Grey scale and power Doppler sonographic changes induced by intra-articular steroid injection treatment

Musculoskeletal ultrasonography in rheumatic diseases

Ultrasonography is an imaging technique based on sound waves used for the evaluation of soft tissues. Sound waves have been used for a long time in nonmedical fields, including military defense systems, radar systems, and detection of icebergs. Technological advances resulted in new techniques becoming available for medical imaging, including ultrasonography, magnetic resonance imaging, and computed tomography. Nowadays, the use of imaging has become a gold standard protocol in the diagnosis of many diseases, and recently developed diagnosis and therapy options provide more efficient treatment of rheumatic diseases. Thus, it has become possible to prevent structural damage and disability in patients with rheumatic disease. Musculoskeletal ultrasonography is becoming a preferred imaging technique for rheumatic diseases, as it has many advantages. Among its advantages are being inexpensive, being radiation-free, having a dynamic image capacity, helping to detect disease activity, and helping with early detection and diagnosis of structural damage. This review summarizes the use of ultrasonography in rheumatic diseases.

Genicular nerve block in juvenile idiopathic arthritis: a randomized clinical trial

OBJECTIVES

This study aimed at evaluating the effect of genicular nerve block (GNB) in juvenile idiopathic arthritis (JIA) patients with persistent unilateral knee arthritis on pain, inflammatory parameters, function, and range of motion.

METHODS

A total of 104 JIA patients were diagnosed according to the International League Against Rheumatism (ILAR) criteria with persistent unilateral knee arthritis. They were allocated randomly into 2 groups: group 1 treated with GNB, while group 2 was treated with intra-articular triamcinolone (TA) only. Visual analogue scale (VAS) on pain, sonography of large joints in rheumatology (SOLAR) scoring system, and Lysholm scores were assessed at 0-, 2-, and 12-week intervals. Swelling and tenderness were clinically evaluated semi-quantitatively (0-3) at the same time intervals.

RESULTS

VAS pain, tenderness, swelling, and SOLAR grey scale (GS) and power Doppler (PD) scores were significantly reduced after 2 weeks in both groups (p < 0.05). This was greater in the GNB group regarding VAS and tenderness, while SOLAR and swelling were stronger reduced in TA group. After 12 weeks, all outcome measures showed lower values in the GNB group compared to TA, and this was significant regarding VAS pain. Moreover, Lysholm functional score was significantly increased in both groups at both intervals; and higher values were seen in the TA group compared to GNB after 2 weeks.

CONCLUSION

GNB was able to control pain and improve function and inflammation of the knee joint in JIA patients. Though steroid attained better results after 2 weeks, GNB achieved an equivalent longer-term improvement after 12 weeks.

TRIAL REGISTRATION IDENTIFYING NUMBER

NCT04687930. Key Points • Persistent knee arthritis treatment in JIA is always challenging. • GNB was approved for treatment of pain in knee osteoarthritis. • GNB in the present study succeeded to control active knee arthritis and this effect was comparable to intra-articular steroid injection.

Can Intra-articular Injection of Glucocorticoids Be an Alternative Intervention to Achieve Remission in Patients With Rheumatoid Arthritis Exhibiting Low Disease Activity? A Single-Center Longitudinal Study

BACKGROUND/OBJECTIVE

This study aimed at investigating whether a single intra-articular (IA) injection of triamcinolone acetonide (TA) could facilitate to achieve clinical remission in patients with rheumatoid arthritis (RA) exhibiting low disease activity (LDA).

METHODS

This longitudinal study included 22 patients with RA exhibiting LDA involving wrist arthritis at our institution between April 2016 and March 2019. A single IA injection of 20 mg TA was administered into the symptomatic wrist joint. Efficacy was assessed by the primary end point of proportion of patients reaching clinical remission. Secondary end points included Clinical Disease Activity Index (CDAI), Simplified Disease Activity Index (SDAI), Health Assessment Questionnaire Disability Index, adverse events, and ultrasonographic assessment of the injected wrist joints.

RESULTS

Remission rates were 40% and 50% at weeks 4 and 12, respectively, and were maintained at approximately 50% until week 24. The secondary outcomes of CDAI, SDAI, and Health Assessment Questionnaire Disability Index were improved significantly at week 4, and the improvements in CDAI and SDAI continued up to week 24. Ultrasonography showed that synovial hypertrophy, power Doppler signals, and the combined score were significantly reduced at weeks 4, 12, and 24 compared with the baseline. No patient developed severe, irreversible adverse events.

CONCLUSIONS

Approximately half of the patients with RA exhibiting LDA who received a single IA injection of TA into the wrist joints achieved clinical remission without serious adverse events in the midterm period, suggesting that IA injection of TA might be considered as an alternative intervention to achieve remission in patients with RA exhibiting LDA.

Ultrasound Effectiveness of Steroid Injection for hand Psoriatic Dactylitis: Results from a Longitudinal Observational Study

Introduction

To assess clinical and ultrasound effectiveness of steroid injection (local treatment, LT) into the digital flexor tendon sheath for the treatment of psoriatic dactylitis compared to systemic treatment (ST) alone.

Methods

In this observational, multicentre, prospective study, 88 cases of symptomatic hand dactylitis were evaluated clinically and sonographically by high-frequency ultrasound (US) probe in both greyscale (GS) and power Doppler (PD). The presence of flexor tenosynovitis (FT), soft tissue oedema (STO), peritendon extensor inflammation and synovitis was assessed (including DACtylitis glObal Sonographic—DACTOS—score) before treatment, at 1-month (T1) and 3-months (T3) follow-up. LT was proposed to all patients. Patients refusing LT were treated with oral NSAIDs. Patients continued the same baseline csDMARDs and/or corticosteroid therapy during the whole follow-up period. US response was defined for DACTOS score < 3 and US remission for DACTOS score = 0.

Results

At T3 evaluation the ST group showed a significantly higher persistence (grade > 1) of FT and STO (p < 0.001 for all) and MCP synovitis (p = 0.001). US remission was achieved only in the LT group (at T3 31% vs. 0, p < 0.001). The percentage of patients with DACTOS < 3 was significantly greater in the LT group compared with ST group, at both T1 (49% vs. 5%, p < 0.001) and T3 evaluation (76% vs. 7%, p < 0.001). In multiple conditional logistic regression analysis, the only factor associated with US remission was LT (T3 odds ratio = 41.21, p < 0.001).

Conclusions

US confirmed the effectiveness of steroid injection for dactylitis by demonstrating that it involves the resolution of extra-articular inflammation, in particular FT and STO.

Reliability of ultrasound in evaluating the plantar skin and fat pad of the foot in the setting of diabetes

Ultrasound can be used to assess injury and structural changes to the soft-tissue structure of the foot. It may be useful to assess the feet of people with diabetes who are at increased risk of plantar soft-tissue pathological changes. The aim of this study was to determine if ultrasound measurements of plantar soft-tissue thickness and assessments of tissue acoustic characteristics are reliable in people with and without diabetes mellitus. A repeated measures design was used to determine intra-observer reliability for ultrasound measurements of plantar skin and fat pad thickness and intra- and inter-observer reliability of plantar skin and fat pad tissue characterisation assessments made at foot sites which are at risk of tissue injury in people with diabetes. Thickness measurements and tissue characterisation assessments were obtained at the heel and forefoot in both the unloaded and compressed states and included discrete layers of the plantar tissues: skin, microchamber, horizontal fibrous band, macrochamber and total soft-tissue depth. At each site, relative intra-observer reliability was achieved for the measurement of at least one plantar tissue layer. The total soft-tissue thickness measured in the unloaded state (ICC 0.925-0.976) demonstrated intra-observer reliability and is the most sensitive for detecting small change on repeated measures. Intra-observer agreement was demonstrated for tissue characteristic assessments of the skin at the heel (k = 0.70), fat pad at the lateral sesamoid region (k = 0.70) and both skin and fat pad at the second (k = 0.80, k = 0.70 respectively) and third metatarsal heads (k = 0.90, k = 0.79 respectively). However, acceptable inter-observer agreement was not demonstrated for any tissue characteristic assessment, therefore the use of multiple observers should be avoided when making these assessments.

Genicular nerve block in rheumatoid arthritis: a randomized clinical trial

OBJECTIVE

This study highlights the effect of a genicular nerve block (GNB) on pain, function, and inflammation outcome measures in rheumatoid arthritis (RA) knees.

METHODS

A total of sixty-four patients diagnosed with RA using ACR/EULAR 2010 criteria with unilateral persistent knee arthritis were recruited to the study. They were randomly assigned into two groups: group 1 received GNB and group 2 received intra-articular triamcinolone. Both groups were examined by the SOLAR scoring system, visual analog scale (VAS), and Lysholm score at 0, 2, and 12 weeks. A semi-quantitative score was used to assess the tenderness and swelling at the same intervals.

RESULTS

Function and inflammation improved significantly in group 2 at a 2-week interval as compared to group 1, whereas pain improved in both groups with non-significant differences. After 12 weeks, group 1 showed significant improvement as compared with group 2 for the three outcome measures. Neither the disease activity nor the current medication was related to the GNB effect. Disease duration was negatively related to GNB-induced improvement.

CONCLUSION

GNB is a new promising local therapy for RA to control pain, improve function, and alleviate inflammation of the knee joint. Although it has a relatively short-term effect, yet it has outperformed the steroid effect. Key Points • Knee monoarthritis treatment in rheumatoid arthritis is always challenging • GNB has been approved for the treatment of pain in knee osteoarthritis • GNB in this study was able to control active knee arthritis and this effect persisted longer thane intra-articular steroid injection.

Therapeutic Potential of Digital Nerve Block in Rheumatoid Arthritis Patients: A Clinical and Sonographic Prospective Study

BACKGROUND

This study attempted to test the effectiveness of digital nerve block (DNB) in active rheumatoid arthritis (RA) joints with respect to local disease control.

METHODS

The study included 83 RA patients aged 18 years or above and diagnosed, after American College of Rheumatology/European League Against Rheumatism criteria 2010, with bilateral proximal interphalangeal (PIP) arthritis. PIPs were examined by European League Against Rheumatism-outcome measures in rheumatoid arthritis clinical trials scoring system at 0, 2, and 8 weeks. Visual analog scales for each hand were also done at the same intervals. DNBs of the second and third PIPs were performed to the dominant hand in 50% of participants. The other hand was used as a control, and saline was injected in the same level at the control side.

RESULTS

At 2 weeks and 8 weeks intervals, the active side showed significantly less clinical and ultrasound scores when compared to the control side and the baseline values. The mean OMERACT score for the active hand dropped from 3.37±1.43 at 0 time to 2.31±1.66 after 2 weeks and 2.55±1.43 at 8 weeks (P<0.001). Also, visual analog scale decreased from 59 at 0 time to 41 at 2 weeks and 43 at 8 weeks (P<0.001). The amelioration was greater when the active side was the dominant one. The injected PIPs showed maximum improvement at 2 weeks. Improvement was more significant in the second PIP. Early patients achieved better outcomes.

CONCLUSION

DNB is a new promising therapy for RA. It can control pain and inflammation of the PIPs. It has relatively short-term effect, yet it could limit escalation of systemic treatment plans.

[Evidence in Infiltrative Pain Therapy of the Musculoskeletal System]

Musculoskeletal pain symptoms frequently generate limitations in daily work and life in many patients. Usually, symptomatic treatment is possible before clarifying the in depth diagnosis. A symptom-based infiltration therapy will never replace a thoroughly done physical examination and thoughtful collection of patient history, however, it can be of great benefit for the patient when done focused on the point of pain and executed with profound anatomical knowledge. Furthermore, the knowledge of the level of evidence of therapeutic infiltrations improves their outcomes and shapes realistic patients' expectations. Ultrasound-guided therapeutic infiltrations improve the outcome despite the use of lower amounts of active agents by pinpointed applications. This article provides an overview of the scientific evidence of effectiveness of (ultrasound-guided) infiltration techniques in diverse musculoskeletal regions.

Advanced Musculoskeletal Ultrasound Techniques: What Are the Applications?

OBJECTIVE. The purpose of this article is to cover technical advances in musculo-skeletal ultrasound from the viewpoint of the radiologist. CONCLUSION. Among the advances in musculoskeletal ultrasound that we highlight the use of ultrahigh-frequency transducers to visualize ever-finer anatomic detail, the expanding practical clinical applications for microvascular imaging, and the use of elastography to predict function and, possibly, healing potential.

The agreement between ultrasound-determined joint inflammation and clinical signs in patients with rheumatoid arthritis

Background

Ultrasound (US) is sensitive for detecting joint and tendon inflammation in patients with rheumatoid arthritis (RA). So far, which grade of abnormalities on US corresponds to clinical manifestations is unclear. This study aimed to investigate the agreement between US-detected joint inflammation and clinical signs (joint swelling and tenderness).

Methods

In this cross-sectional study, 22 joints of the wrists and hands were, respectively, evaluated by physical examination (PE) and ultrasound in RA patients. Gray scale (GS) and power Doppler (PD) of synovitis, detected by ultrasound, were graded by semi-quantitative scoring systems (0–3). Tenosynovitis and peritendinitis were assessed qualitatively (0/1).

Results

A total of 258 consecutive RA patients were included, with median disease duration of 57 months and mean Disease Activity Score based on 28 joints (DAS28)-ESR/DAS28-CRP of 4.47/3.99. In a total of 5676 joints assessed, the overall concordance rate between positive clinical signs and ultrasound-determined joint inflammation was fair (κ = 0.365, p < 0.01). In wrists, joint tenderness showed higher κ coefficient (κ = 0.329, p < 0.01) with ultrasound-determined joint inflammation than swelling (κ = 0.263, p < 0.01); however, swelling showed higher κ coefficient (κ = 0.156–0.536, p < 0.01) with ultrasound-determined joint inflammation than tenderness (κ = 0.061–0.355, p < 0.01) in metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints. Synovitis had consistently higher agreement with tenderness and swelling than tenosynovitis/peritendinitis. Tenderness and swelling had the highest κ coefficient with GS ≥ 1 synovial hyperplasia in most MCP and PIP joints, while with GS ≥ 2 synovial hyperplasia in wrists. For all 22 joints, PD ≥ 1 synovitis had the highest κ coefficient with clinical tenderness and swelling.

Conclusions

Synovitis had better agreement with clinical signs than tenosynovitis/peritendinitis. Joint swelling showed better agreement with US-determined inflammation than tenderness for MCP and PIP joints, while the opposite for wrists. Both tenderness and swelling are more likely to correspond to GS ≥ 2 for wrists, GS ≥ 1 for MCP and PIP joints, and PD ≥ 1 for any joint.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

Doppler versus Histopathology in the Assessment of Egyptian Patients with Psoriasis Treated with Acitretin

Psoriasis is one of the most common chronic inflammatory skin diseases, characterized by erythema and the formation of plaques. The diagnosis of psoriasis is based on clinical examination, and its severity is assessed by the Psoriasis Area and Severity Index. Histologic examination is still the standard method for the final diagnosis. Sonography has proved to be a suitable noninvasive imaging method for studying soft tissue in dermatologic diseases such as psoriasis. This study evaluated the effect of Doppler sonography in the assessment of psoriasis in comparison with histopathology. Clinical, multifrequency sonography, and histological examinations were completed in 30 patients with chronic plaque psoriasis before and after acitertin treatment. After a 12-week treatment period, there was a notable decrease of psoriatic plaques in 28 patients with Psoriasis Area and Severity Index-1 severity and in two patients with Psoriasis Area and Severity Index-2 severity. Multifrequency sonography results after treatment of the same plaques showed normal finding in five patients, mild sonographic changes in 24 patients, and moderate sonographic changes in one patient. Histopathology findings after treatment were normal epidermis and dermis in six patients, mild histopathological changes in 22 patients, and moderate changes in two patients. In conclusion, there were significant correlations between sonography and histopathology in the diagnosis and evaluation of a psoriatic skin treatment regimen.

A new musculoskeletal ultrasound scoring system (US10) of the hands and wrist joints for evaluation of early rheumatoid arthritis patients

OBJECTIVE

To propose a novel ultrasound scoring system for hand and wrist joints (US10) for evaluation of patients with early rheumatoid arthritis (RA) and to correlate the US10 with clinical, laboratory and functional variables.

METHODS

Forty-eight early RA patients underwent clinical and laboratory evaluations as well as blinded ultrasound (US) examinations at baseline, three, six and 12 months. The proposed US10 system involved the assessment of the wrist, second and third metacarpophalangeal and proximal interphalangeal joints. The score consisted of inflammation parameters (synovial proliferation [SP], power Doppler [PD] and tenosynovitis [TN]) and joint damage parameters (bone erosion [BE] and cartilage damage [CD]). SP, PD, BE and CD were scored qualitatively (0-1) and semi-quantitatively (grades 0-3). Tenosynovitis was scored as presence/absence. The evaluation also involved the 28-Joint Disease Activity Score (DAS28), Health Assessment Questionnaire (HAQ) and C-reactive protein level (CRP).

RESULTS

Mean duration of symptoms was 7.58±3.59 months. Significant correlations (p<0.05) were found between inflammation parameters and CRP at baseline and between the changes in these variables throughout the study. Significant correlations (p<0.05) were found between DAS28 score and both PD and TN at baseline and between the changes in DAS28 score and both SP and TN throughout the follow up. Moreover, significant correlations were found between the changes in inflammation parameter scores and HAQ score throughout the follow up.

CONCLUSION

The proposed US10 scoring system proved to be a useful tool for monitoring inflammation and joint damage in early RA patients, demonstrating significant correlations with longitudinal changes in disease activity and functional status.

General applications of ultrasound in rheumatology: why we need it in our daily practice

Ultrasound (US) is a noninvasive imaging technique that continues to gain interest among rheumatologists because of its undoubted utility for the assessment of a wide range of abnormalities in rheumatic diseases. It also has a great potential to be used at the time of consultation as an extension of the clinical examination.Current data demonstrate that the standard clinical approach could result in an insensitive assessment of some the different aspects of the various rheumatic diseases for which US has become a feasible and effective imaging modality that allows early detection of anatomical changes, careful guidance for the aspiration and/or local treatment, and short- and long-term therapy monitoring at the joint, tendon, enthesis, nail, and skin levels. The spectrum of pathological conditions for which US plays a crucial role continues to increase over time and includes rheumatoid arthritis, spondyloarthropathies, osteoarthritis, crystal-related arthropathies, connective tissue disorders, and vasculitis.It is expected that the inclusion of more longitudinal studies with a larger number of patients and more rigorous methodological approach will undoubtedly provide a better understanding of the significance of the abnormal US findings detected in order to provide the proper diagnostic and/or therapeutic approaches. In this article, we analyze the current potential applications of US in rheumatology and discuss the evidence supporting its use in the daily rheumatologic practice.

The Role of Power Doppler Ultrasonography as Disease Activity Marker in Rheumatoid Arthritis

Structural damage in rheumatoid arthritis (RA) occurs early if inflammation is not treated promptly. Treatment targeted to reduce inflammation, in particular, that of synovial inflammation in the joints (synovitis), has been recommended as standard treat-to-target recommendations by rheumatologists. The goal is to achieve disease remission (i.e., no disease activity). Several accepted remission criteria have not always equated to the complete absence of true inflammation. Over the last decade, musculoskeletal ultrasonography has been demonstrated to detect subclinical synovitis not appreciated by routine clinical or laboratory assessments, with the Power Doppler modality allowing clinicians to more readily appreciate true inflammation. Thus, targeting therapy to Power Doppler activity may provide superior outcomes compared with treating to clinical targets alone, making it an attractive marker of disease activity in RA. However, more validation on its true benefits such as its benefits to patients in regard to patient related outcomes and issues with standardized training in acquisition and interpretation of power Doppler findings are required.

Power and color Doppler ultrasound settings for inflammatory flow: impact on scoring of disease activity in patients with rheumatoid arthritis

OBJECTIVE

To determine how settings for power and color Doppler ultrasound sensitivity vary on different high- and intermediate-range ultrasound machines and to evaluate the impact of these changes on Doppler scoring of inflamed joints.

METHODS

Six different types of ultrasound machines were used. On each machine, the factory setting for superficial musculoskeletal scanning was used unchanged for both color and power Doppler modalities. The settings were then adjusted for increased Doppler sensitivity, and these settings were designated study settings. Eleven patients with rheumatoid arthritis (RA) with wrist involvement were scanned on the 6 machines, each with 4 settings, generating 264 Doppler images for scoring and color quantification. Doppler sensitivity was measured with a quantitative assessment of Doppler activity: color fraction. Higher color fraction indicated higher sensitivity.

RESULTS

Power Doppler was more sensitive on half of the machines, whereas color Doppler was more sensitive on the other half, using both factory settings and study settings. There was an average increase in Doppler sensitivity, despite modality, of 78% when study settings were applied. Over the 6 machines, 2 Doppler modalities, and 2 settings, the grades for each of 7 of the patients varied between 0 and 3, while the grades for each of the other 4 patients varied between 0 and 2.

CONCLUSION

The effect of using different machines, Doppler modalities, and settings has a considerable influence on the quantification of inflammation by ultrasound in RA patients, and this must be taken into account in multicenter studies.

Oral low-dose glucocorticoids should be included in any recommendation for the use of non-biologic and biologic disease-modifying antirheumatic drugs in the treatment of rheumatoid arthritis

At present, growing scientific evidence from the medical literature and expert opinion provides strong consideration for a mandatory role of glucocorticoids (GCs) in the management of rheumatoid arthritis (RA). Earlier application strategies were based on initial high doses, with subsequent tapering schedules, resulting in dose-related side effects. Recent low-dose GC schemes are more feasible in routine care, while providing evidence of clinical, functional and structural efficacy. Thus, initial low-dose GC 'bridging' treatment on a disease-modifying antirheumatic drug background should be included in any existing recommendations for RA management, as very recently advocated by the EULAR Task Force 2013 updated guidelines. Long-term low-dose therapy appears to provide acceptable safety, leading to long-standing slowing of structural damage, seen even after GC therapy withdrawal. Gaps in knowledge about the optimal method to taper and possibly discontinue GC treatment remain, and this topic should be addressed in clinical trials and observational studies. Recent efforts in GC medication have also included the introduction of a modified-release drug formulation capable of drug delivery consistent with chronobiological pathogenetic rhythms of disease, which has been quite efficacious in controlling the signs and symptoms related to pathways of circadian cytokines. Long-term data will further clarify the add-on benefits of such modified-release formulations.

Sonographic assessment of healthy peripheral joints: evaluation according to demographic parameters

OBJECTIVES

To describe quantitative and semiquantitative sonographic joint measurements in healthy adults and compare them with demographic parameters.

METHODS

A cross-sectional study was conducted. Bilateral sonographic measurements of small, medium, and large joints were performed in 130 healthy volunteers, stratified into 5 age groups (A, 18-29; B, 30-39; C, 40-49; D, 50-59; and E, 60-80 years). Quantitative synovial hypertrophy measurements and semiquantitative synovial hypertrophy, power Doppler, bone erosion (score 0-3), and articular cartilage (score 0-4) measurements were performed by a blinded radiologist using a 6-18-MHz linear array transducer. The sonographic measurements were correlated with demographic parameters. The significant P value was set at .05.

RESULTS

A total of 6500 joint recesses were studied; the mean age ± SD of the participants was 44.8 ± 14.6 years, and 76.9% were women. The highest quantitative synovial hypertrophy values were found in the hip (6.4 mm) and talonavicular joint (2.6 mm). The joint recesses with a greater frequency of hypothetical pathologic semiquantitative scores were second metatarsophalangeal (78.8%) and first metatarsophalangeal (69.3%) for synovial hypertrophy, radiocarpal (17.7%) and first metatarsophalangeal (15.8%) for power Doppler, and posterior glenohumeral (23.1%) and ulnocarpal (4.2%) for bone erosion. The highest quantitative synovial hypertrophy values and the lowest semiquantitative synovial hypertrophy, power Doppler, bone erosion, and articular cartilage scores were observed in age group E (P < .046). There were positive correlations between the sonographic measurements and height, age, weight, and body mass index in 30.4%, 34.8%, 43.5%, and 47.8%, respectively, of all the joint recesses studied.

CONCLUSIONS

Sonographic changes in healthy peripheral joints were observed predominantly in the oldest group.

Does ultrasound-scored synovitis depend on the pharmacokinetics of subcutaneous anti-TNF agents in patients with rheumatoid arthritis?

OBJECTIVE

The aim of this study was to investigate the influence of the pharmacokinetics of s.c. anti-TNF agents on the grade of US-detected synovitis in RA patients.

METHODS

Fifty RA patients were prospectively recruited from the Biologic Therapy Unit of our hospital. Inclusion criteria were being in treatment with s.c. anti-TNF agents and having had neither changes in therapy nor local corticosteroid injections in the previous 3 months. Patients underwent clinical, laboratory [28-joint DAS (DAS28) and Simplified Disease Activity Index (SDAI)] and US assessment at two time points, i.e. at peak plasma drug concentration and at trough plasma drug concentration. US assessments were performed blindly to the anti-TNF agent, the administration time and the clinical and laboratory data. Twenty-eight joints were investigated for the presence and grade (0-3) of B-mode synovitis and synovial power Doppler signal. Global indices for B-mode synovitis (BSI) and Doppler synovitis (DSI) were calculated for 12 joints and for wrist-hand-ankle-foot joints. B-mode US remission was defined as a BSI <1 and Doppler US remission as a DSI <1.

RESULTS

There were no significant differences between the clinical, laboratory and B-mode and Doppler US parameters at peak time and trough time (P = 0.132-0.986). There were no significant differences between the proportion of patients with active disease and those in remission according to DAS28, SDAI, B-mode US and Doppler US at peak time and trough time assessments (P = 0.070-1).

CONCLUSION

Our results suggested that s.c. anti-TNF pharmacokinetics do not significantly influence US-scored synovitis in RA patients.

Is painless synovitis different from painful synovitis? A controlled, ultrasound, radiographic, clinical trial

OBJECTIVE

This study compares the clinical, ultrasonography, radiography, and laboratory outcomes of painless and painful chronic synovitis in patients with established rheumatoid arthritis.

METHODS

This cross-sectional study involved 60 patients with rheumatoid arthritis and synovitis in the metacarpophalangeal joints; 30 of the patients did not experience pain, and 30 had experienced pain for at least 6 months prior to the study. The radiocarpal, distal radioulnar, and metacarpophalangeal joints were evaluated using the ultrasound gray scale, power Doppler, and radiography. Past and present clinical and laboratory findings were also evaluated.

RESULTS

There were no statistically significant differences between the groups for most of the outcomes. The group with pain scored worse on the disease activity indices (e.g., DAS 28 and SDAI), function questionnaires (HAQ and Cochin), and pinch strength test. A logistic regression analysis revealed that the use of an immunobiological agent was associated with a 3-fold greater chance of belonging to the group that experienced pain. The painless group had worse erosion scores in the second and fifth metacarpophalangeal with odd ratios (ORs) of 6.5 and 3.5, respectively. The painless group had more cartilage with grade 4 damage in the third metacarpophalangeal.

CONCLUSIONS

The rheumatoid arthritis patients with both painless and painful synovitis exhibited similar disease histories and radiographic and ultrasound findings. However, the ultrasonography evaluation revealed worse scores in the second and fifth metacarpophalangeal of the synovitis patients who did not experience pain.

Tracking rheumatic disease through imaging

This review recounts the historical, current, and future involvement of radiology and imaging in the diagnosis, management, and follow-up of patients with various rheumatic conditions. Radiographs are the mainstay of imaging patients with rheumatic conditions, although magnetic resonance imaging and ultrasonography are routinely used for early diagnosis of disease. Computed tomography remains useful in evaluating the extent of involvement of inflammatory spondyloarthropathies that classically involve the axial skeleton and sacroiliac joints. Molecular imaging has begun to play an innovative role in evaluating patients with arthritis, aiming to identify disease earlier and provide greater specificity.

Ultrasound applications for the practicing rheumatologist

Musculoskeletal ultrasound is an increasingly used tool for the evaluation and management of rheumatologic diseases. Its utilisation by rheumatologists is varied around the world and is dependent upon training and local expertise. Its applications can be broadly categorised into three main areas; for the education of patients, to aid the rheumatologist in the diagnosis and monitoring of disease, and therapeutically for joint aspiration and injection. Ultrasound is a safe, portable, easily repeatable, dynamic images in multiple planes and cheap form of imaging. Ultrasound however, is operator dependent and has a number of artefacts that can result in misinterpretation. Musculoskeletal Ultrasound uses a number of modes to characterise joint pathology, including grey scale, colour and power Doppler, spectral Doppler, 3D imaging, elastography. Musculoskeletal ultrasound can detect and monitor multiple joint pathologies including synovitis, tenosynovitis, and tendon pathologies, entheseal processes, bone erosions and osteophytes, cartilage changes and bursal pathologies.

Improvement in wrist pain with ultrasound-guided glucocorticoid injections: a meta-analysis of individual patient data

OBJECTIVES

This meta-analysis compares change in wrist pain following ultrasound-guided (US-guided) intra-articular glucocorticoid injections with change in pain after palpation-guided injections in persons with inflammatory arthritis or osteoarthritis.

METHODS

Data sources included MEDLINE, Cochrane, BIOSIS, CINAHL, ACR/AHRP abstracts, and ClinicalTrials.gov. Studies that assessed change in wrist pain with direct comparison of US-guided and palpation-guided injections were included in the meta-analysis. Subject-level data was sought from authors of all relevant studies. Primary outcome was mean change in wrist pain from baseline to 1-6 week follow-up by visual analog scale (VAS). Mean difference in VAS was calculated for comparative studies. Secondary outcome was proportion attaining Minimal Clinically Important Improvement (MCII), defined as VAS reduction ≥ 20%. Odds ratios (ORs) of MCII were calculated for comparative studies. Mean differences in VAS and ORs for MCII for comparative studies were combined using fixed and random effects meta-analysis.

RESULTS

Ten studies were eligible, and adequate data was available from 4 studies with direct comparison of US-guided and palpation-guided treatment arms. The difference in mean VAS reduction (US-guided minus palpation-guided) ranged from-0.2 to 1.3, with a combined estimate of 1.0 (95% CI 0.3, 1.7). OR for MCII in comparative studies ranged from 1.0 to 12.4, with a combined OR of 3.2 (95% CI 1.2, 8.5) in favor of ultrasound.

CONCLUSIONS

US-guided glucocorticoid injections to the wrist result in greater reductions in pain, and greater likelihood of attaining MCII than palpation-guided injections at 1-6 weeks follow-up.

Linking systemic angiogenic factors (VEGF, angiogenin, TIMP-2) and Doppler ultrasound to anti-inflammatory treatment in rheumatoid arthritis

OBJECTIVE

To evaluate an association between synovial Doppler flow and serum levels of vascular endothelial growth factor (VEGF), angiogenin and TIMP-2 in patients with rheumatoid arthritis during anti-inflammatory treatment with glucocorticoids and TNF-α inhibitors.

METHODS

Inflamed wrists of 15 patients with rheumatoid arthritis (RA) were examined by two independent ultrasound investigators prior to and at days 3, 7, 14 and 42 after the initiation of treatment with glucocorticoids in therapy-naïve patients or after the beginning of a therapy with a TNF-α inhibitor in patients with DMARD failure. Quantitative three-dimensional power Doppler ultrasonographic assessment of synovial vascularization was compared at each visit with serum levels of VEGF, angiogenin and TIMP-2.

RESULTS

In the glucocorticoid group, synovial Doppler signals decreased significantly at day 3 (-44%; P=0.003) in comparison to a delayed decrease in the TNF-α inhibitor group after 6 weeks (-46%; P=0.001). A significant reduction of serum VEGF levels could be determined with a delay of 1 week after the decrease of Doppler activity but no correlation was found between both parameters (rho: P=0.7; r=-0.03). Angiogenin concentrations decreased in the TNF group and increased in the GC group. Levels of TIMP-2 did not change significantly in both groups.

CONCLUSION

The decrease of serum VEGF levels under treatment with glucocorticoids or TNF-α inhibitors followed the reduction of the intra-articular synovial Doppler flow. This result supports the idea that the reduction of synovial perfusion due to anti-inflammatory treatment is not regulated by systemic VEGF, but that the inflamed joints are the source for circulating VEGF.

Ultrasound of metacarpophalangeal joints is a sensitive and reliable endpoint for drug therapies in rheumatoid arthritis: results of a randomized, two-center placebo-controlled study

Introduction

We aimed to investigate the sensitivity and reliability of two-dimensional ultrasonographic endpoints at the metacarpophalageal joints (MCPJs) and their potential to provide an early and objective indication of a therapeutic response to treatment intervention in rheumatoid arthritis (RA).

Methods

A randomized, double-blind, parallel-group, two-center, placebo-controlled trial investigated the effect on ultrasonographic measures of synovitis of repeat dose oral prednisone, 15mg or 7.5mg, each compared to placebo, in consecutive two-week studies; there were 18 subjects in a 1:1 ratio and 27 subjects in a 2:1 ratio, respectively. All subjects met the 1987 American College of Rheumatology criteria for the diagnosis of RA, were ≥18 years-old with RA disease duration ≥6 months, and had a Disease Activity Score 28 based on C-reactive protein (DAS28(CRP)) ≥3.2. Subjects underwent high-frequency (gray-scale) and power Doppler ultrasonography at Days 1 (baseline), 2, 8 and 15 in the dorsal transverse and longitudinal planes of all 10 MCPJs to obtain summated scores of quantitative and semi-quantitative measures of synovial thickness as well as vascularity. The primary endpoint was the summated score of power Doppler area measured quantitatively in all 10 MCPJs in the transverse plane at Day 15. Clinical efficacy was assessed at the same time points by DAS28(CRP).

Results

All randomized subjects completed the trial. The comparison between daily 15 mg prednisone and placebo at Day 15 yielded a statistically significant treatment effect (effect size = 1.17, P = 0.013) in change from baseline in the primary endpoint, but borderline for prednisone 7.5 mg daily versus placebo (effect size = 0.61, P = 0.071). A significant treatment effect for DAS28(CRP) was only observed at Day 15 in the prednisone 15 mg group (effect size = 0.95, P = 0.032). However, significant treatment effects at all time points for a variety of ultrasound (US) endpoints were detected with both prednisone doses; the largest observed effect size = 2.33. Combining US endpoints with DAS28(CRP) improved the registration of significant treatment effects. The parallel scan inter-reader reliability of summated 10 MCPJ scores were good to excellent (ICC values >0.61) for the majority of US measures.

Conclusions

Ultrasonography of MCPJs is an early, reliable indicator of therapeutic response in RA with potential to reduce patient numbers and length of trials designed to give preliminary indications of efficacy.

Trial Registration

Clinicaltrials.gov identifier: NCT00746512

Low-dose oral prednisone improves clinical and ultrasonographic remission rates in early rheumatoid arthritis: results of a 12-month open-label randomised study

INTRODUCTION

In early rheumatoid arthritis (RA), low-dose oral prednisone (PDN) co-medication yields better clinical results than monotherapy with disease-modifying anti-rheumatic drugs (DMARDs). In addition, ultrasonography (US) evaluation reveals rapid and significant effects of glucocorticosteroids on subclinical synovitis. No data currently exist that examine the clinical and US results offered by glucocorticoid co-medication over DMARD monotherapy in early RA patients.

METHODS

Two hundred and twenty patients with early RA (< 1 year from clinical onset) were treated according to a low disease activity (LDA) targeted step-up protocol including methotrexate (MTX) and, in the active treatment arm, low-dose (6.25 mg/day) oral PDN over 12 months. Clinical disease activity measures were collected at baseline, 2, 4, 6, 9 and 12 months, and US examination of hands was performed at baseline, 6 and 12 months. Grey-scale and power Doppler (PD) synovitis were scored (0 to 3) for each joint. At 12 months, clinical remission according to the disease activity score among 28 joints was defined as the clinical outcome, and a total joint PD score of 0 (PD negativity) as the imaging outcome.

RESULTS

Each group included 110 patients with comparable demographic, clinical, laboratory and US characteristics. At 12 months, the LDA rate was similar in the two groups, whilst the clinical remission rate (risk ratio = 1.61 (95% confidence interval = 1.08, 2.04)) and PD negativity rate (risk ratio = 1.31 (95% confidence interval = 1.04, 1.64)) were significantly higher in the MTX+PDN group.

CONCLUSION

In early RA, despite a similar response rate in terms of LDA, low-dose oral PDN co-medication led to a higher proportion of clinical remission and PD negativity compared with MTX monotherapy, thus ensuring a better disease activity control.

TRIAL REGISTRATION NUMBER

Current Controlled Trials ISRCTN2486111.

Feasibility of a standardized ultrasound examination in patients with rheumatoid arthritis: a quality improvement among rheumatologists cohort

Background

Quality improvement is important to facilitate valid patient outcomes. Standardized examination procedures may improve the validity of US.

The aim of this study was to investigate the learning progress for rheumatologists during training of US examination of the hand in patients with rheumatoid arthritis (RA).

Methods

Rheumatologists with varying degrees of experience in US were instructed by skilled tutors. The program consisted of two days with hands-on training followed by personal US examinations performed in their individual clinics. Examinations were sent to the tutors for quality control. The US examinations were evaluated according to a scoring sheet containing 144 items. An acceptable examination was defined as > 80% correct scores.

Results

Thirteen rheumatologists participated in the study. They included a total of 104 patients with RA. Only few of the initial examinations were scored below 80%, and as experience increased, the scores improved (p = 0.0004). A few participants displayed decreasing scores.

The mean time spent performing the standardized examination procedure decreased from 34 min to less than 10 minutes (p = 0.0001).

Conclusion

With systematic hands-on training, a rheumatologist can achieve a high level of proficiency in the conduction of US examinations of the joints of the hand in patients with RA. With experience, examination time decreases, while the level of correctness is maintained. The results indicate that US may be applied as a valid measurement tool suitable for clinical practice and in both single- and multi-centre trials.

CS injection of tenosynovitis in patients with chronic inflammatory arthritis: the role of US

OBJECTIVE

The main aim of this study was to investigate the short-term efficacy of CS loco-regional treatment performed under US guidance in tenosynovitis of patients with chronic inflammatory arthritis.

METHODS

Thirty consecutive patients affected by chronic arthritis and with clinical suspicion of tenosynovitis were recruited to undergo US assessment. In the sonographically proven cases, US-guided CS injection was performed. A visual analogue scale for pain (ranging from 0 to 10) and a tenderness score (ranging from 0 to 3) were used for the clinical evaluation. Sonographic pathological findings indicative of tenosynovitis were scored using a semi-quantitative 4-grade scoring system, for both grey-scale and power Doppler US, at baseline and during a follow-up visit at 2 weeks after the CS injection.

RESULTS

In 21 (70%) of 30 patients, the clinical suspicion of tenosynovitis was confirmed (9 with RA, 11 with PsA and 1 with ReA). In the other nine patients, US revealed synovitis of the adjacent joints, bursitis, oedema of the s.c. tissue or a partial tear. In all cases the appropriate needle placement and subsequent CS injection into the tendon sheath were obtained with US confirmation. A significant reduction in all clinical and sonographic scorings was found during the follow-up visit.

CONCLUSIONS

The present study shows the efficacy of US-guided peritendinous CS injections in the management of patients with chronic inflammatory arthritis presenting as US-proven tenosynovitis.

Development of a preliminary US power Doppler composite score for monitoring treatment in PsA

OBJECTIVE

To develop a preliminary power Doppler (PD) US composite score for global assessment of PsA patients.

METHODS

Sixteen PsA patients receiving anti-TNF-α therapy were enrolled. All patients were involved in multiple psoriatic targets, including joints, tendon, enthesis, skin and nail. The target with the highest PD signal, one for each target area, was selected to be scanned at baseline and at follow-up visit 8 weeks after. For each target, PD was graded according to semi-quantitative scoring systems. Inter- and intra-observer reliability and feasibility was also investigated. The new PD composite score for PsA was called Five Targets PD for Psoriatic Disease (5TPD).

RESULTS

Sixty targets (16 joints, 9 tendons, 11 enthesis, 16 psoriatic plaques and 8 psoriatic onychopathies) were assessed. A significant improvement of the clinical scores was found at follow-up with respect to the baseline: HAQ modified for SpA (HAQ-S) (P = 0.0001); Psoriasis Area and Severity Index (P = 0.0001) and Nail Psoriasis Severity Index (P = 0.35). The 5TPD showed a significant change between baseline and follow-up (P = 0.0001). There was no significant correlation between HAQ-S and 5TPD findings. The inter- and intra-observer κ-values varied from good to excellent at baseline and follow-up. The time spent on baseline US examinations was mean (s.d.) 10.5 (2.0) min and no more than 7 min for follow-up assessment.

CONCLUSION

The present study provides a new working hypothesis that the sonographic core set may be useful to construct a PDUS composite score for the assessment of PsA. The 5TPD formula provides a feasible and reliable approach for multi-target monitoring of psoriatic disease.

The role of Doppler ultrasound in rheumatic diseases

The use of Doppler techniques, including power, colour and spectral Doppler, has greatly increased in rheumatology in recent years. This is due to the ability of Doppler US (DUS) to detect pathological vascularization within joints and periarticular soft tissues, thereby demonstrating the presence of active inflammation, which has been reported to be correlated with the local neo-angiogenesis. In synovitis, DUS showed a high correlation with histological and MRI findings, thus it is considered a valid tool to detect pathological synovial vascularization. Moreover, it is more sensitive than clinical examination in detecting active joint inflammation and in the evaluation of response to treatment. In addition, DUS may be considered as a reference imaging modality in the assessment of enthesitis, MRI being not sensitive and histology not feasible. Moreover, it has been demonstrated to be able to detect changes in asymptomatic enthesis. In conclusion, DUS is a useful and sensitive tool in the evaluation and monitoring of active inflammation. Its widespread use in clinical rheumatological practice is recommended. The aim of this article is to review the current literature about the role of DUS in rheumatic diseases, analysing its validity, reliability and feasibility.

Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study

BACKGROUND

The ankle region is frequently involved in juvenile idiopathic arthritis (JIA) but difficult to examine clinically due to its anatomical complexity. The aim of the study was to evaluate the role of ultrasonography (US) of the ankle and midfoot (ankle region) in JIA. Doppler-US detected synovial hypertrophy, effusion and hyperemia and US was used for guidance of steroid injection and to assess treatment efficacy.

METHODS

Forty swollen ankles regions were studied in 30 patients (median age 6.5 years, range 1-16 years) with JIA. All patients were assessed clinically, by US (synovial hypertrophy, effusion) and by color Doppler (synovial hyperemia) before and 4 weeks after US-guided steroid injection.

RESULTS

US detected 121 compartments with active disease (joints, tendon sheaths and 1 ganglion cyst). Multiple compartments were involved in 80% of the ankle regions. The talo-crural joint, posterior subtalar joint, midfoot joints and tendon sheaths were affected in 78%, 65%, 30% and 55% respectively. Fifty active tendon sheaths were detected, and multiple tendons were involved in 12 of the ankles. US-guidance allowed accurate placement of the corticosteroid in all 85 injected compartments, with a low rate of subcutaneous atrophy (4,7%). Normalization or regression of synovial hypertrophy was obtained in 89%, and normalization of synovial hyperemia in 89%. Clinical resolution of active arthritis was noted in 72% of the ankles.

CONCLUSIONS

US enabled exact anatomical location of synovial inflammation in the ankle region of JIA patients. The talo-crural joint was not always involved. Disease was frequently found in compartments difficult to evaluate clinically. US enabled exact guidance of steroid injections, gave a low rate of subcutaneous atrophy and was proved valuable for follow-up examinations. Normalization or regression of synovial hypertrophy and hyperemia was achieved in most cases, which supports the notion that US is an important tool in the management of ankle involvement in JIA.

Quantitative Power Doppler Ultrasonography Is a Sensitive Measure of Metacarpophalangeal Joint Synovial Vascularity in Rheumatoid Arthritis and Declines Significantly Following a 2-week Course of Oral Low-dose Corticosteroids

Objective.

To investigate the stability over 2 weeks of ultrasonographic assessments of synovial thickness and vascularity in all 10 metacarpophalangeal joints of subjects with rheumatoid arthritis (RA) with a range of disease activities as measured by the validated Disease Activity Score-28 joint score (DAS28-ESR). And in subjects with severe disease activity, to compare the sensitivity of these measurements, acute-phase markers, and vascular endothelial growth factor to change in response to 2 weeks of oral prednisolone (7.5 mg daily).

Methods.

A group of 38 subjects with RA were enrolled, 13 (mean DAS28 2.1), 14 (mean DAS28 5.2), and 11 (mean DAS28 5.7) meriting oral corticosteroid treatment. Synovial thickness and vascularity were assessed by ultrasonography at 3 timepoints. Images were ranked by semiquantitative scale. Vascularity was also measured by quantitative determination of the power Doppler area (PDA).

Results.

In the whole RA cohort, baseline indices of synovial thickness and vascularity correlated with DAS28, as did PDA (r = 0.42, p < 0.05). In the RA groups on stable therapy, synovial thickness and vascularity showed little variation over 2 weeks. In the corticosteroid group, PDA had fold changes of −1.9-fold (p < 0.05) after 1 week and −2.2-fold (p < 0.05) after 2 weeks. These were the largest fold changes of all measured variables.

Conclusion.

Ultrasonographic measures can differentiate disease severity in RA correlating closely with DAS28. Quantitative power Doppler signal was significantly reduced within 1 week of oral prednisolone, a rapid kinetic suggesting that PDA may have value as a sensitive early marker of therapeutic response.

Pan-American League of Associations for Rheumatology (PANLAR) recommendations and guidelines for musculoskeletal ultrasound training in the Americas for rheumatologists

OBJECTIVE

To develop guidelines for Musculoskeletal Ultrasound (MSKUS) training for rheumatologists in the Americas.

METHODS

A total of 25 Rheumatologists from 19 countries of the American Continent participated in a consensus-based interactive process (Delphi method) using 2 consecutive electronic questionnaires. The first questionnaire included the following: the relevance of organizing courses to teach MSKUS to Rheumatologists, the determination of the most effective educational course models, the trainee levels, the educational objectives, the requirements for passing the course(s), the course venues, the number of course participants per instructor, and the percentage of time spent in hands-on sessions. The second questionnaire consisted of questions that did not achieve consensus (>65%) in the first questionnaire, topics, and pathologies to be covered at each course MSKUS level.

RESULTS

General consensus was obtained for MSKUS courses to be divided into 3 educational levels: basic, intermediate, and advanced. These courses should be taught using a theoretical-didactic and hands-on model. In addition, the group established the minimum requirements for attending and passing each MSKUS course level, the ideal number of course participants per instructor (4 participants/instructor), and the specific topics and musculoskeletal pathologies to be covered. In the same manner, the group concluded that 60% to 70% of course time should be focused on hands-on sessions.

CONCLUSION

A multinational group of MSKUS sonographers using a consensus-based questionnaire (Delphi method) established the first recommendations and guidelines for MSKUS course training in the Americas. Pan-American League of Associations for Rheumatology urges that these guidelines and recommendations be adopted in the future by both national and regional institutions in the American continent involved in the training of Rheumatologists for the performance of MSKUS.

Reliability of ultrasonography to detect synovitis in rheumatoid arthritis: a systematic literature review of 35 studies (1,415 patients)

OBJECTIVE

To perform a systematic review on the reliability of ultrasonographic (US) synovitis detection in rheumatoid arthritis (RA) by B-mode and power Doppler (PD) in image acquisition and still-image interpretation. US is a sensitive method for synovitis detection. However, reliability is still a key concern.

METHODS

Articles reporting any US reliability results for synovitis in RA in PubMed, EMBase, the Cochrane Library, and meeting abstracts were selected. Data were extracted from the collection of data on US synovitis detection (either qualitatively [binary] or semiquantitatively [0-3 scale], for intraobserver and interobserver reliability in B-mode and PD, and for image acquisition and still-image interpretation). The type of joints tested, the experience of the ultrasonographer, and the quality of the studies were assessed. Data analysis involved descriptive and graphic interpretation of reliability and its potential determinants.

RESULTS

Thirty-five studies (12 for B-mode, 11 for PD, or 12 for both) with a total of 1,415 patients were analyzed. Intraobserver and interobserver reliability for still images in B-mode and PD was high (kappa = 0.5-1.0 [14,991 joints] for intraobserver reliability for B-mode, kappa = 0.59-1.0 [14,934 joints] for PD, kappa = 0.49-1.0 [3,138 joints] for interobserver for B-mode, and kappa = 0.66-1.0 [3,325 joints] for PD). Interobserver reliability for image acquisition in both US modes was lower than still-image interpretation (kappa = 0.22-0.95). Few studies reported intraobserver image acquisition reliability.

CONCLUSION

Intraobserver and interobserver reliability of still-image interpretation was high, especially for PD, in published studies involving highly trained observers. However, reliability of acquisition of US should be further assessed.

Semi-quantitative analysis of rheumatoid finger joint synovitis using power Doppler ultrasonography: when to perform follow-up study after treatment consisting mainly of antitumor necrosis factor alpha agent

PURPOSE

To determine the timing for follow-up study of power Doppler ultrasonography (PDUS) by evaluating the response of finger joint synovitis in patients with rheumatoid arthritis (RA) to treatment including infliximab, an antitumor necrosis factor alpha agent.

METHODS AND MATERIALS

Bilateral second/third metacarpo-phalangeal (MCP) joints and second proximal inter-phalangeal (PIP) joints (total of six joints) in 21 patients (18 women and three men; median age 53 years) with chronic active RA were assessed by PDUS before and after 2 weeks, 6 weeks, 14 weeks, 30 weeks, 38 weeks, 46 weeks, and 54 weeks of infliximab infusion. Pulse Doppler settings were standardized for each patient and optimized for the detection of synovial blood flow by adjustment of color gain, pulse repetition, and flow optimization. Power Doppler signal was graded for each joint [joint grade for power Doppler (JGPD) signals], and the sum of the grades of six joints was defined as the PDUS index [joint index for power Doppler signals (JIPD)] at each visit. PDUS and clinical parameters [28-joint disease activity score (DAS28), health assessment questionnaire, and C-reactive protein (CRP) level] were independently assessed and compared with baseline values. The American College of Rheumatology (ACR) core set responders and non-responders at week 54 were compared for clinical parameters and PDUS index at each visit.

RESULTS

Fourteen patients completed the planned treatment for 1 year, while six patients dropped out for various reasons and one died suddenly. PDUS was performed a total of 146 times on 467 joints. DAS28 was assessed 127 times. Both DAS28 and JIPD had decreased at the follow-up. Comparative analysis between DAS28 and PDUS was available 125 times. The transverse correlation between the PDUS index and DAS28 was not significant throughout the follow-up period. When responders and non-responders were discriminated at week 54, a logistic regression model for the binary endpoint of responder vs non-responder, with PDUS index as explanatory variable at time point 0, and follow-up revealed statistical significance from week 38 and on.

CONCLUSION

PDUS reflected infliximab's effect on pannus vascular signals; this effect was observed as early as 2 weeks after treatment had begun. Also, the responders to treatment at 54 weeks tended to have fewer JIPD than non-responders in the follow-up period. PDUS may be performed at week 38 or later to foresee the response to the treatment at week 54.

Reproducibility of Joint Swelling Assessment by Sonography in Patients with Long-lasting Rheumatoid Arthritis (SEA-Repro Study Part II)

Objective.

To evaluate the intraobserver and interobserver reproducibility of B-mode and power Doppler (PD) sonography in patients with active long-standing rheumatoid arthritis (RA) comparatively with clinical data.

Methods.

In each of 7 patients being considered for a change in their RA treatment regimen, 7 healthcare professionals examined the 28 joints used in the Disease Activity Score 28-joint count (DAS28). Then 7 sonographers examined each of the 7 patients twice, using previously published B-mode and PD grading systems. The clinical reference standard was presence of synovitis according to at least 4/7 examiners. The sonographic reference standard was at least grade 1 (ALG1) or 2 (ALG2) synovitis according to at least 4/7 sonographers. Interobserver reproducibility of sonography was assessed versus the sonographer having the best intraobserver reproducibility. Agreement was measured by Cohen’s kappa statistic.

Results.

Intraobserver and interobserver reproducibility of B-mode and PD used separately was fair to good. Agreement between clinicians and sonographers at all sites using B-mode, PD, and both was 0.46, 0.37, and 0.36, respectively, for grade 1 synovitis; and 0.58, 0.19, and 0.19 for grade 2 synovitis. The number of joints with synovitis was smaller by physical examination (36.7%) than by B-mode with ALG1 (58.6%; p < 0.001). The number of joints with synovitis was higher by physical examination than by PD with both ALG1 (17.8%; p < 0.0001) and ALG2 (6.6%; p < 0.0001).

Conclusion.

PD findings explain most of the difference between clinical and sonographic joint assessments for synovitis in patients with long-standing RA.

Response of symptoms and synovitis to intra-muscular methylprednisolone in osteoarthritis of the hand: an ultrasonographic study

OBJECTIVE

To examine the relationship between ultrasound (US)-detected synovial pathology in hand OA and the clinical response to parenteral corticosteroids.

METHODS

People with symptomatic OA of the hand completed questionnaires [visual analogue scale (VAS) pain, Australian Canadian Osteoarthritis Hand Index and VAS global] and underwent an US examination of both hands prior to receiving an i.m. dose of methylprednisolone. Four- and twelve-week assessments were performed to assess therapeutic response.

RESULTS

Thirty-six subjects with established OA were enrolled. Twenty-four (67%) subjects met the primary end-point of a 20% reduction in VAS pain, 25 (69.4%) met the Osteoarthritis Research Society International response criteria at 4 weeks. Overall in the group, there was a reduction in levels of pain in the most painful joint, pain in all joints and in global disease activity at 4 weeks (P < 0.001, P < 0.001 and P < 0.001, respectively). Reduction in symptoms was not associated with a statistically significant reduction in US-detected synovial hypertrophy or power Doppler signal.

CONCLUSIONS

In this observational study, parenteral corticosteroids were associated with a statistically significant reduction in symptoms, but no statistically significant reduction in US-detected synovial inflammation. The latter finding may, however, reflect the relatively low levels of synovial inflammation detected ultrasonagraphically in hand joints.

Using ultrasonography to facilitate best practice in diagnosis and management of RA

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

[Color Doppler sonography for investigation of peripheral joints and ligaments]

Doppler ultrasound is able to visualize blood flow by the change in frequency (Doppler shift) of sound waves which are reflected by moving blood cells inside the vessels (Doppler effect). As hyperemia caused by vasodilatation and angiogenesis is the earliest detectable pathologic change in the beginning of synovitis, Doppler ultrasonography can be used to assess inflammatory activity. Several studies could show a strong correlation between magnetic resonance imaging (MRI) as well as histological findings (blood vessel density) and Doppler sonographic determination of synovial perfusion. Equipment settings must be adapted to slow blood flow in very small blood vessels to reach an appropriate imaging quality. Color and power Doppler ultrasound can depict different grades of intra-articular and peritendinous blood flow, which allows an estimation of inflammatory activity and facilitates the differentiation and monitoring of rheumatic diseases during follow up.

Association of ultrasonographic findings of synovitis with anti-cyclic citrullinated Peptide antibodies and rheumatoid factor in patients with palindromic rheumatism during active episodes

OBJECTIVE

The purpose of this study was to investigate whether the presence of ultrasonographic findings of synovitis is associated with the presence of anti-cyclic citrullinated peptide (CCP) antibodies and rheumatoid factor (RF) in patients with palindromic rheumatism (PR) during active episodes.

METHODS

Clinically involved regions of 84 patients with PR during active episodes were examined with high-resolution ultrasonography. Serum levels of anti-CCP antibodies were determined by an enzyme-linked immunosorbent assay, and RF levels were measured by nephelometry.

RESULTS

Thirty patients (36%) had ultrasonographic findings of synovitis during active episodes. Significantly higher positive rates of anti-CCP antibodies and RF were observed in patients with PR who had ultrasonographic findings of synovitis compared with those who had no ultrasonographic findings of synovitis (26.7% versus 5.6%; odds ratio, 6.18; P < .05; and 30.0% versus 5.6%; odds ratio, 7.29; P < .01, respectively). The intraobserver and interobserver agreement for the detection of synovitis and Doppler signals by ultrasonographic assessment was excellent.

CONCLUSIONS

Ultrasonography is a reliable method for assessing the presence of synovitis in patients with PR during active episodes. The ultrasonographic findings of synovitis are associated with the presence of anti-CCP antibodies and RF in patients with PR.

US guided injections in arthritis

US guided procedures for diagnosis or treatment of different forms of arthritis are becoming more and more important. This review describes general considerations for fluid aspiration, articular or periarticular injections and biopsies by US guidance according to the recent literature. Guidelines regarding instrumentation, different techniques, pre- and postprocedural care as well as complications are outlined and in the second part a more detailed overview of different interventions in joints, tendons and other periarticular regions (nerves, bursae, etc.) is included. Furthermore, some newer, more sophisticated techniques are briefly discussed.