Detection of small joint synovitis by ultrasonography: the learning curve of rheumatologists

Deep learning-based automatic scoring models for the disease activity of rheumatoid arthritis based on multimodal ultrasound images

OBJECTIVES

We aimed to investigate the value of deep learning (DL) models based on multimodal ultrasonographic (US) images to quantify RA activity.

METHODS

Static greyscale (SGS), dynamic greyscale (DGS), static power Doppler (SPD) and dynamic power Doppler (DPD) US images were collected and evaluated by two expert radiologists according to the EULAR-OMERACT Synovitis Scoring system. Four DL models were developed based on the ResNet-type structure, evaluated on two separate test cohorts, and finally compared with the performance of 12 radiologists with different levels of experience.

RESULTS

In total, 1244 images were used for the model training, and 152 and 354 for testing (cohort 1 and 2, respectively). The best-performing models for the scores of 0/1/2/3 were the DPD, SGS, DGS and SPD models, respectively (Area Under the receiver operating characteristic Curve [AUC] = 0.87/0.95/0.74/0.95; no significant differences). All the DL models provided results comparable to the experienced radiologists on a per-image basis (intraclass correlation coefficient: 0.239-0.756, P < 0.05). The SPD model performed better than the SGS one on test cohort 1 (score of 0/2/3: AUC = 0.82/0.67/0.95 vs 0.66/0.66/0.75, respectively) and test cohort 2 (score of 0: AUC = 0.89 vs 0.81). The dynamic DL models performed better than the static ones in most of the scoring processes and were more accurate than the most of senior radiologists, especially the DPD model.

CONCLUSION

DL models based on multimodal US images allow a quantitative and objective assessment of RA activity. Dynamic DL models in particular have potential value in assisting radiologists to improve the accuracy of RA US-based grading.

Solid validity evidence for two tools assessing competences in musculoskeletal ultrasound: a validity study

OBJECTIVES

Musculoskeletal ultrasound (MSUS) is increasingly used by rheumatologists in daily clinical practice. However, MSUS is only valuable in trained hands, and assessment of trainee competences is therefore essential before independent practice. Thus, this study aimed to establish validity evidence for the EULAR and the Objective Structured Assessment of Ultrasound Skills (OSAUS) tools used for assessing MSUS competences.

METHODS

Thirty physicians with different levels of MSUS experience (novices, intermediates, and experienced) performed four MSUS examinations of different joint areas on the same rheumatoid arthritis patient. All examinations were video recorded (n = 120), anonymized, and subsequently assessed in random order by two blinded raters using first the OSAUS assessment tool followed by the EULAR tool 1 month after.

RESULTS

The inter-rater reliability between the two raters was high for both the OSAUS and EULAR tools, with a Pearson correlation coefficient (PCC) of 0.807 and 0.848, respectively. Both tools demonstrated excellent inter-case reliability, with a Cronbach's alpha of 0.970 for OSAUS and 0.964 for EULAR. Furthermore, there was a strong linear correlation between the OSAUS and the EULAR performance scores and the participants' experience levels (R2 = 0.897 and R2 = 0.868, respectively) and a significant discrimination between different MSUS experience levels (P < 0.001 for both).

CONCLUSIONS

MSUS operator competences can be assessed reliably and valid using either the OSAUS or the EULAR assessment tool, thereby allowing a uniform competency-based MSUS education in the future. Although both tools demonstrated high inter-rater reliability, the EULAR tool was superior to OSAUS.

TRIAL REGISTRATION

ClinicalTrials.gov, http://clinicaltrials.gov, NCT05256355.

Clinical evaluation of optical spectral transmission imaging for detection of disease activity in rheumatoid arthritis

OBJECTIVE

To investigate the performance and factors of influence of optical spectral transmission (OST) imaging as a new technique for measuring joint inflammation in rheumatoid arthritis (RA).

METHOD

OST was performed in 24 RA patients and 37 controls. Mann-Whitney U-test was used to assess differences in OST score between RA patients and controls. Receiver operating characteristics (ROC), linear regression and generalized estimating equations analysis were used to assess the discriminative capability of OST and the association of OST score with clinical disease parameters, ultrasound, radiographic features and cardiovascular risk parameters.

RESULTS

Median OST score was higher in RA patients than in controls [16.9 (interquartile range 12.77-19.7) vs 12.11 (10.32-14.93)]. At patient level, OST score was moderately associated with ultrasound [beta 0.38 (95% CI 0.16-0.60), p = 0.001] and clinical disease activity [28-joint Disease Activity Score-C-reactive protein beta 0.30 (95% CI 0.04- 0.57), p = 0.024] in RA patients. In controls, male sex, high body mass index, and hypertension were associated with higher OST scores, while these associations were absent in RA. At joint level, the area under the ROC curve for OST score, with ultrasound or clinical swelling as reference, ranged from 0.63 to 0.70. Joint-space narrowing and malalignment were associated with higher OST joint scores, and subchondral sclerosis with lower scores.

CONCLUSION

OST provides an objective measure of synovitis and correlates moderately with other examined disease activity assessment tools. Clinical patient characteristics must be considered when interpreting the results.

E-learning and practical performance in musculoskeletal ultrasound: a multicentre randomized study

OBJECTIVES

To examine the effect of pre-course e-learning on residents' practical performance in musculoskeletal ultrasound (MSUS).

METHODS

This was a multicentre, randomized controlled study following the Consolidated Standards of Reporting Trials (CONSORT) statement. Residents with no or little MSUS experience were randomized to either an e-learning group or a traditional group. One week before a 2-day face-to-face MSUS course, the e-learning group received access to an interactive platform consisting of online lectures, assignments, and practical instruction videos aligned with the content of the course. The traditional group only received standard pre-course information (program, venue, and time). All participants performed a pre- and post-course practical MSUS examination and were assessed by two individual raters, blinded to the group allocation, using the validated Objective Structured Assessment of Ultrasound Skills (OSAUS) tool.

RESULTS

Twenty-eight participants completed the study. There were no statistically significant differences in the pre- or post-course practical MSUS performance between the e-learning group and the traditional group; the mean pre-course OSAUS score (s.d.) in the -learning group was 5.4 (3.7) compared with 5.2 (2.4) in the traditional group (P = 0.8), whereas the post-course OSAUS score in the e-learning group was 11.1 (2.8) compared with 10.9 (2.4) in the traditional group (P = 0.8). There was a significant difference between the mean pre- and post-course scores (5.74 points, P < 0.001). The OSAUS assessment tool demonstrated good inter-rater reliability (intra-class correlation = 0.84).

CONCLUSION

We found no significant impact of pre-course e-learning on novices' acquisition of practical MSUS skills. Hands-on training is of the utmost importance and improves MSUS performance significantly. The OSAUS assessment tool is an applicable tool with high interrater reliability.

TRIAL REGISTRATION

https://clinicaltrials.gov/ NCT04959162.

Training and assessment of musculoskeletal ultrasound and injection skills-a systematic review

OBJECTIVES

To examine how residents are trained and assessed in musculoskeletal ultrasound (MSUS), MSUS-guided and landmark-guided joint aspiration and injection. Additionally, to present the available assessment tools and examine their supporting validity evidence.

METHODS

A systematic search of PubMed, Cochrane Library, and Embase was conducted in accordance with the PRISMA guidelines and studies published from January 1, 2000 to May 31, 2021 were included. Two independent reviewers performed the search and data extraction. The studies were evaluated using the Medical Education Research Quality Instrument (MERSQI).

RESULTS

9,884 articles were screened, and 43 were included; 3 were randomized studies, 21 pre- and post-test studies, 16 descriptive studies, and 3 studies developing assessment tools. The studies used various theoretical training modalities e.g. lectures, anatomical quizzes and e-learning. The practical training models varied from mannequins and cadavers to healthy volunteers and patients. The majority of studies used subjective "comfort level" as assessment, others used practical examination and/or theoretical examination. All training programs increased trainees' self-confidence, theoretical knowledge, and/or practical performance, however few used validated assessment tools to measure the effect. Only one study met the MERSQI high methodical quality cut-off score of 14.

CONCLUSION

The included studies were heterogeneous, and most were of poor methodological quality and not based on contemporary educational theories. This review highlights the need for educational studies using validated theoretical and practical assessment tools to ensure optimal MSUS training and assessment in rheumatology.

Artificial intelligence in musculoskeletal ultrasound imaging

Ultrasonography (US) is noninvasive and offers real-time, low-cost, and portable imaging that facilitates the rapid and dynamic assessment of musculoskeletal components. Significant technological improvements have contributed to the increasing adoption of US for musculoskeletal assessments, as artificial intelligence (AI)-based computer-aided detection and computer-aided diagnosis are being utilized to improve the quality, efficiency, and cost of US imaging. This review provides an overview of classical machine learning techniques and modern deep learning approaches for musculoskeletal US, with a focus on the key categories of detection and diagnosis of musculoskeletal disorders, predictive analysis with classification and regression, and automated image segmentation. Moreover, we outline challenges and a range of opportunities for AI in musculoskeletal US practice.

Evaluation of anterotalofibular and calcaneofibular ligament stress tests utilizing musculoskeletal ultrasound imaging

Study Design: A quasi-experimentalBackground: The talar tilt test and the anterior drawer test are clinically used to evaluate the length of the anterotalofibular (ATFL) and calcaneofibular (CFL) ligaments. Based on the current literature, there is no clear diagnostic utility or preference for either test. This study investigated ligament lengthening during these special tests and compared the talar tilt test to the long axis distraction test for the CFL length.Methods: A convenience sample of 47 healthy subjects were recruited for this study. Musculoskeletal ultrasound imaging (MSK US) was used to measure the length of the ATFL and CFL during the talar tilt and anterior drawer tests. Additionally, CFL lengthening during the talar tilt was compared to the long axis distraction test.Outcomes: A significant difference was found (p < .001) in ATFL length between the talar tilt and anterior drawer test. This indicates that the talar tilt test is preferred to maximally lengthen the ATFL. There was a significant difference in CFL length (p < .001) between the talar tilt test and the long axis distraction test.Discussion: The results of this study identified that the talar tilt test resulted in more ATFL lengthening than the anterior drawer test and thus is the preferred test to assess ligament length. Additionally, both the long axis distraction test and the talar tilt test cause lengthening of the CFL. Therefore, the long axis distraction test can be used as a differentiation test to determine if either the ATFL or the CFL is the structure with increased laxity.

THE MANAGEMENT OF PLANTAR FASCIITIS WITH A MUSCULOSKELETAL ULTRASOUND IMAGING GUIDED APPROACH FOR INSTRUMENT ASSISTED SOFT TISSUE MOBILIZATION IN A RUNNER: A CASE REPORT

BACKGROUND/AND PURPOSE

Musculoskeletal ultrasound imaging (MSK US) is an emerging diagnostic tool in physical therapy, which allows for dynamic visualization of tissues in real time. Plantar fasciitis is a common condition causing heel and arch pain and has been related with degenerative changes in the plantar fascia resulting in tissue thickening. Instrument Assisted Soft Tissue Mobilization (IASTM) is an intervention that allows clinicians deep penetration to treat tissues. The mechanical forces caused by IASTM might cause localized tissue trauma leading to stimulation of the body's natural inflammation and healing processes. The purpose of this case report is to demonstrate the use of ultrasound imaging to guide the decision-making process and to discern the optimal location for the application of IASTM.

CASE DESCRIPTION

The subject was a 46-year-old female yoga practitioner and runner, who presented with right foot pain. The clinical impression was formulated based on the combination of traditional physical therapy examination procedures and MSK US imaging findings of the plantar fascia demonstrating thickness and tendinosis like changes within the plantar fascia 3 cm distally from the calcaneus.

OUTCOMES

The subject was seen for eight treatment sessions over four weeks, at which time the goals of normal ankle dorsiflexion, no pain with palpation of the plantar fascia, negative windlass test, and no reported pain during gait were achieved.

DISCUSSION

This case report illustrates the use of MSK US imaging as a method to objectively assess tissue quality and guide decision-making when managing patients with plantar fascia related pain. MSK US was used to determine the optimal location for the application of IASTM during the conservative management of a runner with plantar fasciitis.

LEVEL OF EVIDENCE

Therapy, Level 5.

Musculoskeletal ultrasound imaging and clinical reasoning in the management of a patient with cervicogenic headache: a case report

Background: Clinical decision-making within the physical therapy treatment process typically follows the hypothetical-deductive method. The accuracy and reliability of clinical tests affect this reasoning process. Musculoskeletal ultrasound imaging (MSK US) is an emerging valid and reliable diagnostic tool in physical therapy. MSK US allows for dynamic visualization of tissues in real time with devices that are often portable.Case Description: The patient was a 55-year-old female, who presented by direct access. She had been suffering from cervicogenic headaches since the age of 18. It was hypothesized that this patient presented with a right rotation positional default of atlas and facet hypomobility at C5-6.Outcomes: After six visits (over 7 weeks) of manual therapy interventions, the patient reported that her headaches and neck pain were no longer present. Her physical therapy goals had been met and she was discharged with the instruction to continue working on her posture correction and self-management.Discussion: This case report describes the use of MSK US imaging as part of the clinical decision-making process when treating a patient with cervicogenic headaches. This case illustrates the successful management using manual therapy to restore position, mobility, decrease muscle tone, and normalize upright posture. Complementary research is necessary to further validate MSK US imaging as the preferred method to objectivize joint mobility and guide decision-making. Additionally, the cause-effect relationship between the treatment and positive outcomes in this case report has to be further validated.

Evaluation of the Acquisition of Ultrasound Proficiency in Hand Surgery Fellows

OBJECTIVES

To evaluate hand surgery fellow ultrasound (US) evaluations and performance of clinically relevant tasks after brief instruction.

METHODS

Six hand surgery fellows completed an US assessment and a survey on US use before and 1 month after a 30-minute US course.

RESULTS

The time to obtain an adequate image decreased from 4 minutes 42 seconds (4:42; range, 3:57-7:55) to 0:52 (range, 0:30-1:14; P < .001). Participants' performance for structure identification improved from 9.7 (range, 8-13) to 12 (range, 10-13) of 14 structures (P < .05). The average time to completion decreased from 14:6 (range, 12:08-18:30) to 9:34 (range, 4:40-15:54; P < .01). After instruction, all 6 participants identified and measured the cross-sectional area of the median nerve, identified and measured a zone 3 flexor tendon gap, and identified a simulated flexor digitorum profundus avulsion and its level of retraction (P < .05). Five of 6 successfully administered an US-guided injection to the extensor carpi ulnaris subsheath.

CONCLUSIONS

After a 30-minute instructional session, hand surgery fellows can achieve a basic level of US competency.

Ultrasound Assessment of Synovial Thickness of Some of the Metacarpophalangeal Joints of Hand in Rheumatoid Arthritis Patients and the Normal Population

Objective. To compare ultrasound synovial thickness of the 2nd, 3rd and 4th metacarpophalangeal joints (MCPJ) in a group of patients with proven rheumatoid arthritis (RA) and a control group of normal individuals. Materials and Methods. This is a cross-sectional study comprising 30 rheumatoid arthritis patients and 30 healthy individuals. Ultrasound scans were performed at the dorsal side of 2nd, 3rd, and 4th MCPJ of both hands in RA patients and the healthy individuals. Synovial thickness was measured according to quantitative method. The synovial thickness of RA patients and healthy individuals was compared and statistical cut-off was identified. Results. Maximum synovial thickness was most often detected at the radial side of the 2nd MCPJ and 3rd MCPJ and ulnar side of the 4th MCPJ of both hands which is significantly higher (p < 0.05) in RA patients compared to healthy individuals. With high specificity (96%) and sensitivity (90%) the optimum cut-off value to distinguish RA patients and healthy individuals' synovial thickness differs for the radial side of the 2nd and 3rd MCPJ and ulnar side of the 4th MCPJ. Conclusion. Patients with early RA appear to exhibit a characteristic pattern of synovitis which shows radial side predominance in the 2nd and 3rd MCPJ and ulnar side in the 4th MCPJ.

Utility of Interobserver Agreement Statistics in Establishing Radiology Resident Learning Curves During Self-directed Radiologic Anatomy Training

RATIONALE AND OBJECTIVES

The aim of the study was to ascertain the learning curves for the radiology residents when first introduced to an anatomic structure in magnetic resonance images (MRI) to which they have not been previously exposed to.

MATERIALS AND METHODS

The iliolumbar ligament is a good marker for testing learning curves of radiology residents because the ligament is not part of a routine lumbar MRI reporting and has high variability in detection. Four radiologists, three residents without previous training and one mentor, studied standard axial T1- and T2-weighted images of routine lumbar MRI examinations. Radiologists had to define iliolumbar ligament while blinded to each other's findings. Interobserver agreement analyses, namely Cohen and Fleiss κ statistics, were performed for groups of 20 cases to evaluate the self-learning curve of radiology residents.

RESULTS

Mean κ values of resident-mentor pairs were 0.431, 0.608, 0.604, 0.826, and 0.963 in the analysis of successive groups (P < .001). The results indicate that the concordance between the experienced and inexperienced radiologists started as weak (κ <0.5) and gradually became very acceptable (κ >0.8). Therefore, a junior radiology resident can obtain enough experience in identifying a rather ambiguous anatomic structure in routine MRI after a brief instruction of a few minutes by a mentor and studying approximately 80 cases by oneself.

CONCLUSIONS

Implementing this methodology will help radiology educators obtain more concrete ideas on the optimal time and effort required for supported self-directed visual learning processes in resident education.

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.

Contributions of ultrasound beyond clinical data in assessing inflammatory disease activity in rheumatoid arthritis: current insights and future prospects

Appropriate measures of disease activity need to be valid, reliable and sensitive to change for use in clinical studies while remaining at the same time feasible and practicable for utilization in daily clinical practice. Ultrasonography was shown to be a valid, sensitive and reliable imaging modality for the detection of synovitis in RA, however, it has so far failed to demonstrate superior sensitivity to change as compared with clinical examination. This review examines the current evidence for the use of established measures and/or US, either as an alternative or as a supplementary measure to clinical examination, as tools for monitoring synovitis in RA. It also includes a summary of results of recent studies evaluating clinical examination-based as well as clinical- and US-based multimodal disease activity indices. We review the rationale and limitations of incorporating US into composite disease activity indices and suggest a research roadmap for further studies in this field.

Maximum intensity projection with magnetic resonance imaging for evaluating synovitis of the hand in rheumatoid arthritis: comparison with clinical and ultrasound findings

Magnetic resonance imaging (MRI) with maximum intensity projection (MIP) is used to evaluate the hand in rheumatoid arthritis (RA). MIP yields clear visualization of synovitis over the entirety of the bilateral hands with a single image. In this study, we assessed synovitis with MIP images, clinical findings, and power Doppler (PD) findings to examine the clinical usefulness of MIP images for RA in the hand. Thirty RA patients were assessed for swelling and tenderness in the joints included in the DAS28, and both contrast-enhanced MRI for bilateral hands and ultrasonography for bilateral wrist and metacarpophalangeal (MCP) joints were performed. Articular synovitis was scored in MIP images, and the scores were compared with those for PD. The agreement on synovitis between MIP and conventional MR images was excellent. Palpation showed low sensitivity and high specificity compared with both MIP and PD images. There were joints that were positive in MIP images only, but there were no joints that were positive in PD images only. A statistically significant correlation between the scores of MIP and PD images was found. Furthermore, the agreement between grade 2 on MIP images and positive on PD images was 0.87 (κ = 0.73) for the wrist and 0.92 (κ = 0.57) for MCP joints. Using MIP images together with palpation makes detailed evaluation of synovitis of the hand in RA easy. MIP images may predict further joint damage, since they allow semiquantitative estimation of the degree of thickening of the synovial membrane.

Musculoskeletal ultrasound training and competency assessment program for rheumatology fellows

OBJECTIVES

The purpose of this study was to establish standards for musculoskeletal ultrasound competency through knowledge and skills testing using criterion-referenced methods.

METHODS

Two groups of rheumatology fellows trained in musculoskeletal ultrasound through a standardized curriculum, which required submission of ultrasound studies for review over 8 months. Both groups then completed written and practical examinations in musculoskeletal ultrasound. Instructors, advanced users, and intermediate users of musculoskeletal ultrasound served as comparison groups. A passing score (competency) was established for the written examination by the Angoff procedure and for the practical examination by the borderline method.

RESULTS

Thirty-eight fellows (19 in each group) took the final examination. Five fellows failed the written examination, and 1 failed the practical examination, whereas none of the advanced users failed. Written examination scores did not differ between the two fellow groups (74% versus 70%; P > .05), were reliable, and were able to discriminate between the intermediate and advanced groups. Practical and written examination results correlated in both groups (first group, r = 0.70; P = .0008; second group, r = 0.59; P = .009).

CONCLUSIONS

Criterion-referenced methods were used for the first time to determine fellow musculoskeletal ultrasound competency. The examination used to determine competency was reproducible, was reliable, and could differentiate musculoskeletal ultrasound users with different levels of experience. Most rheumatology fellows completing our program passed the written and practical examinations, suggesting achievement of basic musculoskeletal ultrasound competency.

Becoming a musculoskeletal ultrasonographer

Over the last decade, increasing numbers of rheumatologists have incorporated musculoskeletal ultrasound (MSUS) as a valuable diagnostic tool into their clinical practice. Some countries have established training programmes for MSUS. The European League Against Rheumatism has developed education guidelines for the content and conductance of MSUS courses and it would be useful to standardise rheumatology MSUS training worldwide. A thorough knowledge of anatomy, US physics and technology, US scanning methods, US pattern of normal and pathological musculoskeletal tissues, definitions for US pathology, artefacts and pitfalls in both greyscale and Doppler modalities is necessary to perform efficient MSUS. MSUS training includes attending theoretical-practical and online courses, as well as studying textbooks and using digital video discs (DVDs). Having access to US equipment and performing supervised normal and pathological MSUS examinations for a training period are mandatory for consolidating MSUS learning. A proposal to accredit and certificate competence in MSUS is now being discussed.

Longitudinal analysis of effects of operator experience on accuracy for ultrasound detection of supraspinatus tears

BACKGROUND

Magnetic resonance imaging (MRI) is highly accurate in diagnosing full-thickness rotator cuff tears but has the limitations of high cost and patient-based inconveniences. Diagnostic ultrasound of the rotator cuff has become popular, but its accuracy is operator dependent. We hypothesized that the incremental learning associated with initiation of shoulder ultrasonography in the orthopedic office setting could be quantified.

MATERIALS AND METHODS

Ultrasound was performed by 2 surgeons in different patient populations each consisting of 200 patients within the clinical setting. Analysis of the operator learning curves based on sensitivity, specificity, positive predictive value, negative predictive value, and κ agreement scores was performed with MRI used as the reference standard.

RESULTS

Surgeon 1 detected 67 (ultrasound) of 72 (MRI) full-thickness supraspinatus tears, and surgeon 2 detected 92 (ultrasound) of 95 (MRI) full-thickness tears. Agreement between ultrasound and MRI improved with increasing number of ultrasounds performed. The maximal rate of increase in sensitivity occurred by the 50th ultrasound for both surgeons. The maximal rate of increase in specificity occurred by the 75th ultrasound for both surgeons. Overall accuracy to detect full-thickness supraspinatus tears plateaued after 100 ultrasounds.

CONCLUSIONS

The majority of learning to detect full-thickness supraspinatus tears by ultrasound occurred in the surgeons' first 50 cases. The ability to accurately distinguish a normal supraspinatus tendon by ultrasound took longer, occurring within the first 75 cases. The majority of learning before accuracy plateaued occurred within the first 100 ultrasounds. The recommended operator experience necessary to evaluate the supraspinatus tendon before clinical application was 100 ultrasounds.

LEVEL OF EVIDENCE

Level I, Diagnostic Study.

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

Advances in imaging

PURPOSE OF REVIEW

Imaging of inflammatory activity is of increasing importance, and among available modalities, ultrasonography and magnetic resonance imaging (MRI) seem to be of highest impact. The present review includes recent studies describing several aspects of these modalities as well as short descriptions of other promising imaging methods in rheumatoid arthritis (RA).

RECENT FINDINGS

High reliability has been shown for evaluation of ultrasonography still images. Recently excellent reliability was found when an atlas was used as reference for scoring dynamic images with ultrasonography. The optimal number of joints to examine by ultrasonography for follow-up during therapeutic interventions needs to be further explored. Use of ultrasonographic guidance for injections has showed improved clinical results when compared with blind injections. Ultrasonographic pathology, especially power Doppler, was found to be of predictive value in patients with arthritis. Cartilage damage is an important aspect of structural joint damage in RA, and a reliable assessment system of joint space narrowing has been developed for use with conventional MRI, and various biochemical MRI techniques are being developed to visualize cartilage quality, of which delayed gadolinium-enhanced magnetic resonance imaging of cartilage seems to be the most promising method in RA.

SUMMARY

Novel imaging modalities, especially ultrasonography and MRI, will be of increasing importance to visualize joint inflammation and aid in the diagnosis, treatment and follow-up of patients with RA.

Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment

The utility of musculoskeletal ultrasound (MSK US) is being extensively explored and evaluated amongst European rheumatologists. However, utilization of MSK US by rheumatologists in Canada is much less common. This study aimed to evaluate the current use of MSK US in Canadian rheumatology practice, to determine beliefs and attitudes towards MSK US, and to determine factors that may encourage or limit its use. A 13-question needs assessment questionnaire was developed. All Canadian rheumatologists were invited via e-mail to participate in the survey. The overall response rate was 156/470 (33%). Fifty-one percent of participants used MSK US in their clinical practice. Lack of training appeared to be the main obstacle to its current use. Eighty-three percent believed that MSK US should be performed by rheumatologists and expressed a willingness to learn the technique. Skills offering greatest clinical utility were the assessment of inflammatory arthritis in small joints (i.e., hands (metacarpophalyngeal and proximal interphalangeal joints), wrists, feet (metatarsophalyngeal), shoulders, and ankles. Limited available time, equipment costs, and difficulties with billing were the main obstacles to MSK US utilization in the clinical setting. There is a great level of interest in learning and applying MSK US in Canadian rheumatology practice. The balance between added clinical value and lack of remuneration, equipment associated costs, and time to complete training is the major limiting factor influencing rheumatologists' willingness to take on MSK US. Training programs must be relevant to rheumatologists' needs before MSK US will be adopted into routine clinical practice in Canada.

Is musculoskeletal ultrasonography an operator-dependent method or a fast and reliably teachable diagnostic tool? Interreader agreements of three ultrasonographers with different training levels

Objectives. To assess interreader agreements and a learning curve between three (senior, junior, and beginner) different experienced musculoskeletal ultrasonographers. Senior served as the imaging "gold standard". Methods. Clinically dominant joints (finger, shoulder, knee, tibiotalar, and talonavicular) of 15 rheumatoid arthritis (RA) patients were examined by three different experienced ultrasonographers (senior 10 years, junior 10 months, and beginner one month). Each patient's ultrasonographic findings were reported unaware of the other investigators' results. κ coefficients, percentage agreements, sensitivities, and specificities were calculated. Results. 120 joints of 15 RA patients were evaluated. Comparing junior's and beginner's results each to the senior's findings, the overall κ for all examined joints was 0.83 (93%) for junior and 0.43 (76%) for beginner. Regarding the different joints, junior's findings correlate very well with the senior's findings (finger joints: κ = 0.82; shoulder: κ = 0.9; knee: κ = 0.74; tibiotalar joint: κ = 0.84; talonavicular joint: κ = 0.84) while beginner's findings just showed fair to moderate agreements (finger joints: κ = 0.4; shoulder: κ = 0.42; knee: κ = 0.4; tibiotalar joint: κ = 0.59; talonavicular joint: κ = 0.35). In total, beginner's results clearly improved from κ = 0.34 (agreement of 67%) at baseline to κ = 0.78 (agreement of 89%) at the end of the evaluation period. Conclusions. Ultrasonographic evaluation of a ten-month-experienced investigator in comparison to a senior ultrasonographer was of substantial agreement. Agreements between a beginner and a highly experienced ultrasonographer were only fair at the beginning, but during the study including ultrasonographical sessions of 15 RA patients, the beginner clearly improved in musculoskeletal ultrasonography.

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.

Reproducibility of Joint Swelling Assessments in Long-lasting Rheumatoid Arthritis: Influence on Disease Activity Score-28 Values (SEA-Repro Study Part I)

Objectives.

To evaluate the reproducibility of clinical synovitis assessments in rheumatoid arthritis and the effect of variability on the Disease Activity Score-28 (DAS28).

Methods.

Seven healthcare professionals from different cities examined the same patients with active non-early rheumatoid arthritis (RA; duration > 4 yrs), for whom a treatment change was being considered. There was no training session and the examination was to be performed as quickly as possible. The healthcare professionals assessed the 28 joints of the DAS28 in 7 patients (196 joints), then reexamined the same 28 joints in 4 of these 7 patients (112 joints), who had been rendered unrecognizable. Then 7 sonographers examined each of the 7 patients twice, using B-mode and power Doppler ultrasound (PD). The reference standards were presence of synovitis according to at least 50% of clinical examiners and 50% of sonographers. Agreement was assessed by Cohen’s kappa statistic.

Results.

Intraobserver reliability ranged from 0.31 (least experienced research technician) to 0.77 (most experienced physician). Interobserver reliability ranged from 0.18 to 0.62. The largest difference between the lowest and the highest swollen joint counts in the same patient was 15, and the greatest variation in the DAS28 score was 0.92. Agreement between clinical and sonographic reference standards was 0.46, 0.37, and 0.36 for B-mode, PD, and both, respectively.

Conclusion.

Clinical inter- and intraobserver reliability is highly dependent on the examiner. Consequences on the DAS28 score can be substantial. Agreement with sonography is poor when both B-mode and PD are used but seems better, although low, when B-mode is used alone.

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.

Superiority of SDAI over DAS-28 in assessment of remission in rheumatoid arthritis patients using power Doppler ultrasonography as a gold standard

OBJECTIVE

To investigate the accuracy of composite scores in classifying RA patients who are in remission using the absence of inflammatory activity detected by ultrasound (US) as a gold standard.

METHODS

Ninety-seven RA patients who were classified by their rheumatologists as being in remission were studied. Disease activity was assessed by the DAS-28 and simplified disease activity index (SDAI). US examination was performed in mode B and power Doppler (PD) in 42 joints.

RESULTS

Synovial hypertrophy (SH) and PD were present in 92 (94.8%) and 41 (42.3%) patients. If we consider 'remission' to be the absence of joints with PD signal, no differences were found by DAS-28 between patients in remission and those not in remission, although differences were present by SDAI. We then calculated the sensitivity (S), specificity (Sp) and positive likelihood ratio (LR) of different SDAI cut-off points to predict absence of PD signal. SDAI < 5 had an S of 65% (95% CI 52, 76), Sp of 55% (95% CI 39, 69) and LR of 1.45 (95% CI 0.98, 2.15), whereas SDAI < 3.3 had an S of 57% (95% CI 44, 69), Sp of 74% (95% CI 58, 85) and LR of 2.24 (95% CI 1.25, 4.01).

CONCLUSIONS

Our results suggest that the SDAI classification of remission is closer to the concept of an absence of inflammatory activity, as defined by the absence of positive PD signal by US.

Ultrasound guidance for intra-articular injections of the foot and ankle

BACKGROUND

Ultrasound has been increasingly utilized in procedures involving intra-articular injections. This study's purpose was to compare the accuracy of intra-articular injections of the foot and ankle using palpation versus dynamic ultrasound in a cadaver model.

MATERIALS AND METHODS

Fourteen lightly embalmed cadaver specimens without notable osteoarthritis were used. A 0.22-gauge needle was placed by a foot and ankle orthopaedic surgeon into the first and second tarsometatarsal joints, subtalar joint, and ankle joint. The needle was initially placed using palpation, evaluated with ultrasound by an experienced rheumatologist, and re-inserted if necessary. Needle placement was confirmed with injection of an Omnipaque/methylene blue solution and examined under fluoroscopy, followed by dissection.

RESULTS

Palpation and ultrasound were 100% accurate in subtalar and ankle joint injections. Using palpation, the needle was correctly placed into the first TMT joint in three of 14 cadavers, and in four of 14 cadavers for the second TMT joint. Using ultrasound, the needle was correctly placed into the first TMT joint in ten of 14 cadavers, and into the second TMT joint in eight of 14 cadavers. When grouped, ultrasound was significantly more accurate for intra-articular needle placement compared to palpation in the midfoot (p = 0.003). On three specimens, dye extended beyond the second TMT joint.

CONCLUSION

Intra-articular injections of the subtalar and ankle joints can be successfully performed utilizing palpation alone. Ultrasound guidance significantly increases injection accuracy into the TMT joints compared to palpation alone and therefore US or Fluoroscopy is performed when injecting these TMT joints. When using selective diagnostic injections into a TMT joint to assess for the symptomatic joint and potential need for arthrodesis, the injected anesthetic may not remain isolated within that joint. These isolated TMT injections should not be done to answer that question without fluoroscopy confirmation with radiopaue dye demonstrating the injected fluid remained within the one joint of interest.

Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients

OBJECTIVE

To date, early diagnosis of stress fractures depends on magnetic resonance imaging (MRI) or bone scan scintigraphy, as radiographs are usually normal at onset of symptoms. These examinations are expensive or invasive, time-consuming, and poorly accessible. A recent report has shown the ability of ultrasonography (US) to detect early stress fractures. Our objective was to evaluate sensitivity and specificity of US versus dedicated MRI (0.2 Tesla), taken as the gold standard, in early diagnosis of metatarsal bone stress fractures.

METHODS

A case-control study from November 2006 to December 2007 was performed. All consecutive patients with mechanical pain and swelling of the metatarsal region for less than 3 months and with normal radiographs were included. US and dedicated MRI examinations of the metatarsal bones were performed the same day by experienced rheumatologists with expertise in US and MRI. Reading was undertaken blind to the clinical assessment and MRI/US results.

RESULTS

Forty-one feet were analyzed on US and dedicated MRI from 37 patients (28 women, 9 men, mean age 52.7 +/- 14.1 yrs). MRI detected 13 fractures in 12 patients. Sensitivity of US was 83%, specificity 76%, positive predictive value 59%, and negative predictive value 92%. Positive likehood ratio was 3.45, negative likehood ratio 0.22.

CONCLUSION

In cases of normal radiographs, US is indicated in the diagnosis of metatarsal bone stress fractures, as it is a low cost, noninvasive, rapid, and easy technique with good sensitivity and specificity. From these data, we propose a new imaging algorithm including US.

Becoming a musculoskeletal ultrasonographer

Over the last decade, increasing numbers of rheumatologists have incorporated musculoskeletal ultrasound (MSUS) as a valuable diagnostic tool into their clinical practice. Some countries have established training programmes for MSUS. The European League Against Rheumatism has developed education guidelines for the content and conducting of MSUS courses and it would be useful to standardize rheumatology MSUS training worldwide. A thorough knowledge of sectional anatomy, ultrasound physics and technology, joint US scanning methods, the sonographic pattern of normal and pathological musculoskeletal tissues, artefacts, diagnostic criteria and Doppler technique are necessary to perform efficient MSUS. MSUS training includes attending theoretical and practical courses, as well as studying textbooks, DVDs or websites. Having access to US equipment and performing supervised normal and pathological MSUS examinations for a training period is mandatory for consolidating MSUS learning. A proposal to accredit and certificate competence in MSUS is now being discussed.

The Belfast musculoskeletal ultrasound course

OBJECTIVES

To conduct a training course in musculoskeletal ultrasound (MSUS) for rheumatologists in Northern Ireland with the aim of equipping the participants with a basic knowledge of the theoretical and practical aspects of MSUS as they are applied to rheumatology.

METHODS

Between September 2007 and June 2008, 10 rheumatologists attended a course in basic MSUS that was delivered by 7 rheumatologists with experience in MSUS. The course consisted of five separate modules that included tutorials on MSUS, self-directed learning of scanning techniques and personal mentoring. Progress was monitored throughout the course by the use of personal logbooks. Competency was formally assessed using the Royal College of Physicians' Direct Operational Procedural Skills (DOPS) assessment and an exit examination.

RESULTS

Five trainees completed the entire course and passed both the practical and written elements of the exit examination. All were deemed to have attained a basic level of competency in MSUS. The main obstacle to completion of the course was a lack of scanning practice and an inability to complete the required number of scans and DOPS assessments. Participants were more likely to fulfil the requirements of the course if they were employed full time in the regional rheumatology unit where the course was based. All participants reported high levels of confidence in their basic scanning skills at the conclusion of the course. They also felt that the training enhanced their clinical examination skills and their understanding of musculoskeletal anatomy.

CONCLUSIONS

A basic MSUS training course can be successfully delivered using a modular design that takes account of the trainee's level of experience and their work schedule. Important elements of such a course should include personal mentoring and the recording of scanning activity using a logbook. Periodic assessment of the trainee's performance is a useful means to motivate learning. Basic training in MSUS should become an accepted part of the routine training of rheumatologists in the UK.

Musculoskeletal ultrasound imaging of the plantar forefoot in patients with rheumatoid arthritis: inter-observer agreement between a podiatrist and a radiologist

BACKGROUND

The use of musculoskeletal ultrasound (MSUS) in the diagnosis and management of foot and ankle musculoskeletal pathology is increasing. Due to the wide use of MSUS and the depth and breadth of training required new proposals advocate tailored learning of the technique to discrete fields of practice. The aims of the study were to evaluate the inter-observer agreement between a MSUS radiologist and a podiatrist, who had completed basic skills training in MSUS, in the MSUS assessment of the forefoot of patients with Rheumatoid Arthritis.

METHODS

A consecutive sample of thirty-two patients with rheumatoid arthritis was assessed for presence of synovitis, erosions and bursitis within the forefoot using MSUS. All MSUS assessments were performed independently on the same day by a podiatrist and one of two Consultant Radiologists experienced in MSUS.

RESULTS

Moderate agreement on image acquisition and interpretation was achieved for bursitis (kappa 0.522; p < 0.01) and erosions (kappa 0.636; p < 0.01) and fair agreement for synovitis (kappa 0.216; p < 0.05) during the primary assessments. Following a further training session, substantial agreement (kappa 0.702) between the two investigators was recorded. The sensitivity of the podiatrist using MSUS was 82.4% for detection of bursitis, 83.0% for detection of erosion and 84.0% for detection of synovitis. Specificity of the podiatrist using MSUS was 88.9% for detection of bursitis, 80.7% for detection of erosion and 35.9% for detection of synovitis.

CONCLUSION

This study demonstrated good inter-observer agreement between a podiatrist and radiologist on MSUS assessment of the forefoot, particularly for bursitis and erosions, in patients with rheumatoid arthritis. There is scope to further evaluate and consider the role of podiatrists in the MSUS imaging of the foot following appropriate training and also in the development of reliable protocols for MSUS assessment of the foot.

E-learning in ultrasonography: a web-based approach

OBJECTIVE

To propose e-learning methods that address the fundamental problems related to sonographic training in rheumatology.

METHODS

The project was designed for rheumatologists with strong motivation to learn ultrasound. A modular approach was constructed, consisting of a basic 3-day residential course, followed by a 6-month period of web-based tutoring, and culminating in a final 2-day residential course with a formal assessment of competency.

RESULTS

The website (http://www.e-sonography.com) was accessed by all 60 participants. A mean of 20 (range 10-80) log-on sessions were registered for each participant, and a mean of 250 min (range 60-600 min) of web access was recorded. A total of 163 sonographic images were submitted by 18 (30%) participants. The majority of the images focused on the following anatomical areas: shoulder 49 (30%), hand 34 (21%) and knee 20 (12%). A total time investment of approximately 14 h was made by the US tutors over the 6-month period for interaction with the participants.

CONCLUSIONS

The e-learning methods described in this report represent the first attempt to adopt a novel technique to circumvent several of the inherent barriers to the many facets of teaching musculoskeletal ultrasound to a wide audience.

Ultrasonography for rheumatologists: the development of specific competency based educational outcomes

BACKGROUND

A competency based approach to the education of rheumatologists in musculoskeletal ultrasonography (MSK US) ensures standards are documented, transparent, accountable, and defensible, with clear benefit to all stakeholders. Specific competency outcomes will facilitate informed development of a common curriculum and structured programme of training and assessment.

OBJECTIVE

To determine explicit competency based learning outcomes for rheumatologists undertaking MSK US.

METHODS

International experts in MSK US, satisfying specific selection criteria, were asked to define the minimum standards required by a rheumatologist to be judged competent in MSK US. They reviewed 115 MSK US skills, comprising bone and soft tissue pathology, in seven joints regions of the upper and lower limbs, and rated their relative importance according to specific criteria. These data are presented as specific educational outcomes within designated competency categories.

RESULTS

57 expert MSK US practitioners were identified and 35 took part in this study. Ten generic core competency outcomes were recognised including physics, anatomy, technique, and interpretation. Regarding specific regional competencies, 53% (61/115) were considered "must know" core learning outcomes, largely comprising inflammatory joint/tendon/bone pathology and guided procedures; 45% (52/115) were required at an intermediate/advanced level (18/115 "should know", 34/115 "could know"), and 2% (2/115) were deemed inappropriate/unnecessary for rheumatologist ultrasonographers.

CONCLUSIONS

This is the first study to developing a competency model for the education of rheumatologists in MSK US based on the evidence of international experts. A specific set of learning outcomes has been defined, which will facilitate future informed education and practice development and provide a blueprint for a structured rheumatology MSK US curriculum and assessment process.

Musculoskeletal ultrasound training in rheumatology: the Belfast experience

OBJECTIVES

Despite the increasing use of musculoskeletal ultrasound (MSUS) as a clinical tool in rheumatology, there is no consensus yet regarding the standards required to achieve a basic level of competence in the use of this imaging technique. A number of sonographers worldwide are developing curricula and standardizing teaching methods in order to improve training in MSUS for rheumatologists. In the meantime, clinicians are devising informal means of training in order to acquire these new skills. Here we describe the informal team approach to MSUS training adopted by a group of rheumatologists from the Regional Rheumatology Centre in Belfast, UK.

METHODS

Over a 5-yr period, eight rheumatologists from Musgrave Park Hospital in Belfast used a variety of means to learn the basic skills of MSUS.

RESULTS

Seven of the team underwent a formal assessment of their competency in a practical examination devised by an experienced sonographer. All were judged to have attained a basic competency in MSU.

CONCLUSIONS

This Belfast experience shows what can be achieved despite the absence of formal MSUS training. Nevertheless, the development of recognized training programmes and international standards of competency are important goals on the way to achieving more widespread acceptance of MSUS as a useful tool in everyday clinical practice.

How should we manage early rheumatoid arthritis? From imaging to intervention

PURPOSE OF REVIEW

Rheumatoid arthritis is a chronic systemic and progressive inflammatory disorder of the synovium characterised by destruction of bone and cartilage. It is associated with significant morbidity and economic costs. Recent advances have shown that early diagnosis and timely, intensive therapy of rheumatoid arthritis can modify disease outcomes.

RECENT FINDINGS

Current investigations into the role of ultrasonography and magnetic resonance imaging in early rheumatoid arthritis suggest these modalities will provide information to assist in the early diagnosis of rheumatoid arthritis, identify poor prognostic factors, and aid in the monitoring of response to therapy. New developments in pharmacologic therapy, particularly the development of biologic agents, allow better disease control than was previously achievable, and the early application of these drugs in combination with conventional disease-modifying antirheumatic drugs seems to produce the best outcomes.

SUMMARY

The application of novel imaging techniques will aid the target application of biologic therapy within the window of opportunity and aid in the monitoring of response to therapy. This is likely to significantly decrease the rate of structural damage and offers hope of a future when the normal outcome for rheumatoid arthritis will be remission.