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Di Matteo A, De Lorenzis E, Duquenne L, Nam JL, Garcia-Montoya L, Harnden K, Chowdhury R, Wakefield RJ, Emery P, Mankia K. Ultrasound in anti-CCP+ at-risk individuals without clinical synovitis: development of a novel 6-joint protocol for feasible risk prediction. Rheumatology (Oxford) 2024; 63:2213-2221. [PMID: 37934127 PMCID: PMC11292136 DOI: 10.1093/rheumatology/kead570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/05/2023] [Accepted: 10/14/2023] [Indexed: 11/08/2023] Open
Abstract
OBJECTIVES To investigate, in anti-CCP antibody-positive individuals with musculoskeletal symptoms but no clinical synovitis (CCP+ at-risk), the additional value of US for the prediction of inflammatory arthritis. Furthermore, to define a concise US protocol for feasible risk prediction. METHODS Demographic and clinical data were collected in 417 CCP+ at-risk (Leeds CCP cohort) with a baseline US scan assessing synovitis and bone erosions in 36 joints, and a follow-up duration ≥24 months. Multivariable binary regression models for inflammatory arthritis development at 24 months evaluated routine clinical variables associated with inflammatory arthritis alone ('clinical' model) and combined with a 36-joint US scanning protocol ('clinical-US extended' model). A 'clinical-US short' model was also developed. RESULTS At 24 months, 92/417 (22.1%) CCP+ at-risk developed inflammatory arthritis (median time 7 months, interquartile range 3-12). The 'clinical-US extended' model performed better than the 'clinical' model [area under the curve (AUC) 0.788 vs AUC 0.731, respectively, P < 0.001] with an odds ratio for inflammatory arthritis development of 3.18 (95% CI 1.80-5.63) for US synovitis and 2.54 (95% CI 1.21-5.37) for bone erosions. The 'clinical-US short' model, which retained the wrists, knees and MTP5 joints, performed better (AUC 0.782) than the 'clinical' model (P < 0.001) and similarly (difference in Akaike information criteria <2) to the 'clinical-US extended' model. CONCLUSIONS US provides valuable information for predicting progression to inflammatory arthritis in CCP+ individuals both alone and in addition to clinical variables. US synovitis was associated with a 3-fold increase risk of inflammatory arthritis development. A concise US protocol of six joints provides clinically feasible risk prediction in CCP+ at-risk.
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Affiliation(s)
- Andrea Di Matteo
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Enrico De Lorenzis
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Division of Rheumatology, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario Agostino-Gemelli IRCSS, Rome, Italy
| | - Laurence Duquenne
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Leticia Garcia-Montoya
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Harnden
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rahaymin Chowdhury
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard J Wakefield
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Rheumatology Department, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- National Institute for Health Research, Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Daskareh M, Vakilpour A, Barzegar-Golmoghani E, Esmaeilian S, Gilanchi S, Ezzati F, Alikhani M, Rahmanipour E, Amini N, Ghorbani M, Pezeshk P. Predicting Rheumatoid Arthritis Development Using Hand Ultrasound and Machine Learning-A Two-Year Follow-Up Cohort Study. Diagnostics (Basel) 2024; 14:1181. [PMID: 38893708 PMCID: PMC11171890 DOI: 10.3390/diagnostics14111181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 05/25/2024] [Accepted: 06/01/2024] [Indexed: 06/21/2024] Open
Abstract
BACKGROUND The early diagnosis and treatment of rheumatoid arthritis (RA) are essential to prevent joint damage and enhance patient outcomes. Diagnosing RA in its early stages is challenging due to the nonspecific and variable clinical signs and symptoms. Our study aimed to identify the most predictive features of hand ultrasound (US) for RA development and assess the performance of machine learning models in diagnosing preclinical RA. METHODS We conducted a prospective cohort study with 326 adults who had experienced hand joint pain for less than 12 months and no clinical arthritis. We assessed the participants clinically and via hand US at baseline and followed them for 24 months. Clinical progression to RA was defined according to the ACR/EULAR criteria. Regression modeling and machine learning approaches were used to analyze the predictive US features. RESULTS Of the 326 participants (45.10 ± 11.37 years/83% female), 123 (37.7%) developed clinical RA during follow-up. At baseline, 84.6% of the progressors had US synovitis, whereas 16.3% of the non-progressors did (p < 0.0001). Only 5.7% of the progressors had positive PD. Multivariate analysis revealed that the radiocarpal synovial thickness (OR = 39.8), PIP/MCP synovitis (OR = 68 and 39), and wrist effusion (OR = 12.56) on US significantly increased the odds of developing RA. ML confirmed these US features, along with the RF and anti-CCP levels, as the most important predictors of RA. CONCLUSIONS Hand US can identify preclinical synovitis and determine the RA risk. The radiocarpal synovial thickness, PIP/MCP synovitis, wrist effusion, and RF and anti-CCP levels are associated with RA development.
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Affiliation(s)
- Mahyar Daskareh
- Department of Radiology, University of California San Diego, San Diego, CA 92093, USA;
| | - Azin Vakilpour
- Division of Cardiovascular Diseases, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
| | | | - Saeid Esmaeilian
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz 71348, Iran;
| | - Samira Gilanchi
- Proteomics Research Center, Shahid Beheshti University of Medical Sciences, Tehran 19839-63113, Iran;
| | - Fatemeh Ezzati
- Division of Rheumatic Disease, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX 75390, USA;
| | - Majid Alikhani
- Department of Internal Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran;
| | - Elham Rahmanipour
- Immunology Research Center, Mashhad University of Medical Sciences, Mashhad 91779-48564, Iran;
| | - Niloofar Amini
- Department of Internal Medicine, Rheumatology Research Center, Shariati Hospital, Tehran University of Medical Sciences, Tehran 14117-13135, Iran;
| | - Mohammad Ghorbani
- Orthopedic Research Center, Mashhad University of Medical Sciences, Mashhad 91779-48564, Iran;
| | - Parham Pezeshk
- Division of Musculoskeletal Imaging, Department of Radiology, UT Southwestern Medical Center, Dallas, TX 75390, USA
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Liu C, Yan Z, Zhang X, Xia T, Ashaolu JO, Olatunji OJ, Ashaolu TJ. Food-derived bioactive peptides potentiating therapeutic intervention in rheumatoid arthritis. Heliyon 2024; 10:e31104. [PMID: 38778960 PMCID: PMC11109807 DOI: 10.1016/j.heliyon.2024.e31104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 05/09/2024] [Accepted: 05/09/2024] [Indexed: 05/25/2024] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects the joints of the human body and is projected to have a prevalence age-standardized rate of 1.5 million new cases worldwide by 2030. Several conventional and non-conventional preventive and therapeutic interventions have been suggested but they have their side effects including nausea, abdominal pain, liver damage, ulcers, heightened blood pressure, coagulation, and bleeding. Interestingly, several food-derived peptides (FDPs) from both plant and animal sources are increasingly gaining a reputation for their potential in the management or therapy of RA with little or no side effects. In this review, the concept of inflammation, its major types (acute and chronic), and RA identified as a chronic type were discussed based on its pathogenesis and pathophysiology. The conventional treatment options for RA were briefly outlined as the backdrop of introducing the FDPs that potentiate therapeutic effects in the management of RA.
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Affiliation(s)
- Chunhong Liu
- Second People's Hospital of Wuhu City, 241001, Anhui, China
| | - Zheng Yan
- Second People's Hospital of Wuhu City, 241001, Anhui, China
| | - Xiaohai Zhang
- Second People's Hospital of Wuhu City, 241001, Anhui, China
| | - Taibao Xia
- Second People's Hospital of Wuhu City, 241001, Anhui, China
| | - Joseph Opeoluwa Ashaolu
- Department of Public Health, Faculty of Basic Medical Sciences, Redeemers University, PMB 230, Ede, Osun State, Nigeria
| | | | - Tolulope Joshua Ashaolu
- Institute for Global Health Innovations, Duy Tan University, Da Nang, 550000, Viet Nam
- Faculty of Medicine, Duy Tan University, Da Nang, 550000, Viet Nam
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4
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Garcia-Montoya L, Kang J, Duquenne L, Di Matteo A, Nam JL, Harnden K, Chowdhury R, Mankia K, Emery P. Factors associated with resolution of ultrasound subclinical synovitis in anti-CCP-positive individuals with musculoskeletal symptoms: a UK prospective cohort study. THE LANCET. RHEUMATOLOGY 2024; 6:e72-e80. [PMID: 38267105 DOI: 10.1016/s2665-9913(23)00305-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 01/26/2024]
Abstract
BACKGROUND Subclinical synovitis occurs in a third of individuals at risk of rheumatoid arthritis. The objective of this study was to assess the reversibility of subclinical synovitis in individuals at risk of rheumatoid arthritis who are positive for anti-cyclic citrullinated peptide (CCP) antibody with musculoskeletal symptoms and investigate factors associated with its resolution within 12 months. METHODS We conducted a single-centre, prospective, cohort study in the UK, recruiting individuals aged 18 years or older who were anti-CCP-positive with a new non-specific musculoskeletal symptom but no clinical synovitis. Referrals were made through primary or secondary care. Participants attended a baseline visit, which included a clinical assessment, blood tests, patient questionnaires, and a musculoskeletal ultrasound scan (ie, of wrists and metacarpophalangeal, proximal interphalangeal, and metatarsophalangeal joints), and then follow-up visits every 3 months for the first year, with a repeat ultrasound scan every 12 months. Participants with subclinical synovitis (ie, grey scale ≥1 and power Doppler ≥1) in at least one joint at baseline were selected for this analysis. Investigation of good prognostic factors by 12 months was done first using univariable analysis to identify significant factors in participants with no missing data. Then receiver operating characteristic (ROC) curves were used to establish the optimal cutoffs for significant continuous variables. Finally, a modified Poisson regression approach was performed to identify the best prediction model and was adjusted for confounders, using data from all participants, with missing values imputed. This study is registered with ClinicalTrials.gov, NCT02012764. FINDINGS Between June 30, 2008, and Feb 24, 2020, 451 participants consented to participate in the CCP study and 122 (27%) individuals had subclinical synovitis at baseline, of whom 90 (74%) had data available at 12 months. Mean age was 54·1 years (SD 12·5), and 63 (70%) of 90 participants were women and 27 (30%) were men. Subclinical synovitis resolved in 43 (48%) of 90 participants, whereas subclinical synovitis persisted in 47 (52%) participants, 27 (57%) of whom developed clinical synovitis within 12 months. In the multivariable analysis, low anti-CCP titre (relative risk [RR] 1·52, 95% CI 1·04-2·22), negative rheumatoid factor (1·54, 0·92-2·58), subclinical synovitis in only one joint (1·62, 1·04-2·50), and an erythrocyte sedimentation rate of 15 mm/h or lower (1·82, 1·15-2·87) were predictors of subclinical synovitis resolution within 12 months (ie, good prognostic factors). ROC curve showed an area under the curve of 0·84 (95% CI 0·76-0·92; p<0·0001). Resolution occurred in seven (100%) of seven participants with all four factors present, and in only one (7%) of 14 participants with none of the factors present. INTERPRETATION In individuals who were anti-CCP-positive, subclinical synovitis disappeared in approximately half of the participants by 12 months and was associated with the presence of good prognostic factors. Subclinical synovitis should be interpreted in the context of these additional factors. FUNDING National Institute for Health Research Leeds Biomedical Research Centre.
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Affiliation(s)
- Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Rotherham General Hospital, Rotherham NHS Foundation Trust, Rotherham, UK
| | - Jing Kang
- School of Dentistry, University of Leeds, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kate Harnden
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Rahaymin Chowdhury
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK; National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Paroli M, Sirinian MI. When Autoantibodies Are Missing: The Challenge of Seronegative Rheumatoid Arthritis. Antibodies (Basel) 2023; 12:69. [PMID: 37987247 PMCID: PMC10660552 DOI: 10.3390/antib12040069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/25/2023] [Accepted: 10/23/2023] [Indexed: 11/22/2023] Open
Abstract
Seronegative rheumatoid arthritis (SNRA) is characterized by the absence of both rheumatoid factor (RF) and antibodies against the cyclic citrullinated protein (ACPA) in serum. However, the differences between the two forms of RA are more complex and have not yet been definitively characterized. Several lines of evidences support the idea that there are specific elements of the two forms, including genetic background, epidemiology, pathogenesis, severity of progression over time, and response to therapy. Clinical features that may differentiate SNRA from SPRA are also suggested by data obtained from classical radiology and newer imaging techniques. Although new evidence seems to provide additional help in differentiating the two forms of RA, their distinguishing features remain largely elusive. It should also be emphasized that the distinctive features of RA forms, if not properly recognized, can lead to the underdiagnosis of SNRA, potentially missing the period called the "window of opportunity" that is critical for early diagnosis, timely treatment, and better prognosis. This review aims to summarize the data provided in the scientific literature with the goal of helping clinicians diagnose SNRA as accurately as possible, with emphasis on the most recent findings available.
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Affiliation(s)
- Marino Paroli
- Center for Allergy and Immunology, Department of Clinical, Internal, Anesthesiologic and Cardiovascular Sciences, Sapienza University of Rome c/o Polo Pontino, 04100 Latina, Italy
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Khidir SJH, van Dijk BT, Krijbolder DI, Verstappen M, van Mulligen E, van der Helm-van Mil AHM. Joint involvement in RA starts predominantly in the hands: functional, clinical and imaging studies in clinically suspect arthralgia and during progression to RA. RMD Open 2023; 9:e003107. [PMID: 37328293 DOI: 10.1136/rmdopen-2023-003107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/28/2023] [Indexed: 06/18/2023] Open
Abstract
OBJECTIVES It is unknown whether rheumatoid arthritis (RA) starts in hands or feet. To investigate this, we performed functional, clinical and imaging studies during progression from clinically suspect arthralgia (CSA) to RA. Additionally, we studied whether functional disabilities of hands/feet at CSA onset contribute to predicting RA development. METHODS 600 patients with CSA were followed for clinical inflammatory arthritis (IA) during median follow-up of 25 months, during which 99 developed IA. Functional disabilities were measured at baseline/4/12/24 months with the Health Assessment Questionnaire Disability Index (HAQ); HAQ items assessing hand disabilities and foot disabilities were selected. The course of disabilities towards IA development (here considered as t=0) was depicted by increasing incidences and analysed using linear mixed models. To evaluate robustness of findings, tender hand/foot joints and subclinical joint inflammation (measured with CE-1.5TMRI) of hand/foot were additionally studied. Associations between disabilities at CSA presentation (here t=0) and future IA development were studied using Cox regression in the total CSA population. RESULTS During IA development, hand disabilities occurred earlier and more frequently than foot disabilities. Despite both hand disabilities and foot disabilities rose significantly towards IA development, hand disabilities were more severe during this course (mean difference over time: 0.41 units, 95% CI 0.28 to 0.55, p<0.001, on a range 0-3). Similar to functional disabilities, tender joints and subclinical joint inflammation occurred earlier in the hands than feet. In the total CSA population, a single HAQ question on difficulties with dressing (hand functioning) was independently predictive for IA development: HR=2.2, 95% CI 1.4 to 3.5, p=0.001. CONCLUSION Evaluation of functional disabilities, supported by clinical and imaging findings, revealed that joint involvement starts predominantly in the hands during RA development. Additionally, a single question on dressing difficulties adds value to risk stratification in patients with CSA.
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Affiliation(s)
- Sarah J H Khidir
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Bastiaan T van Dijk
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Doortje I Krijbolder
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
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7
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Yen TH, Wu YD, Chen HH, Tseng CW, Chen YH, Chen YM, Lai KL. The role of ultrasound synovitis scores for patients who are at risk of rheumatoid arthritis. Int J Rheum Dis 2023; 26:922-929. [PMID: 36944587 DOI: 10.1111/1756-185x.14675] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/15/2023] [Accepted: 03/10/2023] [Indexed: 03/23/2023]
Abstract
OBJECTIVES The development of rheumatoid arthritis (RA) has been classified into 6 phases A-F according to the present risk factors in sequence of genes, environments, autoimmunity, arthralgia and joint swelling. To clarify the ultrasound synovitis scores in at-risk patients (phases C-E) and RA (phase F). METHODS Patients who had been experiencing hand joint symptoms for at least 6 weeks and asymptomatic patients with positive rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies were enrolled. A 40-joint ultrasonography with semiquantitative synovitis scoring for gray scale (GS) and power Doppler (PD) images was performed. RESULTS A total of 139 patients were enrolled and classified into non-RA, phase C, phase D, phase E and phase F. Total GS scores in phases C (17.4 ± 7.0), D (16.0 ± 5.4), E (18.5 ± 7.7) and F (21.8 ± 9.1) were higher than those in non-RA (9.8 ± 4.0, P < 0.001). The total PD score in phase F (3.1 ± 4.6) was higher than that in phases C (0.2 ± 0.5), D (0.1 ± 0.4), and E (0.1 ± 0.3), as well as in non-RA (0.0 ± 0.0, P < 0.01). A total GS score ≥14 differentiated patients at risk for RA from patients with non-RA (area under curve [AUC] 0.82), while a total PD score ≥2 differentiated patients with RA from patients at risk for RA (AUC 0.71). CONCLUSION Total GS score may differentiate patients at risk for RA from non-RA patients, while total PD score may differentiate patients with RA from those who are at risk for RA.
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Affiliation(s)
- Tsai-Hung Yen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Da Wu
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Hsin-Hua Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Chih-Wei Tseng
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yi-Hsin Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Yi-Ming Chen
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
| | - Kuo-Lung Lai
- Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, Taiwan
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8
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Rogier C, Frazzei G, Kortekaas MC, Verstappen M, Ohrndorf S, van Mulligen E, van Vollenhoven RF, van Schaardenburg D, de Jong PHP, van der Helm-van Mil AHM. An ultrasound negative for subclinical synovitis in arthralgia patients: is it helpful in identifying those not developing arthritis? Rheumatology (Oxford) 2022; 61:4892-4897. [PMID: 35416958 PMCID: PMC9707035 DOI: 10.1093/rheumatology/keac239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/03/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE To investigate the negative predictive value (NPV) of musculoskeletal US (MSUS) in arthralgia patients at risk for developing inflammatory arthritis. METHODS An MSUS examination of hands and feet was performed in arthralgia patients at risk for inflammatory arthritis in four independent cohorts. Patients were followed for one-year on the development of inflammatory arthritis. Subclinical synovitis was defined as greyscale ≥2 and/or power Doppler ≥1. NPVs were determined and compared with the prior risks of not developing inflammatory arthritis. Outcomes were pooled using meta-analyses and meta-regression analyses. In sensitivity analyses, MSUS imaging of tender joints only (rather than the full US protocol) was analysed and ACPA stratification applied. RESULTS After 1 year 78, 82, 77 and 72% of patients in the four cohorts did not develop inflammatory arthritis. The NPV of a negative US was 86, 85, 82 and 90%, respectively. The meta-analysis showed a pooled non-inflammatory arthritis prevalence of 79% (95% CI 75%, 83%) and a pooled NPV of 86% (95% CI 81, 89%). Imaging tender joints only (as generally done in clinical practice) and ACPA stratification showed similar results. CONCLUSION A negative US result in arthralgia has a high NPV for not developing inflammatory arthritis, which is mainly due to the high a priori risk of not developing inflammatory arthritis. The added value of a negative US (<10% increase) was limited.
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Affiliation(s)
- Cleo Rogier
- Department of Rheumatology, Erasmus MC, Rotterdam
| | - Giulia Frazzei
- Amsterdam Rheumatology and Immunology Center, Department of Rheumatology, Reade, Amsterdam
| | - Marion C Kortekaas
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Marloes Verstappen
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | - Sarah Ohrndorf
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Elise van Mulligen
- Department of Rheumatology, Erasmus MC, Rotterdam
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
| | | | | | | | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Erasmus MC, Rotterdam
- Department of Rheumatology, Leiden University Medical Centre (LUMC), Leiden, The Netherlands
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9
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Harnden K, Di Matteo A, Mankia K. When and how should we use imaging in individuals at risk of rheumatoid arthritis? Front Med (Lausanne) 2022; 9:1058510. [PMID: 36507546 PMCID: PMC9726914 DOI: 10.3389/fmed.2022.1058510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
In recent years rheumatologists have begun to shift focus from early rheumatoid arthritis (RA) to studying individuals at risk of developing the disease. It is now possible to use blood, clinical and imaging biomarkers to identify those at risk of progression before the onset of clinical synovitis. The use of imaging, in particular ultrasound (US) and magnetic resonance imaging (MRI), has become much more widespread in individuals at-risk of RA. Numerous studies have demonstrated that imaging can help us understand RA pathogenesis as well as identifying individuals at high risk of progression. In addition, imaging techniques are becoming more sophisticated with newer imaging modalities such as high-resolution peripheral quantitative computed tomography (HR-pQRCT), nuclear imaging and whole body-MRI (WB-MRI) starting to emerge. Imaging studies in at risk individuals are heterogeneous in nature due to the different at-risk populations, imaging modalities and protocols used. This review will explore the available imaging modalities and the rationale for their use in the main populations at risk of RA.
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10
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Hammer HB, Caporali R. Controversies in rheumatology: Ultrasound for monitoring of RA - do we need it? Rheumatology (Oxford) 2022; 61:4245-4251. [PMID: 35394009 DOI: 10.1093/rheumatology/keac228] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/10/2022] [Accepted: 04/03/2022] [Indexed: 11/14/2022] Open
Abstract
Clinical joint examination is the cornerstone for evaluation of patients with rheumatoid arthritis (RA). However, since large discrepancies have been shown even between experienced rheumatologists in evaluation of joint inflammation, and tender joints may have limited value in reflecting inflammation, ultrasound has in the last decennials been introduced in the clinical assessments of RA patients. Ultrasound has high accordance with other imaging modalities and enables detection of clinically difficult pathologies and contributes to assessments of joints difficult to evaluate clinically. However, there is no general agreement on the optimal use of ultrasound in rheumatology and the prevalence of machines as well as the level of experience is highly different across the countries. In addition, standardized use of ultrasound in treat-to-target follow-up of RA patients was found not to have any added value. Thus, how to use ultrasound in monitoring of RA patients is open for debate. The present article will discuss the pros and cons for using ultrasound in the clinical setting.
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Affiliation(s)
- Hilde Berner Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.,Faculty of medicine, University of Oslo, Norway
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Rheumatology and Medical Sciences, ASST Pini-CTO, Milan, Italy
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11
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Di Matteo A, Duquenne L, Cipolletta E, Nam JL, Garcia-Montoya L, Wakefield RJ, Mahler M, Mankia K, Emery P. Ultrasound subclinical synovitis in anti-CCP+ at-risk individuals with MSK symptoms: an important and predictable stage in the RA continuum. Rheumatology (Oxford) 2021; 61:3192-3200. [PMID: 34849610 PMCID: PMC9348771 DOI: 10.1093/rheumatology/keab862] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/11/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives To investigate whether anti-CCP2-positive at-risk individuals with musculoskeletal (MSK) symptoms but without clinical synovitis (CCP2+ at-risk) develop US subclinical synovitis before inflammatory arthritis and if US subclinical synovitis can be predicted. Methods First, US scans of CCP2+ at-risk individuals who developed inflammatory arthritis (‘progressors’) were reviewed for subclinical synovitis prior to inflammatory arthritis development. Patients in whom the pre-progression US scan was negative but the scan was conducted >6 months before progression were excluded. Subsequently, regression analyses were performed to identify predictors of US synovitis in CCP2+ at-risk individuals without baseline US abnormalities who had one or more longitudinal US scan and a complete dataset. Results US subclinical synovitis was detected in one or more scan in 75 of 97 progressors (77.3%) {median time to inflammatory arthritis development from first evidence of US synovitis 26.5 weeks [interquartile range (IQR) 7–60]}, in whom one or more scan was available, excluding those with a negative scan >6 months from inflammatory arthritis development (n = 38). In 220 CCP2+ at-risk individuals with normal baseline US scans, who had one or more longitudinal US scan and a complete dataset, US synovitis was detected in 69/220 (31.4%) [median time to first developing US synovitis 56.4 weeks (IQR 33.0–112.0)]. In the multivariable analysis, only anti-CCP3 antibodies were predictive for the development of US synovitis [odds ratio 4.75 (95% CI 1.97, 11.46); P < 0.01]. Conclusions In anti-CCP2+ at-risk individuals, a stage of subclinical synovitis usually precedes the development of inflammatory arthritis. Anti-CCP2+/CCP3+ individuals without clinical or US subclinical synovitis may represent the optimal window of opportunity for intervention to prevent joint disease.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom.,Polytechnic University of Marche, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Edoardo Cipolletta
- Polytechnic University of Marche, Rheumatology Unit, Department of Clinical and Molecular Sciences, "Carlo Urbani" Hospital, Jesi, Ancona, Italy
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | | | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
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12
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van Dijk BT, Wouters F, van Mulligen E, Reijnierse M, van der Helm-van Mil AHM. During development of rheumatoid arthritis, intermetatarsal bursitis may occur before clinical joint swelling: a large imaging study in patients with clinically suspect arthralgia. Rheumatology (Oxford) 2021; 61:2805-2814. [PMID: 34791051 PMCID: PMC9258544 DOI: 10.1093/rheumatology/keab830] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 10/27/2021] [Indexed: 11/24/2022] Open
Abstract
Objectives Intermetatarsal bursitis (IMB) represents juxta-articular synovial inflammation of the intermetatarsal bursae. Recent MRI studies identified IMB as feature of early RA, but whether IMB already occurs in the pre-arthritic phase is unknown. We performed a large MRI study in clinically suspect arthralgia (CSA) to assess the occurrence and prognostic value of IMB. Methods A total of 577 consecutive CSA patients underwent contrast-enhanced MRI of the forefoot, metacarpophalangeal joints and wrist. MRIs were evaluated for subclinical synovitis/tenosynovitis/osteitis in line with the RA MRI scoring system (summed as RAMRIS inflammation) and for IMB. IMB was considered present if uncommon in the general population at the same location (i.e. size scored above the 95th percentile in age-matched symptom-free controls). The relation of IMB with other MRI-detected subclinical inflammation (synovitis/tenosynovitis/osteitis) was studied. Cox-regression assessed the association with clinical arthritis development during median 25 months follow-up. ACPA stratification was performed. Results At presentation with CSA, 23% had IMB. IMB was more frequent in ACPA-positive than ACPA-negative CSA (47% vs 19%, P < 0.001). Patients with IMB were more likely to also have subclinical synovitis [OR 3.4 (95% CI 1.8, 6.5)] and tenosynovitis [5.9(2.8, 12.6)]. IMB conferred higher risk of developing arthritis [HR 1.6(1.0–2.7) adjusted for other subclinical inflammation]. IMB-presence predicted arthritis development in ACPA-positive CSA [adjusted HR 2.2(1.0–4.7)], but not in ACPA-negative CSA-patients [0.8(0.4–1.7)]. Conclusion Approximately a quarter of CSA patients have IMB, which is frequently accompanied by subclinical synovitis and tenosynovitis. IMB precedes development of clinical arthritis, particularly in ACPA-positive CSA. These results reinforce the notion that juxta-articular synovial inflammation is involved in the earliest phases of RA development.
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Affiliation(s)
- Bastiaan T van Dijk
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Fenne Wouters
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Elise van Mulligen
- Department of Rheumatology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Monique Reijnierse
- Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, the Netherlands
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13
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Mankia K, Siddle HJ, Kerschbaumer A, Alpizar Rodriguez D, Catrina AI, Cañete JD, Cope AP, Daien CI, Deane KD, El Gabalawy H, Finckh A, Holers VM, Koloumas M, Ometto F, Raza K, Zabalan C, van der Helm-van Mil A, van Schaardenburg D, Aletaha D, Emery P. EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis. Ann Rheum Dis 2021; 80:1286-1298. [PMID: 34362746 PMCID: PMC8458095 DOI: 10.1136/annrheumdis-2021-220884] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 07/24/2021] [Indexed: 01/26/2023]
Abstract
BACKGROUND Despite growing interest, there is no guidance or consensus on how to conduct clinical trials and observational studies in populations at risk of rheumatoid arthritis (RA). METHODS An European League Against Rheumatism (EULAR) task force formulated four research questions to be addressed by systematic literature review (SLR). The SLR results informed consensus statements. One overarching principle, 10 points to consider (PTC) and a research agenda were proposed. Task force members rated their level of agreement (1-10) for each PTC. RESULTS Epidemiological and demographic characteristics should be measured in all clinical trials and studies in at-risk individuals. Different at-risk populations, identified according to clinical presentation, were defined: asymptomatic, musculoskeletal symptoms without arthritis and early clinical arthritis. Study end-points should include the development of subclinical inflammation on imaging, clinical arthritis, RA and subsequent achievement of arthritis remission. Risk factors should be assessed at baseline and re-evaluated where appropriate; they include genetic markers and autoantibody profiling and additionally clinical symptoms and subclinical inflammation on imaging in those with symptoms and/or clinical arthritis. Trials should address the effect of the intervention on risk factors, as well as progression to clinical arthritis or RA. In patients with early clinical arthritis, pharmacological intervention has the potential to prevent RA development. Participants' knowledge of their RA risk may inform their decision to participate; information should be provided using an individually tailored approach. CONCLUSION These consensus statements provide data-driven guidance for rheumatologists, health professionals and investigators conducting clinical trials and observational studies in individuals at risk of RA.
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Affiliation(s)
- Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Heidi J Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Centre, Leeds, UK
| | - Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | | | - Juan D Cañete
- Department of Rheumatology, Arthritis Unit, Hospital Clinic and IDIBAPS, Barcelona, Spain
| | - Andrew P Cope
- Faculty of Life Sciences and Medicine, Centre for Rheumatic Diseases, King's College London, London, UK
| | - Claire Immediato Daien
- Department of Rheumatology, CHU de Montpellier, University of Montpellier, PhyMedExp, INSERM, CNRS UMR, Montpellier, France
| | - Kevin D Deane
- Division of Rheumatology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Hani El Gabalawy
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Axel Finckh
- Division of Rheumatology, University of Geneva, Geneva, Switzerland
| | - V Michael Holers
- Division of Rheumatology, Department of Medicine, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Francesca Ometto
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Karim Raza
- Centre for Musculoskeletal Ageing Research and Research into Inflammatory Arthritis, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | | | - Annette van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dirkjan van Schaardenburg
- Department of Rheumatology, Academic Medical Center, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Rheumatology, Reade, Amsterdam Rheumatology and Immunology Center, Amsterdam, The Netherlands
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, UK
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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14
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Mankia K, Siddle H, Di Matteo A, Alpízar-Rodríguez D, Kerry J, Kerschbaumer A, Aletaha D, Emery P. A core set of risk factors in individuals at risk of rheumatoid arthritis: a systematic literature review informing the EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis. RMD Open 2021; 7:rmdopen-2021-001768. [PMID: 34531306 PMCID: PMC8449955 DOI: 10.1136/rmdopen-2021-001768] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/01/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND There is significant interest in determining risk factors in individuals at risk of rheumatoid arthritis (RA). A core set of risk factors for clinical arthritis development has not been defined. METHODS A literature search and systematic literature review (SLR) was conducted to identify risk factors in individuals at risk of RA using Medline, Embase, PubMed and Central databases. RESULTS 3854 articles were identified by the literature search. After screening of titles, 138 abstracts were reviewed and 96 articles finally included. Fifty-three articles included data on risk factors including autoantibodies, subclinical inflammation on imaging, clinical features, serum and cellular biomarkers and genetic markers. Risk factors were dependent on the at-risk population. There was good evidence for serum anticitrullinated protein antibodies (ACPA) levels, as risk factors for arthritis in all at-risk populations (n=13 articles). Subclinical inflammation on ultrasound (n=12) and MRI (n=6) was reported as a risk factor in multiple studies in at-risk individuals with musculoskeletal (MSK) symptoms and undifferentiated arthritis (UA). Clinical features were reported as a risk factor in at-risk individuals with MSK symptoms and UA (n=13). Other risk factors, including serum and cellular markers were less frequently reported. CONCLUSIONS Risk factors for arthritis development in RA are specific to the at-risk population. Serum ACPA confers risk in all populations; subclinical inflammation on imaging and clinical features confer risk in at-risk individuals with MSK symptoms. This SLR informed the EULAR taskforce for points to consider on conducting clinical trials and studies in individuals at risk of RA.
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Affiliation(s)
- Kulveer Mankia
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK .,Department of Rheumatology, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Heidi Siddle
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - Andrea Di Matteo
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Clinica Reumatologica, Universita Politecnica delle Marche, Ancona, Italy
| | | | - Joel Kerry
- Library and Information Service, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Andreas Kerschbaumer
- Department of Medicine III, Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Emery
- Department of Rheumatology, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Department of Rheumatology, NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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15
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Di Matteo A, Mankia K, Nam JL, Cipolletta E, Garcia-Montoya L, Duquenne L, Rowbotham E, Emery P. In anti-CCP+ at-risk individuals, radiographic bone erosions are uncommon and are not associated with the development of clinical arthritis. Rheumatology (Oxford) 2021; 60:3156-3164. [PMID: 33415335 DOI: 10.1093/rheumatology/keaa761] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/08/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To investigate the prevalence, distribution and predictive value for the development of inflammatory arthritis (IA) of conventional radiography (CR) bone erosions (BE) in anti-CCP positive (CCP+) at-risk individuals with musculoskeletal (MSK) symptoms but without clinical synovitis. METHODS Baseline CR of the hands and feet of 418 CCP+ at-risk individuals were analysed. The presence of US-BE was explored in the anatomical areas in which CR-BE were reported. Hands and feet CR at the time of progression were analysed in a subset of individuals who developed IA (73/123, 59.3%). Logistic regression analyses were performed to calculate the predictive value of baseline CR-BE for the development of IA in 394 CCP+ individuals with ≥1 follow-up visit. RESULTS BE were detected in 17/418 (4.1%) CCP+ at-risk individuals (median Simple Erosions Narrowing Score-BE = 2.0, IQR: 1.0-2.0; median Sharp van der Heijde score-BE = 4.0, IQR: 3.0-8.5), most frequently in the foot joints (11/17, 64.7% individuals). A total of 123/394 (31.2%) CCP+ at-risk individuals developed IA; 7/17 (41.2%) with, and 116/377 (30.8%) without BE on CR (P = 0.37). US-BE were found in 4/7 (57.1%) individuals with CR-BE who developed IA, but only in 1/10 (10.0%) who did not. At the time of progression, new BE were detected in 4/73 (5.5%) CCP+ individuals on repeated CR. In the regression analyses, baseline CR-BE were not predictive for the development of IA. CONCLUSIONS In CCP+ at-risk individuals with MSK symptoms, CR-detected BE are uncommon and do not predict the development of IA.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline L Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Edoardo Cipolletta
- Rheumatology Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, 'Carlo Urbani' Hospital, Ancona, Italy
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Emma Rowbotham
- National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK.,Department of Radiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds.,National Institute for Health Research Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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16
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Rogier C, Wouters F, van Boheemen L, van Schaardenburg D, de Jong PHP, van der Helm-van Mil AHM. Subclinical synovitis in arthralgia: how often does it result in clinical arthritis? Reflecting on starting points for disease-modifying anti-rheumatic drug treatment. Rheumatology (Oxford) 2021; 60:3872-3878. [PMID: 33331633 PMCID: PMC8328495 DOI: 10.1093/rheumatology/keaa774] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/07/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES According to guidelines, clinical arthritis is mandatory for diagnosing RA. However, in the absence of clinical synovitis, imaging-detected subclinical synovitis is increasingly used instead and is considered as a starting point for DMARD therapy. To search for evidence we studied the natural course of arthralgia patients with subclinical synovitis from three longitudinal cohorts and determined the frequencies of non-progression to clinically apparent inflammatory arthritis (IA) (i.e. 'false positives'). METHODS Subclinical synovitis in the hands or feet of arthralgia patients was visualized with US (two cohorts; definition: greyscale ≥2 and/or power Doppler ≥1) or MRI (one cohort; definition: synovitis score ≥1 by two readers). Patients were followed for 1 year on for IA development; two cohorts also had 3 year data. Analyses were stratified for ACPA. RESULTS Subclinical synovitis at presentation was present in 36%, 41% and 31% in the three cohorts. Of the ACPA-positive arthralgia patients with subclinical synovitis, 54%, 44% and 68%, respectively, did not develop IA. These percentages were even higher in the ACPA-negative arthralgia patients: 66%, 85% and 89%, respectively. Similar results were seen after 3 years of follow-up. CONCLUSION Replacing clinical arthritis with subclinical synovitis to identify RA introduces a high false-positive rate (44-89%). These data suggest an overestimation regarding the value of ACPA positivity in combination with the presence of subclinical synovitis in patients with arthralgia, which harbours the risk of overtreatment if DMARDs are initiated in the absence of clinical arthritis.
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Affiliation(s)
- Cleo Rogier
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Fenne Wouters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Pascal H P de Jong
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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17
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What Is the Value of Ultrasound in Individuals 'At-Risk' of Rheumatoid Arthritis Who Do Not Have Clinical Synovitis? Healthcare (Basel) 2021; 9:healthcare9060752. [PMID: 34207207 PMCID: PMC8233794 DOI: 10.3390/healthcare9060752] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 06/10/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022] Open
Abstract
The identification of biomarkers that help identify individuals at imminent risk of progression to rheumatoid arthritis (RA) is of crucial importance for disease prevention. In recent years, several studies have highlighted the value of musculoskeletal (MSK) ultrasound (US) in predicting progression to inflammatory arthritis (IA) in individuals ‘at-risk’ of RA. These studies have highlighted the following main aspects: first, in RA-related autoantibody-positive individuals, MSK symptoms seem to develop before ‘sub-clinical’ joint inflammation occurs on US. Second, the detection of ‘sub-clinical’ synovitis (and/or bone erosions) greatly increases the risk of IA development in these ‘at-risk’ individuals. US has a potential key role for better understanding the ‘pre-clinical’ stages in individuals ‘at-risk’ of RA, and for the early identification of those individuals at high risk of developing IA. Further research is needed to address questions on image analysis and standardization. In this review, we provide an overview of the most relevant studies which have investigated the value of US in the prediction of RA development in individuals ‘at-risk’ of RA who have MSK symptoms, but no clinical evidence of IA. We highlight recent insights, limitations, and future perspectives of US use in this important population.
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18
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Ziegelasch M, Eloff E, Hammer HB, Cedergren J, Martinsson K, Reckner Å, Skogh T, Magnusson M, Kastbom A. Bone Erosions Detected by Ultrasound Are Prognostic for Clinical Arthritis Development in Patients With ACPA and Musculoskeletal Pain. Front Med (Lausanne) 2021; 8:653994. [PMID: 33834034 PMCID: PMC8021704 DOI: 10.3389/fmed.2021.653994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/01/2021] [Indexed: 11/14/2022] Open
Abstract
Anti-citrullinated protein antibodies (ACPA) often precede onset of rheumatoid arthritis (RA) by years, and there is an urgent clinical need for predictors of arthritis development among such at-risk patients. This study assesses the prognostic value of ultrasound for arthritis development among ACPA-positive patients with musculoskeletal pain. We prospectively followed 82 ACPA-positive patients without clinical signs of arthritis at baseline. Ultrasound at baseline assessed synovial hypertrophy, inflammatory activity by power Doppler, and erosions in small joints of hands and feet. We applied Cox regression analyses to examine associations with clinical arthritis development during follow-up (median, 69 months; range, 24–90 months). We also compared the ultrasound findings among the patients to a control group of 100 blood donors without musculoskeletal pain. Clinical arthritis developed in 39/82 patients (48%) after a median of 6 months (range, 1–71 months). One or more ultrasound erosions occurred in 13/82 patients (16%), with none in control subjects (p < 0.001). Clinical arthritis development was more common among patients with baseline ultrasound erosions than those without (77 vs. 42%, p = 0.032), and remained significant in a multivariable Cox regression analysis that included previously described prognostic factors (HR 3.9, 95% CI 1.6–9.4, p = 0.003). Ultrasound-detected tenosynovitis was more frequent among the patients and associated with clinical arthritis development in a univariable analysis (HR 2.5, 95% CI 1.1–5.7, p = 0.031), but did not remain statistically significant in multivariable analysis. Thus, bone erosions detected by ultrasound are independent predictors of clinical arthritis development in an ACPA-positive at-risk population. Trial Registration: Regional Ethics Committee in Linköping, Sweden, Dnr M220-09. Registered 16 December 2009, https://etikprovningsmyndigheten.se/.
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Affiliation(s)
- Michael Ziegelasch
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Emma Eloff
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
| | - Jan Cedergren
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Klara Martinsson
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Åsa Reckner
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Thomas Skogh
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Mattias Magnusson
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Alf Kastbom
- Department of Rheumatology, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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19
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The pre-clinical phase of rheumatoid arthritis: From risk factors to prevention of arthritis. Autoimmun Rev 2021; 20:102797. [PMID: 33746022 DOI: 10.1016/j.autrev.2021.102797] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/29/2021] [Indexed: 02/06/2023]
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease considered as a multistep process spanning from the interaction of genetic (e.g., shared epitope or non-HLA loci), environmental and behavioral risk factors (e.g., smoking) leading to breaking immune tolerance and autoimmune processes such as the production of autoantibodies (e.g., antibodies against citrullinated proteins ACPA or rheumatoid factors, RF), development of the first symptoms without clinical arthritis, and, finally, the manifestation of arthritis. Despite the typical joint involvement in established RA, the pathogenesis of the disease likely begins far from joint structures: in the lungs or periodontium in association with citrullination, intestinal microbiome, or adipose tissue, which supports normal findings in synovial tissue in ACPA+ patients with arthralgia. The presence of ACPA is detectable even years before the first manifestation of RA. The pre-clinical phase of RA is the period preceding clinically apparent RA with ACPA contributing to the symptoms without subclinical inflammation. While the combination of ACPA and RF increases the risk of progression to RA by up to 10 times, increasing numbers of novel autoantibodies are to be investigated to contribute to the increased risk and pathogenesis of RA. With growing knowledge about the course of RA, new aspiration emerges to cure and even prevent RA, shifting the "window of opportunity" to the pre-clinical phases of RA. The clinical definition of individuals at risk of developing RA (clinically suspect arthralgia, CSA) makes it possible to unify these at-risk individuals' clinical characteristics for "preventive" treatment in ongoing clinical trials using mostly biological or conventional synthetic disease-modifying drugs. However, the combination of symptoms, laboratory, and imaging biomarkers may be the best approach to select the correct target at-risk population. The current review aims to explore different phases of RA and discuss the potential of (non)pharmacological intervention aiming to prevent RA.
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Gessl I, Popescu M, Schimpl V, Supp G, Deimel T, Durechova M, Hucke M, Loiskandl M, Studenic P, Zauner M, Smolen JS, Aletaha D, Mandl P. Role of joint damage, malalignment and inflammation in articular tenderness in rheumatoid arthritis, psoriatic arthritis and osteoarthritis. Ann Rheum Dis 2021; 80:884-890. [PMID: 33436384 DOI: 10.1136/annrheumdis-2020-218744] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 12/21/2020] [Accepted: 12/29/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To determine whether clinical tenderness can be considered a sign of inflammatory joint activity in patients with rheumatoid arthritis (RA), osteoarthritis (OA) or psoriatic arthritis (PsA) and to assess other possible factors associated with tenderness. METHODS Patients diagnosed with RA, PsA and OA underwent clinical and ultrasound examination of wrists and finger joints. Radiographs of the hands were scored for erosions, joint space narrowing (JSN), osteophytes and malalignment. A binary damage score (positive if ≥1 erosion, JSN and/or presence of malalignment) was calculated. Differences in grey scale signs of synovitis and power Doppler (PD) between tender non-swollen (TNS) versus non-tender non-swollen (NTNS) joints were calculated. Disease duration was assessed,<2 years was regarded as early and >5 years as long-standing arthritis. RESULTS In total, 34 patients (9 early and 14 long-standing) from patients with RA, 31 patients (7 early and 15 long-standing) with PsA and 30 with OA were included. We found equal frequencies of PD signal between TNS and NTNS joints in RA (p=0.18), PsA (p=0.59) or OA (p=0.96). However, PD had a significant association with tenderness in early arthritis both in RA (p=0.02) and in PsA (p=0.02). The radiographic damage score showed significant association with tenderness in RA (p<0.01), PsA (p<0.01) and OA (p=0.04). CONCLUSION Tenderness might not always be a sign of active inflammation in RA, PsA and OA. While tenderness in early arthritis may be more related to inflammation, established disease is better explained by joint damage and malalignment.
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Affiliation(s)
- Irina Gessl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Mihaela Popescu
- Department of Rheumatology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Victoria Schimpl
- Department of Pediatric and Adolescent Medicine, Klinik Donaustadt, Vienna, Austria
| | - Gabriela Supp
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Deimel
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Martina Durechova
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Miriam Hucke
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Kärnten, Austria
| | - Michaela Loiskandl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Paul Studenic
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Michael Zauner
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
| | - Peter Mandl
- Department of Rheumatology, Medical University of Vienna, Vienna, Austria
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Duquenne L, Chowdhury R, Mankia K, Emery P. The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on "At-Risk" Individuals. Front Med (Lausanne) 2020; 7:587827. [PMID: 33195348 PMCID: PMC7662561 DOI: 10.3389/fmed.2020.587827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/12/2020] [Indexed: 02/04/2023] Open
Abstract
In individuals at-risk of developing inflammatory arthritis, the value of an ultrasound (US) scan assessment to predict progression has been demonstrated repeatedly. However, depending on recruitment criteria, these individuals may be at different stages in the arthritis development continuum, therefore representing a heterogeneous population. As a consequence, the predictive value of ultrasound results may differ between cohorts. As other reviews have focused on the challenges in population recruitment or have combined biomarkers predicting value according to one recruitment pathway, we wanted to focus on the sole use of ultrasound assessment and its variation according to population recruitment criteria. In this review, we discuss the use of ultrasound in the different at-risk populations across the inflammatory arthritis disease continuum. This review demonstrates that although some sub-population data is scarce, ultrasound is best predictive in three at-risk populations: those with a positive ACPA test in the context of non-specific MSK symptoms, those with clinically suspect arthralgia and those with palindromic rheumatism. We consider that ultrasound assessment will be a cornerstone in prediction risk modeling and prevention studies of the preclinical phases of IA in the future.
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Affiliation(s)
- Laurence Duquenne
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | | | - Kulveer Mankia
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
| | - Paul Emery
- Leeds Biomedical Research Centre—NIHR, Leeds, United Kingdom
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, United Kingdom
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22
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Renner N, Kleyer A, Krönke G, Simon D, Söllner S, Rech J, Uder M, Janka R, Schett G, Welsch GH, Pachowsky ML. T2 Mapping as a New Method for Quantitative Assessment of Cartilage Damage in Rheumatoid Arthritis. J Rheumatol 2020; 47:820-825. [PMID: 31416926 DOI: 10.3899/jrheum.180728] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Rheumatoid arthritis (RA) is associated with damage of the articular cartilage and the periarticular bone. While imaging of bone damage has substantially improved in recent years, direct imaging of the articular cartilage of the hand joints in patients with RA is still challenging. The study used T2 mapping of the finger joints to assess cartilage damage in RA. METHODS Magnetic resonance imaging (MRI) at 3 Tesla was done in 30 patients with RA, and T2 relaxation times visualizing alteration in the collagen network and hydration of articular cartilage were mapped in 6 cartilage regions of the metacarpophalangeal (MCP) joints 2 and 3. Values were related to autoantibody status [anticitrullinated protein antibodies (ACPA), rheumatoid factor (RF)], disease duration, and disease activity as well as sex and age of the patients. RESULTS T2 relaxation times could be reliably measured in the 6 regions of the MCP joints. Significantly higher relaxation times indicating more advanced cartilage alterations were observed in the metacarpal heads of ACPA-positive (p = 0.001-0.010) and RF-positive patients (p = 0.013-0.025) as well as those with longer disease duration (> 3 yrs; p = 0.028-0.043). Current disease activity, sex, and age did not influence T2 relaxation times. CONCLUSION These data show that cartilage damage can be localized and quantified in the hand joints of patients with RA by T2 mapping. Further, ACPA and RF positivity as well as disease duration appear to be the crucial factors influencing cartilage damage.
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Affiliation(s)
- Nina Renner
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Arnd Kleyer
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Gerhard Krönke
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - David Simon
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Stefan Söllner
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Jürgen Rech
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Michael Uder
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Rolf Janka
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Georg Schett
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Goetz H Welsch
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany.,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen
| | - Milena L Pachowsky
- From the Department of Trauma and Orthopaedic Surgery, the Department of Internal Medicine 3, and the Department of Radiology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU); Universitätsklinikum Erlangen, Erlangen; UKE Athleticum, University Hospital of Hamburg-Eppendorf, Hamburg, Germany. .,N. Renner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; A. Kleyer, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G. Krönke, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; D. Simon, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; S. Söllner, MD, Department of Trauma and Orthopaedic Surgery, FAU, and Universitätsklinikum Erlangen; J. Rech, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; M. Uder, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; R. Janka, MD, Department of Radiology, FAU, and Universitätsklinikum Erlangen; G. Schett, MD, Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen; G.H. Welsch, MD, UKE Athleticum, University Hospital of Hamburg-Eppendorf; M.L. Pachowsky, MD, MHBA, Department of Trauma and Orthopaedic Surgery and Department of Internal Medicine 3, FAU, and Universitätsklinikum Erlangen.
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23
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Di Matteo A, Mankia K, Duquenne L, Cipolletta E, Wakefield RJ, Garcia-Montoya L, Nam JL, Emery P. Ultrasound erosions in the feet best predict progression to inflammatory arthritis in anti-CCP positive at-risk individuals without clinical synovitis. Ann Rheum Dis 2020; 79:901-907. [PMID: 32366522 DOI: 10.1136/annrheumdis-2020-217215] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 03/23/2020] [Accepted: 04/08/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To investigate, in anti-cyclic citrullinated peptide antibody positive (CCP+) at-risk individuals without clinical synovitis, the prevalence and distribution of ultrasound (US) bone erosions (BE), their correlation with subclinical synovitis and their association with the development of inflammatory arthritis (IA). METHODS Baseline US scans of 419 CCP+ at-risk individuals were analysed. BE were evaluated in the classical sites for rheumatoid arthritis damage: the second and fifth metacarpophalangeal (MCP2 and MCP5) joints, and the fifth metatarsophalangeal (MTP5) joints. US synovitis was defined as synovial hypertrophy (SH) ≥2 or SH ≥1+power Doppler signal ≥1. Subjects with ≥1 follow-up visit were included in the progression analysis (n=400). RESULTS BE were found in ≥1 joint in 41/419 subjects (9.8%), and in 55/2514 joints (2.2%). The prevalence of BE was significantly higher in the MTP5 joints than in the MCP joints (p<0.01). A significant correlation between BE and US synovitis in the MTP5 joints was detected (Cramer's V=0.37, p<0.01). The OR for the development of IA (ever) was highest for the following: BE in >1 joint 10.6 (95% CI 1.9 to 60.4, p<0.01) and BE and synovitis in ≥1 MTP5 joint 5.1 (95% CI 1.4 to 18.9, p=0.02). In high titre CCP+ at-risk individuals, with positive rheumatoid factor and BE in ≥1 joint, the OR increased to 16.9 (95% CI 2.1-132.8, p<0.01). CONCLUSIONS In CCP+ at-risk individuals, BE in the feet appear to precede the onset of clinical synovitis. BE in >1 joint, and BE in combination with US synovitis in the MTP5 joints, are the most predictive for the development of clinical arthritis.
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Affiliation(s)
- Andrea Di Matteo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,Clinica Reumatologica, Polytechnic University of Marche, Ancona, Marche, Italy
| | - Kulveer Mankia
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Laurence Duquenne
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Edoardo Cipolletta
- Clinica Reumatologica, Polytechnic University of Marche, Ancona, Marche, Italy
| | - Richard J Wakefield
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Leticia Garcia-Montoya
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Jacqueline Leong Nam
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK .,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds, UK
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Greenblatt HK, Kim HA, Bettner LF, Deane KD. Preclinical rheumatoid arthritis and rheumatoid arthritis prevention. Curr Opin Rheumatol 2020; 32:289-296. [PMID: 32205569 PMCID: PMC7340337 DOI: 10.1097/bor.0000000000000708] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW This review is to provide an update on the current understanding of rheumatoid arthritis (RA) development related to disease development prior to the onset clinically apparent synovitis (i.e. Pre-RA), and opportunities for disease prevention. RECENT FINDINGS A growing number of studies have demonstrated that serum elevations of autoantibodies rheumatoid factor, antibodies to citrullinated protein/peptide antigens (ACPAs) and antibodies to other posttranslationally modified proteins (e.g. carbamylated proteins) are highly predictive of future development of inflammatory arthritis/RA during a period that can be termed Pre-RA. Other factors including genetic, environmental, symptoms and imaging findings can also enhance prediction. Moreover, several novel biomarkers and changes in autoantibodies (e.g. glycosylation of variable domains) have been identified in Pre-RA. There has also been growing evidence that initiation and propagation of RA-related autoimmunity during the Pre-RA phase may be related to mucosal processes. The discovery of Pre-RA has also underpinned the development of several clinical prevention trials in RA; specifically, the PRAIRI study demonstrated that a single dose of rituximab can delay the onset of clinically apparent IA in at-risk individuals. Additional studies are evaluating the ability of drugs including abatacept, hydroxychloroquine and methotrexate to prevent or delay future RA. SUMMARY The results from ongoing natural history and prevention trials in RA should further inform several critical issues in RA prevention including identification and enrolment of individuals at high-risk of imminent RA, the efficacy, safety and cost-effectiveness of prevention, and potentially the identification of new targets for prevention.
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Affiliation(s)
| | - Hyoun-Ah Kim
- University of Colorado Anschutz Medical Campus
- Department of Rheumatology, Ajou University School of Medicine, Suwon, Republic of Korea
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Iqbal K, Lendrem DW, Hargreaves B, Isaacs JD, Thompson B, Pratt AG. Routine musculoskeletal ultrasound findings impact diagnostic decisions maximally in autoantibody-seronegative early arthritis patients. Rheumatology (Oxford) 2020; 58:1268-1273. [PMID: 30753709 DOI: 10.1093/rheumatology/kez008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 12/21/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The diagnostic value added by musculoskeletal ultrasound (MSUS) over standard clinical and laboratory parameters has proved difficult to quantify. The additive contribution to diagnostic classification of a pragmatic, 15 min MSUS protocol was appraised in a large, unselected cohort of early arthritis clinic attendees. METHODS Detailed baseline characteristics were recorded. Semi-quantitative MSUS scoring of the most symptomatic wrist, second/third MCPs and PIPs and second/fifth MTPs was recorded, along with the sonographer's scan impression (definitely inflammatory, possibly inflammatory or non-inflammatory). MSUS findings were available to rheumatologist diagnosticians during subsequent consultations. Persistent inflammatory arthritis (PIA) was classified only where patients were started on ≥1 DMARD. Multivariate and receiver operating characteristic (ROC) curve analyses were used to identify independent discriminators of PIA, and the added value of MSUS parameters. RESULTS Eight hundred and thirty-one patients were enrolled, of whom 31.3% acquired a PIA diagnosis. Swollen joint count, CRP, age and ACPA status were non-redundant clinical/laboratory predictors of a PIA diagnosis by consulting rheumatologists, with good discriminatory utility (area under the ROC curve, AUROC, 0.88). While the additive contribution of summed parameters from the seven-joint MSUS protocol to this model was statistically significant (P = 0.004), it was numerically small (ΔAUROC 0.02). However, the additive contribution to diagnostic outcome of sonographer's scan impression over clinical parameters alone became substantial in the sub-cohort of ACPA-negative patients, increasing the AUROC by 9% from 0.81 to 0.90 (P < 0.0001). CONCLUSION The clinical utility of a 15-min MSUS screen for diagnosing PIA requiring DMARDs is most evident among ACPA-negative patients attending an early arthritis clinic.
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Affiliation(s)
- Kundan Iqbal
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Dennis W Lendrem
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Ben Hargreaves
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Ben Thompson
- Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Arthur G Pratt
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK.,Musculoskeletal Services Directorate, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Abstract
Multiple studies have shown that there is a pre-clinical period preceding the development of rheumatoid arthritis (RA). During this period, complex interactions between the environmental and genetic causes occur, and the expression "preclinical RA" has been proposed to define it. Early treatment intervention is associated with less joint damage and has an increased possibility of achieving remission. In this review, we provide an overview of the preclinical phases of RA, new immunological and imaging biomarkers, and the clinical features, and the management of individuals at-risk of developing RA.
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Affiliation(s)
- Patrícia Martins
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação Em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Portugal.
| | - João Eurico Fonseca
- Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Portugal; Unidade de Investigação Em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Portugal
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27
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Brulhart L, Alpízar-Rodríguez D, Nissen MS, Zufferey P, Ciubotariu I, Fleury G, Lazarou I, Gabay C, Finckh A. Ultrasound is not associated with the presence of systemic autoimmunity or symptoms in individuals at risk for rheumatoid arthritis. RMD Open 2019; 5:e000922. [PMID: 31565240 PMCID: PMC6744083 DOI: 10.1136/rmdopen-2019-000922] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 06/09/2019] [Accepted: 06/29/2019] [Indexed: 12/19/2022] Open
Abstract
Objective To identify whether musculoskeletal ultrasound (MSUS) abnormalities are associated with specific phases of rheumatoid arthritis (RA) development in individuals at risk of RA. Methods This is a prospective cohort study of individuals at risk of developing RA, namely first-degree relatives of patients with RA (RA-FDRs) without evidence of established rheumatic disease at inclusion. The inflammatory activity on MSUS was assessed according to a validated score (SONAR). Active MSUS was defined as a total B-mode score greater than 8, including at least one joint with significant synovitis (grade 2 or 3) or significant synovial hyperaemia (Doppler score greater than 1). We used logistic regression to analyse associations between MSUS findings and recognised preclinical phases of RA development, adjusting for other demographic and biological characteristics. Results A total of 273 RA-FDRs were analysed, of whom 23 (8%) were anticitrullinated protein autoantibodies-positive, 58 (21%) had unclassified arthritis and 96 (35%) had an active MSUS, which was only associated with unclassified arthritis (OR: 1.8, 95% CI 1.0 to 3.3). Conclusion In individuals at risk of RA, active MSUS was associated with the presence of unclassified arthritis, but not with any of the earlier described phases of RA development. These findings do not support an indiscriminate use of ultrasound in a screening strategy for preclinical RA.
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Affiliation(s)
- Laure Brulhart
- Rheumatology, Hopital neuchatelois La Chaux-de-Fonds, La Chaux-de-Fonds, Switzerland
| | | | - Michael S Nissen
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | | | - Ileana Ciubotariu
- Rheumatology Division, Hôpital du Sacré-Coeur de Montréal (HSCM), Montreal, Quebec, Canada
| | - Gregory Fleury
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - Ilias Lazarou
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - Cem Gabay
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
| | - Axel Finckh
- Division of Rheumatology, University Hospital of Geneva, Geneva, Switzerland
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Al-Laith M, Jasenecova M, Abraham S, Bosworth A, Bruce IN, Buckley CD, Ciurtin C, D'Agostino MA, Emery P, Gaston H, Isaacs JD, Filer A, Fisher BA, Huizinga TWJ, Ho P, Jacklin C, Lempp H, McInnes IB, Pratt AG, Östor A, Raza K, Taylor PC, van Schaardenburg D, Shivapatham D, Wright AJ, Vasconcelos JC, Kelly J, Murphy C, Prevost AT, Cope AP. Arthritis prevention in the pre-clinical phase of RA with abatacept (the APIPPRA study): a multi-centre, randomised, double-blind, parallel-group, placebo-controlled clinical trial protocol. Trials 2019; 20:429. [PMID: 31307535 PMCID: PMC6633323 DOI: 10.1186/s13063-019-3403-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/06/2019] [Indexed: 01/01/2023] Open
Abstract
TRIAL DESIGN We present a study protocol for a multi-centre, randomised, double-blind, parallel-group, placebo-controlled trial that seeks to test the feasibility, acceptability and effectiveness of a 52-week period of treatment with the first-in-class co-stimulatory blocker abatacept for preventing or delaying the onset of inflammatory arthritis. METHODS The study aimed to recruit 206 male or female subjects from the secondary care hospital setting across the UK and the Netherlands. Participants who were at least 18 years old, who reported inflammatory sounding joint pain (clinically suspicious arthralgia) and who were found to be positive for serum autoantibodies associated with rheumatoid arthritis (RA) were eligible for enrolment. All study subjects were randomly assigned to receive weekly injections of investigational medicinal product, either abatacept or placebo treatment over the course of a 52-week period. Participants were followed up for a further 52 weeks. The primary endpoint was defined as the time to development of at least three swollen joints or to the fulfilment of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for RA using swollen but not tender joints, whichever endpoint was met first. In either case, swollen joints were confirmed by ultrasonography. Participants, care givers, and those assessing the outcomes were all blinded to group assignment. Clinical assessors and ultrasonographers were also blinded to each other's assessments for the duration of the study. CONCLUSIONS There is limited experience of the design and implementation of trials for the prevention of inflammatory joint diseases. We discuss the rationale behind choice and duration of treatment and the challenges associated with defining the "at risk" state and offer pragmatic solutions in the protocol to enrolling subjects at risk of RA. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN46017566 . Registered on 4 July 2014.
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Affiliation(s)
- Mariam Al-Laith
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
| | - Marianna Jasenecova
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Sonya Abraham
- Department of Rheumatology, National Institute for Health Research-Wellcome Clinical Research Facility, Hammersmith Hospital, Imperial College, London, W12 0HS, UK
| | - Aisla Bosworth
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Ian N Bruce
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Christopher D Buckley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Coziana Ciurtin
- Department of Adolescent and Adult Rheumatology, University College London Hospitals NHS Trust, 3rd Floor Central, 250 Euston Road, London, NW1 2PG, UK
| | - Maria-Antonietta D'Agostino
- Rheumatology Department, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France
| | - Paul Emery
- Section of Musculoskeletal Disease, Leeds Institute of Molecular Medicine, University of Leeds, UK NIHR Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, LS4 7SA, UK
| | - Hill Gaston
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - John D Isaacs
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Filer
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Benjamin A Fisher
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Thomas W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Pauline Ho
- Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, Stopford Building, University of Manchester, Oxford Road, Manchester, M13 9PT, UK
- National Institute for Health Research Biomedical Research Centre and the Kellgren Centre for Rheumatology, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, M13 9WL, UK
| | - Clare Jacklin
- National RA Society, The Switchback Office Park, Gardner Road, Maidenhead, SL6 7RJ, UK
| | - Heidi Lempp
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, 120 University Place, Glasgow, G12 8TA, UK
| | - Arthur G Pratt
- Musculoskeletal Research Group, Institute of Cellular Medicine, Newcastle University, 3rd Floor William Leech Building, The Medical School, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN, UK
| | - Andrew Östor
- Department of Medicine, University of Cambridge and Addenbrookes Hospital NHS Trust, Cambridge, UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Queen Elizabeth Hospital, Birmingham, B15 2WB, UK
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, West Midlands, B71 4HJ, UK
| | - Peter C Taylor
- Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center, locations Reade and Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dharshene Shivapatham
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK
| | - Alison J Wright
- Clinical, Education & Health Psychology Division of Psychology & Language Sciences, Faculty of Brain Sciences, University College London, London, WC1E 6BT, UK
| | - Joana C Vasconcelos
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, King's College London, Institute of Psychiatry, 16 De Crespigny Park, London, SE5 8AF, UK
| | - A Toby Prevost
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | - Andrew P Cope
- Centre for Rheumatic Diseases, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Weston Education Centre, 10 Cutcombe Road, London, SE5 9RJ, UK.
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29
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Predicting Rheumatoid Arthritis in At-risk Individuals. Clin Ther 2019; 41:1286-1298. [DOI: 10.1016/j.clinthera.2019.04.017] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 03/26/2019] [Accepted: 04/10/2019] [Indexed: 12/18/2022]
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Cope AP. Considerations for Optimal Trial Design for Rheumatoid Arthritis Prevention Studies. Clin Ther 2019; 41:1299-1311. [PMID: 31196650 DOI: 10.1016/j.clinthera.2019.04.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 03/07/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022]
Abstract
The field of rheumatology has made major contributions to medicine through the identification of cellular and molecular targets and with the development of therapies for the treatment of an impressive range of immune-mediated rheumatic diseases. In recent years new milestones have been achieved. These include the recognition of an "at risk" state, defined by distinct clusters of characteristics, including disease-specific autoantibodies in serum and symptom complexes that include inflammatory joint pain. Studies seeking to prevent high-risk individuals from progressing to a state of clinically apparent arthritis have been initiated. Here, exploiting the current evidence base, an experimental framework to inform trial design is described, taking into consideration study patient phenotypes and highlighting the impact of risk stratification and the options available for therapeutic intervention according to the different phases of the preclinical syndrome. Pragmatic primary end points and suggestions for a set of risk-focused trial outcome measures are proposed, including both clinical assessments and patient-reported outcome measures. Rheumatoid arthritis prevention studies provide an important experimental framework for generating deeper insights into risk stratification and for refining trial design in the future. To this end, a research agenda is suggested, together with some considerations for imaging and for biological sampling. This commentary concludes with some of the operational issues that arise from such studies and addresses some of the challenges associated with recruitment and retention of the at-risk trial participant.
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Affiliation(s)
- Andrew P Cope
- Centre for Rheumatic Diseases, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, Guys Campus, London, United Kingdom.
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31
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Ohrndorf S, Boer AC, Boeters DM, Ten Brinck RM, Burmester GR, Kortekaas MC, van der Helm-van Mil AHM. Do musculoskeletal ultrasound and magnetic resonance imaging identify synovitis and tenosynovitis at the same joints and tendons? A comparative study in early inflammatory arthritis and clinically suspect arthralgia. Arthritis Res Ther 2019; 21:59. [PMID: 30764862 PMCID: PMC6376767 DOI: 10.1186/s13075-019-1824-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/14/2019] [Indexed: 11/26/2022] Open
Abstract
Objective Ultrasound (US) and magnetic resonance imaging (MRI) are recommended in the diagnostic process of rheumatoid arthritis. Research on its comparability in early disease phases is scarce. Therefore, we compared synovitis and tenosynovitis detected by US and MRI on joint/tendon level. Methods Eight hundred forty joints and 700 tendons of 70 consecutive patients, presenting with inflammatory arthritis or clinically suspect arthralgia, underwent US and MRI of MCP (2–5), wrist and MTP (1–5) joints at the same day. Greyscale (GS) and power Doppler (PD) synovitis were scored according to the modified Szkudlarek method (combining synovial effusion and hypertrophy) and the recently published EULAR-OMERACT method (synovial hypertrophy regardless of the presence of effusion) on static images. US-detected tenosynovitis was scored according to the OMERACT. MRI scans were scored according to the RAMRIS. Test characteristics were calculated on joint/tendon level with MRI as reference. Cut-off for US scores were ≥ 1 and ≥ 2 and for MRI ≥ 1. Results Compared to MRI, GS synovitis according to EULAR-OMERACT (cut-off ≥ 1) had a sensitivity ranging from 29 to 75% for the different joint locations; specificity ranged from 80 to 98%. For the modified Szkudlarek method, the sensitivity was 68–91% and specificity 52–71%. PD synovitis had a sensitivity of 30–54% and specificity 97–99% compared to MRI. The sensitivity to detect GS tenosynovitis was 50–78% and the specificity 80–94%. For PD tenosynovitis, the sensitivity was 19–58% and specificity 98–100%. Conclusion Current data showed that US is less sensitive than MRI in the early detection of synovitis and tenosynovitis, but resulted in only few non-specific findings. The higher sensitivity of MRI is at the expense of less accessibility and higher costs. Electronic supplementary material The online version of this article (10.1186/s13075-019-1824-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Ohrndorf
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany. .,Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.
| | - Aleid C Boer
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Debbie M Boeters
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Robin M Ten Brinck
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Gerd-R Burmester
- Department of Rheumatology and Clinical Immunology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany
| | - Marion C Kortekaas
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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Burgers L, ten Brinck R, van der Helm-van Mil A. Is joint pain in patients with arthralgia suspicious for progression to rheumatoid arthritis explained by subclinical inflammation? A cross-sectional MRI study. Rheumatology (Oxford) 2019; 58:86-93. [PMID: 30137540 PMCID: PMC6319603 DOI: 10.1093/rheumatology/key220] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Indexed: 11/12/2022] Open
Abstract
Objectives The development of RA includes a phase of arthralgia preceding clinical arthritis. The aetiology of symptoms of arthralgia is unclear. Since subclinical joint inflammation is expected to be causally related to pain, we aimed to study associations between subclinical MRI-detected inflammation and pain in patients with arthralgia suspicious for progression to RA. Methods Unilateral MRIs of the wrist, MCP (2-5) and MTP (1-5) joints of 325 patients who fulfilled the EULAR definition of arthralgia suspicious for progression to RA were scored by two readers on subclinical inflammation (synovitis, bone marrow oedema and tenosynovitis). Associations between MRI-detected inflammation and overall pain severity at patient level (measured using the visual analogue scale), as well as with local joint tenderness, were studied. Analyses were stratified for ACPA. Results At patient level, synovitis (β = 0.10, P = 0.048) and tenosynovitis (β = 0.11, P = 0.026) associated with the visual analogue scale pain. Of the 1620 imaged joints, 447 (28%) were tender. MRI-detected synovitis associated independently with joint tenderness in all patients (odds ratio 1.74, P < 0.001), and in the ACPA-negative stratum (odds ratio 1.96, P < 0.001). In the ACPA-positive stratum only bone marrow oedema (osteitis) was independently associated with tenderness (odds ratio 2.39, P = 0.005). Sensitivity analyses in patients who developed inflammatory arthritis during follow-up (n = 61) revealed similar associations. Subclinical inflammation was present in 51% of tender joints and 39% of non-tender joints. Conclusion In patients with arthralgia suspicious for progression to RA, MRI-detected subclinical inflammation is associated with overall pain and local joint tenderness. However, the association is partial, indicating that subclinical inflammation is not the sole explanation of the arthralgia.
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Affiliation(s)
- L.E. Burgers
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
| | - R.M. ten Brinck
- Department of Rheumatology, Leiden University Medical Centre, Leiden, the Netherlands
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The importance of ultrasound examination in early arthritis. Reumatologia 2018; 56:354-361. [PMID: 30647481 PMCID: PMC6330678 DOI: 10.5114/reum.2018.80712] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 12/05/2018] [Indexed: 11/22/2022] Open
Abstract
Objectives To assess the importance of ultrasound (US) examination of joints in hands and feet in patients with early arthritis and perform comparative analysis of the diagnostic value of US examination for 8, 12 and 52 selected joints. Material and methods 123 patients (87 women, 36 men) with arthritis lasting less than 12 months, naive to disease-modifying anti-rheumatic drugs and glucocorticosteroids. Necessary differential diagnostics was performed for each patient. After the preliminary analysis, 72 patients met the classification criteria for rheumatoid arthritis (RA) according to ACR/EULAR of 2010, and undifferentiated arthritis (UA) was diagnosed in 51 patients. UA patients were followed up after 6 and 12 months, and verification of the initial diagnosis yielded the following groups of patients: patients meeting classification criteria for RA, patients with maintained diagnosis of UA, patients in remission, and patients with other diagnoses. Ultrasound examination was performed considering the volume of joint effusion (JE), synovial membrane hypertrophy (GS), and synovial membrane hyperaemia assessed by power Doppler (PD). Results were assessed using the semi-qualitative scale. Coefficients being the sum of US scores for the assessment of JE, GS and PD for 52 and 12 joints in hands and feet, and 8 joints in hands were determined for the purpose of the study. Results In patients meeting classification criteria for RA during the initial assessment the US examination yielded significantly higher PD-52I, PD-12I and PD-8I coefficients. In UA patients who were diagnosed with RA after 12 months, the GS-8I coefficient was significantly higher. Conclusions Ultrasonography is a valuable tool in diagnostics of early arthritis. The GS assessment has prognostic value for UA patients. The assessment of 8 or 12 selected joints is often sufficient for the diagnostics of patients with early arthritis.
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van Beers-Tas MH, Blanken AB, Nielen MMJ, Turkstra F, van der Laken CJ, Meursinge Reynders M, van Schaardenburg D. The value of joint ultrasonography in predicting arthritis in seropositive patients with arthralgia: a prospective cohort study. Arthritis Res Ther 2018; 20:279. [PMID: 30567606 PMCID: PMC6300036 DOI: 10.1186/s13075-018-1767-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 11/12/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The value of joint ultrasonography (US) in the prediction of clinical arthritis in individuals at risk of developing rheumatoid arthritis (RA) is still a point of debate, due to varying scanning protocols and different populations. We investigated whether US abnormalities assessed with a standard joint protocol can predict development of arthritis in seropositive patients with arthralgia. METHODS Anti-citrullinated protein antibodies and/or rheumatoid factor positive patients with arthralgia, but without clinical arthritis were included. US was performed at baseline in 16 joints: bilateral metacarpophalangeal 2-3, proximal interphalangeal 2-3, wrist and metatarsophalangeal (MTP) joints 2-3 and 5. Images were scored semi-quantitatively for synovial thickening and for positive signs on power Doppler (PD). Association between US abnormalities and arthritis development at the joint and at the patient level was evaluated. Also, we investigated the added value of US over clinical parameters. RESULTS Out of 163 patients who underwent US examination, 51 (31%) developed clinical arthritis after a median follow-up time of 12 (interquartile range 5-24) months, of which 44 (86%) satisfied the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. US revealed synovial thickening and PD in at least one joint in 49 patients (30%) and 7 patients (4%), respectively. Synovial thickening was associated with both development and timing of clinical arthritis in any joint (patient level) when MTP joints were excluded from the US assessment (odds ratio 6.6, confidence interval (CI) 1.9-22), and hazard ratio 3.4, CI 1.6-6.8, respectively, with a mean time to arthritis of 23 versus 45 months when synovial thickening was present versus not present). There was no association between US and arthritis development at the joint level. Predictive capacity was highest in the groups with an intermediate and high risk of developing arthritis based on a prediction rule with clinical parameters. CONCLUSIONS Synovial thickening on US predicted clinical arthritis development at the patient level in seropositive patients with arthralgia when MTPs were excluded from the US assessment. Positive PD signs were infrequently seen in these at-risk individuals and was not predictive. In patients at intermediate risk of RA, US may help to identify those at higher risk of developing arthritis.
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Affiliation(s)
- Marian H van Beers-Tas
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands.
| | - Annelies B Blanken
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Mark M J Nielen
- Netherlands Institute for Health Services Research (NIVEL), Otterstraat 118-124, 3513 CR, Utrecht, The Netherlands
| | - Franktien Turkstra
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Conny J van der Laken
- Amsterdam Rheumatology and immunology Center, VU University Medical Center, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - Marlies Meursinge Reynders
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands
| | - Dirkjan van Schaardenburg
- Amsterdam Rheumatology and immunology Center
- Reade, Dr. Jan van Breemenstraat 2, 1056 AB, Amsterdam, The Netherlands.,Amsterdam Rheumatology and immunology Center
- Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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van den Berg R, Ohrndorf S, Kortekaas MC, van der Helm-van Mil AHM. What is the value of musculoskeletal ultrasound in patients presenting with arthralgia to predict inflammatory arthritis development? A systematic literature review. Arthritis Res Ther 2018; 20:228. [PMID: 30305156 PMCID: PMC6235211 DOI: 10.1186/s13075-018-1715-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE Musculoskeletal ultrasound (US) is frequently used in several rheumatology practices to detect subclinical inflammation in patients with joint symptoms suspected for progression to inflammatory arthritis. Evaluating the scientific basis for this specific US use, we performed this systematic literature review determining if US features of inflammation are predictive for arthritis development and which US features are of additive value to other, regularly used biomarkers. METHODS Medical literature databases were systematically searched up to May 2017 for longitudinal studies reporting on the association between greyscale (GSUS) and Power Doppler (PDUS) abnormalities and inflammatory arthritis development in arthralgia patients. Quality of studies was assessed by two independent reviewers using a set of 18 criteria. Studies were marked high quality if scored ≥ 80.6% (which is the median score). Best-evidence synthesis was performed to determine the level of evidence (LoE). Positive and negative likelihood ratios (LR+, LR-) were determined. RESULTS Of 3061 unique references, six fulfilled inclusion criteria (three rated high quality), of which two reported on the same cohort. Heterogeneity in arthralgia populations, various US machines and scoring systems hampered the comparability of results. LoE for GSUS as predictor was limited and moderate for PDUS; LoE for the additive value of GSUS and PDUS with other biomarkers was limited to moderate. Estimated LR+ values were mostly < 4 and LR- values > 0.5. CONCLUSIONS Data on the value of GSUS and PDUS abnormalities for predicting inflammatory arthritis development are sparse. Although a potential benefit is not excluded, current LoE is limited to moderate. Future studies are required, preferably performed in clearly defined, well-described arthralgia populations, using standardized US acquisition protocols and scoring systems.
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Affiliation(s)
| | - Sarah Ohrndorf
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marion C. Kortekaas
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Annette H. M. van der Helm-van Mil
- Department of Rheumatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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Ten Brinck RM, van Steenbergen HW, van der Helm-van Mil AHM. Development of clinically apparent synovitis: a longitudinal study at the joint level during progression to inflammatory arthritis. RMD Open 2018; 4:e000748. [PMID: 30233813 PMCID: PMC6135411 DOI: 10.1136/rmdopen-2018-000748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction Subclinical inflammation, detected by MRI, in patients with arthralgia is predictive for development of inflammatory arthritis (IA). However, within patients that develop IA, the course of inflammation at the joint level during this transition is unknown. This longitudinal study assessed progression of inflammation at the joint level. Methods 350 joints (unilateral metacarpophalangeals (MCPs), wrist, metatarsophalangeal (MTP) joints) of 35 patients presenting with clinically suspect arthralgia (CSA) that progressed to IA were studied at presentation with CSA and subsequently when clinical synovitis was first identified at joint examination (median time interval 17 weeks). At both time points, subclinical inflammation (bone marrow oedema, synovitis, tenosynovitis) was evaluated with MRI and joint examination was performed. Results At presentation with CSA, 71 joints showed subclinical inflammation. During progression to IA, 20% of these joints had resolution of inflammation, 60% had persistent inflammation and 20% progressed to clinical synovitis. Of all joints that had developed clinical synovitis (n = 45), no prior subclinical inflammation was detected in 69%. Similar results were observed for anticitrullinated protein antibodies (ACPA)-positive and ACPA-negative patients. Conclusions This longitudinal study demonstrated moderate correlations between joints with subclinical inflammation and joints that developed clinical synovitis. These data imply that IA development is a more systemic rather than a locally outgrowing process.
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Affiliation(s)
- Robin M Ten Brinck
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands.,Department of Rheumatology, Erasmus Medical Centre, Rotterdam, The Netherlands
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37
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Ehrenstein B, Pongratz G, Fleck M, Hartung W. The ability of rheumatologists blinded to prior workup to diagnose rheumatoid arthritis only by clinical assessment: a cross-sectional study. Rheumatology (Oxford) 2018; 57:1592-1601. [PMID: 29850885 DOI: 10.1093/rheumatology/key127] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Indexed: 11/14/2022] Open
Abstract
Objectives We aimed to study the ability of board-certified rheumatologists, blinded to all prior diagnostic test results, to establish the presence/absence of an inflammatory rheumatic disease (IRD) or RA among polyarthralgia or arthritis patients, solely relying on clinical assessment. Methods We performed a prospective, examiner-blinded, cross-sectional study documenting the diagnostic work in four sequential steps (medical history, physical examination, musculoskeletal ultrasonography and laboratory tests) of board-certified rheumatologists in a convenience cohort of 100 patients referred for inpatient diagnostic workup to a tertiary care rheumatology centre. Results The ability to correctly identify patients with or without an IRD (diagnostic accuracy) increased from 27% after the clinical assessment to 53% after the ultrasonography and to 70% after taking laboratory test results into account. The corresponding values for correctly identifying patients with or without RA were 19, 42 and 60%, respectively. Therefore the diagnostic accuracy of solely clinical assessment for determining the diagnosis of IRD or RA compared with the diagnosis established by a consecutive thorough in-patient workup was only 27 and 19% in our cohort, respectively. Pretreatment with corticosteroids (in the prior 7 days) vs none did not alter these results substantially (20 vs 29% for IRD, 15% vs 20% for RA). Conclusion Experienced rheumatologists, if deprived of information on prior external imaging and laboratory workup by blinding, were not able to correctly classify the majority of patients presenting with polyarthralgia or arthritis symptoms for inpatient workup, relying only on a brief symptom-focused medical history and physical examination.
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Affiliation(s)
- Boris Ehrenstein
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Internal Medicine I, University Medical Center Regensburg, Düsseldorf, Germany
| | - Georg Pongratz
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Rheumatology & Hiller Research Center for Rheumatology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Martin Fleck
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany.,Department of Internal Medicine I, University Medical Center Regensburg, Düsseldorf, Germany
| | - Wolfgang Hartung
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center Bad Abbach, Bad Abbach, Germany
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Abstract
PURPOSE OF REVIEW This review is to provide an update on the current understanding of rheumatoid arthritis (RA) development related to disease development prior to the onset clinically apparent synovitis and opportunities for disease prevention. RECENT FINDINGS A growing number of studies have demonstrated that serum elevations of autoantibodies rheumatoid factor and antibodies to citrullinated protein/peptide antigens (ACPA) are highly predictive of future development of IA/RA. This has underpinned the development of several prevention trials in RA. The full results from most of these prevention trials are pending, but ultimately, they should further inform several critical issues in RA prevention including identification and enrollment of individuals at high risk of imminent RA, the efficacy, safety and cost-effectiveness of prevention, and potentially the identification of new targets for prevention. Results from studies in RA prevention as well as other ongoing natural history studies of RA will help to change the paradigm of how RA is managed, potentially adding prevention to the possibilities for management.
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Affiliation(s)
- Kevin D Deane
- Division of Rheumatology, University of Colorado School of Medicine, 1775 Aurora Court, Mail Stop B-115, Aurora, CO, 80045, USA.
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39
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Targeting lymphatic function as a novel therapeutic intervention for rheumatoid arthritis. Nat Rev Rheumatol 2018; 14:94-106. [PMID: 29323343 DOI: 10.1038/nrrheum.2017.205] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Although clinical outcomes for patients with rheumatoid arthritis (RA) have greatly improved with the use of biologic and conventional DMARDs, approximately 40% of patients do not achieve primary clinical outcomes in randomized trials, and only a small proportion achieve lasting remission. Over the past decade, studies in murine models point to the critical role of the lymphatic system in the pathogenesis and therapy of inflammatory-erosive arthritis, presumably by the removal of catabolic factors, cytokines and inflammatory cells from the inflamed synovium. Murine studies demonstrate that lymphatic drainage increases at the onset of inflammatory-erosive arthritis but, as inflammation progresses to a more chronic phase, lymphatic clearance declines and both structural and cellular changes are observed in the draining lymph node. Specifically, chronic damage to the lymphatic vessel from persistent inflammation results in loss of lymphatic vessel contraction followed by lymph node collapse, reduced lymphatic drainage, and ultimately severe synovitis and joint erosion. Notably, clinical pilot studies in patients with RA report lymph node changes following treatment, and thus draining lymphatic vessels and nodes could represent a potential biomarker of arthritis activity and response to therapy. Most importantly, targeting lymphatics represents an innovative strategy for therapeutic intervention for RA.
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40
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Boeters DM, Raza K, van der Helm-van Mil AHM. Which patients presenting with arthralgia eventually develop rheumatoid arthritis? The current state of the art. RMD Open 2017; 3:e000479. [PMID: 29177078 PMCID: PMC5687532 DOI: 10.1136/rmdopen-2017-000479] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Accepted: 10/13/2017] [Indexed: 01/13/2023] Open
Abstract
Early initiation of treatment in patients with inflammatory arthritis at risk of persistence and/or erosive progression is important because it is associated with a reduced rate of progression of joint damage and functional disability. It has been proposed that a window of opportunity exists, during which disease processes are less matured and disease modification can be more effective. The phase of arthralgia preceding clinical arthritis is likely to be an important part of this window of opportunity, during which treatment might prevent progression to clinical arthritis. Several proof-of-concept trials in individuals with arthralgia are now evaluating this hypothesis. Central to such trials is the ability to identify groups at high risk of rheumatoid arthritis (RA) in whom preventive treatment can be tested. This review describes the relevance of adequate prediction making, as well as the accuracy of different types of predictors (including imaging and serological markers) with their value in predicting the progression of arthralgia to arthritis. Despite promising results, studies have been performed in heterogeneous patient populations and most findings have not been validated in independent studies. Future observational or preventive studies should be conducted with homogeneous patient groups (eg, patients fulfilling the European League Against Rheumatism criteria for arthralgia at risk of RA) in order to increase interstudy comparability and to allow result validation.
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Affiliation(s)
- Debbie M Boeters
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Annette H M van der Helm-van Mil
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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41
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Abstract
Early treatment is associated with improved outcomes in patients with rheumatoid arthritis (RA), suggesting that a 'window of opportunity', in which the disease is most susceptible to disease-modifying treatment, exists. Autoantibodies and markers of systemic inflammation can be present long before clinical arthritis, and maturation of the immune response seems to coincide with the development of RA. The pre-arthritis phase associated with symptoms such as as joint pain without clinical arthritis (athralgia) is now hypothesized to fall within the aforementioned window of opportunity. Consequently, disease modulation in this phase might prevent the occurrence of clinically apparent arthritis, which would result in a persistent disease course if untreated. Several ongoing proof-of-concept trials are now testing this hypothesis. This Review highlights the importance of adequate risk prediction for the correct design, execution and interpretation of results of these prevention trials, as well as considerations when translating these findings into clinical practice. The patients' perspectives are discussed, and the accuracy with which RA development can be predicted in patients presenting with arthralgia is evaluated. Currently, the best starting position for preventive studies is proposed to be the inclusion of patients with an increased risk of RA, such as those identified as fulfilling the EULAR definition of 'arthralgia suspicious for progression to RA'.
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42
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Schett G. The role of ACPAs in at-risk individuals: Early targeting of the bone and joints. Best Pract Res Clin Rheumatol 2017; 31:53-58. [PMID: 29221598 DOI: 10.1016/j.berh.2017.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 09/07/2017] [Indexed: 12/22/2022]
Abstract
Autoimmunity precedes inflammation in patients with rheumatoid arthritis (RA), opening the possibility to search for early changes in the tissue preceding the onset of systemic inflammation. Autoantibodies are important and early drivers of bone damage in RA. This article summarizes current evidence for the role of RA-related autoantibodies in mediating bone loss. Rheumatoid factor (RF) and antibodies recognizing modified (citrullinated) proteins have been used as diagnostic markers for RA over many years. Their role as pathogenic players, however, has long been unrecognized. Recently, several pieces of evidence suggested that bone-resorbing osteoclasts are highly responsive to RA-related autoantibodies, providing a novel association between autoimmunity and bone. These developments have allowed the unraveling of the underlying mechanisms, which are responsible for the well-known clinical observation that anti-citrullinated protein antibodies and RF are associated with a more severe disease course. Furthermore, these mechanisms also explain the onset of inflammation in the joints of RA patients.
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Affiliation(s)
- Georg Schett
- Department of Internal Medicine 3 and Institute for Clinical Immunology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU) and Universitätsklinikum, Erlangen, Germany.
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Jutley GS, Latif ZP, Raza K. Symptoms in individuals at risk of rheumatoid arthritis. Best Pract Res Clin Rheumatol 2017; 31:59-70. [PMID: 29221599 DOI: 10.1016/j.berh.2017.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 08/04/2017] [Accepted: 08/04/2017] [Indexed: 11/27/2022]
Abstract
An increasing interest in treating individuals at risk of rheumatoid arthritis (RA) to prevent the development of this chronic condition has focussed attention on the identification of risk factors of this disease. Most patients who develop RA progress through a preceding symptomatic phase that may take the form of arthralgia, palindromic rheumatism or unclassified arthritis before a disease currently classifiable as RA is established. An understanding of symptoms that identify individuals as being at risk of RA is a critical issue. Constellations of relevant symptoms could (1) form the basis of public health campaigns to encourage rapid consultation, (2) inform primary health care providers regarding which patients to perform additional tests in or whom to refer to a rheumatologist and (3) be included in algorithms to predict RA development. In this review, we present qualitative and quantitative data summarising current understanding of the symptoms experienced by individuals at risk of RA.
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Affiliation(s)
- Gurpreet Singh Jutley
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK
| | - Zahira P Latif
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK
| | - Karim Raza
- Rheumatology Research Group, Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT UK.
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Role of ultrasound imaging in individuals at risk of RA. Best Pract Res Clin Rheumatol 2017; 31:71-79. [PMID: 29221600 DOI: 10.1016/j.berh.2017.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/06/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022]
Abstract
Early diagnosis and treatment improves outcomes for patients with rheumatoid arthritis (RA). Studies have shown that musculoskeletal ultrasound is more sensitive than clinical examination in identifying synovitis. This review aims to address the role of ultrasound in identifying (1) patients with early inflammatory arthritis (IA) at risk of progression to RA and (2) those without clinical synovitis at risk of progression to early IA and therefore early RA.
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van der Ven M, Kuijper TM, Gerards AH, Tchetverikov I, Weel AE, van Zeben J, Hazes JM, Luime JJ. No clear association between ultrasound remission and health status in rheumatoid arthritis patients in clinical remission. Rheumatology (Oxford) 2017; 56:1276-1281. [PMID: 28407127 DOI: 10.1093/rheumatology/kex080] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Indexed: 01/04/2023] Open
Abstract
Objectives Although RA patients achieve clinical remission, risk of flare still exists. Given the association between US synovitis and increased risk of flare, it is of clinical interest whether these patients report a different health status. Therefore, our aim was to evaluate the frequency of US remission in RA patients in clinical remission and to compare the health status of RA patients in clinical remission with those who were also in US remission. Methods In a prospective study, we included 89 RA patients (aged >17 years) treated with a synthetic DMARD and a TNF inhibitor who were in remission (DAS in 44 joints ⩽2.4 and swollen joint count ⩽1). Demographic characteristics, swollen and tender joints, laboratory variables, US (MCP2-5, PIP2-5, wrists and MTP2-5) and patient-reported outcomes (general health, functional ability, fatigue, depression and anxiety, pain and morning stiffness) were recorded at two consecutive visits (3 months apart). US remission was defined as grey scale grade ⩽1 and power Doppler = 0. Results At visit 1, 39% of patients were in US remission. At visit 2, 32% of patients were in US remission. At visit 1, functional ability (HAQ) was scored lower by patients in US remission (P = 0.029). At visit 2, HAQ scores were similar (P = 0.928). At visit 2, Hospital Anxiety and Depression Scale anxiety score and visual analog scale pain were significantly higher in patients in US remission. Similar levels were found for the other patient-reported outcomes. Conclusion One-third of RA patients in clinical remission were in US remission. In our study population, we could not find a clear association between health status of RA patients and being in US remission.
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Affiliation(s)
- Myrthe van der Ven
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam
| | - T Martijn Kuijper
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam
| | | | | | - Angelique E Weel
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam.,Department of Rheumatology, Maasstad Hospital
| | - Jendé van Zeben
- Department of Rheumatology, Sint Franciscus Gasthuis, Rotterdam, The Netherlands
| | - Johanna M Hazes
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam
| | - Jolanda J Luime
- Department of Rheumatology, Erasmus MC, University Medical Center Rotterdam, Rotterdam
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van der Ven M, van der Veer-Meerkerk M, Ten Cate DF, Rasappu N, Kok MR, Csakvari D, Hazes JMW, Gerards AH, Luime JJ. Absence of ultrasound inflammation in patients presenting with arthralgia rules out the development of arthritis. Arthritis Res Ther 2017; 19:202. [PMID: 28915847 PMCID: PMC5602837 DOI: 10.1186/s13075-017-1405-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 08/15/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND To decrease the burden of disease of rheumatoid arthritis (RA), patients at risk for RA need to be identified as early as possible, preferably when no clinically apparent synovitis can be detected. Up to now, it has been fairly difficult to identify those patients with arthralgia who develop inflammatory arthritis (IA), but recent studies using ultrasound (US) suggest that earlier detection is possible. We aimed to identify patients with arthralgia developing IA within 1 year using US to detect subclinical synovitis at first consultation. METHODS In a multi-centre cohort study, we followed patients with arthralgia with at least two painful joints of the hands, feet or shoulders without clinical synovitis over 1 year. Symptom duration was < 1 year, and symptoms were not explained by other conditions. At baseline and at 6 and 12 months, data were collected for physical examinations, laboratory values and diagnoses. At baseline, we examined 26 joints ultrasonographically (bilateral metacarpophalangeal joints 2-5, proximal interphalangeal joints 2-5, wrist and metatarsophalangeal joints 2-5). Scoring was done semi-quantitatively on greyscale (GS; 0-3) and power Doppler (PD; 0-3) images. US synovitis was defined as GS ≥ 2 and/or PD ≥ 1. IA was defined as clinical soft tissue swelling. Sensitivity and specificity were used to assess the diagnostic value of US for the development of IA. Univariate logistic regression was used to analyse the association between independent variables and the incidence of IA. For multivariate logistic regression, the strongest variables (p < 0.157) were selected. Missing values for independent variables were imputed. RESULTS A total of 196 patients were included, and 159 completed 12 months of follow-up. Thirty-one (16%) patients developed IA, of whom 59% showed US synovitis at baseline. The sensitivity and specificity of US synovitis were 59% and 68%, respectively. If no joints were positive on US, negative predictive value was 89%. In the multivariate logistic regression, age (OR 1.1), the presence of morning stiffness for > 30 minutes (OR 3.3) and PD signal (OR 3.4) were associated with incident IA. CONCLUSIONS The presence of PD signal, morning stiffness for > 30 minutes and age at baseline were independently associated with the development of IA. Regarding the value of US in the diagnostic workup of patients with early arthralgia at risk for IA, US did perform well in ruling out IA in patients who did not have US synovitis.
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Affiliation(s)
- Myrthe van der Ven
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - M van der Veer-Meerkerk
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Rheumatology, Zuyderland Medical Centre, Heerlen, The Netherlands
| | - D F Ten Cate
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - N Rasappu
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M R Kok
- Department of Rheumatology, Maasstad Hospital, Rotterdam, The Netherlands
| | - D Csakvari
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - J M W Hazes
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - A H Gerards
- Department of Rheumatology, Vlietland Hospital, Schiedam, The Netherlands
| | - J J Luime
- Department of Rheumatology (Na609), Erasmus MC, University Medical Centre Rotterdam, PO Box 2040, 3000 CA, Rotterdam, The Netherlands
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Demoruelle MK, Harrall KK, Ho L, Purmalek MM, Seto NL, Rothfuss HM, Weisman MH, Solomon JJ, Fischer A, Okamoto Y, Kelmenson LB, Parish MC, Feser M, Fleischer C, Anderson C, Mahler M, Norris JM, Kaplan MJ, Cherrington BD, Holers VM, Deane KD. Anti-Citrullinated Protein Antibodies Are Associated With Neutrophil Extracellular Traps in the Sputum in Relatives of Rheumatoid Arthritis Patients. Arthritis Rheumatol 2017; 69:1165-1175. [PMID: 28182854 DOI: 10.1002/art.40066] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Accepted: 02/02/2017] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Studies suggest that rheumatoid arthritis (RA)-related autoimmunity is initiated at a mucosal site. However, the factors associated with the mucosal generation of this autoimmunity are unknown, especially in individuals who are at risk of future RA. Therefore, we tested anti-cyclic citrullinated peptide (anti-CCP) antibodies in the sputum of RA-free first-degree relatives (FDRs) of RA patients and patients with classifiable RA. METHODS We evaluated induced sputum and serum samples from 67 FDRs and 20 RA patients for IgA anti-CCP and IgG anti-CCP, with cutoff levels for positivity determined in a control population. Sputum was also evaluated for cell counts, neutrophil extracellular traps (NETs) using sandwich enzyme-linked immunosorbent assays for protein/nucleic acid complexes, and total citrulline. RESULTS Sputum was positive for IgA and/or IgG anti-CCP in 14 of 20 RA patients (70%) and 17 of 67 FDRs (25%), including a portion of FDRs who were serum anti-CCP negative. In the FDRs, elevations of sputum IgA and IgG anti-CCP were associated with elevated sputum cell counts and NET levels. IgA anti-CCP was associated with ever smoking and with elevated sputum citrulline levels. CONCLUSION Anti-CCP is elevated in the sputum of FDRs, including seronegative FDRs, suggesting that the lung may be a site of anti-CCP generation in this population. The association of anti-CCP with elevated cell counts and NET levels in FDRs supports a hypothesis that local airway inflammation and NET formation may drive anti-CCP production in the lung and may promote the early stages of RA development. Longitudinal studies are needed to follow the evolution of these processes relative to the development of systemic autoimmunity and articular RA.
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Affiliation(s)
| | | | - Linh Ho
- University of Colorado Denver at Aurora
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Emerging therapies for pre-RA. Best Pract Res Clin Rheumatol 2017; 31:99-111. [DOI: 10.1016/j.berh.2017.08.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/07/2017] [Indexed: 01/20/2023]
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Mankia K, Emery P. What can palindromic rheumatism tell us? Best Pract Res Clin Rheumatol 2017; 31:90-98. [DOI: 10.1016/j.berh.2017.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 09/05/2017] [Accepted: 09/05/2017] [Indexed: 10/18/2022]
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D'Agostino MA, Haavardsholm EA, van der Laken CJ. Diagnosis and management of rheumatoid arthritis; What is the current role of established and new imaging techniques in clinical practice? Best Pract Res Clin Rheumatol 2016; 30:586-607. [PMID: 27931956 DOI: 10.1016/j.berh.2016.10.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 10/19/2016] [Indexed: 01/05/2023]
Abstract
Ultrasound and magnetic resonance imaging (MRI) have become established imaging techniques for the management of rheumatoid arthritis. Several publications have pointed out the advantages of these techniques for a more complete evaluation of the inflammation and structural damage at joint level. Recently new imaging techniques as the positron emission tomography (PET) associated with computed tomography (CT) or MRI scan, and the optical imaging have been introduced in the panorama. This article presents the advantages and limitations of each imaging techniques in light with the recent publications.
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Affiliation(s)
- Maria Antonietta D'Agostino
- Rheumatology Department, APHP, Hôpital Ambroise Paré, 92100, Boulogne-Billancourt, France; INSERM U1173, Laboratoire d'Excellence INFLAMEX, UFR Simone Veil, Versailles-Saint-Quentin University, 78180, Saint-Quentin en Yvelines, France.
| | - Espen A Haavardsholm
- Department of Rheumatology, Diakonhjemmet Hospital, Box 23 Vindern, 0319, Oslo, Norway
| | - Conny J van der Laken
- Department of Rheumatology, Amsterdam Rheumatology & Immunology Center - Location VU University Medical Center, Amsterdam, The Netherlands
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