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Boeren AMP, Oei EHG, van der Helm-van Mil AHM. The value of MRI for detecting subclinical joint inflammation in clinically suspect arthralgia. RMD Open 2022; 8:e002128. [PMID: 35820736 PMCID: PMC9277386 DOI: 10.1136/rmdopen-2021-002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/26/2022] [Indexed: 11/04/2022] Open
Abstract
In the last decade, much research has focused on the development of rheumatoid arthritis (RA) and the symptomatic phase preceding the onset of clinical arthritis. Observational studies on imaging have revealed that subclinical joint inflammation in patients with arthralgia at risk for RA precedes and predicts the onset of clinically apparent arthritis. Moreover, the results of two placebo-controlled randomised proof-of-concept trials in patients with arthralgia and MRI-detected subclinical inflammation studies will soon be available. The initial results are encouraging and suggest a beneficial effect of DMARD treatment on subclinical inflammation. Since this may increase the necessity to detect subclinical joint inflammation in persons with arthralgia that are at risk for RA, we will here review what has been learnt about subclinical inflammation in at-risk individuals by means of imaging. We will focus on MRI as this method has the best sensitivity and reproducibility. We evaluate the prognostic value of MRI-detected subclinical inflammation and assess the lessons learnt from MRIs about the tissues that are inflamed early on and are associated with the clinical phenotype in arthralgia at risk for RA, for example, subclinical tenosynovitis underlying pain and impaired hand function. Finally, because long scan times and the need for intravenous-contrast agent contribute to high costs and limited feasibility of current MRI protocols, we discuss progress that is being made in the field of MRI and that can result in a future-proof way of imaging that is useful for assessment of joint inflammation on a large scale, also in a society with social distancing due to COVID-19 restrictions.
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Affiliation(s)
- Anna M P Boeren
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Edwin H G Oei
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
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2
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Silvagni E, Zandonella Callegher S, Mauric E, Chiricolo S, Schreiber N, Tullio A, Zabotti A, Scirè CA, Dejaco C, Sakellariou G. Musculoskeletal ultrasound for treating rheumatoid arthritis to target-a systematic literature review. Rheumatology (Oxford) 2022; 61:4590-4602. [PMID: 35512175 PMCID: PMC9707059 DOI: 10.1093/rheumatology/keac261] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE We aimed to systematically review the literature to retrieve evidence on the diagnostic and prognostic value of musculoskeletal ultrasound for a treat to target (T2T) approach in RA. METHODS Eight research questions were developed addressing the role of ultrasound (including different ultrasound scores and elementary lesions) for diagnosis, monitoring and prognosis of RA. PubMed and EMBASE were searched (2005-2020). Articles on RA and reporting data on musculoskeletal ultrasound were included and extracted according to the underlying questions, and risk of bias assessed according to the study design. RESULTS Out of 4632 records, 60 articles were included. Due to clinical heterogeneity, meta-analysis was not possible. Ultrasound better predicted disease relapses with respect to clinical examination in patients in remission, while both methods performed similarly in predicting response to therapy, achievement of remission and radiographic progression. Ultrasound was superior to clinical examination in diagnosing joint involvement using another imaging modality, such as magnetic resonance imaging, as reference. Limited ultrasound scores performed like more extensive evaluations for the detection of joint inflammation and for outcome prediction. Higher ultrasound scores of synovitis were linked to poor outcomes at all disease stages, but a specific cut-off distinguishing between low- and high-risk groups did not emerge. CONCLUSIONS These data confirm the pivotal role of ultrasound when evaluating synovial inflammation and when identifying RA patients at higher risk of relapse. Further research is needed to better define the role of ultrasound in a T2T management strategy in moderately-to-highly active RA.
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Affiliation(s)
| | | | - Eleonora Mauric
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, PV, Italy
| | - Sofia Chiricolo
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, PV, Italy
| | | | | | - Alen Zabotti
- Rheumatology Clinic, Department of Medical Area, Academic Hospital ‘Santa Maria della Misericordia’, Udine, UD
| | - Carlo Alberto Scirè
- Rheumatology Unit, School of Medicine and Surgery, University of Milano-Bicocca,Epidemiology Unit, Italian Society for Rheumatology, Milan
| | - Christian Dejaco
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, BZ,Department of Rheumatology, Medical University of Graz, Graz, Austria
| | - Garifallia Sakellariou
- Correspondence to: Garifallia Sakellariou, Istituti Clinici Scientifici Maugeri, University of Pavia, Via Maugeri, 10, 27100 Pavia, Italy.
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3
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Hammer HB, Caporali R. Controversies in rheumatology: Ultrasound for monitoring of RA - do we need it? Rheumatology (Oxford) 2022; 61:4245-4251. [PMID: 35394009 DOI: 10.1093/rheumatology/keac228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/10/2022] [Accepted: 04/03/2022] [Indexed: 11/14/2022] Open
Abstract
Clinical joint examination is the cornerstone for evaluation of patients with rheumatoid arthritis (RA). However, since large discrepancies have been shown even between experienced rheumatologists in evaluation of joint inflammation, and tender joints may have limited value in reflecting inflammation, ultrasound has in the last decennials been introduced in the clinical assessments of RA patients. Ultrasound has high accordance with other imaging modalities and enables detection of clinically difficult pathologies and contributes to assessments of joints difficult to evaluate clinically. However, there is no general agreement on the optimal use of ultrasound in rheumatology and the prevalence of machines as well as the level of experience is highly different across the countries. In addition, standardized use of ultrasound in treat-to-target follow-up of RA patients was found not to have any added value. Thus, how to use ultrasound in monitoring of RA patients is open for debate. The present article will discuss the pros and cons for using ultrasound in the clinical setting.
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Affiliation(s)
- Hilde Berner Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of medicine, University of Oslo, Norway
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Rheumatology and Medical Sciences, ASST Pini-CTO, Milan, Italy
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Abdelghani KB, Miladi S, Mahmoud I, Ajlani H, Haddouche A, Maghraoui AE, Slimani S, Fazaa A, Tekaya AB, Abdelmoula L, Laatar A, Bahiri R. Ultrasonography of Shoulder in Rheumatoid Arthritis: A Reliability Exercise Using Consensual Definitions among Maghrebian Rheumatologists. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:3343-3348. [PMID: 34600768 DOI: 10.1016/j.ultrasmedbio.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 06/13/2023]
Abstract
The shoulder may be affected in a large portion of patients with rheumatoid arthritis (RA) worldwide. However, this joint does not receive the attention required during follow-up. Indeed, although numerous clinical tests for diagnosis of a painful shoulder are available, differentiating articular from peri-articular lesions may be difficult in daily practice. Fortunately, the precise diagnosis of shoulder pain in RA has benefited from a reliable imaging modality used to detect its exact origin-ultrasonography (US). This study was aimed at assessing the intra- and inter-observer reliability of ultrasonographic findings for patients with established RA with shoulder pain in a patient-based exercise as a clinical challenge among Maghrebian rheumatologist experts in US. A total of 7 operators examined 10 patients in two rounds independently and blindly of each other. Before beginning the session, all of the rheumatologists reached a consensus on sites and US settings by performing a brief exercise on a normal shoulder. Outcome Measures in Rheumatology Clinical Trials (OMERACT) definitions of US-detected pathologies were used. Each patient underwent US scanning of the painful shoulder in predefined sites based on US technical guidelines of the European Society of Musculoskeletal Radiology: long head of biceps (LHB), subscapularis recess, posterior recess and axillary recess. The presence of subdeltoid or subcoracoid bursitis or full rupture of the suprasupinatus was identified if present. Intra- and inter-observer reliability measures were calculated using the κ coefficient. Intra-observer reliability was good for gray-scale (GS) synovitis in subscapularis and posterior recesses (κ = 0.77 and 0.73, respectively). It was moderate in the presence of GS synovitis and effusion in LHB (κ =0.53 and 0.40, respectively), posterior and subscapularis recess effusion (κ = 0.56 and 0.60, respectively) and GS and power Doppler (PD) synovitis in axillary recesses (κ = 0.58 and 0.49, respectively). Inter-observer reliability was good for PD for LHB signals (κ = 0.78). It was moderate for GS for LHB synovitis (κ = 0.54). Inter-observer agreement was poor for effusion and GS synovitis for subscapularis, posterior and axillary recesses, and very poor for PD signals in these recesses. US was a reliable imaging tool for detecting tenosynovitis in the LHB. However, reliability was moderate to poor in detecting synovitis in subscapularis, posterior and axillary recesses. These findings could be optimized by standardization of sites to assess.
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Affiliation(s)
- Kawther Ben Abdelghani
- Rheumatology Department, University of Tunis El Manar, Faculty of Medicine of Tunis, Mongi Slim Hospital, Tunis, Tunisia; Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco
| | - Saoussen Miladi
- Rheumatology Department, University of Tunis El Manar, Faculty of Medicine of Tunis, Mongi Slim Hospital, Tunis, Tunisia.
| | - Ines Mahmoud
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia
| | - Houda Ajlani
- Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco; Rheumatology Department, El Yasminet Hospital, Ben Arous, Tunisia
| | - Assia Haddouche
- Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco; Department of Rheumatology, Algiers Faculty of Medicine, Ben Aknoun Specialized Hospital in the Musculoskeletal System, Algiers, Algeria
| | - Abdellah El Maghraoui
- Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco; Mohamed V University, Rheumatology Private Office, Mohamed V, Rabat, Morocco
| | - Samy Slimani
- Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco; Atlas Clinic of Rheumatology, Batna, Algeria
| | - Alia Fazaa
- Rheumatology Department, University of Tunis El Manar, Faculty of Medicine of Tunis, Mongi Slim Hospital, Tunis, Tunisia
| | - Aicha Ben Tekaya
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia
| | - Leila Abdelmoula
- Rheumatology Department, Charles Nicolle Hospital, Tunis, Tunisia
| | - Ahmed Laatar
- Rheumatology Department, University of Tunis El Manar, Faculty of Medicine of Tunis, Mongi Slim Hospital, Tunis, Tunisia
| | - Rachid Bahiri
- Comité d'Experts Maghrébins en Imagerie Rhumatologique, Rabat, Morocco; Rheumatology Department, Mohamed V University, El Ayachi Hospital, Rabat-Salé, Morocco
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Roodenrijs NMT, Kedves M, Hamar A, Nagy G, van Laar JM, van der Heijde D, Welsing PMJ. Diagnostic issues in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2020-001511. [PMID: 33514671 PMCID: PMC7849901 DOI: 10.1136/rmdopen-2020-001511] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/21/2020] [Accepted: 01/09/2021] [Indexed: 12/21/2022] Open
Abstract
Objectives To summarise the evidence on diagnostic issues in difficult-to-treat rheumatoid arthritis (D2T RA) informing the EULAR recommendations for the management of D2T RA. Methods A systematic literature review (SLR) was performed regarding the optimal confirmation of a diagnosis of rheumatoid arthritis (RA) and of mimicking diseases and the assessment of inflammatory disease activity. PubMed and Embase databases were searched up to December 2019. Relevant papers were selected and appraised. Results Eighty-two papers were selected for detailed assessment. The identified evidence had several limitations: (1) no studies were found including D2T RA patients specifically, and only the minority of studies included RA patients in whom there was explicit doubt about the diagnosis of RA or presence of inflammatory activity; (2) mostly only correlations were reported, not directly useful to evaluate the accuracy of detecting inflammatory activity in clinical practice; (3) heterogeneous, and often suboptimal, reference standards were used and (4) (thus) only very few studies had a low risk of bias. To ascertain a diagnosis of RA or relevant mimicking disease, no diagnostic test with sufficient validity and accuracy was identified. To ascertain inflammatory activity in patients with RA in general and in those with obesity and fibromyalgia, ultrasonography (US) was studied most extensively and was found to be the most promising diagnostic test. Conclusions This SLR highlights the scarcity of high-quality studies regarding diagnostic issues in D2T RA. No diagnostic tests with sufficient validity and accuracy were found to confirm nor exclude the diagnosis of RA nor its mimicking diseases in D2T RA patients. Despite the lack of high-quality direct evidence, US may have an additional value to assess the presence of inflammatory activity in D2T RA patients, including those with concomitant obesity or fibromyalgia.
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Affiliation(s)
- Nadia M T Roodenrijs
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Melinda Kedves
- Rheumatology, Bacs-Kiskun Megyei Korhaz, Kecskemet, Hungary
| | - Attila Hamar
- Rheumatology, University of Debrecen, Debrecen, Hungary
| | - György Nagy
- Rheumatology & Clinical Immunology, Semmelweis University, Budapest, Hungary.,Genetics, Cell and Immunobiology, Semmelweis University, Budapest, Hungary
| | - Jacob M van Laar
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Paco M J Welsing
- Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Xiao L, Huang Y, Zhan F. Knee alterations in rheumatoid arthritis: Comparison of US and MRI. Open Med (Wars) 2021; 16:913-918. [PMID: 34222666 PMCID: PMC8231465 DOI: 10.1515/med-2021-0310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/08/2021] [Accepted: 05/16/2021] [Indexed: 11/15/2022] Open
Abstract
Objective This study was designed to compare the diagnostic efficacy of ultrasonography (US) and magnetic resonance imaging (MRI) in detecting changes in the knee of patients with rheumatoid arthritis (RA) and discover the possible association between the serological index and bone erosion detected by US. Patients and methods In this retrospective study, the US images and MRI findings of the knee in patients with RA from December 2017 to January 2020 were evaluated. Diagnostic outcomes were compared. The rheumatoid factor, C-reactive protein, erythrocyte sedimentation rate, and anti-cyclic citrullinated peptide antibody (ACPA) levels of the patients were recorded. The relation between laboratory index and US findings was analyzed by multivariable logistic regression. Results US showed remarkable accuracy, sensitivity, and specificity in diagnosing synovitis, bone erosion, and soft tissue swelling. In terms of reliability, the agreement between US and MRI was moderate to almost perfect. Meanwhile, a positive association between ACPA level and bone erosion was observed in patients with RA. Conclusions US may have a role as the initial imaging modality in patients with RA. Patients with higher ACPA levels may need more active treatment because they are more likely to have bone erosion detected by US.
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Affiliation(s)
- Lu Xiao
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan 570311, China
| | - Yanyan Huang
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan 570311, China
| | - Feng Zhan
- Department of Rheumatology, Hainan General Hospital (Hainan Affiliated Hospital of Hainan Medical University), Hainan 570311, China
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Ranganath VK, Hammer HB, McQueen FM. Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI. Best Pract Res Clin Rheumatol 2020; 34:101593. [PMID: 32988757 DOI: 10.1016/j.berh.2020.101593] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.
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Affiliation(s)
- Veena K Ranganath
- University of California, David Geffen School of Medicine, Los Angeles, USA.
| | - Hilde B Hammer
- Diakonhjemmet Hospital and University of Oslo, Oslo, Norway
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