Three dimensional power Doppler ultrasonography confirms early reduction of synovial perfusion after 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.

EULAR recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVE

To produce European League Against Rheumatism (EULAR) recommendations for the reporting of ultrasound studies in rheumatic and musculoskeletal diseases (RMDs).

METHODS

Based on the literature reviews and expert opinion (through Delphi surveys), a taskforce of 23 members (12 experts in ultrasound in RMDs, 9 in methodology and biostatistics together with a patient research partner and a health professional in rheumatology) developed a checklist of items to be reported in every RMD study using ultrasound. This checklist was further refined by involving a panel of 79 external experts (musculoskeletal imaging experts, methodologists, journal editors), who evaluated its comprehensibility, feasibility and comprehensiveness. Agreement on each proposed item was assessed with an 11-point Likert scale, grading from 0 (total disagreement) to 10 (full agreement).

RESULTS

Two face-to-face meetings, as well as two Delphi rounds of voting, resulted in a final checklist of 23 items, including a glossary of terminology. Twenty-one of these were considered 'mandatory' items to be reported in every study (such as blinding, development of scoring systems, definition of target pathologies) and 2 'optional' to be reported only if applicable, such as possible confounding factors (ie, ambient conditions) or experience of the sonographers.

CONCLUSION

An EULAR taskforce developed a checklist to ensure transparent and comprehensive reporting of aspects concerning research and procedures that need to be presented in studies using ultrasound in RMDs. This checklist, if widely adopted by authors and editors, will greatly improve the interpretability of study development and results, including the assessment of validity, generalisability and applicability.

Point-of-care musculoskeletal ultrasound is critical for the diagnosis of hemarthroses, inflammation and soft tissue abnormalities in adult patients with painful haemophilic arthropathy

We previously demonstrated in adult patients with haemophilia (PWH) that hemarthrosis is present in only ~1/3rd of acutely painful joints by using point-of-care-musculoskeletal ultrasound (MSKUS). Therefore, other unrecognized tissue abnormalities must contribute to pain. Using high resolution MSKUS, employing grey scale and power Doppler, we sought to retrospectively (i) investigate soft tissue abnormalities in painful haemophilic joints and (ii) to determine to what extent MSKUS findings, functional or radiographic joint scores correlate with biomarkers of inflammation in PWH. Findings were correlated with Hemophilia Joint Health Scores (HJHS), Pettersson scores, high sensitivity C-reactive protein and von Willebrand factor activity and antigen levels. A total of 65 MSKUS examinations for acute and chronic joint pains were performed for 34 adult haemophilia patients, mostly for chronic joint pains (72.3%). The most prominent findings (66.5%) pertained to inflammatory soft tissue changes including synovitis, tendinitis, enthesitis, bursitis and fat pad inflammation. Effusions were present in 55.5% and 46.8% of MSKUS performed for acute and chronic pain, respectively. Of those, 90.0% were bloody during acute and 47.6% during persistent pains. While inflammatory biomarkers correlated well with overall HJHS and total Pettersson scores (P < 0.05), they did not differ between those patients with synovitis and those without. MSKUS is emerging as an important modality to diagnose treatable musculoskeletal abnormalities contributing to pain in haemophilic arthropathy, and therefore seems critical for a personalized approach to haemophilia care. The role of biomarkers in this setting remains less clear and requires further investigation.

Imaging in rheumatoid arthritis--status and recent advances for magnetic resonance imaging, ultrasonography, computed tomography and conventional radiography

Sensitive and reproducible tools for diagnosis, monitoring of disease activity and damage, and prognostication are essential in the management of patients with rheumatoid arthritis (RA). Conventional radiography (X-ray), the traditional gold standard for imaging in RA, is not able to detect early disease manifestations such as inflammatory changes in the soft tissues (synovitis, tensynovitis, enthesitis etc.) and the earliest stages of bone erosion. In contrast, magnetic resonance imaging (MRI) and ultrasonography (US) allow direct visualization of early inflammatory and destructive joint changes, and have several documented and potential applications in RA patients. This chapter will review key aspects of the current status and recent important advances in imaging in RA, briefly discussing X-ray and computed tomography, and particularly focusing on MRI and US. Suggestions for use in clinical trials and practice are provided.

Reliability of different Doppler ultrasound quantification methods and devices in the assessment of therapeutic response in arthritis

OBJECTIVE

To evaluate the metric qualities of power Doppler ultrasound (PDUS) for different quantification methods and devices in the assessment of arthritis during anti-inflammatory treatment.

METHODS

Twenty-four patients with active arthritis and first-time treatment with the TNF-alpha inhibitor adalimumab underwent sequential clinical, laboratory and US examination at baseline, weeks 2, 6 and 12. 2D and 3D PDUS was performed by two independent investigators. The images and movies were scored from 0 to 3 and the amount of colour pixels and voxels was calculated. In addition, the resistance index of a synovial artery was measured. Thirteen patients were examined with a second US machine.

RESULTS

Treatment response was already observed at week 2 with a significant reduction of 2D (P < 0.01) and 3D scores (P < 0.001). A moderate correlation to 28-joint disease activity score was found for 3D voxel count (r(s) = 0.35, P < 0.001). Interobserver agreement was kappa or ICC >or= 0.8 for all methods except the resistance index (ICC = 0.60). Intermachine agreement was kappa = 0.57 for 2D PDUS score.

CONCLUSIONS

The study demonstrates good to excellent interobserver and moderate intermachine reliability of different PDUS assessment methods in a longitudinal open-label study.