The role of imaging in early diagnosis and prevention of joint damage in inflammatory arthritis

The clinical application of high-resolution peripheral computed tomography (HR-pQCT) in adults: state of the art and future directions

High-resolution peripheral computed tomography (HR-pQCT) was developed to image bone microarchitecture in vivo at peripheral skeletal sites. Since the introduction of HR-pQCT in 2005, clinical research to gain insight into pathophysiology of skeletal fragility and to improve prediction of fractures has grown. Meanwhile, the second-generation HR-pQCT device has been introduced, allowing novel applications such as hand joint imaging, assessment of subchondral bone and cartilage thickness in the knee, and distal radius fracture healing. This article provides an overview of the current clinical applications and guidance on interpretation of results, as well as future directions. Specifically, we provide an overview of (1) the differences and reference data for HR-pQCT variables by age, sex, and race/ethnicity; (2) fracture risk prediction using HR-pQCT; (3) the ability to monitor response of anti-osteoporosis therapy with HR-pQCT; (4) the use of HR-pQCT in patients with metabolic bone disorders and diseases leading to secondary osteoporosis; and (5) novel applications of HR-pQCT imaging. Finally, we summarize the status of the application of HR-pQCT in clinical practice and discuss future directions. From the clinical perspective, there are both challenges and opportunities for more widespread use of HR-pQCT. Assessment of bone microarchitecture by HR-pQCT improves fracture prediction in mostly normal or osteopenic elderly subjects beyond DXA of the hip, but the added value is marginal. The prospects of HR-pQCT in clinical practice need further study with respect to medication effects, metabolic bone disorders, rare bone diseases, and other applications such as hand joint imaging and fracture healing. The mostly unexplored potential may be the differentiation of patients with only moderately low BMD but severe microstructural deterioration, which would have important implications for the decision on therapeutical interventions.

DGEMRIC in the Assessment of Pre-Morphological Cartilage Degeneration in Rheumatic Disease: Rheumatoid Arthritis vs. Psoriatic Arthritis

Background: Even though cartilage loss is a known feature of psoriatic (PsA) and rheumatoid arthritis (RA), research is sparse on its role in the pathogenesis of PsA, its potential use for disease monitoring and for differentiation from RA. We therefore assessed the use of delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) to evaluate biochemical cartilage changes in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in PsA patients and compared these to RA patients. Materials and Methods: A total of 17 patients with active PsA and 20 patients with active RA were evaluated by high-resolution 3 Tesla dGEMRIC using a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices and joint space width (JSW) at MCP and PIP joint levels. Results: No significant differences of dGEMRIC values could be found between both study populations (PsA 472.25 ms, RA 461.11 ms; p = 0.763). In all RA and most PsA patients, PIP joints showed significantly lower dGEMRIC indices than MCP joints (RA: D2: p = 0.009, D3: p = 0.008, D4: p = 0.002, D5: p = 0.002; PsA: D3: p = 0.001, D4: p = 0.004). Most joint spaces had similar widths in both disease entities and no significant differences were found. Conclusions: As evaluated by dGEMRIC, the molecular composition of the MCP and PIP joint cartilage of PsA patients is similar to that of RA patients, demonstrating the scientific and clinical feasibility of compositional magnetic resonance (MR) imaging in these disease entities. Patterns and severity of compositional cartilage degradation of the finger joints may therefore be assessed beyond mere morphology in PsA and RA patients.

Cartilage Degradation in Psoriatic Arthritis Is Associated With Increased Synovial Perfusion as Detected by Magnetic Resonance Imaging

Objective: Even though cartilage loss is a known feature of psoriatic arthritis (PsA), research is sparse on its role in the pathogenesis of PsA and its potential use for disease detection and monitoring. Using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and dynamic contrast-enhanced MRI (DCE MRI), research has shown that early cartilage loss is strongly associated with synovial inflammation in rheumatoid arthritis (RA). The aim of this study was to determine if acute inflammation is associated with early cartilage loss in small finger joints of patients with PsA.

Methods: Metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of 17 patients with active PsA were evaluated by high-resolution 3 Tesla dGEMRIC and DCE MRI using a dedicated 16-channel hand coil. Semi-quantitative and quantitative perfusion parameters were calculated. Images were analyzed by two independent raters for dGEMRIC indices, PsA MRI scores (PsAMRIS), total cartilage thickness (TCT), and joint space width (JSW).

Results: We found significant negative correlations between perfusion parameters (except K_ep) and dGEMRIC indices, with the highest value at the MCP joints (K_Trans: τ = −0.54, p = 0.01; K_ep: τ = −0.02, p = 0.90; IAUC: τ = −0.51, p = 0.015; Initial Slope: τ = −0.54, p = 0.01; Peak: τ = −0.67, p = 0.002). Heterogeneous correlations were detected between perfusion parameters and both, total PsAMRIS and PsAMRIS synovitis sub-scores. No significant correlation was seen between any perfusion parameter and JSW and/or TCT.

Conclusion: As examined by DCE MRI and dGEMRIC, there is a potential association between early cartilage loss and acute synovial inflammation in small finger joints of PsA patients.

Proteoglycan loss in the articular cartilage is associated with severity of joint inflammation in psoriatic arthritis-a compositional magnetic resonance imaging study

Background

Even though cartilage loss is a known feature of psoriatic arthritis (PsA), little is known about its role in the pathogenesis of PsA. Using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) as a non-invasive marker of the tissue’s proteoglycan content, such early (i.e., pre-morphological) changes have been associated with inflammation in rheumatoid arthritis (RA). Yet, this association has not been studied before in PsA.

Methods

The metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of 17 patients with active PsA were evaluated by high-resolution clinical standard morphological and dGEMRIC sequences using a 3T MRI scanner (Magnetom Skyra, Siemens) and a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices, PsA MRI scores (PsAMRIS), and total cartilage thickness (TCT). Kendall tau correlation coefficients (τ) were calculated.

Results

We found significant negative correlations between dGEMRIC indices and total PsAMRIS (τ = − 0.5, p = 0.012), synovitis (τ = − 0.56, p = 0.006), flexor tenosynovitis (τ = − 0.4, p = 0.049), and periarticular inflammation (τ = − 0.72, p < 0.001). Significant positive correlations were found between TCT and dGEMRIC indices at all joint levels (τ = 0.43, p < 0.001). No significant correlations were determined between dGEMRIC indices and bone erosion, bone edema, or bone proliferation.

Conclusion

In PsA, proteoglycan loss as assessed by dGEMRIC is associated with periarticular inflammation, synovitis, and flexor tenosynovitis, but not with bone erosion or proliferation. Thereby, these findings contribute to in vivo concepts of the disease’s pathophysiology. Beyond morphology, advanced MRI techniques may be used to assess cartilage composition in PsA and to identify early changes in the cartilage as an imaging biomarker with potential application in detection, monitoring, and prediction of outcomes of PsA.

Trial registration

2014123117, December 2014.

Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis?

INTRODUCTION

A growing body of evidence indicates the benefits of early diagnosis of rheumatoid arthritis (RA) and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDS) in terms of relieving symptoms, improving prognosis, and reducing long-term complications. There is however some controversy over the most beneficial method of imaging in providing accurate early diagnosis. Though current practice favours clinical and radiological assessment, this is increasingly supplemented by ultrasound techniques (and, to a lesser extent, CT and MRI scanning). While EULAR and ESSR favour the use of ultrasonography (US) as the first-line investigation in cases of suspected RA, a recent NICE review upholds the traditional place of plain film radiographs of hands and feet to detect erosions as early signs of synovitis. This review considers the evidence for US in the early diagnosis of RA and the case for it becoming the primary assessment modality in rheumatology clinics.

AIMS

This paper aims to assess the current literature on the efficacy of ultrasonography in diagnosing early RA, by comparing US with alternative imaging modalities. The goal is to propose the most appropriate method of diagnosis to improve early initiation of DMARD treatment for optimum disease outcomes.

METHODS

Searches for related studies and review articles were carried out using electronic databases and hand searches. Additional references were gleaned from the bibliographies of included papers. Related articles and pop-outs from PubMed were also used. The search was refined in PubMed, by only using reviews which were written in English and published in past 10 years and had full free text available.

RESULTS

This review confirms that US has a high level of sensitivity in diagnosing RA (and hence a low risk of missing cases of RA which might benefit from early treatment with DMARDs). It also has a high level of specificity (and hence a low risk of falsely diagnosing somebody with RA who may suffer adverse effects of DMARD therapy). US is already widely available and well accepted by clinicians and patients. It does not involve exposure to radiation and can be readily delivered by appropriately trained staff.

CONCLUSION

This review of relevant studies indicates that US should become accepted as the investigation with the most favourable balance of benefits to risks in the early diagnosis of RA. Given the continuing controversy surrounding studies of different imaging techniques in RA, further research into the diagnostic role of US in RA is indicated.

Terpenes as possible drugs for the mitigation of arthritic symptoms - A systematic review

BACKGROUND

Arthritis is a syndrome associated with exacerbated inflammation, joint destruction and chronic pain and disability. Chronic treatment of arthritis is associated with several side effects and high abandonment. Therefore, there has been an ongoing search for alternative treatments to overcome these problems.

PURPOSE

Natural products, which are already widely used for their biological, cosmetic and pharmacotechnic properties, are a possible source for new drugs. Terpenes, a large class of organic compounds produced mainly by plants and trees, are a promising natural product and have already been shown to be effective in treating chronic pain, particularly of an inflammatory origin.

STUDY DESIGN AND METHODS

This review identifies the main terpenes with anti-arthritic activity reported in the last 10 years. A survey was conducted between December 2017 and June 2018 in the PUBMED, SCOPUS and Science Direct databases using combinations of the descriptors terpenes, arthritis and inflammation.

RESULTS

The results showed that terpenes have promising biological effects in relation to the treatment of arthritis, with the 24 terpenes identified in our survey being effective in the modulation of inflammatory mediators important to the physiopathology of arthritis, such as IL-6, IL-17, TNF-α, NFκB, and COX-2, among others. It is important to note that most of the studies used animal models, which limits, at least in part, the direct translation to humans of the experimental evidence produced by the studies.

CONCLUSION

Together, our finds suggest that terpenes can modulate the immuno-regulatory and destructive tissue events that underlie the clinical presentation and the progression of arthritis and are worthy of further clinical investigation.

The SPECTRA Collaboration OMERACT Working Group: Construct Validity of Joint Space Outcomes with High-resolution Peripheral Quantitative Computed Tomography

OBJECTIVE

We assessed construct validity of high-resolution peripheral quantitative computed tomography (HR-pQCT) joint space outcomes by comparison with radiographs in patients with rheumatoid arthritis.

METHODS

In 43 patients, quantitative, volumetric, HR-pQCT measurements were compared with ordinal Sharp/van der Heijde scoring (SvdH) in the 2nd and 3rd metacarpophalangeal joints.

RESULTS

Generalized estimating equations showed that joint space minimum, SD, and asymmetry by HR-pQCT were associated with SvdH scores (p < 0.05). There was a considerable range in HR-pQCT measurements at SvdH equal to 0.

CONCLUSION

HR-pQCT demonstrated construct validity outcomes and provides improved 3-D visualization of joint space.