Evaluation of Magnetic Resonance Imaging-Detected Tenosynovitis in the Hand and Wrist in Early Arthritis

Abatacept inhibits inflammation and onset of rheumatoid arthritis in individuals at high risk (ARIAA): a randomised, international, multicentre, double-blind, placebo-controlled trial

BACKGROUND

Individuals with anti-citrullinated protein antibodies (ACPAs) and subclinical inflammatory changes in joints are at high risk of developing rheumatoid arthritis. Treatment strategies to intercept this pre-stage clinical disease remain to be developed. We aimed to assess whether 6-month treatment with abatacept improves inflammation in preclinical rheumatoid arthritis.

METHODS

The abatacept reversing subclinical inflammation as measured by MRI in ACPA positive arthralgia (ARIAA) study is a randomised, international, multicentre, double-blind, placebo-controlled trial done in 14 hospitals and community centres across Europe (11 in Germany, two in Spain, and one in the Czech Republic). Adults (aged ≥18 years) with ACPA positivity, joint pain (but no swelling), and signs of osteitis, synovitis, or tenosynovitis in hand MRI were randomly assigned (1:1) to weekly subcutaneous abatacept 125 mg or placebo for 6 months followed by a double-blind, drug-free, observation phase for 12 months. The primary outcome was the proportion of participants with any reduction in inflammatory MRI lesions at 6 months. The primary efficacy analysis was done in the modified intention-to-treat population, which included participants who were randomly assigned and received study medication. Safety analyses were conducted in participants who received the study medication and had at least one post-baseline observation. The study was registered with the EUDRA-CT (2014-000555-93).

FINDINGS

Between Nov 6, 2014, and June 15, 2021, 139 participants were screened. Of 100 participants, 50 were randomly assigned to abatacept 125 mg and 50 to placebo. Two participants (one from each group) were excluded due to administration failure or refusing treatment; thus, 98 were included in the modified intention-to-treat population. 70 (71%) of 98 participants were female and 28 (29%) of 98 were male. At 6 months, 28 (57%) of 49 participants in the abatacept group and 15 (31%) of 49 participants in the placebo group showed improvement in MRI subclinical inflammation (absolute difference 26·5%, 95% CI 5·9-45·6; p=0·014). Four (8%) of 49 participants in the abatacept group and 17 (35%) of 49 participants in the placebo group developed rheumatoid arthritis (hazard ratio [HR] 0·14 [0·04-0·47]; p=0·0016). Improvement of MRI inflammation (25 [51%] of 49 participants in the abatacept group, 12 [24%] of 49 in the placebo group; p=0·012) and progression to rheumatoid arthritis (17 [35%] of 49, 28 [57%] of 49; HR 0·14 [0·04-0·47]; p=0·018) remained significantly different between the two groups after 18 months, 12 months after the end of the intervention. There were 12 serious adverse events in 11 participants (four [8%] of 48 in the abatacept group and 7 [14%] of 49 in the placebo group). No deaths occurred during the study.

INTERPRETATION

6-month treatment with abatacept decreases MRI inflammation, clinical symptoms, and risk of rheumatoid arthritis development in participants at high risk. The effects of the intervention persist through a 1-year drug-free observation phase.

FUNDING

Innovative Medicine Initiative.

Distinction and prognosis of early arthritis phenotypes: an analysis in three European cohorts

OBJECTIVES

The objective of this study is to evaluate whether there are differences in the long-term prognosis across various phenotypes of early arthritis (EA).

METHODS

Three EA cohorts (Reade, Etude et Suivi des Polyarthrites Indifférenciées Récentes (ESPOIR) and Early Arthritis Clinic (EAC)) were analysed. Clinical data were collected up to 24 years. Hands and feet radiographs were scored according to the Sharp van der Heijde (SvdH) method. Latent class analysis was applied to determine the EA phenotypes at baseline. Each class received a label reflecting its most prominent features. Prognostic outcomes included Health Assessment Questionnaire (HAQ), Short Form 36 (SF36) and SvdH score. The association between class membership and outcomes over time was tested in multivariable models.

RESULTS

In total, 390 (Reade), 798 (ESPOIR) and 3991 (EAC) patients were analysed separately. Two classes with symmetrical polyarthritis emerged; one of these labelled as autoimmune inflammatory polyarthritis (AIPA), had high likelihood of acute phase reactants (APR) elevation and autoantibody positivity, while the other (mild-inflammatory polyarthritis; MIPA) had not. A third class had oligoarthritis of upper limbs (OAUL) and could be subdivided into autoimmune OAUL and mild-inflammatory OAUL. A fifth class had oligoarthritis of lower limbs. The SvdH scores were worse in patients with APR/autoantibodies (AIPA) than in those without (MIPA). No clinically meaningful differences across classes in HAQ or SF36 over time were found.

CONCLUSION

Radiographic progression over time primarily occurs in EA patients with APR/autoantibodies. The absence of these markers, however, does not necessarily translate into better long-term function and quality of life. Clinicians should not only aim at preventing joint damage, but look beyond structural progression in order to further improve the lives of people with EA.

Association between PYTPN22 rs2476601, VEGF rs833070, TNFAIP3 rs6920220 Polymorphisms and Risk for Rheumatoid Arthritis in Early Undifferentiated Arthritis Patients: A Pilot Study

Background and Objectives: About 40% of early undifferentiated arthritis (UA) progresses to rheumatoid (RA) or other chronic arthritis. Novel diagnostic tools predicting the risk for this progression are needed to identify the patients who would benefit from early aggressive treatment. Evidence on the role of single-nucleotide polymorphisms (SNPs) in the development of RA has emerged. The aim of our study was to investigate the association between rs2476601, rs833070, and rs6920220 SNPs and UA progression to RA. Materials and Methods: Ninety-two UA patients were observed for 12 months. At study entry, demographic and clinical characteristics were recorded, musculoskeletal ultrasonography was performed, and blood samples were drawn to investigate levels of inflammatory markers, rheumatoid factor (RF), anti-citrullinated protein antibodies (anti-CCP)detect SNPs. After 12 months, UA outcomes were assessed, and patients were divided into two (RA and non-RA) groups. The association between the risk of progression to chronic inflammatory arthritis and analyzed SNPs was measured by computing odds ratios (OR). Results: After a 12-month follow-up, 27 (29.3%) patients developed RA, and 65 (70.7%) patients were assigned to the non-RA group. The arthritis of 21 patients (22.8%) from the non-RA group resolved completely, while the other 44 (47.2%) patients were diagnosed with another rheumatic inflammatory disease. The patients who developed RA had a significantly greater number of tender and swollen joints (p = 0.010 and p = 0.021 respectively) and were more frequently RF or anti-CCP (p < 0.001), and both RF and anti-CCP positive (p < 0.001) at the baseline as compared with the patients in the non-RA group. No significant association between rs2476601 (OR = 0.99, p = 0.98), rs833070 (OR = 1.0, p = 0.97), and rs6920220 (OR = 0.48, p = 0.13) polymorphisms and the risk of developing RA were found. Conclusions: No association between analyzed SNPs and a greater risk to progress from UA to RA was confirmed, although patients with rs6920220 AA + AG genotypes had fewer tender joints at the disease onset.

Value of Hands Ultrasonography in the Differential Diagnosis Between Psoriatic Arthritis and Rheumatoid Arthritis

OBJECTIVES

Psoriatic arthritis (PsA) can mimic rheumatoid arthritis (RA) at an early stage, especially when psoriasis is lacking. In the absence of specific radiological and immunological markers, the differential diagnosis between these two diseases can be challenging. We aimed to determine whether hands ultrasonography (US) may be useful in the differential diagnosis between PsA and RA.

METHODS

We conducted a cross-sectional study including patients with PsA and RA. All wrists and small joints of the hands were examined using gray-scale and Power Doppler US. The evaluated US lesions were: synovitis, tenosynovitis of extensor carpi ulnaris, extensor communis and flexor tendons, enthesitis of extensor tendons at distal interphalangeal joints, peritendon inflammation of extensor tendons, and soft tissue edema.

RESULTS

Six hundred joints in 20 PsA patients and 900 joints in 30 RA patients were assessed. Extensor enthesitis was significantly more observed in PsA compared with RA (39.4 vs 26.3%, P = .006) with a significant higher frequency of enthesophytes and calcifications (P = .022 and P = .002, respectively). Peritendon inflammation of extensor digitorum tendons was observed in 13% of metacarpophalangeal joints in PsA patients versus 3% in RA patients with a significant difference (P < .001). Soft tissue edema was exclusively observed in PsA (1.5 vs 0%, P = .033). Power Doppler synovitis was significantly more frequent in RA (9.2 vs 5%, P = .002). Extensor carpi ulnaris tenosynovitis was significantly more frequent in RA (18.3 vs 2.5%, P = .017).

CONCLUSION

Extrasynovial US findings may be helpful to distinguish PsA from RA especially in patients with immunonegative polyarthritis and no evidence of psoriasis.

Predictive Value of Magnetic Resonance Imaging-detected Tenosynovitis of the Metacarpophalangeal and Wrist Joints for the Development of Rheumatoid Arthritis among Patients with Undifferentiated Arthritis

Objective The early diagnosis of rheumatoid arthritis (RA) improves disease outcomes. Using bilateral magnetic resonance imaging (MRI), we investigated whether or not tenosynovitis at the level of the metacarpophalangeal (MCP) and wrist joints, as well as non-symmetrical versus symmetrical involvement, predicts RA development in undifferentiated arthritis (UA) patients. Methods We collected the clinical and serological findings as well as bilateral gadolinium-enhanced 1.5-T MRI data of UA patients after 1 year. A multivariate logistic regression analysis was used to determine the association of tenosynovitis in UA with RA development. Ninety-one UA patients from the Nagasaki Early Arthritis Clinic who did not meet the 2010 European League Against Rheumatism/American College of Rheumatology classification criteria for RA were selected. Tenosynovitis at the MCP and wrist joints was scored according to the RA MRI scoring system. Results Of these 91 UA patients, 29 (31.9%) progressed to RA, with a median disease duration of 3 months, despite only 10.9% being positive for anti-cyclic citrullinated peptide antibody (ACPA). A univariate analysis showed higher MCP tenosynovitis scores, MCP flexor tenosynovitis, and symmetrical MCP tenosynovitis in the RA development group than in the non-development group (p<0.05). A multivariate analysis showed that symmetrical MCP tenosynovitis was independently associated with RA development after adjusting for age, gender, swollen joint count, C-reactive protein level, and ACPA positivity (odds ratio: 4.96). The presence of symmetrical MCP tenosynovitis had low sensitivity (35%) but high specificity (87%) for RA development. Conclusion MRI-detected tenosynovitis, especially symmetrical findings at the MCP joint, is predictive of RA development in a UA population with low ACPA positivity.

A survey of artificial intelligence in rheumatoid arthritis

The article offers a survey of currently notable artificial intelligence methods (released between 2019-2023), with a particular emphasis on the latest advancements in detecting rheumatoid arthritis (RA) at an early stage, providing early treatment, and managing the disease. We discussed challenges in these areas followed by specific artificial intelligence (AI) techniques and summarized advances, relevant strengths, and obstacles. Overall, the application of AI in the fields of RA has the potential to enable healthcare professionals to detect RA at an earlier stage, thereby facilitating timely intervention and better disease management. However, more research is required to confirm the precision and dependability of AI in RA, and several problems such as technological and ethical concerns related to these approaches must be resolved before their widespread adoption.

Evaluation of tenosynovitis in patients with seronegative rheumatoid arthritis using microvascular flow imaging

OBJECTIVES

The purpose of this research was investigate the potential use of MVFI (microvascular flow imaging) in the assessment of tenosynovitis in cases with SNRA (seronegative rheumatoid arthritis).

METHODS

Fifty-six SNRA cases and 20 HCs (healthy controls) were enrolled, and all of them were subjected to ultrasonographic examination of the compartments I-VI of the extensor tendons of the wrist, flexor carpi radialis and flexor tendons of the five digits. Each tendon synovial sheath was semi-quantitatively scored by GS (gray-scale) ultrasound, PD (power Doppler) ultrasound, and MVFI. The PD and MVFI scores for each tendon synovial sheath were added up for each patient to get the total scores. GS scores, PD scores, and MVFI scores of tendon synovial sheaths were compared between the two groups. The correlations of total PD scores and total MVFI scores with DAS28 (disease activity scores in 28 joints), ESR (erythrocyte sedimentation rate), and CRP (C-reactive protein) were analyzed.

RESULTS

(1) In the HC group (480 tendons), GS revealed abnormalities in 29 (6.04%) tendon synovial sheaths. The GS score was 1.03 ± 0.18 with the predominance of GS grade 1 (96.55%). In the SNRA group (1,344 tendons), GS detected abnormalities in 418 tendon synovial sheaths (31.10%). The GS score was 1.97 ± 0.53 with the predominance of GS grade 2 (71.77%). There were significant differences in the GS examination rate and grade for tenosynovitis between the two groups (P < 0.05). (2) In the SNRA group, involvement of the extensor carpi ulnaris in the 6^th dorsal compartment was the most common among all extensor tendons; the flexor tendon of the third digit was the most commonly affected among all flexor tendons. (3) In the HC group, the MVFI and PD scores were 0 for tendon synovial sheaths upon GS examination. In the SNRA group, the blood flow display rate of abnormal tendon synovial sheaths indicated by GS was 83.49% and 64.59% upon MVFI and PD, respectively. The results of the two imaging techniques were significantly different (P < 0.05). The blood flow grade of abnormal tendon synovial sheaths indicated by GS was significantly different between MVFI and PD (P < 0.05), which was higher upon MVFI than PD. (4) The total MVFI score and the total PD score in the SNRA group were correlated positively with CRP, ESR and DAS28 (P < 0.05).

CONCLUSION

MVFI is a more sensitive way in detection of blood flow in the tendon synovial sheaths of SNRA cases, which may be used in clinic to evaluate disease activity and tenosynovitis in SNRA cases.

Evidence for the presence of synovial sheaths surrounding the extensor tendons at the metacarpophalangeal joints: a microscopy study

MRI-detected inflammation around the extensor tendons of metacarpophalangeal (MCP-) joints is prevalent in RA and poses a markedly increased risk of RA development when present in arthralgia patients. Such inflammation is called 'peritendinitis' since anatomy literature reports no presence of a tenosynovial sheath at these tendons. However, the presence or absence of tenosynovium at these extensor tendons has never been studied. Therefore, an anatomical and histological study of extensor tendons at the MCP-joints of three embalmed human hands was performed. Immunohistochemical staining showed the presence of markers for synovial macrophages and fibroblast-like synoviocytes bordering a natural dorsal space next to the extensor tendon, suggesting the presence of a synovial lining. This implies that contrast-enhancement on MRI around extensor tendons at MCP-joints observed in early RA and pre-RA likely represents tenosynovitis and that inflammation of this synovial tissue is an early feature of RA.

Systematic review of imaging tests to predict the development of rheumatoid arthritis in people with unclassified arthritis

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.

MRI detected synovitis of the small joints predicts rheumatoid arthritis development in large joint undifferentiated inflammatory arthritis

Objectives

New onset undifferentiated large joint inflammatory arthritis can be diagnostically challenging. It is unknown how often these patients progress to RA, and how they can be identified at first presentation. We assessed clinical and serological features associated with RA development in patients with an undifferentiated mono- or oligo-articular large joint arthritis, and with keen interest in whether an MRI of the small joints of the hand and foot would aid diagnosis.

Methods

Leiden Early Arthritis Clinic includes 4018 patients; this prospective study follows 221 consecutively included patients with new onset undifferentiated large joint arthritis. Baseline clinical data and serology were obtained. Forty-five patients had MRIs (hand and foot). MRIs were scored according to the OMERACT RAMRIS. Univariable and multivariable logistic regression were assessed. Test characteristics, predictive values and net reclassification index (NRI) for RA were determined.

Results

Patients mostly presented with knee or ankle mono-arthritis. During the 12 months’ follow-up 17% developed RA. Autoantibody positivity (ACPA and/or RF) and MRI-detected synovitis in hands and feet were independently associated with RA development in multivariable analyses [odds ratio 10.29 (P = 0.014) and 7.88 (P = 0.017), respectively]. Positive predictive value of autoantibodies, MRI-detected synovitis and combination of both features was 63%, 55% and 100%, respectively. The addition of MRI-detected synovitis to autoantibody status improved diagnostic accuracy (NRI 18.1%).

Conclusion

In patients presenting with undifferentiated large joint arthritis, 17% will develop RA. Autoantibody positivity and subclinical synovitis are independent predictors. The data suggest MRI of small joints is beneficial for early identification of RA in large joint arthritis.

Quantifying Potential Cost-Savings Through an Alternative Imaging-Based Diagnostic Process in Presumptive Seronegative Rheumatoid Arthritis

Background

Seronegative rheumatoid arthritis (SRA) is a condition that is not well understood and difficult to confirm by a conventional diagnostic process. We aimed to quantify the potential cost-savings of an alternative diagnostic process (ADP) imaging-based, for patients with presumptive SRA from everyday clinical practice.

Methods

We performed a retrospective analysis for patients with presumptive SRA who tested negative for both rheumatoid factor and anti-cyclic citrullinated peptide antibodies, through an ADP imaging-based, that is a standard clinical practice in our center. After we confirmed the diagnosis of SRA or reclassified patients in terms of another proper diagnosis, we estimate direct costs in two scenarios: a conventional and ADP. We compared the cost of RA treatment during the first year against the cost of the most misdiagnosed treatment (osteoarthritis) found after applying the ADP to determine potential cost-savings.

Results

We included 440 patients with a presumptive diagnosis of SRA. According to the imaging-based ADP, SRA was confirmed in 106/440 (24.1%), unspecified RA in 9/440 (2.0%), and osteoarthritis in 325/440 (73.9%) of those patients. Although the costs of conventional diagnosis per patient is lower than those of ADP ($59,20 USD vs $269,57 USD), we found a potential drug cost-savings of $1,570,775.20 US Dollars after 1 year of correct treatment.

Conclusion

An alternative diagnosis process, including X-rays, US and MRI imaging, and clinical and blood-test assessment, not only increased diagnostic certainty in patients referred for evaluation of presumptive SRA but also suggested a potential cost-savings in pharmacological treatments avoided in misdiagnosed patients.

Predictors of joint damage progression and stringent remission in patients with established rheumatoid arthritis in clinical remission

OBJECTIVES

To study if clinical, radiographic and MRI markers can predict MRI and radiographic damage progression and achievement of stringent remission in patients with established RA in clinical remission followed by a targeted treatment strategy.

METHODS

RA patients (DAS28-CRP <3.2, no swollen joints) receiving conventional synthetic DMARDs were randomized to conventional or MRI-targeted treat-to-target strategies with predefined algorithmic treatment escalations. Potentially predictive baseline variables were tested in multivariate logistic regression analyses.

RESULTS

In the 171 patients included, baseline MRI osteitis independently predicted progression in MRI erosion [odds ratio (OR) 1.13 (95% CI 1.06, 1.22)], joint space narrowing [OR 1.15 (95% CI 1.07, 1.24)] and combined damage [OR 1.23 (95% CI 1.13, 1.37)], while tenosynovitis independently predicted MRI erosion progression [OR 1.13 (95% CI 1.03, 1.25)]. A predictor of radiographic erosion progression was age, while gender predicted progression in joint space narrowing. Following an MRI treat-to-target strategy predicted stringent remission across all remission definitions: Clinical Disease Activity Index remission OR 2.94 (95% CI 1.25, 7.52), Simplified Disease Activity Index remission OR 2.50 (95% CI 1.01, 6.66), ACR/EULAR Boolean remission OR 5.47 (95% CI 2.33, 14.13). Similarly, low tender joint count and low patient visual analogue scale pain and global independently predicted achievement of more stringent remission.

CONCLUSION

Baseline MRI osteitis and tenosynovitis were independent predictors of 2 year MRI damage progression in RA patients in clinical remission, while independent predictors of radiographic damage progression were age and gender. Following an MRI treat-to-target strategy, low scores of patient-reported outcomes and low tender joint count predicted achievement of stringent remission.

TRIAL REGISTRATION

ClinicalTrials.gov (https://clinicaltrials.gov), NCT01656278.

[Rheumatoid arthritis of the hand : Part 2: Imaging]

BACKGROUND

Rheumatoid arthritis can cause joint destruction, especially joints of the hands. Diagnosed at an early stage, which often includes imaging methods, can minimize structural joint damage and resulting disabilities as well as avoid systemic manifestations such as cardiovascular damage through rapid and continuous so-called targeted treatment approaches.

OBJECTIVE

The aim of this work is the systematic description and report of imaging findings in rheumatoid arthritis as the most common autoimmunologic rheumatologic disease, which is characterized by a typical pattern of synovitis of the hands.

MATERIALS AND METHODS

Narrative review based on the current literature on the subject from the radiological and rheumatological point of view.

RESULTS

Inflammation of the hands represents the most frequently affected area of the body in rheumatoid arthritis. Taking into consideration the topology and typical synovitis patterns of the hands, differences between early and late stages are described. Knowledge regarding image-based morphological changes associated with this complex disease, especially in the hands, is important in the differential diagnosis, especially in early stages of the disease.

CONCLUSIONS

For the diagnosis of rheumatoid arthritis of the hands, the radiologist must be familiar with basic knowledge of arthritis in the hands to confidently analyze the typical patterns present in the diagnostic imaging at initial diagnosis and during the course of the disease, which serve as a guide for therapy decisions.

Differentiating Rheumatoid and Psoriatic Arthritis of the Hand: Multimodality Imaging Characteristics

Accurate diagnosis and therapeutic intervention at an early stage is paramount for the management of rheumatoid arthritis (RA) and psoriatic arthritis (PsA), which are the two major types of inflammatory arthritis that involve the hand joints. As more disease-specific medications are developed, medication selection according to the correct diagnosis becomes more important. A delay in diagnosis and inappropriate medication selection may result in poor functional prognosis. However, clinical differentiation between RA and PsA can be challenging and may become largely dependent on imaging interpretation results. Although there is substantial overlap in the imaging findings of RA and PsA, there are differences in the affected primary target sites, reflected by the various patterns of joint involvement, and different microanatomic localization of abnormalities within a single joint in each disease. Therefore, appropriate use of various imaging modalities and accurate image interpretation add significant value to the diagnosis and treatment process. The synovio-entheseal complex is an important concept for understanding the imaging features of PsA. The authors review the different features of RA and PsA of the hands seen with various imaging modalities, including radiography, US, MRI, and dual-energy CT, with updates on the contemporary role of imaging in diagnosis and treatment. The radiologist should have sufficient knowledge to interpret imaging findings and understand the strengths and weaknesses of each modality to recommend the appropriate imaging method and differentiate both diseases accurately. ^©RSNA, 2020.

Artificial intelligence in detecting early RA

To prevent chronicity of Rheumatoid Arthritis (RA) by early treatment, detecting inflammatory signs in an early phase is essential. Since Magnetic Resonance Imaging (MRI) of the wrist, hand and foot can detect inflammation before it is clinically detectable, this modality may play an important role in achieving very early diagnoses. By collecting large amounts of MRI data from healthy controls and patients with arthralgia suspicious for progression to RA, patterns can be studied that are most specific for early development of RA. Furthermore, MRI can be used as outcome parameter for randomized placebo-controlled trials on early RA treatment, by detecting subtle changes in image intensities originating from natural progression or treatment effects. Very large amounts of MRI data, however, make manual quantification impractical and the coarse scale used in visual scoring systems (i.e. whole values between 0 and 3) limits its sensitivity to detect changes that are likely to be very subtle in such an early phase. In recent years, advances in artificial intelligence and especially 'deep learning' in interpreting medical images have shown that -in specific areas- a computerized analysis can outperform human observers. Therefore, research has been initiated into applying these artificial intelligence techniques to the quantification of early RA from MRI data. In this paper, an overview is given on the background and history of artificial intelligence, with a special focus on recent developments in 'deep learning', and how these techniques could be applied to detect subtle inflammatory changes in MRI data.

T2 Mapping as a New Method for Quantitative Assessment of Cartilage Damage in Rheumatoid Arthritis

OBJECTIVE

Rheumatoid arthritis (RA) is associated with damage of the articular cartilage and the periarticular bone. While imaging of bone damage has substantially improved in recent years, direct imaging of the articular cartilage of the hand joints in patients with RA is still challenging. The study used T2 mapping of the finger joints to assess cartilage damage in RA.

METHODS

Magnetic resonance imaging (MRI) at 3 Tesla was done in 30 patients with RA, and T2 relaxation times visualizing alteration in the collagen network and hydration of articular cartilage were mapped in 6 cartilage regions of the metacarpophalangeal (MCP) joints 2 and 3. Values were related to autoantibody status [anticitrullinated protein antibodies (ACPA), rheumatoid factor (RF)], disease duration, and disease activity as well as sex and age of the patients.

RESULTS

T2 relaxation times could be reliably measured in the 6 regions of the MCP joints. Significantly higher relaxation times indicating more advanced cartilage alterations were observed in the metacarpal heads of ACPA-positive (p = 0.001-0.010) and RF-positive patients (p = 0.013-0.025) as well as those with longer disease duration (> 3 yrs; p = 0.028-0.043). Current disease activity, sex, and age did not influence T2 relaxation times.

CONCLUSION

These data show that cartilage damage can be localized and quantified in the hand joints of patients with RA by T2 mapping. Further, ACPA and RF positivity as well as disease duration appear to be the crucial factors influencing cartilage damage.

Rheumatoid Arthritis and Tenosynovitis at the Metatarsophalangeal Joints: An Anatomic and MRI Study of the Forefoot Tendon Sheaths

Background Although tenosynovitis in the hands is associated with rheumatoid arthritis (RA), it is unknown whether tenosynovitis of the forefoot is associated with RA. Purpose To determine the anatomy of tendon sheaths of the forefoot and the relationship between MRI-detected tenosynovitis at metatarsophalangeal (MTP) joints and RA. Materials and Methods Fourteen forefeet of donated bodies were examined at flexor tendons and extensor tendons for the presence and course of tendon sheaths. In the prospective study between June 2013 and March 2016, newly presenting patients with RA, patients with other early arthritides, and healthy control participants all underwent MRI of unilateral MTP joints 1-5. MRI studies were scored by two independent readers for tenosynovitis, synovitis, and bone marrow edema. The association between the presence of these features and RA was examined by using logistic regression. Results Macroscopically, all extensor and flexor tendons crossing MTP joints demonstrated sheaths surrounding tendons. Microscopically, a synovial sheath was present. MRI evaluation was performed in 634 participants: 157 newly presenting patients with RA (109 women; mean age, 59 years ± 11 [standard deviation]), 284 patients with other early arthritides (158 women; mean age, 56 years ± 17), and 193 healthy control participants (136 women; mean age, 50 years ± 16). MRI-detected tenosynovitis was associated with RA, both when compared with patients with other arthritides (odds ratio [OR], 2.5; 95% confidence interval [CI]: 1.7, 3.9; P < .001) and healthy control participants (OR, 46; 95% CI: 14, 151; P < .001). The association was OR of 2.4 (95% CI: 1.5, 3.8; P < .001) for flexor tendons and OR of 3.1 (95% CI: 1.9, 5.2; P < .001) for extensor tendons. The sensitivity of tenosynovitis in RA was 65 of 157 (41%; 95% CI: 35%, 50%). The specificity for RA was 63 of 284 (78%; 95% CI: 72%, 82%) compared with other arthritides, and three of 193 (98%; 95% CI: 96%, 99%) compared with healthy control participants. Conclusion Tendons at metatarsophalangeal joints are surrounded by tenosynovium. MRI-detected tenosynovitis at metatarsophalangeal joints was specific for rheumatoid arthritis when compared with findings in patients with other arthritides and findings in healthy control participants. © RSNA, 2020 Online supplemental material is available for this article.

Future use of musculoskeletal ultrasonography and magnetic resonance imaging in rheumatoid arthritis

PURPOSE OF REVIEW

Musculoskeletal ultrasonography (MSUS) and magnetic resonance imaging (MRI) play important roles in diagnosis, monitoring, and prognostication of rheumatoid arthritis. This review highlights recent literature in this field and aims to provide insight into the future use in clinical practice.

RECENT FINDINGS

Recent studies concerning the use of MSUS and MRI in clinical practice show how MSUS and MRI can improve diagnosis and monitoring of rheumatoid arthritis and how they can predict both radiographic progression and clinical outcome (e.g., successful tapering of medical treatment). Moreover, novel technical developments of the two imaging modalities, such as 3D ultrasonography, ultrasound image reading with convolutional neural network, image fusion (MSUS and MRI) and whole-body MRI show promising results. Further validation of these novel techniques is required prior to implementation.

SUMMARY

MSUS and MRI will be important parts of the future management of rheumatoid arthritis patients, mostly because of their ability to detect rheumatoid arthritis changes at a very early stage and to predict the course of disease. However, the exact role in routine clinical practice is still to be defined.

The value of MRI examination on bilateral hands including proximal interphalangeal joints for disease assessment in patients with early rheumatoid arthritis: a cross-sectional cohort study

Background

Bilateral hands including proximal interphalangeal joints (PIPJs) are recommended on physical, X-ray radiographic, or ultrasonographic examination by clinical guidelines of rheumatoid arthritis (RA), but MRI still tends to examine unilateral wrists and/or MCPJs. We aimed to demonstrate the advantages of MRI examination on bilateral hands including PIPJs for disease assessment in early RA patients.

Methods

Active early RA patients received 3.0T whole-body MRI examination with contrast-enhanced imaging on bilateral wrists, MCPJs, and PIPJs. MRI features were scored referring to the updated RAMRIS. Clinical assessments were conducted on the day of MRI examination.

Results

The mean time of MRI examination was 24 ± 3 min. MRI bone erosion in MCPJs would be missed-diagnosed in 23% of patients if non-dominant MCPJs were scanned unilaterally, while osteitis in MCPJs would be missed-diagnosed in 16% of patients if dominant MCPJs were scanned unilaterally. MRI synovitis severity was also asymmetric: 21% of patients showing severe synovitis unilaterally in non-dominant MCPJs/PIPJs and other 20% showing severe synovitis unilaterally in dominant MCPJs/PIPJs. Among these early RA patients, MRI tenosynovitis occurred the most frequently in wrist extensor compartment I, while MRI examination on bilateral hands demonstrated no overuse influence present. However, overuse should be considered in dominant PIPJ2, PIPJ4, and IPJ of thumb of which MRI tenosynovitis prevalence was respectively 18%, 17%, or 16% higher than the non-dominant counterparts. Early MRI abnormality of nervus medianus secondary to severe tenosynovitis occurred either in dominant or non-dominant wrists; MRI of unilateral hands would take a risk of missed-diagnosis. Common MRI findings in PIPJs were synovitis and tenosynovitis, respectively in 87% and 69% of patients. MRI tenosynovitis prevalence in IPJ of thumb or PIPJ5 was much higher than the continued wrist flexor compartments. MRI synovitis or tenosynovitis in PIPJs independently increased more than twice probability of joint tenderness (OR = 2.09 or 2.83, both p < 0.001).

Conclusions

In consideration of asymmetric MRI features in early RA, potential overuse influence for certain tenosynovitis in dominant hands, and high prevalence of MRI findings in PIPJs, MRI examination on bilateral hands including PIPJs is deserved for disease assessment in early RA patients.

Automatic quantification of tenosynovitis on MRI of the wrist in patients with early arthritis: a feasibility study

OBJECTIVES

Tenosynovitis (inflammation of the synovial lining of the sheath surrounding tendons) is frequently observed on MRI of early arthritis patients. Since visual assessment of tenosynovitis is a laborious task, we investigated the feasibility of automatic quantification of tenosynovitis on MRI of the wrist in a large cohort of early arthritis patients.

METHODS

For 563 consecutive early arthritis patients (clinically confirmed arthritis ≥ 1 joint, symptoms < 2 years), MR scans of the wrist were processed in three automatic stages. First, super-resolution reconstruction was applied to fuse coronal and axial scans into a single high-resolution three-dimensional image. Next, 10 extensor/flexor tendon regions were segmented using atlas-based segmentation and marker-based watershed. A measurement region of interest (ROI) was defined around the tendons. Finally, tenosynovitis was quantified by identifying image intensity values associated with tenosynovial inflammation using fuzzy clustering and measuring the fraction of voxels with these characteristic intensities within the measurement ROI. A subset of 60 patients was used for training and the remaining 503 patients for validation. Correlation between quantitative measurements and visual scores was assessed through Pearson correlation coefficient.

RESULTS

Pearson correlation between quantitative measurements and visual scores across 503 patients was r = 0.90, p < 0.001. False detections due to blood vessels and synovitis present within the measurement ROI contributed to a median offset from zero equivalent to 13.8% of the largest measurement value.

CONCLUSION

Quantitative measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. Further improvements in segmentation and exclusion of false detections are warranted.

KEY POINTS

• Automatic measurement of tenosynovitis on MRI of the wrist is feasible and largely consistent with visual scores. • Blood vessels and synovitis in the vicinity of evaluated tendons can contribute to false detections in automatic measurements. • Further improvements in segmentation and exclusion of false detections are important directions of future work on the path to a robust quantification framework.

Magnetic resonance imaging-assessed synovial and bone changes in hand and wrist joints of rheumatoid arthritis patients

BACKGROUND/AIMS

Magnetic resonance imaging (MRI) is a sensitive and useful method for the detection of synovitis and joint destruction in rheumatoid arthritis (RA) patients. However, the patterns of MRI-detected bone erosion, bone marrow edema (BME), synovitis, and tenosynovitis have received insufficient attention. Therefore, this study evaluated the patterns of bone erosion, BME, synovitis, and tenosynovitis, and calculated the RA-MRI score (RAMRIS) of patients with RA at the carpal and metacarpophalangeal (MCP) joints using MRI.

METHODS

MRI datasets from 43 RA patients were analyzed. All patients had undergone MRI of one wrist. In addition, 36 patients had MCP joint images taken, and three had also received MRI of the contralateral wrist and MCP joints. The MR images were evaluated for bone erosion, BME, and synovitis in consensus by two blinded readers according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) RAMRIS. The MRI-detected tenosynovitis was evaluated based on Haavardsholm's tenosynovitis score.

RESULTS

The capitate, lunate, triquetrum, and hamate bones were the most common sites of erosion and BME and showed the highest RAMRIS erosion and BME scores. Moreover, MRI-detected tenosynovitis was present in 78.3% of all patients with RA, and the extensor compartment 4 and flexor digitorum profundus and superficialis were frequently affected.

CONCLUSION

This study identified the distribution and prevalence of MRI-detected bone erosion, BME, synovitis, and tenosynovitis of the wrist and MCP joints in RA patients. The patterns of the MRI-detected abnormalities may help to select sites for the application of MRI protocols in clinical trials and practice.

MRI inflammation of the hand interosseous tendons occurs in anti-CCP-positive at-risk individuals and may precede the development of clinical synovitis

Interosseous tendon inflammation (ITI) has been described in rheumatoid arthritis (RA). Whether ITI occurs in at-risk individuals before the onset of clinical synovitis is unknown.

Objectives

To investigate, by MRI, ITI in anti-cyclic citrullinated peptide (CCP)-positive at-risk individuals (CCP +at risk) and to describe the anatomy, prevalence and clinical associations across the RA continuum.

Methods

Hand MRI was performed in 93 CCP + at risk, 47 early RA (ERA), 28 established ‘late’ RA (LRA) and 20 healthy controls (HC) and scored for ITI, flexor tenosynovitis (TSV) and RA MRI scoring at the metacarpophalangeal joints (MCPJs). Cadaveric and histological studies were performed to explore the anatomical basis for MRI ITI.

Results

The proportion of subjects with ITI and the number of inflamed interosseous tendons (ITs) increased along the disease continuum (p<0.001): 19% of CCP +at risk, 49% of ERA and 57% of LRA had ≥1 IT inflamed . ITI was not found in any HC. ITI was more frequently identified in tender MCPJs compared with nontender MCPJs (28% vs 12%, respectively). No IT tenosynovial sheath was identified in cadavers on dissection or histological studies suggesting MRI findings represent peritendonitis. Dye studies indicated no communication between the IT and the joint.

Conclusions

ITI occurs in CCP + at-risk individuals and can precede the onset of clinical synovitis. The ITs may be important nonsynovial extracapsular targets in the development and progression of RA.

Oral and Subcutaneous Administration of a Near-Infrared Fluorescent Molecular Imaging Agent Detects Inflammation in a Mouse Model of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that causes irreversible damage to the joints. However, effective drugs exist that can stop disease progression, leading to intense interest in early detection and treatment monitoring to improve patient outcomes. Imaging approaches have the potential for early detection, but current methods lack sensitivity and/or are time-consuming and expensive. We examined potential routes for self-administration of molecular imaging agents in the form of subcutaneous and oral delivery of an integrin binding near-infrared (NIR) fluorescent imaging agent in an animal model of RA with the long-term goal of increasing safety and patient compliance for screening. NIR imaging has relatively low cost, uses non-ionizing radiation, and provides minimally invasive spatial and molecular information. This proof-of-principle study shows significant uptake of an IRDye800CW agent in inflamed joints of a collagen antibody induced arthritis (CAIA) mouse model compared to healthy joints, irrespective of the method of administration. The imaging results were extrapolated to clinical depths in silico using a 3D COMSOL model of NIR fluorescence imaging in a human hand to examine imaging feasability. With target to background concentration ratios greater than 5.5, which are achieved in the mouse model, these probes have the potential to identify arthritic joints following oral delivery at clinically relevant depths.

Do musculoskeletal ultrasound and magnetic resonance imaging identify synovitis and tenosynovitis at the same joints and tendons? A comparative study in early inflammatory arthritis and clinically suspect arthralgia

Objective

Ultrasound (US) and magnetic resonance imaging (MRI) are recommended in the diagnostic process of rheumatoid arthritis. Research on its comparability in early disease phases is scarce. Therefore, we compared synovitis and tenosynovitis detected by US and MRI on joint/tendon level.

Methods

Eight hundred forty joints and 700 tendons of 70 consecutive patients, presenting with inflammatory arthritis or clinically suspect arthralgia, underwent US and MRI of MCP (2–5), wrist and MTP (1–5) joints at the same day. Greyscale (GS) and power Doppler (PD) synovitis were scored according to the modified Szkudlarek method (combining synovial effusion and hypertrophy) and the recently published EULAR-OMERACT method (synovial hypertrophy regardless of the presence of effusion) on static images. US-detected tenosynovitis was scored according to the OMERACT. MRI scans were scored according to the RAMRIS. Test characteristics were calculated on joint/tendon level with MRI as reference. Cut-off for US scores were ≥ 1 and ≥ 2 and for MRI ≥ 1.

Results

Compared to MRI, GS synovitis according to EULAR-OMERACT (cut-off ≥ 1) had a sensitivity ranging from 29 to 75% for the different joint locations; specificity ranged from 80 to 98%. For the modified Szkudlarek method, the sensitivity was 68–91% and specificity 52–71%. PD synovitis had a sensitivity of 30–54% and specificity 97–99% compared to MRI. The sensitivity to detect GS tenosynovitis was 50–78% and the specificity 80–94%. For PD tenosynovitis, the sensitivity was 19–58% and specificity 98–100%.

Conclusion

Current data showed that US is less sensitive than MRI in the early detection of synovitis and tenosynovitis, but resulted in only few non-specific findings. The higher sensitivity of MRI is at the expense of less accessibility and higher costs.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1824-z) contains supplementary material, which is available to authorized users.

What is the additional value of MRI of the foot to the hand in undifferentiated arthritis to predict rheumatoid arthritis development?

Background

MRI-detected subclinical joint inflammation in the hand joints of patients with undifferentiated arthritis (UA) predicts progression to rheumatoid arthritis (RA). It is unknown if adding MRI of the foot increases predictive accuracy compared to the hand alone.

Methods

1.5-T contrast-enhanced MRI of the unilateral foot (MTP-1-5) and hand (MCP-2-5 and wrist) was performed in 123 patients presenting with UA (not fulfilling the 2010 RA criteria) and scored for bone marrow edema (BME), synovitis and tenosynovitis. Symptom-free controls (n = 193) served as a reference for defining an abnormal MRI. Patients were followed for RA development ≤ 1 year, defined as fulfilling the classification criteria or initiation of disease-modifying antirheumatic drugs because of the expert opinion of RA. The added predictive value of foot MRI to hand MRI was evaluated.

Results

Fifty-two percent developed RA. Foot tenosynovitis was predictive (OR 2.55, 95% CI 1.01–6.43), independent of BME and synovitis (OR 3.29, 95% CI 1.03–10.53), but not independent of CRP and number of swollen joints (OR 2.14, 95% CI 0.77–5.95). Hand tenosynovitis was also predictive independent of BME and synovitis (OR 3.99, 95% CI 1.64–9.69) and independent of CRP and swollen joints (OR 2.36, 95% CI 1.04–5.38). Adding foot tenosynovitis to hand tenosynovitis changed the sensitivity from 72 to 73%, specificity from 59 to 54% and AUC from 0.66 to 0.64; the net reclassification index was − 3.5.

Conclusion

MRI-detected tenosynovitis of the foot predicts progression to RA. However, adding MRI of the foot does not improve the predictive accuracy compared to MRI of the hand alone. In view of cost reduction, the performance of foot MRI for prognostic purposes in UA can be omitted.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1845-7) contains supplementary material, which is available to authorized users.

Identifying MRI-detected inflammatory features specific for rheumatoid arthritis: two-fold feature reduction maintains predictive accuracy in clinically suspect arthralgia patients

OBJECTIVE

MRI-detected inflammation is considered of diagnostic value for rheumatoid arthritis (RA), but its evaluation involves a time-consuming scoring of 61 joint-level features. It is not clear, however, which of these features are specific for RA and whether evaluating a subset of specific features is sufficient to differentiate RA patients. This study aimed to identify a subset of RA-specific features in a case-control setting and validate them in a longitudinal cohort of arthralgia patients.

METHODS

The difference in frequency of MRI-detected inflammation (bone marrow edema, synovitis, and tenosynovitis) between 199 RA patients and 193 controls was studied in 61 features across the wrist, metacarpophalangeal, and metatarsophalangeal joints. A subset of RA-specific features was obtained by applying a cutoff on the frequency difference while maximizing discriminative performance. For validation, this subset was used to predict arthritis development in 225 clinically suspect arthralgia (CSA) patients. Diagnostic performance was compared to a reference method that uses the complete set of 61 features normalized for inflammation levels in age-matched controls.

RESULTS

Subset of 30 features, mainly (teno)synovitis, was obtained from the case-control setting. Validation in CSA patients yielded an area of 0.69 (95% CI: 0.59-0.78) under the ROC curve and a positive predictive value (PPV) of 31%, compared to 0.68 (95% CI: 0.60-0.77) and 29% PPV of the reference method with 61 features.

CONCLUSION

Subset of 30 MRI-detected inflammatory features, dominated by (teno)synovitis, offers a considerable reduction of scoring efforts without compromising accuracy for prediction of arthritis development in CSA patients.

Fasciae of the musculoskeletal system: normal anatomy and MR patterns of involvement in autoimmune diseases

Abstract

The fascial system is a three-dimensional continuum of connective tissues present everywhere throughout the body, from the head to the toes and from the skin to the bone. The current article aims to review the normal anatomy of the fasciae of the musculoskeletal system with macroscopic and microscopic correlations and to describe their appearance at MRI in normal subjects and in patients with autoimmune diseases of the musculoskeletal system.

Key Points

• The fascial system is a three-dimensional continuum of connective tissues.

• It is present everywhere throughout the body, from the head to the toes and from the skin to the bone.

• The normal fascial system is barely visible at MRI.

• MR patterns of fascial involvement in autoimmune diseases reflect the complex anatomy of the fasciae of the musculoskeletal system.

The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development

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.

Frequency of inflammatory-like MR imaging findings in asymptomatic fingers of healthy volunteers

OBJECTIVE

To describe the frequency of inflammatory-like findings on MR imaging in asymptomatic volunteers and compare them with patients with known rheumatoid arthritis and psoriatic arthritis.

MATERIALS AND METHODS

MR images of fingers in 42 asymptomatic volunteers and 33 patients with rheumatoid/psoriatic arthritis were analyzed. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid/Psoriatic Arthritis MRI Scoring System (RAMRIS/PsAMRIS) and tenosynovitis scoring system were used to assess: bone marrow edema (BME), erosions, tendon sheath fluid/tenosynovitis, joint effusion, and soft-tissue edema. Findings and scores were compared between volunteers and patients. Inter-reader agreement was calculated (intraclass correlation coefficients, ICC).

RESULTS

In volunteers, tendon sheath fluid was very common in at least one location (42/42 volunteers for reader 1, 34/42 volunteers for reader 2). BME, erosions, joint effusion, and soft-tissue edema were absent (except one BME in the 3rd proximal phalanx for reader 1). Tendon sheath fluid scores in volunteers and tenosynovitis scores in patients were high (reader 1, 7.17 and 5.39; reader 2, 2.31 and 5.45). Overall, inter-reader agreement was substantial (ICC = 0.696-0.844), except for tendon sheath fluid (ICC = 0.258).

CONCLUSION

Fluid in the finger flexor tendon sheaths may be a normal finding and without gadolinium administration should not be interpreted as tenosynovitis. Bone marrow edema, erosions, joint effusion, and soft-tissue edema in the fingers most likely reflect pathology if present.

The Use of the OMERACT Ultrasound Tenosynovitis Scoring System in Multicenter Clinical Trials

OBJECTIVE

To test the sensitivity to change of the Outcome Measures in Rheumatology Clinical Trials (OMERACT) ultrasound (US) scoring system for tenosynovitis when applied in a multicenter design.

METHODS

RA patients with US-verified tenosynovitis were recruited when scheduled for treatment intensification. Tenosynovitis was assessed at baseline, and 3 and 6 months followup, using the semiquantitative OMERACT scoring system.

RESULTS

Expressed in median (25th; 75th percentiles), the overall greyscale and Doppler score decreased significantly from baseline at 4 (2; 7) and 3 (2; 6), to 6 months at 2 (0; 3) and 0 (0; 1, p < 0.01), respectively, and showed high responsiveness (standardized response mean ≥ 0.8).

CONCLUSION

The OMERACT US scoring system for tenosynovitis showed high responsiveness, supporting its use for diagnosing and monitoring tenosynovitis in multicenter trials.

Magnetic resonance imaging in individuals at risk of rheumatoid arthritis

Individuals with rheumatoid arthritis (RA) benefit from early diagnosis and initiation of therapy. There can be delays in both due to diagnostic uncertainties. Imaging modalities, including magnetic resonance imaging (MRI), can detect inflammation earlier than clinical examination alone in early RA patients. Furthermore, the predictive role of MRI for the future development of RA has recently been explored in 'at-risk' individuals. This review details the use of MRI in early and undifferentiated arthritis and summarises the studies to date in individuals at risk of RA.

Role of ultrasound imaging in individuals at risk of RA

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.

Cost-Effectiveness Model for Evaluating New Diagnostic Tests in the Evaluation of Patients With Inflammatory Arthritis at Risk of Having Rheumatoid Arthritis

OBJECTIVE

New opportunities have emerged for early diagnosis with the arrival of new technologies that assess the impact of genomics, proteomics, metabolomics, and cytomics on rheumatoid arthritis (RA) risk. This early health technology assessment study assesses the short-term cost effectiveness of 4 add-on diagnostic tests in early inflammatory arthritis patients at risk of RA.

METHODS

We modeled 4 diagnostic add-on tests to the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria, covering the first year after diagnosis, using Rotterdam Early Arthritis Cohort data. Sensitivity, specificity, and costs were assigned to the magnetic resonance imaging of hands and feet (sensitivity 0.90, specificity 0.60, cost €756), interleukin-6 (IL-6) serum level test (sensitivity 0.70, specificity 0.53, cost €50), B cell-related gene expression (sensitivity 0.60, specificity 0.90, cost €150), and gene assay for RA (sensitivity 0.40, specificity 0.85, cost €750), based on literature and expert opinion. Outcomes were evaluated using the unweighted diagnostic net benefit (UDNB) and the incremental cost-effectiveness ratio (ICER) in all patients (n = 552), intermediate-risk patients (n = 263), and seronegative patients (n = 329).

RESULTS

The highest UDNB was found when using the B cell assay in intermediate-risk patients (43%, ICER €5,314), while the IL-6 test in seronegative patients resulted in the lowest UDNB (-11.4%, ICER €7,650). If a threshold of €20,000 is applied, the B cell assay would be preferred over the other alternatives, with a 78% probability of being cost effective for intermediate-risk patients, 57% for all patients, and 73% for seronegative patients.

CONCLUSION

Diagnostic add-on tests favoring specificity over sensitivity with a headroom less than €370 per test are cost effective, with the largest diagnostic benefit occurring in intermediate-risk patients.

Dual energy CT iodine map for delineating inflammation of inflammatory arthritis

Iodine mapping is an image-processing technique used with dual-energy computed tomography (DECT) to improve iodine contrast resolution. CT, because of its high spatial resolution and thin slice reconstruction, is well suited to the evaluation of the peripheral joints. Recent developments in the treatment of inflammatory arthritis that require early diagnosis and precise therapeutic assessment encourage radiological evaluation. To facilitate such assessment, we describe DECT iodine mapping as a novel modality for evaluating rheumatoid arthritis and psoriatic arthritis of the hands and feet.

KEY POINTS

• Dual-energy CT iodine mapping can delineate inflammation of peripheral inflammatory arthritis. • DECT iodine mapping has high spatial resolution compared with MRI. • DECT iodine mapping has a high iodine contrast resolution. • DECT iodine mapping may reflect therapeutic effects.

Sonographic Characteristics of Extensor Tendon Abnormalities and Relationship With Joint Disease Activity in Rheumatoid Arthritis: A Pilot Study

OBJECTIVES

To characterize abnormalities in the dorsal extensor tendons of the hand and determine the importance of these findings in rheumatoid arthritis.

METHODS

A retrospective cross-sectional study was done on 26 patients with rheumatoid arthritis who had sonography of their hands. B-mode and power Doppler joint activity were scored, and the extensor tendons were examined for B-mode changes and power Doppler signals. B-mode changes included anechoic fluid around tendons, hypoechoic tissue around tendons, paratendon tissue and tendon thickening, as well as vascularity around the tendon, for which peritendon power Doppler signals were recorded.

RESULTS

Forty-one hands and 205 joints were reviewed. Anechoic fluid around the tendons and peritendon power Doppler signals were observed in 41% and 39%, respectively; 44% and 28% of patients had B-mode and power Doppler scores in the upper tertile, respectively. For both B-mode and power Doppler scores, 3 categories or tertiles were created, 0 to 0.9, 1 to 1.9, and 2 to 3. We reported the percentage of patients with power Doppler and B-mode scores in this category. The severity of synovitis was associated with anechoic fluid around the tendons and peritendon power Doppler signals according to the Cochran-Mantel-Haenszel test. The common odds ratio was 3.52 (95% confidence interval, 1.45- 8.53) for anechoic fluid around the tendons and severe synovitis. The common odds ratio was 2.52 (95% confidence interval, 1.13-5.63) for peritendon power Doppler signals and severe synovitis.

CONCLUSIONS

Findings at the dorsal extensor tendons were anechoic fluid around tendons, hypoechoic tissue around tendons, peritendon power Doppler signals, and tendon thickening. Patients with anechoic fluid and power Doppler signals were found to have more severe disease activity at the joints based on B-mode and power Doppler scores.

Development and Validation of the OMERACT Rheumatoid Arthritis Magnetic Resonance Tenosynovitis Scoring System in a Multireader Exercise

OBJECTIVE

To develop and validate a magnetic resonance imaging (MRI) tenosynovitis (TS) score for tendons at the wrist and metacarpophalangeal (MCP) joint levels in patients with rheumatoid arthritis (RA).

METHODS

Axial T1-weighted precontrast and postcontrast fat-saturated MR image sets of the hands of 43 patients with RA initiating rituximab therapy were obtained at baseline and after 14, 26, 38, or 52 weeks. The MR images were scored twice by 4 readers. Nine tendon compartments of the wrist and 4 flexor tendon compartments at the MCP joints were assessed. Tenosynovitis was scored as follows: 0: No; 1: < 1.5 mm; 2: ≥ 1.5 mm but < 3 mm; 3: ≥ 3 mm peritendinous effusion and/or postcontrast enhancement. Intrareader and interreader intraclass correlation coefficients (ICC), smallest detectable change (SDC), percentage of exact and close agreement (PEA/PCA), and standardized response mean (SRM) were calculated.

RESULTS

Intrareader and interreader ICC for status and change scores were very good (≥ 0.80) for total scores for all readers. Intrareader SDC was ≤ 3.0 and interreader SDC was < 2.0. The overall PEA/PCA intrareader and interreader agreements for change scores in all tendons were 73.8%/97.6% and 47.9%/85.0%, respectively. Average SRM was moderate for total scores and 60.5% of the patients had a tenosynovitis change score ≥ SDC.

CONCLUSION

The TS score showed high intrareader and interreader agreement for wrist and finger tendons, with moderate responsiveness, and the majority of the patients showed a change above the SDC. This scoring system may be included as a component of the RAMRIS.

Diagnostic value of a 3-day course of prednisolone in patients with possible rheumatoid arthritis - the TryCort study

Background

In patients with tender and swollen finger joints, the differential diagnosis between rheumatoid arthritis (RA) and osteoarthritis (OA) of the hands can be initially difficult. This prospective study (the TryCort study) was performed to study the diagnostic value of prednisolone in differentiating between RA and hand OA. We present the results of this potentially diagnostic test in patients with possible RA in daily clinical practice by demonstrating the results of a pilot and a validation part of this ‘prednisolone test’ (pred-test).

Methods

We investigated the response to a 3-day course of 20 mg of prednisolone in patients with suspicion of RA. All patients received 1 g of paracetamol per day for 5 days for pain relief. On days 3–5, a morning dose of 20 mg of prednisolone was added. Hand pain was quantified on a 0–10 Numerical Rating Scale, and the subjective percentage of improvement (0–100%) was recorded. Thresholds for response to prednisolone were investigated in a pilot phase with differentiation in response between patients with RA and patients with OA of the hands, both with pain in the hands ≥4. In a validation phase, the best differentiating cut-off of the pilot phase was applied to discriminate responders from non-responders in consecutive patients with hand pain ≥4 referred because of suspected RA. Final diagnoses were made by the expert upon re-examination at week 12. Primary outcomes were the sensitivity and specificity of a positive test in relation to the diagnosis.

Results

A percentage of 40% subjective improvement of pain in the hands on day 3 discriminated best between RA and OA in the pilot phase. Among 95 patients with complete data in the validation phase, RA was diagnosed in about 50%. Patients with RA had more swollen joints, higher C-reactive protein levels and slightly higher Health Assessment Questionnaire scores. The pred-test was positive in 42.1% of all patients (40 of 95). The median percentage of improvement on day 5 was higher in RA than in non-RA: 50% (IQR 30–60%) vs. 20% (IQR 10–30%) (p < 0.001). The sensitivity and specificity of the pred-test were 0.6 (95% CI 0.5–0.8) and 0.8 (95% CI 0.7–0.9), respectively, and the positive and negative predictive values were 0.77 and 0.70, respectively.

Conclusions

To our knowledge, this is the first evaluation of the widely used pred-test that has ever been performed. The pred-test had a moderate sensitivity and a good specificity. We conclude that rheumatologists may use this test in unclear clinical situations to better differentiate between inflammatory and other conditions.

Trial registration

ClinicalTrials.gov identifier: NCT01395251. Registered on 14 Jul 2011.

EudraCT number: 2011-002633-19. Registered on 21 Dec 2011.

Diagnosis, prognosis and classification of early arthritis: results of a systematic review informing the 2016 update of the EULAR recommendations for the management of early arthritis

OBJECTIVE

To update the evidence pertaining to the diagnosis, prognosis and classification of patients with early arthritis (EA), and to inform the 2016 European League Against Rheumatism (EULAR) recommendations for the management of patients with EA.

METHODS

MEDLINE, EMBASE and Cochrane databases were searched up to October 2015. The first part of the systematic literature review (SLR) involved a search for studies investigating the recognition and referral of EA. The second part involved a search for studies to identify the place of laboratory and imaging tests in establishing a diagnosis and a prognosis in patients with EA.

RESULTS

Regarding the issue of referral of patients with EA (1643 hits), 4 studies were included. These studies were in support of early referral for patients with EA. Regarding the issue of diagnosis and prognosis of patients with EA (11 435 hits), 88 studies were included, evaluating mainly the value of rheumatoid factor (RF) and anticitrullinated-peptide antibodies (ACPAs). Sensitivity of these antibodies for a RA diagnosis in patients with EA was moderate (40-80%). Specificity was higher, notably for ACPAs (frequently >80%). ACPAs also showed better prognostic performance than RF (negative predictive values around 80%). We confirmed that structural damage on baseline X-rays is predictive of further radiographic progression in patients with EA. Regarding other imaging modalities, data are sparse.

CONCLUSIONS

This SLR highlights the importance of early referral for patients with EA and confirms that RF and mainly ACPAs as well as a search for structural X-rays changes may help in the diagnosis and prognosis of patients with EA.

2016 update of the EULAR recommendations for the management of early arthritis

OBJECTIVES

Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis.

METHODS

In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process.

RESULTS

The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research.

CONCLUSIONS

These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.

2016 update of the EULAR recommendations for the management of early arthritis

OBJECTIVES

Since the 2007 recommendations for the management of early arthritis have been presented, considerable research has been published in the field of early arthritis, mandating an update of the 2007 European League Against Rheumatism (EULAR) recommendations for management of early arthritis.

METHODS

In accordance with the 2014 EULAR Standardised Operating Procedures, the expert committee pursued an approach that was based on evidence in the literature and on expert opinion. The committee involved 20 rheumatologists, 2 patients and 1 healthcare professional representing 12 European countries. The group defined the focus of the expert committee and target population, formulated a definition of 'management' and selected the research questions. A systematic literature research (SLR) was performed by two fellows with the help of a skilled librarian. A set of draft recommendations was proposed on the basis of the research questions and the results of the SLR. For each recommendation, the categories of evidence were identified, the strength of recommendations was derived and the level of agreement was determined through a voting process.

RESULTS

The updated recommendations comprise 3 overarching principles and 12 recommendations for managing early arthritis. The selected statements involve the recognition of arthritis, referral, diagnosis, prognostication, treatment (information, education, pharmacological and non-pharmacological interventions), monitoring and strategy. Eighteen items were identified as relevant for future research.

CONCLUSIONS

These recommendations provide rheumatologists, general practitioners, healthcare professionals, patients and other stakeholders with an updated EULAR consensus on the entire management of early arthritis.

Imaging of regional pain syndromes; from syndromes to conditions using imaging?

Musculoskeletal regional pain syndromes often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can in most cases reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods have to support the clinical assessment. This paper presents the underlying pathologies of the most frequently encountered regional pain syndromes and the role of musculoskeletal ultrasonography and magnetic resonance imaging in their visualization. It presents data, where available, on diagnostic accuracy and comparisons with gold standards. The article stresses the advantages and disadvantages of the analyzed imaging modalities and suggests the future research agenda.

Validity and sensitivity to change of the semi-quantitative OMERACT ultrasound scoring system for tenosynovitis in patients with rheumatoid arthritis

OBJECTIVES

The aim was to evaluate the metric properties of the semi-quantitative OMERACT US scoring system vs a novel quantitative US scoring system for tenosynovitis, by testing its intra- and inter-reader reliability, sensitivity to change and comparison with clinical tenosynovitis scoring in a 6-month follow-up study.

METHODS

US and clinical assessments of the tendon sheaths of the clinically most affected hand and foot were performed at baseline, 3 and 6 months in 51 patients with RA. Tenosynovitis was assessed using the semi-quantitative scoring system (0-3) proposed by the OMERACT US group and a new quantitative US evaluation (0-100). A sum for US grey scale (GS), colour Doppler (CD) and pixel index (PI), respectively, was calculated for each patient. In 20 patients, intra- and inter-observer agreement was established between two independent investigators. A binary clinical tenosynovitis score was performed, calculating a sum score per patient.

RESULTS

The intra- and inter-observer agreements for US tenosynovitis assessments were very good at baseline and for change for GS and CD, but less good for PI. The smallest detectable change was 0.97 for GS, 0.93 for CD and 30.1 for PI. The sensitivity to change from month 0 to 6 was high for GS and CD, and slightly higher than for clinical tenosynovitis score and PI.

CONCLUSION

This study demonstrated an excellent intra- and inter-reader agreement between two investigators for the OMERACT US scoring system for tenosynovitis and a high ability to detect changes over time. Quantitative assessment by PI did not add further information.

MRI-detected osteitis is not associated with the presence or level of ACPA alone, but with the combined presence of ACPA and RF

Background

In rheumatoid arthritis (RA) bone marrow edema (BME, osteitis) and anti-citrullinated protein antibodies (ACPA) are associated with radiographic progression. ACPA have been associated with BME, but it is unknown if this association is confined to ACPA and BME. We performed cross-sectional analysis of the association of ACPA, rheumatoid factor (RF) and anti-carbamylated protein (anti-CarP) antibodies with BME and other types of inflammation (synovitis, tenosynovitis) detected by magnetic resonance imaging (MRI).

Methods

Disease-modifying antirheumatic drug (DMARD)-naïve patients with early arthritis (n = 589), included in the Leiden Early Arthritis Clinic cohort, underwent contrast-enhanced 1.5 T MRI of unilateral wrist, metacarpophalangeal and metatarsophalangeal-joints at baseline. BME, synovitis and tenosynovitis were scored by two readers. ACPA, rheumatoid factor (RF) and anti-CarP were determined at baseline.

Results

In univariable analyses ACPA-positive patients had higher BME scores than ACPA-negative patients (median 4.5 vs. 2.0, p < 0.001), but not more synovitis and tenosynovitis. Also RF (median 3.75 vs. 2.0, p < 0.001) and anti-CarP antibodies (median 3.5 vs. 2.5, p = 0.012) were associated with higher BME scores. Because the autoantibodies were concomitantly present, analyses were stratified for the presence of different autoantibody combinations. ACPA-positive (ACPA+), RF-negative (RF-), anti-CarP-negative (anti-CarP-) patients did not have higher BME-scores than ACPA-negative (ACPA-), RF-, anti-CarP- patients. However ACPA+, RF-positive (RF+), anti-CarP- patients and ACPA+, RF+, anti-CarP-positive (anti-CarP+) patients had higher BME scores than ACPA-, RF-, anti-CarP- patients (median 5.0 and 4.5 vs. 2.0, p < 0.001 and p < 0.001). ACPA levels were not associated with BME scores. Analyses within RA- and UA-patients revealed similar results.

Conclusions

The presence of ACPA alone or ACPA level was not statistically significantly associated with BME scores, but the combined presence of ACPA and RF was associated with more BME. This suggests an additive role of RF to ACPA in mediating osteitis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-016-1076-0) contains supplementary material, which is available to authorized users.

A five-year model to assess the early cost-effectiveness of new diagnostic tests in the early diagnosis of rheumatoid arthritis

BACKGROUND

There is a lack of information about the sensitivity, specificity and costs new diagnostic tests should have to improve early diagnosis of rheumatoid arthritis (RA). Our objective was to explore the early cost-effectiveness of various new diagnostic test strategies in the workup of patients with inflammatory arthritis (IA) at risk of having RA.

METHODS

A decision tree followed by a patient-level state transition model, using data from published literature, cohorts and trials, was used to evaluate diagnostic test strategies. Alternative tests were assessed as add-on to or replacement of the ACR/EULAR 2010 RA classification criteria for all patients and for intermediate-risk patients. Tests included B-cell gene expression (sensitivity 0.60, specificity 0.90, costs €150), MRI (sensitivity 0.90, specificity 0.60, costs €756), IL-6 serum level (sensitivity 0.70, specificity 0.53, costs €50) and genetic assay (sensitivity 0.40, specificity 0.85, costs €750). Patients with IA at risk of RA were followed for 5 years using a societal perspective. Guideline treatment was assumed using tight controlled treatment based on DAS28; if patients had a DAS28 >3.2 at 12 months or later patients could be eligible for starting biological drugs. The outcome was expressed in incremental cost-effectiveness ratios (€2014 per quality-adjusted life year (QALY) gained) and headroom.

RESULTS

The B-cell test was the least expensive strategy when used as an add-on and as replacement in intermediate-risk patients, making it the dominant strategy, as it has better health outcomes and lower costs. As add-on for all patients, the B-cell test was also the most cost-effective test strategy. When using a willingness-to-pay threshold of €20,000 per QALY gained, the IL-6 and MRI strategies were not cost-effective, except as replacement. A genetic assay was not cost-effective in any strategy. Probabilistic sensitivity analysis revealed that the B-cell test was consistently superior in all strategies. When performing univariate sensitivity analysis for intermediate-risk patients, specificity and DAS28 in the B-cell add-on strategy, and DAS28 and sensitivity in the MRI add-on strategy had the largest impact on the cost-effectiveness.

CONCLUSIONS

This early cost-effectiveness analysis indicated that new tests to diagnose RA are most likely to be cost-effective when the tests are used as an add-on in intermediate-risk patients, and have high specificity, and the test costs should not be higher than €200-€300.