Ultrasonographic criteria for the diagnosis of erosive rheumatoid arthritis using osteoarthritic patients as controls compared to validated radiographic criteria

Clinical implications of persistent joint pain after gout flare

OBJECTIVES

A subset of gout patients developed persistent joint pain after flares. Analysis of this clinical phenomenon may shed further light on the factors related to worsening gout and even provide clues to its pathogenesis.

METHODS

We analyzed the clinical, laboratory, and ultrasound data of gout patients to explore the associations of these data with persistent joint pain after gout flares.

RESULTS

A total of 1029 gout patients were included: 182 (17.7%) patients with persistent joint pain and 847 (82.3%) patients with nonpersistent joint pain. Patients with persistent joint pain had more total involved joints, more gout flares in the past year, and more joints with simultaneous gout flares (P<0.01). Among the ultrasound-detected lesions, patients with persistent joint pain had a higher incidence of tophus (36.4% vs. 21.1%) and bone erosion (18.6% vs. 8.6%) (P<0.05). Higher UA and lower TBil were found in patients with persistent joint pain (P<0.001). Hypertension (54.9% vs. 38.7%) and metabolic syndrome (58.8% vs. 46.4%) were both more frequent in patients with persistent joint pain (P<0.05). TBil was negatively correlated with the incidence of persistent joint pain (P<0.001, r=-0.190), UA values (P<0.001, r=-0.125), and metabolic syndrome scores (P<0.001, r=-0.192). A correlation curve was fitted using LOESS (locally weighted region).

CONCLUSION

Persistent joint pain after gout flares is a marker of increased disease burden in gout. The significance of the level of total bilirubin for the exacerbation of gout deserves further study.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part II: Joint Pathologies, Pediatric Applications, and Guided Procedures

The second part of the Guidelines and Recommendations for Musculoskeletal Ultrasound (MSUS), produced under the auspices of EFSUMB, following the same methodology as for Part 1, provides information and recommendations on the use of this imaging modality for joint pathology, pediatric applications, and musculoskeletal ultrasound-guided procedures. Clinical application, practical points, limitations, and artifacts are described and discussed for every joint or procedure. The document is intended to guide clinical users in their daily practice.

Practical Implementation of Artificial Intelligence-Based Deep Learning and Cloud Computing on the Application of Traditional Medicine and Western Medicine in the Diagnosis and Treatment of Rheumatoid Arthritis

Rheumatoid arthritis (RA), an autoimmune disease of unknown etiology, is a serious threat to the health of middle-aged and elderly people. Although western medicine, traditional medicine such as traditional Chinese medicine, Tibetan medicine and other ethnic medicine have shown certain advantages in the diagnosis and treatment of RA, there are still some practical shortcomings, such as delayed diagnosis, improper treatment scheme and unclear drug mechanism. At present, the applications of artificial intelligence (AI)-based deep learning and cloud computing has aroused wide attention in the medical and health field, especially in screening potential active ingredients, targets and action pathways of single drugs or prescriptions in traditional medicine and optimizing disease diagnosis and treatment models. Integrated information and analysis of RA patients based on AI and medical big data will unquestionably benefit more RA patients worldwide. In this review, we mainly elaborated the application status and prospect of AI-assisted deep learning and cloud computation-oriented western medicine and traditional medicine on the diagnosis and treatment of RA in different stages. It can be predicted that with the help of AI, more pharmacological mechanisms of effective ethnic drugs against RA will be elucidated and more accurate solutions will be provided for the treatment and diagnosis of RA in the future.

The sonographic identification of cortical bone interruptions in rheumatoid arthritis: a morphological approach

Bone erosions are the hallmark of structural damage in rheumatoid arthritis (RA). Among imaging techniques, ultrasonography (US) has emerged as an accurate, reliable, repeatable, low-cost and non-invasive imaging modality to detect erosive changes in RA. However, small interruptions of the cortical bone detectable by last generation US equipment do not necessarily represent bone erosions. According to the available data, in addition to cortical bone interruption itself, only a few morphological US findings have been proposed to define RA bone erosions. However, other additional features may be considered to facilitate the interpretation of US cortical bone interruptions in RA. These could be summarised using the following four domains: size, site, shape and scenery. This hypothesis article provides a critical literature review of US features characteristic of RA bone erosions and pictorial evidence supporting the potential role of a morphological analysis in the US identification of bone erosions in RA patients.

Plain language summary

The ultrasonographic morphology of cortical interruptions is helpful for the identification of bone erosions in rheumatoid arthritis: the "four Ss" approach Bone erosions are characteristic features of rheumatoid arthritis. They are associated with a more aggressive disease and with irreversible physical disability. In recent years, ultrasonography has emerged as an accurate and reliable technique for the detection of bone erosions, that appear as interruptions of the cortical bone with variable size. However, cortical bone interruptions do not necessarily represent bone erosions. Since bone erosions represent the earliest evidence of the destructive behaviour of RA, their identification is crucial.Besides the cortical interruption itself, only a few morphological ultrasonographic features were proposed to characterise bone erosions in rheumatoid arthritis.We believe that a morphological approach, including size, site, shape and scenery, may be considered to facilitate the interpretation of ultrasonographic cortical bone interruptions in rheumatoid arthritis.In this hypothesis article we carried out a critical review of the scientific literature and provided extensive pictorial evidence of the ultrasonographic spectrum of cortical interruptions supporting the potential role of considering the "four Ss" for the ultrasonographic identification of bone erosions in rheumatoid arthritis.

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Performance of ultrasound to assess erosion progression in rheumatoid arthritis

OBJECTIVES

To analyse the performance of ultrasonography (US) to detect bone erosion progression at the patient level and at the joint level by the US score for erosions (USSe) in early-stage and late-stage rheumatoid arthritis (RA) over a 2-year follow-up.

METHODS

Clinical and demographic information was recorded at baseline, and hands and feet RX were scored according to the Sharp erosion score. USSe was performed at baseline and over 2 years of follow-up on six bilateral joints (MCP2, 3, 5; MTP2, 3, 5). Inter-examiner reproducibility was performed on 14 patients, and the smallest detectable change (SDC) was calculated. US progression was defined as a change in USSe > SDC.

RESULTS

71 patients were included: 22 (31.0 %) early RA, and 49 (69.0 %) late RA. The intra-class correlation coefficient values of the USSe for intra- and inter-examiner studies were 0.96 (CI95: 0.93-0.98), and 0.92 (CI95: 0.75-0.97), respectively. On US, erosions prevailed at baseline in MTP5 joints followed by MCP2 and MCP5 joints. With an SDC calculated at 2.3, 28 patients (39.4 %) were classified as progressors, 30 (42.3 %) were stable, and 13 (18.3 %) were regressors during the follow-up. At the joint level, erosion progression was significant on the MCP2 and MTP5 joints in early RA (p < 0.01) and on the MCP5 and MTP5 joints for all RA (p < 0.05).

CONCLUSIONS

US is a highly reproducible method that is able to detect erosion progression at the patient level for both early and late RA and at the joint level (MCP2 and MTP5) for only early RA.

Establishment and verification of an osteoporosis risk model in patients with rheumatoid arthritis: a valuable new model

To establish a model for osteoporosis risk in patients with rheumatoid arthritis and validate the model. A newly generated predictive model has been suggested to have good differentiation, calibration, and clinical validity and may be a useful clinical model for predicting osteoporosis in patients with rheumatoid arthritis.

PURPOSE

To establish a prediction model for osteoporosis risk in patients with rheumatoid arthritis and validate the model internally and externally.

METHODS

A total of 270 patients with rheumatoid arthritis who underwent bone mineral density measurement at our hospital from June 2019 to June 2020 were enrolled in the study. The patients were divided into two groups according to their entry time: a training set containing the first 2/3 of the patients (n = 180) and a validation set containing the remaining 1/3 of the patients (n = 90). Binary logistic regression analysis was used to establish the regression models, and the concordance index (C-index), calibration plot, and decision curve analysis were used to evaluate the prediction model.

RESULTS

Five variables, including age (X1), course of disease (X2), the disease activity score using 28 joint counts (DAS28) (X4), anti-cyclic citrullinated peptide antibody (CCP) (X7), and 7-joint ultrasonic bone erosion (X14), were selected to enter the model. The prediction model is Logit Y = - 12.647 + 0.133X1 + 0.011X2 + 0.754X4 + 0.001X7 + 0.605X14. The model had good differentiation; the C-index in the internal verification was 0.947 (95% CI is 0.932-0.977) and the C-index in the external verification was 0.946 (95% CI is 0.940-0.994). The calibration plot of the model showed excellent consistency between the prediction probability and actual probability. When > 0.483 was taken as the cutoff value for the diagnosis of osteoporosis, the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and Jordan index of the model were 90.24%, 87.76%, 7.37, 0.11, and 78.00%, respectively.

CONCLUSION

A newly generated predictive model has been suggested to have good differentiation, calibration, and clinical validity and may be a useful clinical model for predicting osteoporosis in patients with rheumatoid arthritis.

Evaluation of Bone Erosions in Rheumatoid Arthritis: The Ultrasound Score for Erosions Versus the Modified Sharp/van der Heijde Score for Erosions

OBJECTIVE

To evaluate the relationship between the UltraSound Score for Erosions (USSe) and the modified Sharp/van der Heijde score for erosions (SHSe).

METHODS

One hundred eight patients with rheumatoid arthritis (RA) were included. On radiography, SHSe was evaluated by 2 or 3 blinded readers (in case of discordance). On ultrasonography, erosions were scored on 6 bilateral joints (metacarpophalangeal joints 2,3,5; metatarsophalangeal joints 2,3,5) with a 4-point scale to calculate the USSe.

RESULTS

The Pearson correlation was good (r = 0.68, P < 0.001) and the agreement illustrated by a Bland-Altman plot was excellent (91%) between the 2 scores, which were complementary in detecting erosions.

CONCLUSION

The USSe seems to be a valuable tool for assessing erosive damage in RA.

ACPA-positive versus ACPA-negative rheumatoid arthritis: two distinct erosive disease entities on radiography and ultrasonography

The objective of this study is to assess the prevalence, localization, and severity of bone erosions on radiography (RX) and ultrasonography (US) according to ACPA status in patients with rheumatoid arthritis (RA). 78 patients with ACPA-positive (ACPA+) RA and 30 patients with ACPA-negative (ACPA-) RA fulfilling the ACR 1987 and/or ACR/EULAR 2010 criteria were consecutively included. On RX, a modified Sharp erosion score (SHSe) was evaluated by two blinded readers and one adjudicator for discordant cases (number of eroded joints ≤ three). On US, erosions were scored on six bilateral joints (MCP2, 3, 5; MTP2, 3, 5) with a four-point scale to calculate the total US score for erosions (USSe). The mean total SHSe and USSe were 3.7 and 4.4 times higher in the ACPA+ group than in the ACPA- group, respectively (P < 0.001). On both RX and US, the most discriminating joint between the two groups was MTP5, especially in cases with bilateral erosion. Based on multivariate analyses, ACPA + status was associated with erosive RA on RX according to the EULAR 2013 definition criteria [OR 4.4 (95% CI 1.2-16.4)], and on US according to the following two definitions: the presence of at least two eroded joint facets [OR 3.7 (95% CI 1.4-9.9)] or at least one grade 2 joint facet erosion [OR 9.0 (95% CI 2.8-28.4)]. Compared to ACPA- RA, ACPA + RA is associated independently with more severe erosive disease on RX and US. Both US and RX bilateral erosions in MTP5 joints are highly discriminant for ACPA + RA patients (97.8% in US and 100% in RX).