasound, clinical assessment, and patient-reported assessment of joint synovitis in RA. METHODS Fifty patients with RA (84% female, median age 69 years, median disease duration 31 months, and median Disease Activity Score in 28 joints 3.8) completed the self-evaluation of joint symptoms, including pain and considerable stiffness in the (proximal) interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, knee, and ankle joints. These joints were also examined by a physician in order to assess the presence of tenderness or swelling; the presence of imaging synovitis was assessed by ultrasonography. RESULTS In a total of 1,492 evaluated joints, symptoms (pain and stiffness), tenderness, and swelling were noted in 288 (19.3%), 182 (12.2%), and 220 (14.7%) joints, respectively, while ultrasound indicated synovitis in 317 (21.2%) joints. Overall concordance with ultrasound findings was lowest for joint tenderness (κ = 0.30), followed by symptoms (κ = 0.39), and by swelling (κ = 0.43), irrespective of the evaluated joint, except for the elbow. Moreover, the percentages of inflamed joints detected only on the basis of symptoms, tenderness, or swelling were 18.6%, 2.2%, and 8.5%, respectively, of all joints with signs of synovitis on ultrasonography. CONCLUSION Joint swelling showed the best concordance with ultrasonography, followed by patient-reported joint symptoms, and joint tenderness. Joint symptoms, rather than tenderness evaluation, may be a better clinical indicator of synovitis in RA patients.
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Horton SC, Tan AL, Wakefield RJ, Freeston JE, Buch MH, Emery P. Ultrasound-detectable grey scale synovitis predicts future fulfilment of the 2010 ACR/EULAR RA classification criteria in patients with new-onset undifferentiated arthritis. RMD Open 2017; 3:e000394. [PMID: 28469936 PMCID: PMC5387989 DOI: 10.1136/rmdopen-2016-000394] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/16/2017] [Indexed: 11/29/2022] Open
Abstract
Objective To determine the clinical outcomes for patients with new-onset undifferentiated arthritis (UA), not fulfilling the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) classification criteria, and the clinical and imaging predictors of disease progression in these patients. Methods A prospective observational study was conducted in treatment-naïve UA patients. Baseline ultrasound involved semiquantitative assessment of grey scale (GS) synovitis and power Doppler activity (PD) at 26 joints. Outcomes were fulfilment of 2010 RA criteria (joint involvement determined clinically) and initiation of methotrexate over 12 months. Cox proportional hazards analysis was used to investigate predictors of outcome. Results Of 60 patients, 13(22%) progressed to RA and 32(53%) ever received methotrexate. Analyses of predictors of outcome were conducted in the subgroup (n=41) of patients with complete baseline data. The presence of GS was associated with progression to RA and methotrexate use: HRs (95% CI) were 1.25(1.07 to 1.45) and 1.16(1.02 to 1.32), respectively, for the number of joints with GS≥ grade 2 after adjustment for swollen joints. PD was not predictive in the low levels at which it was observed. Progression to RA was also associated with fulfilment of the 2010 criteria using ultrasound synovitis for enumerating joint involvement, higher baseline disability and radiographic erosion. Conclusions This is the first report of ultrasound findings in early UA (defined by presence of clinical synovitis and non-fulfilment of 2010 RA criteria). A significant proportion of patients with UA progressed to RA and/or required methotrexate. GS synovitis was predictive of disease progression.
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Affiliation(s)
- Sarah C Horton
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ai Lyn Tan
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jane E Freeston
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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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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Kobayashi Y, Ikeda K, Nakamura T, Yamagata M, Nakazawa T, Tanaka S, Furuta S, Umibe T, Nakajima H. Severity and Diurnal Improvement of Morning Stiffness Independently Associate with Tenosynovitis in Patients with Rheumatoid Arthritis. PLoS One 2016; 11:e0166616. [PMID: 27851825 PMCID: PMC5113064 DOI: 10.1371/journal.pone.0166616] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 11/01/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Although morning stiffness has long been recognized as a characteristic feature of rheumatoid arthritis (RA), it is no more included in the 2010 ACR/EULAR Classification Criteria or in the current major instruments for evaluating disease activity of RA. In this cross-sectional study, we aimed to determine the independent value and the optimal measurement of morning stiffness by clarifying the associations between morning stiffness and synovial inflammation. PATIENTS AND METHODS We enrolled 76 consecutive RA patients who underwent musculoskeletal ultrasound examination and agreed to participate in the study. In addition to asking the duration of morning stiffness, we asked patients to complete a diagram which represents the time course of their morning stiffness in the dominant hand. Based on this diagram, we calculated the severity and the diurnal improvement of morning stiffness. We also determined the activity of intra-articular synovitis in 11 joints and tenosynovitis in 8 tendons/tendon compartments in the same hand by using power Doppler (PD) ultrasound with a semiquantitative score (0-3). RESULTS For intra-articular synovitis, swollen/tender joint counts more strongly correlated with total PD scores (ρ = 0.379-0.561, p ≤ 0.001) than did any parameters of morning stiffness (ρ = 0.217-0.314, p = 0.006-0.021). For tenosynovitis, however, the severity on awakening and the improvement of morning stiffness more strongly correlated with total PD scores (ρ = 0.503-0.561, p < 0.001) than did swollen/tender joint counts (ρ = 0.276-0.388, p = 0.001-0.016). Multivariate analyses identified the severity on awakening and the improvement but not the duration of morning stiffness as factors that independently associate with the total tenosynovial PD score. CONCLUSIONS Our data demonstrate a pathophysiological link between morning stiffness and tenosynovitis and also give an insight into the optimal measurement of morning stiffness. Our data support an independent value of evaluating morning stiffness in the management of RA.
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Affiliation(s)
- Yoshihisa Kobayashi
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Rheumatology Center, Matsudo City Hospital, Matsudo, Chiba, Japan
- Department of Internal Medicine, Chiba Aoba Municipal Hospital, Chiba, Japan
| | - Kei Ikeda
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- * E-mail:
| | - Takayuki Nakamura
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Research Center for Allergy and Clinical Immunology, Asahi General Hospital, Asahi, Chiba, Japan
| | - Mieko Yamagata
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, National Hospital Organization Shimoshizu Hospital, Yotsukaido, Chiba, Japan
| | - Takuya Nakazawa
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
- Department of Rheumatology, Allergy, and Clinical Immunology, National Hospital Organization Chiba-East Hospital, Chiba, Japan
| | - Shigeru Tanaka
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Takeshi Umibe
- Rheumatology Center, Matsudo City Hospital, Matsudo, Chiba, Japan
| | - Hiroshi Nakajima
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
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Ogura T, Hirata A, Hayashi N, Takenaka S, Ito H, Mizushina K, Fujisawa Y, Imamura M, Yamashita N, Nakahashi S, Kujime R, Kameda H. Comparison of ultrasonographic joint and tendon findings in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis. Lupus 2016; 26:707-714. [PMID: 27837198 DOI: 10.1177/0961203316676375] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Although both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may lead to joint deformity, SLE arthritis is typically non-erosive and often accompanied by Jaccoud's deformity. Therefore, we examined characteristics of joint and tendon lesions in patients with SLE and RA by ultrasonography. Fifteen treatment-naïve SLE patients and 40 treatment-naïve RA patients with joint symptoms were included in this study. The hand joints and related tendons were ultrasonographically examined using grey-scale (GS) and power Doppler (PD). Joint involvement was comparably observed in patients with SLE and RA (80% versus 95%, p = 0.119). However, tendon involvement was more frequent in SLE than in RA (93% versus 65%, p = 0.045), especially in the wrist joints (73% versus 40%, p = 0.037). When we investigated the intensity of US findings, the joint synovitis score (GS + PD) per affected joint was lower in SLE than RA (2.0 versus 2.6, p = 0.019), while tendon inflammation score was not significantly different (2.1 versus 2.2, p = 0.738). Finally, the examination of concordance between joint and tendon involvement in the same finger revealed that joint lesion appeared in only 49% of fingers having tendon involvement in the SLE group, which was significantly less than 74% in the RA group ( p = 0.010). Thus, as compared with RA, SLE arthropathy is characterized by the predominance of tenosynovitis/periextensor tendon inflammation, which is likely to develop independently from joint synovitis.
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Affiliation(s)
- T Ogura
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - A Hirata
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - N Hayashi
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - S Takenaka
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - H Ito
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - K Mizushina
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Y Fujisawa
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - M Imamura
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - N Yamashita
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - S Nakahashi
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - R Kujime
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - H Kameda
- Division of Rheumatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
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Lage-Hansen PR, Lindegaard H, Chrysidis S, Terslev L. The role of ultrasound in diagnosing rheumatoid arthritis, what do we know? An updated review. Rheumatol Int 2016; 37:179-187. [DOI: 10.1007/s00296-016-3587-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2016] [Accepted: 10/21/2016] [Indexed: 10/20/2022]
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Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis. ACTA ACUST UNITED AC 2016; 14:9-19. [PMID: 28029551 DOI: 10.1016/j.reuma.2016.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 08/10/2016] [Accepted: 08/13/2016] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA). METHODS Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist. RESULTS A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies. CONCLUSIONS These recommendations will help clinicians use US and MRI in RA patients.
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