A Systematic Literature Review Analysis of Ultrasound Joint Count and Scoring Systems to Assess Synovitis in Rheumatoid Arthritis According to the OMERACT Filter

Significance of High-Frequency Sonography for the Subclinical Progression of Rheumatoid Arthritis

OBJECTIVES

This study aims to investigate the use of high-frequency sonography as a tool for detecting inflammatory and destructive changes in the hand and foot joints of patients with early and long-term RA.

METHODS

This study employs a prospective cohort design involving 162 patients diagnosed with Rheumatoid arthritis (RA) who meet the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria. Patients were divided into two groups based on disease duration: Group 1 (n = 74) included patients with a disease duration of up to 2 years, or early РА (ERA;), Group 2 (n = 88) consisted of patients with a disease duration exceeding 2 years, or long-term persistent РА (LtRA). All patients underwent a clinical assessment of their joints, as well as radiography and arthrosonography, at the beginning of the study and again at 6 and 12 months later.

RESULTS

In the general group of patients, ultrasound examination revealed signs of synovitis in the joints of the hands more frequently (66%) compared with clinical examination (56% by a number of swollen joints [NSJ] and 55% by a number of painful joints [NPJ], P < .01). After 6 months of treatment, 12% of the patients achieved full US remission and 24% achieved partial US remission.

CONCLUSIONS

Within the scope of comprehensive RA diagnostics, arthrosonography of the joints of the hands and feet, utilizing a combination of greyscale and power Doppler, may surpass radiography in detecting early RA. This method allows for a more accurate assessment of disease activity and progression rates.

Correlation of US-7 and US-9 Scores with Disease Activity Score using 28 Joint Counts (DAS28) in Patients with Rheumatoid Arthritis

Background

The attentive management of rheumatoid arthritis (RA) has attracted particular attention. The German 7-joint Ultrasound (US-7) is the first scoring system that combines bone erosions and soft tissue lesions in a single composite scoring system. This study aimed to assess the correlation between US-7 and Disease Activity Score Using 28 Joint Counts (DAS28) in clinically active RA patients. The efficacy of a novel ultrasound score-based system, the US-9 score (joints assessed with US-7 plus knees), was also compared with the standard US-7 score.

Methods

All the RA patients referred to the outpatient rheumatology clinic of Ghaem Hospital, Mashhad, Iran, during 2019-2020 were included. 28 joints were clinically examined to calculate DAS28. Nine joints were assessed comprising the German US-7 plus knees using grayscale ultrasonography (GSUS) and power Doppler ultrasonography (PDUS). Retrieved data were analyzed by SPSS software, version 22. The Spearman Correlation test was used to find the correlation between DAS28 and ultrasonographic findings. The statistical significance level was set at P<0.05.

Results

This study was composed of thirty-five RA patients with a mean age of 49.1±12.0 years. US-7 synovitis scores in GSUS and PDUS were significantly correlated with DAS28 (P=0.02, r=0.38 and P=0.003, r=0.48, respectively). US-9 synovitis scores in GSUS and PDUS were also significantly correlated with DAS28 (P=0.003, r=0.49 and P=0.006, r=0.45, respectively). The synovitis score measured by GSUS was significantly correlated with the GSUS knee synovial score (P=0.01, r=0.42).

Conclusion

Ultrasound assessment of large joints such as knees can be an effective approach to determining RA severity. However, it can be proposed that adding more involved joints into the sonographic assessment does not necessarily provide a better clinical correlation.

JAK inhibitors improve ATP production and mitochondrial function in rheumatoid arthritis: a pilot study

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disease associated by inflammation of the synovial tissue and autoantibody production. Oxidative stress and free radicals are known to be indirectly implicated in joint damage and cartilage destruction in RA. Several studies describe the presence of mitochondrial dysfunction in RA, but few of them follow the dynamics in energy parameters after therapy. The aim of our investigation is to evaluate the direct effect of JAK inhibitors on cellular metabolism (and under induced oxidative stress) in RA patients. Ten newly diagnosed RA patients were included in the study. Peripheral blood mononuclear cells (PBMCs) and plasma were isolated before and 6 months after therapy with JAK inhibitors. A real-time metabolic analysis was performed to assess mitochondrial function and cell metabolism in PBMCs. Sonographic examination, DAS28 and conventional clinical laboratory parameters were determined also prior and post therapy. A significant decrease in proton leak after therapy with JAK inhibitors was found. The increased production of ATP indicates improvement of cellular bioenergetics status. These findings could be related to the catalytic action of JAK inhibitors on oxidative phosphorylation which corresponds to the amelioration of clinical and ultra-sonographic parameters after treatment. Our study is the first to establish the dynamics of mitochondrial parameters in PBMCs from RA patients before and after in vivo therapy with JAK inhibitors.

The Clinical Utility of Musculoskeletal Ultrasound for Disease Activity Evaluation and Therapeutic Response Prediction in Rheumatoid Arthritis Patients: A Narrative Review

Rheumatoid arthritis (RA) is characterized by persistent synovitis and joint/bone destruction. There is an unmet need to predict the therapeutic response to disease-modifying anti-rheumatic drugs (DMARDs) and achieve a treat-to-target goal. Musculoskeletal ultrasound (MSUS) is widely used to identify structural change and assess therapeutic response in RA. This review aims to summarize the available evidence regarding the clinical application of MSUS in evaluating disease activity and predicting therapeutic responses to DMARDs. We searched the MEDLINE database using the PubMed interface and reviewed English-language literature from 2000 to 2022. This review focuses on the updated role of MSUS in assessing disease activity and predicting therapeutic responses to DMARDs in RA patients. MSUS is now widely applied to identify articular structural change and assess the disease activity of RA. Combined use of gray scale and power Doppler MSUS is also superior to clinical assessment and laboratory examination in evaluating disease activity of RA. With portable use, good viability, and high sensitivity to articular inflammation, MSUS would be useful in assessing therapeutic response to biologic/targeted synthetic DMARDs (b/tsDMARDs) in RA patients. Given MSUS could also detect subclinical inflammation in a substantial proportion of RA patients with clinical remission, it is recommended to assess b/tsDMARDs-treated RA patients who have achieved low disease activity or remission. Although substantial literature data have revealed clinical utility of MSUS for monitoring disease activity and evaluating therapeutic response in RA patients, the evidence regarding its predictive value for the effectiveness of b/tsDMARDs is limited.

High-resolution ultrasound and MRI in the evaluation of the forefoot and midfoot

Radiography is the appropriate initial imaging modality to assess for midfoot and forefoot pathology before turning to advanced imaging techniques. While most lesions of the mid- and forefoot can be diagnosed clinically, the exact nature and severity of the pathology is often unclear. This review addresses the use of the ultrasound, as well as the added value of magnetic resonance imaging, in diagnosing conditions of the midfoot and forefoot. Ultrasound allows a dynamic assessment as well as enabling imaging-guided interventions for diagnostic and therapeutic purposes. Practical tips for optimal examination of this area with ultrasound and magnetic resonance imaging are provided. Metatarsal stress fracture, Chopart's injury, Lisfranc injury, as well as the 1st metatarsophalangeal joint injury and lesser metatarsophalangeal plantar plate injury are injuries unique to the mid- and forefoot. The imaging anatomy of the 1st and lesser metatarsophalangeal joints is reviewed, as such knowledge is key to correctly assessing injury of these joints. Characteristic imaging features of masses commonly encountered in the mid- and forefoot, such as ganglion cyst, Morton neuroma, gouty tophus, plantar fibroma, foreign body granuloma, and leiomyoma are reviewed. The use of ultrasound and magnetic resonance imaging in assessing degenerative and inflammatory joint disorders, and in particular rheumatoid arthritis, of the mid- and forefoot region is also reviewed. In summary, when necessary, most lesions of the mid-and forefoot can be adequately assessed with ultrasound, supplemented on occasion with radiographs, computed tomography, or magnetic resonance imaging.

Factors associated with subclinical inflammation of wrist joints in rheumatoid arthritis patients with low or no disease activity- a RA ultrasound registry study

BACKGROUND

To evaluate the factors to predict subclinical inflammation of wrist joints in patients with RA who are in clinical remission or low disease activity.

METHODS

Gray scale and power Doppler ultrasound were performed on the dorsal radio-lunate of both wrists. The presence of synovitis, comorbidities, and use of disease modifying anti-rheumatic drugs were recorded. A Multivariable forward logistical regression model was used to identify factors associated with subclinical inflammation.

RESULTS

There were 1248 patients (1010 females, 238 males; mean age: 60.0 ± 10.5 years ). 57.4% of patients in complete remission and low disease activity had sonographic inflammation. Multivariable forward logistic regression analysis indicated that male sex, smoking are positively associated with inflammation and that age, alcohol consumption, and use of methotrexate, glucocorticoid, or a biological therapy are negatively associated with inflammation. Use of biological agents decreased the risk of inflammation by 40.9%.

CONCLUSIONS

There was evidence of subclinical inflammation in most patients who were in low or no disease activity, those with biological therapy had lower risk of subclinical inflammation.

Seeing is believing: Smart use of musculoskeletal ultrasound in rheumatology practice

Musculoskeletal ultrasonography has become an increasingly valuable tool as a complement to the physical exam in rheumatology practice. Its point-of-care access, low cost, safety, portability, and reliability in trained hands, make this technique especially useful in patients with inflammatory arthritis. Growing evidence has demonstrated the value of musculoskeletal ultrasound in the detection of inflammatory and structural changes in patients with joint pain without obvious joint swelling, in differentiating various inflammatory diagnoses, in the monitoring of inflammatory arthritis, and interventional procedures. The potential role of ultrasound guiding treat-to-target strategies or tapering treatment in inflammatory arthritis requires further research. However, musculoskeletal ultrasound can also have pitfalls and limitations that a clinician should be aware of.

Musculoskeletal Ultrasound in Childhood Arthritis Limited Examination: A Comprehensive, Reliable, Time-Efficient Assessment of Synovitis

OBJECTIVE

To develop and initially validate a comprehensive pediatric musculoskeletal ultrasound (MSUS) joint-specific scoring system, and to determine the minimum number of joints needed to identify active disease.

METHODS

A semiquantitative scoring system was developed by consensus and initially validated by interrater reliability using intraclass correlation coefficients (ICCs). Subsequently, newly diagnosed juvenile idiopathic arthritis patients with an active joint count of >4 had a 42-joint MSUS performed at baseline and 3 months using this protocol. A minimum set of joints needed to identify all patients with synovitis on MSUS was obtained through a data reduction process. Spearman's correlation (rs ) was calculated to determine the association between MSUS findings and clinical Juvenile Arthritis Disease Activity Score in 10 joints (cJADAS10). Standardized response means (SMRs) were used to assess change over time.

RESULTS

The final joint-specific scoring system revealed an excellent interrater reliability (ICC 0.81-0.96) for all joints. Thirty patients were enrolled. Scanning 5 joints bilaterally (wrists, second and third metacarpophalangeal joints, knees and ankles) captured 100% of children with B-mode synovitis and had moderate correlation with the cJADAS10 at baseline (rs  = 0.45). Mean ultrasound scores at baseline and follow-up were 28.3 and 22.3, with an SRM of 0.69 (P = 0.002) for 42 joints, and 36 and 27.7, with an SRM of 0.76 (P = 0.003) for the reduced joints, respectively.

CONCLUSION

A limited MSUS examination called musculoskeletal ultrasound in childhood arthritis limited examination (MUSICAL) captures all patients with active synovitis, and our new joint-specific scoring system is highly reliable and sensitive to change.

Receiver operating characteristic analysis using a novel combined thermal and ultrasound imaging for assessment of disease activity in rheumatoid arthritis

We aim to determine whether combined thermal and ultrasound (CTUS) imaging can identify rheumatoid arthritis (RA) patients with at least moderate disease activity (DAS28 > 3.2). Temperature differences of maximum (T_max), average (T_avg) and minimum (T_min) temperatures from a control temperature at 22 joints (bilateral hands) were summed up to derive the respective MAX, AVG and MIN per patient. MAX (PD), AVG (PD) and MIN (PD) are CTUS results derived by multiplying MAX, AVG and MIN by a factor of 2 when a patient's total ultrasound power Doppler (PD) joint inflammation score > median score, which otherwise remained unchanged. Receiver operating characteristic (ROC) analysis was used to determine whether CTUS imaging can identify patients with DAS28 > 3.2. In this cross-sectional study, 814 joints were imaged among 37 RA patients (mean disease duration, 31 months). CTUS (but not single modality) imaging parameters were all significantly greater comparing patients with DAS28 > 3.2 versus those with DAS28 ≤ 3.2 (all P < 0.01). Area under the ROC curves (AUCs) using cut-off levels of ≥ 94.5, ≥ 64.6 and ≥ 42.3 in identifying patients with DAS28 > 3.2 were 0.73 , 0.76 and 0.76 for MAX (PD), AVG (PD) and MIN (PD), respectively (with sensitivity ranging from 58 to 61% and specificity all 100%). The use of CTUS in detecting a greater severity of joint inflammation among patients with at least moderate disease activity (DAS28 > 3.2) appears promising and will require further validation in independent RA cohorts.

Hematological markers and ultrasound 7-joint inflammation score as add-on tools in the assessment of inflammation in rheumatoid arthritis patients

Background

Rheumatoid arthritis (RA) is an autoimmune disease characterized by synovial inflammation and joint destruction that eventually induces severe disability. Inflammation is the key determinant and primary underlying mechanism leading to disability and increased mortality in patients with RA. This study aimed to correlate the hematological markers and ultrasound 7-joint inflammation score to disease activity in rheumatoid arthritis patients.

Results

The current study involved 54 RA patients diagnosed according to the 2010 ACR/EULAR classification criteria for RA and thirty healthy control subjects. There were 48 females (88.9%) and 6 males (11.1%). The age of patients ranged from 32 to 60 years, with a mean of 46.04 ± 5.65 years. Using disease activity score 28-ESR, total white blood cell count and absolute lymphocytic count were significantly lower in RA patients with high disease activity. Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, mean platelet volume, ESR, and CRP were significantly higher in patients with high disease activity using disease activity score 28 CRP. Also, a statistically significant positive correlation was detected between neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio and both clinical disease activity scores. Red cell distribution width but not platelet distribution width was significantly higher in RA patients but both parameters had no association or correlation with clinical disease activity scores. Neutrophil-to-lymphocyte ratio was found to have a statistically significant positive correlation with the tenosynovitis score by powered Doppler ultrasound. There were statistically significant positive correlations between disease activity score 28 ESR and CRP and synovitis and tenosynovitis scores by greyscale and powered Doppler ultrasound using the ultrasound 7 score.

Conclusion

Neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and mean platelet volume could be potential inflammatory markers for follow-up of disease activity in RA patients. The ultrasound 7 score is a simple and practical scoring system for use in the detection of inflammation, even subclinically in RA patients, which may help the physician in his clinical decisions. The combined use of both hematological markers and the ultrasound 7 score may be of great value.

Musculoskeletal ultrasound as a screening-tool for rheumatoid arthritis: results of the "Rheuma-Truck" screening and awareness initiative

OBJECTIVE

To evaluate musculoskeletal ultrasound (MSUS) as a screening tool for rheumatoid arthritis (RA) and osteoarthritis (OA) patients in a rheumatology-screening program.

PATIENTS AND METHODS

To raise awareness for rheumatic diseases, a mobile rheumatology office was deployed in different cities of Germany ("Rheuma-Truck"). Standardized questionnaire assessment, testing for rheumatoid factor and citrullinated peptide antibodies and medical student driven MSUS of the clinically dominant hand/foot including wrist, MCP-II, -III, -V, PIP-II, -III, MTP-II and -V were offered free of charge to the population. In case of suspicious results, a rheumatologist was consulted.

RESULTS

In MSUS, 192 of 560 selected volunteers (aged 18-89, mean 52.7 years; 72.9% female) had suspicious findings including synovitis or erosions primarily affecting the MTP-II (11.8%), dorsal wrist (8.9%), and MCP-II (7%). 354 of the 560 volunteers further visited a rheumatologist of whom 76 were diagnosed with RA. According to the 'US7 Score', a sum scores ≥ 5 was significantly predictive for RA (odds ratio (OR) 5.06; confidence interval (CI) 0.83-35.32). 313 volunteers displayed signs of OA including osteophytes, while MCP-II (36.2%), MCP-III (14.8%), and the wrist (10.5%) were mostly affected. Diagnosis of RA was favoured over OA if the wrist (OR 4.2; CI 1.28-13.95), MTP-II (OR 1.62; CI 1.0-2.6), and MCP-V (OR 2.0; CI 1.0-3.8) were involved.

CONCLUSION

Medical student driven MSUS by the 'US7 Score' can facilitate diagnosis of RA in rheumatology-screening programs due to the level of the score and the affected joints. A high rate of unknown OA signs was detected by MSUS. A mobile rheumatology office displays an opportunity to screen patients for RA and OA.

EULAR points to consider for the management of difficult-to-treat rheumatoid arthritis

OBJECTIVE

To develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).

METHODS

An EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A-D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0-10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.

RESULTS

Two overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4-9.6).

CONCLUSIONS

These PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

Ultrasonography of auricular cartilage is a potential tool for diagnosing relapsing polychondritis and monitoring disease activity

Aim

To assess the clinical utility of ultrasonography in the diagnosis and monitoring of disease activity in relapsing polychondritis (RP).

Methods

Auricular and nasal chondritis of 6 patients with RP were assessed by ultrasonography before treatment initiation. Changes in the ultrasonographic and clinical findings and serum inflammatory markers were longitudinally assessed. Ultrasonography was also performed in 6 patients with repeat ear trauma, 6 patients with auricular cellulitis and 6 healthy controls for comparison among groups.

Results

In all cases of RP, ultrasonographic findings before treatment revealed low‐echoic swollen auricular and nasal cartilage and perichondral soft‐tissue with increased power Doppler signals (PDS) corresponding to biopsy findings. After 2‐month treatment with prednisolone (PSL) combined with methotrexate, clinical and serum inflammatory markers were completely resolved. Although swollen perichondral soft‐tissue, cartilage and PDS on auricular ultrasonography were also significantly improved, PDS remained in 2 of 6 cases, which showed flare early after tapering PSL. Finally, ultrasonographic findings of RP were substantially differentiated between patients with repeat trauma and cellulitis and healthy controls based on the thickness of soft tissue around the cartilage, PDS and subperichondral serous effusion.

Conclusion

Assessment of RP lesions by ultrasonography is useful for the evaluation of cartilaginous lesions and monitoring of disease activity, especially when considering the treatment response and the timing of drug tapering.

Ultrasonography Reliability in the Detection of Inflammatory and Structural Abnormalities: An Exercise in Multiple Joints

BACKGROUND

Ultrasonography is an image technique that allows rheumatologists to visualize structural and inflammatory changes within a joint. The objective of this study was to assess the interobserver and intraobserver reliability of musculoskeletal ultrasound (US) in the detection of inflammatory and destructive joint changes in patients with polyarthritis.

METHODS

A Delphi exercise was undertaken to standardize and adapt the EULAR-OMERACT elementary US definitions of inflammatory lesions (effusion, synovial hypertrophy, power Doppler, bone erosions, and synovitis) for each joint. Fifteen patients were analyzed, and video clips of 600 joints were collected. Each joint was scored for the presence of each elementary component, on 2 separate occasions, by 6 examiners. Interobserver and intraobserver agreement analysis was assessed through Fleiss κ coefficient (κ).

RESULTS

Considering all patients and all joints, the interobserver values were highest for erosions and lowest for effusion (κ = 0.7314 and κ = 0.6044, respectively). When analyzing different regions, the highest interobserver agreement was for tibiotalar joint (κ = 0.8043) and the lowest for wrist (κ = 0.6767). Intraobserver reliability was excellent for each and all elementary components and anatomical region.

CONCLUSIONS

The present study showed either a good or excellent US interobserver and intraobserver reliability in elementary elements and anatomical region. This kind of US reliability exercises are important for standardization of exploration in everyday practice by reducing the variability associated with this imaging technique, and ensuring a greater degree of homogeneity and future comparability in the assessment of disease activity in polyarthritis patients.

Construct validity and response to therapy of the U9 ultrasonographic scale for assessment of disease activity in rheumatoid arthritis

Objectives

To test the construct validity of the U9 ultrasonographic scale, to determine the cut-off points for different degrees of rheumatoid arthritis (RA) activity, and to determine whether or not US assessment with the U9 score is useful for monitoring the response to treatment of RA.

Material and methods

A prospective, multicenter study was conducted in 4 different centers in Egypt. All RA patients who were recruited were subject to evaluation of clinical disease activity by the Clinical Disease Activity Index (CDAI) and Disease Activity Score of 28 joints based on erythrocyte sedimentation rate (DAS28-ESR). Assessment of the Functional Status by the Health Assessment Questionnaire (HAQ) and U9 ultrasound score was performed. All the targeted joints were assessed by EULAR recommendations and the combined score of EULAR/OMERACT (0–3). Targeted tendons scored 0–3. After three months of treatment, CDAI and DAS28-ESR, HAQ, and U9 were repeated to detect the response.

Results

One hundred and forty patients with mean age 39.26 ±11.30 were recruited from 4 centers. With regard to convergent validity, the U9 ultrasonographic scale was significantly associated with clinical parameters (CDAI and DAS28-ESR) as well as functional state (HAQ) at both visits. Likewise, concerning discriminative validity, the U9 scale showed the ability to distinguish different grades of RA activity, presenting well-defined cut-off points of different grades (severe, moderate, and mild), with very good specificity and sensitivity (11.5, 5.5, and 3.5, respectively). A significant parallel decrease was detected in clinical and sonographic scales at the follow-up assessment.

Conclusions

The U9 ultrasound scale showed good construct (convergent and discriminative) validity and can be used to monitor the disease and therapeutic response to treatment in RA.

Diagnostic issues in difficult-to-treat rheumatoid arthritis: a systematic literature review informing the EULAR recommendations for the management of difficult-to-treat rheumatoid arthritis

Objectives

To summarise the evidence on diagnostic issues in difficult-to-treat rheumatoid arthritis (D2T RA) informing the EULAR recommendations for the management of D2T RA.

Methods

A systematic literature review (SLR) was performed regarding the optimal confirmation of a diagnosis of rheumatoid arthritis (RA) and of mimicking diseases and the assessment of inflammatory disease activity. PubMed and Embase databases were searched up to December 2019. Relevant papers were selected and appraised.

Results

Eighty-two papers were selected for detailed assessment. The identified evidence had several limitations: (1) no studies were found including D2T RA patients specifically, and only the minority of studies included RA patients in whom there was explicit doubt about the diagnosis of RA or presence of inflammatory activity; (2) mostly only correlations were reported, not directly useful to evaluate the accuracy of detecting inflammatory activity in clinical practice; (3) heterogeneous, and often suboptimal, reference standards were used and (4) (thus) only very few studies had a low risk of bias.

To ascertain a diagnosis of RA or relevant mimicking disease, no diagnostic test with sufficient validity and accuracy was identified. To ascertain inflammatory activity in patients with RA in general and in those with obesity and fibromyalgia, ultrasonography (US) was studied most extensively and was found to be the most promising diagnostic test.

Conclusions

This SLR highlights the scarcity of high-quality studies regarding diagnostic issues in D2T RA. No diagnostic tests with sufficient validity and accuracy were found to confirm nor exclude the diagnosis of RA nor its mimicking diseases in D2T RA patients. Despite the lack of high-quality direct evidence, US may have an additional value to assess the presence of inflammatory activity in D2T RA patients, including those with concomitant obesity or fibromyalgia.

Value of MRI and ultrasound for prediction of therapeutic response and erosive progression in patients with early rheumatoid arthritis managed by an aggressive treat-to-target strategy

OBJECTIVES

To investigate if inflammation detected by MRI or ultrasound at rheumatoid arthritis (RA) onset is predictive of erosive progression or poor response to methotrexate monotherapy, and to investigate if subclinical inflammation in remission is predictive of future treatment escalation or erosive progression.

METHODS

In a 2-year study, 218 patients with disease-modifying antirheumatic drug-naïve early RA were treated by a tight-control treat-to-target strategy corresponding to current recommendations. MRI and ultrasound were performed at regular intervals. Baseline imaging-based inflammation measures were analysed as predictors for early methotrexate failure and erosive progression using univariate and multivariate regression adjusted for clinical, laboratory and radiographic measures. In patients in remission after 1 year, imaging measures were analysed as predictors of treatment escalation and erosive progression during the second year. The added value of imaging in prediction models was assessed using receiver operating characteristic analyses.

RESULTS

Baseline MRI inflammation was associated with MRI erosive progression and ultrasound with radiographic erosive progression. No imaging inflammation measure was associated with early methotrexate failure. Imaging inflammation was present in a majority of patients in clinical remission. Tenosynovitis was associated with treatment escalation, and synovitis and tenosynovitis with MRI/radiographic erosive progression during the second year. Imaging information did not improve prediction models for any of the outcomes.

CONCLUSIONS

Imaging-detected inflammation, both at diagnosis and in remission, is associated with elements of future disease development. However, the lack of a significant effect on prediction models indicates limited value of systematic MRI and ultrasound in management of early RA.

Evaluation of Synovitis of Hand in Patients With Rheumatoid Arthritis Using Diffusion Kurtosis Magnetic Resonance Imaging: Initial Findings

OBJECTIVE

To explore the role of diffusion kurtosis magnetic resonance (MR) imaging in the noninvasive identification of synovitis in hand arthritis.

METHODS

A total of 30 patients with rheumatoid arthritis (RA) and 10 patients suspected of RA were enrolled in the prospective study. A 3.0-T MR imaging including the diffusion kurtosis MR imaging sequence (b = 0, 500, 1000, 1500, 2000 s·mm2) was performed. A total of 210 regions of interest were confirmed and diffusion kurtosis MR imaging parameters were generated. The suspected synovitis or effusion was scored on a scale of 0 (effusion) to 3 (mild, moderate, severe synovitis), according to RA-MR imaging scoring system. The performance of diffusion kurtosis MR imaging parameters (the apparent diffusion coefficient [ADC], diffusion coefficient [D], and kurtosis [K]) in distinguishing different synovitis scores was evaluated.

RESULTS

There were significant differences in ADC, D, and K values among different synovitis scores (all P < 0.001). Synovitis scores were negatively correlated with the ADC and D values significantly (r = -0.725, -0.757, respectively, all P < 0.001), but positively correlated with the K values significantly (r = 0.429, P < 0.001). The area under the curve values of D, ADC, and K values were 0.884, 0.874, and 0.728 for differentiating score 1-3 from score 0, respectively. Diffusion coefficient and ADC had similar diagnostic performance, and both were higher than K in detecting synovitis. No significant difference was found between the ADC and D values in detecting synovitis.

CONCLUSIONS

The diffusion kurtosis MR imaging may be feasible as a noninvasive method for the diagnosis and grading of synovitis in the hands of RA patients, and the D and ADC values showed similar diagnostic performance, both of which were higher than K values.

A musculoskeletal ultrasound program as an intervention to improve disease modifying anti-rheumatic drugs adherence in rheumatoid arthritis: a randomized controlled trial

Objectives: To evaluate the effect of a musculoskeletal ultrasound programme (MUSP) applying real-time ultrasonography with reinforcement of findings by a rheumatologist on improving disease-modifying anti-rheumatic drugs (DMARDs) adherence in rheumatoid arthritis (RA).Method: Eligible RA patients with low adherence score (< 6) on the 8-item Morisky Medication Adherence Scale (MMAS-8) were randomized to either an intervention group (receiving MUSP at baseline) or a control group (no MUSP), and followed up for 6 months. Adherence measures (patient-reported and pharmacy dispensing records) and clinical efficacy data were collected. The MUSP's feasibility and acceptability were assessed.Results: Among 132 recruited RA patients, six without baseline visits were excluded; therefore, 126 patients were analysed (62 intervention and 64 control). The primary outcome (proportion of patients with 1 month MMAS-8 score < 6) was significantly smaller (p = 0.019) in the intervention (35.48%) than the control group (56.25%). However, 3 and 6 month adherence and clinical efficacy outcomes were not significantly different between the two groups (all p > 0.05). All 62 patients completed the MUSP (mean time taken, 9.2 min), with the majority reporting moderately/very much improved understanding of their joint condition (71%) and the importance of regularly taking their RA medication(s) (79%). Most patients (90.3%) would recommend the MUSP to another RA patient.Conclusions: The MUSP improved RA patients' DMARDs adherence in the short term and was feasible and well accepted by patients. Future studies could evaluate whether repeated feedback using MUSP could help to sustain the improvement in DMARD adherence in RA patients, and whether this may be clinically impactful and cost-effective.

SWE and SMI ultrasound techniques for monitoring needling treatment of ankylosing spondylitis: study protocol for a single-blinded randomized controlled trial

Background

Ankylosing spondylitis (AS) is a high-incidence disease in young men that interferes with patients’ physical and mental wellbeing and overall quality of life (QoL). It is often accompanied by arthralgia, stiffness, and limited lumbar flexibility. Acupuncture is safe and effective for reducing the symptoms of AS, but the underlying mechanisms by which it does so are not fully understood. Therefore, to objectively assess acupuncture efficacy, which is critical for patients making informed decisions about appropriate treatments, we will use shear-wave elastography (SWE) and superb microvascular imaging (SMI) ultrasound techniques to evaluate elasticity of lumbar paraspinal muscles and blood flow to the sacroiliac joint (SIJ) in AS.

Methods

We will recruit a total of 60 participants diagnosed with AS and 30 healthy subjects. Participants will be randomly allocated 1:1 to either an acupuncture group or a sham control acupuncture group. Primary-outcome measures will be musculoskeletal ultrasound, Ankylosing Spondylitis Quality of Life Scale (ASQoL), Bath Ankylosing Spondylitis Metrology Index (BASMI), and the Visual Analogue Scale (VAS) for pain. Secondary outcome measures will be the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Function Index (BASFI), and Fatigue Scale-14 (FS-14). We will monitor the effect of acupuncture or sham acupuncture on blood flow and SIJ inflammation using SMI, lumbar-muscle stiffness using SWE and the lumbar paraspinal-muscle cross-sectional area (CSA) using a two-dimensional (2D) grayscale imaging. QoL, physical function, and fatigue will be assessed using an evaluation scale or questionnaire developed for this study, with outcomes measured by the ASQoL, BASMI, BASDAI, BASFI, and FS-14. Healthy subjects will not receive acupuncture but undergo only musculoskeletal ultrasound at baseline. Acupuncture and sham control acupuncture interventions will be conducted for 30 min, 2–3 times/week for 12 weeks. Musculoskeletal ultrasound will be conducted at baseline and post-intervention, while other outcomes will be measured at baseline, 6 weeks, and post-intervention. The statistician, outcome assessor, and participants will be blinded to treatment allocation.

Discussion

The results of this single-blinded, randomized trial with sham controls could help demonstrate the efficacy of acupuncture and clarify whether musculoskeletal ultrasound could be used to evaluate AS.

Trial registration

ClinicalTrials.gov ChiCTR2000031476. Registered 3 April 2020.

Ultrasound evaluation of the hands and wrists in patients with systemic sclerosis: Osteophytosis is a major contributor to tender joints

OBJECTIVE

To evaluate the prevalence and clinical associations of ultrasound (US) findings of inflammatory arthritis and joint and soft tissue pathology in patients with systemic sclerosis (SSc).

METHODS

The hands and wrists of 43 SSc patients and 35 age-balanced controls were evaluated by clinical exam and musculoskeletal US. Synovial and tenosynovial pathology were assessed using semi-quantitative Gray Scale (GS) and Power Doppler (PD) scoring. US evaluation for osteophytes, erosions, ulnar artery occlusion, and median nerve cross-sectional areas was performed. Tender joints (TJ), swollen joints (SJ), modified Rodnan skin score (mRSS), digital ulcers, contractures, and calcinosis were evaluated. Concordance between US and physical exam findings at each joint region were assessed, and associations between their severity were analyzed.

RESULTS

TJs and SJs were present in 44.2% and 62.8% of SSc patients, respectively. Inflammatory arthritis, defined as having both GS>0 and PD>0, was observed in 18.6% of SSc patients and no controls. There was a high concordance by joint region between GS synovial hypertrophy and osteophytes (κ=0.88) as well as TJs (κ=0.72). SSc patients had more osteophytes compared to controls (48.8% vs 22.9%, p = 0.018) as well as higher osteophyte severity (p = 0.033).

CONCLUSIONS

Despite a high percentage of tender and swollen joints, less than 20% of SSc patients met criteria for inflammatory arthritis on US. The high concordance of osteophytes with GS synovial hypertrophy and tender joints suggest that osteophytosis may be a significant contributor to joint pain in SSc patients.

Recommendations for the pragmatic use of ultrasound in rheumatoid arthritis by the GEISPER French group

OBJECTIVE

To develop recommendations for the appropriate use of ultrasound in the management of rheumatoid arthritis (RA) in routine practice based on data from the literature and of experts opinion.

METHODS

Based on a systematic literature review, a scientific committee decided on themes and relevant questions to draw up an initial draft of recommendations. These recommendations were submitted to a group of experts in ultrasound in rheumatic and musculoskeletal diseases using a Delphi method, which produced preliminary recommendations. These were submitted to an expanded group of ultrasound experts for relevance, comprehensibility and comprehensiveness. The level of agreement of the experts were recorded during a face-to-face meeting.

RESULTS

Following two rounds of the Delphi, a consensus was reached on three overarching principles, including definitions of joints, tendons and articular sites to be examined, and 10 recommendations. These recommendations underline the benefit of ultrasound for the diagnosis of RA in cases of inflammatory arthralgia or undifferentiated arthritis as well as in assessing the extent of initial structural and inflammatory damage. They also define the role of ultrasound during follow-up or when considering treatment reduction once clinical remission has been achieved. Lastly, they illustrate the utility of ultrasound in facilitating technical procedures.

CONCLUSION

These 10 consensus-based recommendations should harmonize and optimize clinical practice and thus improve the management of RA patients.

Clinical utility of F-18 sodium fluoride PET/CT for estimating disease activity in patients with rheumatoid arthritis

Background

The present study aimed to investigate the clinical implication of F-18 sodium fluoride (NaF) positron emission tomography/computed tomography (PET/CT) for assessing the disease activity of rheumatoid arthritis.

Methods

Seventeen patients with rheumatoid arthritis according to the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria were prospectively enrolled. All enrolled patients underwent F-18 NaF PET/CT along with physical examination, blood test, and ultrasonography. On PET/CT images, two quantitative parameters, F-18 NaF uptake of the joint (joint SUV) and joint-to-bone uptake ratio, were measured for each of the 28 joints included in calculating the disease activity score in 28 joints using erythrocyte sedimentation rate (DAS28-ESR). The relationship between PET/CT parameters and clinical factors and the predictive values of PET/CT parameters for joints with synovitis and high disease activity were evaluated.

Results

Tender joints (joint SUV, 13.6±8.4; joint-to-bone uptake ratio, 1.70±1.02) and both tender and swollen joints (joint SUV, 13.9±5.4; joint-to-normal bone uptake ratio, 1.81±0.76) had significantly higher joint SUV and joint-to-bone uptake ratio than joints without synovitis (joint SUV, 6.0±2.4; joint-to-bone uptake ratio, 0.74±0.31; P<0.001). On correlation analysis, summed joint SUV (P=0.002, correlation coefficient=0.705) and summed joint-to-bone uptake ratio (P<0.001, correlation coefficient=0.861) of 28 joints showed strong positive correlation with DAS28-ESR after adjustment for age and body mass index. Summed joint SUV showed significant positive correlations with ultrasonography findings (grey scale ultrasonography: P=0.047, correlation coefficient =0.468; power Doppler ultrasonography: P=0.045, correlation coefficient =0.507). On the receiver operating characteristic curve analysis, the sensitivity and specificity for predicting synovitis were 83.2% and 92.7%, respectively, for joint SUV and 81.5% and 90.7%, respectively, for joint-to-bone uptake ratio. Moreover, the summation of both PET/CT parameters of 28 joints showed a diagnostic accuracy of 100.0% for predicting high disease activity in rheumatoid arthritis.

Conclusions

Summed joint uptake on F-18 NaF PET/CT had a strong positive correlation with DAS28-ESR and accurately predicted high disease activity. F-18 NaF PET/CT parameters might be used as an imaging biomarker for disease activity in rheumatoid arthritis.

Trial registration

This study was registered at the Clinical Research Information Service of the Korea (CRIS, http://cris.nih.go.kr/cris/en; registry number, KCT0002597; registered November 2017).

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Pragmatic Application of Ultrasonography for the Assessment of Disease Activity in Patients with Early Inflammatory Arthritis

The aim of the study was to examine the usefulness of targeted musculoskeletal ultrasonography (MSUS) in assessing the disease activity of patients with early inflammatory arthritis (EIA). Twenty-eight patients with EIA were enrolled. The MSUS examination of joints with arthritic signs (tenderness or swelling), measurement of 28-joint Disease Activity Score (DAS28), and its components were performed at four-week interval visits until power doppler (PD) US remission was achieved. Various MSUS parameters of grey scale (GS) and PD synovitis were measured. Pearson or Spearman correlation coefficients were determined for the purpose of the study. Data were gathered from a total of 85 visits. The Sum of GS grade correlated better with physical examination findings, while the Sum of PD grade correlated better with serum inflammatory markers and patient global health. However, Global OMERACT-EULAR Synovitis Score (GLOESS), which reflected both PD and GS grades, correlated evenly well with each clinical parameter. In addition, GLOESS correlated best with DAS28 in the overall study population (p < 0.01). Conclusively, our targeted MSUS parameters of arthritic joints, especially sums of semi-quantitative grades of synovitis, could be useful in monitoring patients with EIA.

Role of joint damage, malalignment and inflammation in articular tenderness in rheumatoid arthritis, psoriatic arthritis and osteoarthritis

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.

Joint damage in rheumatoid arthritis: Lessons learned from an extended 36-joint ultrasonography and 28-joint Disease Activity Score assessments

AIM

To study joint damage severity in rheumatoid arthritis (RA) patients classified using ultrasound power Doppler (PD) and gray-scale (GS) joint inflammation outcomes and the 28-joint Disease Activity Score (DAS28).

METHOD

Ultrasound erosion scores were compared between (a) patients in group 1 (PD positive and GS ≥ median score), group 2 (PD negative and GS ≥ median score) and group 3 (PD positive and GS < median score) vs group 4 (PD negative and GS < median score) and (b) patients with high, moderate and low DAS28 scores vs those in DAS28 remission. Comparative analyses were performed using the 2-sample Student's t test.

RESULTS

There were 1080 joints and 1800 joint recesses from 36 joints scanned in 30 RA adult patients (mean DAS28, 3.58; mean disease duration, 70.3 months) in this cross-sectional study. The mean and 95% CI ultrasound erosion scores were significantly higher (P = .026) for groups 1 (9.75, 6.69-12.81) vs 4 (3.4, 1.11-5.69) with a difference (95% CI) of 6.35 (0.78-11.83), but not significantly different (P values all > .05) for (a) groups 2 and 3 vs 4 and (b) patients with high, moderate and low DAS28 scores vs those in DAS28 remission.

CONCLUSION

Severity of ultrasound-detected bone erosions was significantly greater when both positive PD and a greater degree of GS joint inflammation were present in RA. This association was not observed when either component was absent. Single time point ultrasound joint inflammation assessment - and not DAS28 - is reflective of joint damage severity in RA patients.

Sentinel joint scoring in rheumatoid arthritis: an individualized power Doppler assessment strategy

OBJECTIVE

Musculoskeletal ultrasound quantifies the total synovial inflammatory burden in rheumatoid arthritis (RA) but is time consuming when scanning numerous joints. This study evaluated a novel patient-centered method for constructing a longitudinal ultrasound score in RA patients.

METHODS

Fifty-four RA patients starting intravenous tocilizumab were evaluated with power Doppler ultrasound (PDUS) of 34 joints and DAS28-ESR was assessed at baseline and weeks 4, 12, 16, and 24. The sentinel joint score (SJS) was derived from the reduced subset of joints with PDUS ≥ 1 at baseline. Total PDUS (tPDUS) score and US7 were also calculated. Changes in tPDUS and SJS were correlated. Effect sizes were calculated for tPDUS, SJS, and US7. The proportion of "flipped" joints without baseline PDUS signal that later developed PDUS signal was estimated.

RESULTS

At baseline, 1236/1829 joints scanned (67.5%) did not have PDUS signal. The proportion of "flipped" joints at 24 weeks was 5.6% for ≥ 1, 2.9% for ≥ 2, and 1.0% for = 3 PD. tPDUS and SJS scores were highly correlated (r = 0.91 to 0.97). Overall the effect sizes for tPDUS, SJS, and US7 increased over 24 weeks, where SJS was the highest (SJS 1.00 4-week, 1.07 12-week, 1.26 24-week) and tPDUS and US7 were comparable (tPDUS 0.32 4-week, 0.52 12-week, 0.84 24-week; US7 0.23 4-week, 0.52 12-week, 0.74 24-week).

CONCLUSION

In RA patients starting a biologic, scanning only joints with baseline PDUS signal can substantially reduce the number of joints requiring follow-up scanning by 67.5% and improves feasibility. "Flipped" joints are infrequently seen after starting therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01717859 Key messages • Only a small percent of joints develop power Doppler signal after baseline scanning. • Changes in the SJS correlate well with changes in clinical activity measured by DAS28-ESR over time. • The SJS effect size is higher than total PDUS and US7 scores, and may improve examination feasibility.

The Role of Musculoskeletal Ultrasound Imaging in Rheumatoid Arthritis

Musculoskeletal ultrasound (MSUS) is gaining popularity among rheumatologists, especially in the context of rheumatoid arthritis (RA) joint assessment, as it is a non-invasive, radiation-free imaging modality that is relatively easy to set up in a clinic setting. Although ultrasonography (US) is often regarded as being operator dependent with associated reproducibility issues, the use of consensus-based scoring system along with standardized definition of joint inflammation in RA has been shown to improve its performance/reliability as an outcome measurement tool. Through this review article, we have (i) gone through the principle US findings in RA joint assessment, (ii) discussed various scoring systems for evaluation of US joint pathologies, (iii) described the literature in the use of US in areas of RA diagnosis and disease prognostication and (iv) examined the findings of recent major randomized controlled trials incorporating US as monitoring tools to help target treatment in RA. By doing so, we hope to provide clinicians with an insight into the role of musculoskeletal US imaging in areas of RA diagnosis, prognosis and disease monitoring.

Doubtful swelling on clinical examination reflects synovitis in rheumatoid arthritis

Aims

The aim of this study was to evaluate the implication of doubtful joint swelling on clinical examination with respect to objective markers of synovitis by ultrasound (US) in patients with rheumatoid arthritis (RA).

Methods

Two independent observers performed a modified 28 swollen joint assessment (28SJC), in which joints could be graded as either definitely swollen, non-swollen, or doubtfully swollen. Two examiners blinded to clinical information performed US assessment of the hands. We performed descriptive statistics and models to analyse the links between clinical assessment and objective markers of inflammation.

Results

A total of 1204 joints were evaluated in 43 RA patients; 93% (40/43) of patients had ⩾1 joint with doubtful swelling (range: 0-4/patient). Inter-reader reliability for the modified 28SJC was good (0.74). Generally, both grey scale (GS) and power Doppler (PD) discriminated across not swollen, doubtful, and swollen joints. GS signals discriminated better than PD between doubtful swelling and no swelling [odds ratio (OR) for GS: 5.2; 95% confidence interval (CI) 1.2-23.3 versus OR for PD 1.7; 95% CI 0.2-13.0], whereas PD discriminated better than GS between swelling and doubtful swelling (OR for PD: 28.7; 95% CI 3.6-228.2 versus GS: 1.7; 95% CI 0.3-8.4). Joint osteophytes did not increase the degree of doubtfulness.

Conclusion

Clinical doubt in the assessment of joint swelling constitutes an intermediate state between unequivocal swelling and the lack thereof also regarding the objectively quantified level of inflammation. In order to increase sensitivity for joint inflammation, the historical clinical approach of considering doubtful swelling the absence of swelling should be revisited to interpret clinical doubtfulness as an indication of swelling.

T2 Mapping as a New Method for Quantitative Assessment of Cartilage Damage in Rheumatoid Arthritis

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.

The role of ultrasound and magnetic resonance imaging for treat to target in rheumatoid arthritis and psoriatic arthritis

The treat-to-target (T2T) approach has revolutionized the way we treat patients with rheumatic and musculoskeletal diseases. Recent attention has focused on imaging techniques, in particular musculoskeletal ultrasound and MRI as a focus for T2T strategies. Recently, a number of randomized clinical trials have been performed that compared tight clinical control vs control augmented by imaging techniques. While the three published trials have concluded that imaging does not add to tight clinical care, implementing imaging into the T2T strategy has actual advantages, such as the detection of subclinical involvement, and information on joint involvement/pathology and may possess potential advantages as evidenced by certain secondary endpoints. This review examines the findings of these studies and discusses the advantages and disadvantages of incorporating imaging into the T2T strategy.

Validity of 7-Joint Versus Simplified 12-Joint Ultrasonography Scoring Systems in Assessment of Rheumatoid Arthritis Activity

INTRODUCTION

Musculoskeletal ultrasonography (US) is an objective tool for the evaluation of disease activity in rheumatoid arthritis (RA) patients. There is no consensus on the exact number of joints that should be examined. Examination of reduced joint count is more practical than the comprehensive one.

OBJECTIVES

This is a cross-sectional study investigated the validity of a 7-joint US score (US7) in assessment of joint inflammation in RA patients compared with a simplified 12-joint US score (US12) and correlated both to composite disease activity indices.

METHODS

The activity status of 50 RA patients was assessed clinically and ultrasonographically. The disease activity was calculated using 3 composite indices. Ultrasonography was performed by 1 blinded rheumatologist, using power Doppler (PD) and gray-scale (GS) US examination. The US7 and simplified US12 were performed as originally described. However, the GS synovitis and PD synovitis of US12 were computed in 2 separate scores instead of 1. Two sum US7 scores were added, sum (GS) US7 and sum (PD) US7 after summating synovitis and tenosynovitis scores. Ultrasonography interobserver/intraobserver reliability was evaluated on 40 stored images.

RESULTS

Correlation coefficient between the different ultrasonographic scores showed no difference. The GS scores showed no correlation with disease activity parameters; however, the PD scores did. The sum (PD) US7 was the only score that showed significant correlation with the 3 different composite disease indices.

CONCLUSIONS

All studied US scores proved valid in assessment of disease activity status in RA. This is in favor of using the less-time-consuming US7 scores. The strongest correlation found with sum (PD) US7 confirmed the importance of incorporating the tendon in the disease activity assessment.

Ultrasound detects synovitis in replaced and other surgically operated joints in rheumatoid arthritis patients

Background

Joint replacements continue to occur during a rheumatoid arthritis (RA) patient’s lifetime despite significant advances in available treatment options. The purpose of this study was to examine and quantify synovitis in surgically operated joints by ultrasound (US) in RA patients starting a new therapeutic agent.

Methods

RA subjects were enrolled in either tocilizumab or tofacitinib open-label, investigator-initiated trials and were assessed by ultrasound. In a subset of RA patients with joint replacements and/or operations of joint areas (OJA; e.g. joint arthroscopies, fusions, and synovectomies), joint-level scores of synovitis were compared between replaced joints, OJAs, and native joints. Joint-level synovitis was measured by grayscale (GSUS (0–3)) and power Doppler (PDUS (0–3)) at baseline and follow-up (3–6 months). McNemar’s test or Wilcoxon signed rank test utilized the mixed effects ordinal logistic regression models.

Results

Twenty RA patients had a total of 25 replaced joints and 24 OJA. All replaced joints had GSUS> 1 and 92% had PDUS> 1 at baseline, while OJA and native joints had lower evidence of GSUS> 1 (37.5, 38% respectively) and PDUS> 1 (45.8, 62% respectively). GSUS and PDUS semiquantitative scores improved significantly with treatment in replaced joints (p = 0.01, p = 0.007), and native joints (p < 0.001 both), but not OJA.

Conclusions

In RA, joint replacement does not eliminate or prevent ultrasound measured synovitis, where all replaced joints have some evidence of US synovitis. US can also act as a potential marker of response to therapy in replaced joints. Scoring US synovitis in replaced joints should be considered in ultrasound RA clinical trials.

Trial registration

ClinicalTrials.gov NCT01717859 (registered 10/31/2012); ClinicalTrials.gov NCT02321930 (registered 12/22/2014).

Ultrasound assessment in psoriatic arthritis (PsA) and psoriasis vulgaris (non-PsA): which sites are most commonly involved and what features are more important in PsA?

Background

The aim of this study was to find out the most commonly involved sites and the most important ultrasonic features in psoriatic arthritis (PsA).

Methods

In total, 120 PsA patients and 320 psoriasis vulgaris (non-PsA) patients were assessed by grayscale and power Doppler (PD) ultrasound (US). Joints, tendons, enthesis, and bursa changes were observed. Weights of affected anatomical sites of PsA patients (overall weights >90%) were calculated. Affected anatomical sites between PsA and non-PsA patients were compared. Ultrasonic features of joint, tendon, entheses, and bursa changes between PsA and non-PsA patients were also compared. Finally, the test performance of ultrasonic features for the diagnosis of PsA was calculated.

Results

The anatomical sites with the highest weights were the Achilles tendon, quadriceps tendon, and knee; weights of these anatomical sites were all more than 5%. Among the affected anatomical sites of PsA patients, most of the anatomical sites were more greatly affected in the PsA patients than in the non-PsA patients (all P<0.05). The comparison of the affected Achilles tendon, quadriceps tendon, MTP1, subacromial-subdeltoid bursa, MCP4, and MCP3 showed no significance between PsA and non-PsA patients (all P>0.05). Joint synovial thickening, joint PD signal grades, joint bone erosions, tendon sheath synovial thickening, tendon sheath PD signals, enthesis bone erosions, and enthesis PD signals in PsA patients were higher than in non-PsA patients (all P<0.05). Joint PD signal grades, joint bone erosions, enthesis bone erosions, and enthesis PD signals showed the highest specificities, which were 96.06%, 95.15%, 96.93%, and 94.63% respectively.

Conclusions

The most common involvement sites of PsA were the Achilles tendon, quadriceps tendon, and knee, and some sites in non-PsA patients were also highly involved. The most important features in PsA included joint PD signal grades, joint bone erosion, entheses bone erosions, and entheses PD signals in US assessment.

Characterization of a Subset of Patients With Rheumatoid Arthritis for Whom Current Management Strategies are Inadequate

Objective

A subset of patients with seropositive rheumatoid arthritis (RA) do not mount a C‐reactive protein (CRP) response during flares. We hypothesize that these patients are more likely to experience poor clinical care and less likely to respond to traditional therapy. This study questioned whether this presentation was associated with worse disease outcome and distinct immunological features.

Methods

Using Power Doppler ultrasound, 48 RA patients with active synovitis were recruited; 30 had normal (n)CRP (5 mg/L or less) and 18 had high (h)CRP (more than 5 mg/L) levels. All had equivalent disease burden assessed by other clinical and laboratory parameters.

Results

Time to diagnosis and time to first disease‐modifying antirheumatic drug were significantly longer in nCRP compared with hCRP patients (P < 0.05). Significantly more nCRP patients needed escalation to biologics after 2‐year follow‐up (P = 0.01). The inflammatory milieu was also different between the two subgroups. Synergy between inflammatory cytokines observed in hCRP patients was lost in nCRP patients, and nCRP patients had significantly increased regulatory T‐cell (Treg) frequencies that correlated positively with predictors of poor disease outcome. Conversely, hCRP but not nCRP patients demonstrated a significant upregulation of alternative complement pathway factors that correlated negatively with Treg frequency.

Conclusion

Patients with nCRP during flares of RA had an altered immunological profile compared with hCRP patients and experienced diagnostic delays and responded less favorably to conventional treatment.

OMERACT Definitions for Ultrasonographic Pathologies and Elementary Lesions of Rheumatic Disorders 15 Years On

OBJECTIVE

The Outcome Measures in Rheumatology (OMERACT) Ultrasound (US) Working Group (WG) operates research activities for the validation of US as an outcome measurement instrument according to the Filter 2.0 framework.

METHODS

Original publications on definitions and scoring systems for pathophysiological manifestations and elementary lesions of various rheumatic disorders were reviewed from the onset of the WG research in 2005.

RESULTS

Definitions and scoring systems according to new terminology are provided.

CONCLUSION

We have redefined OMERACT US pathology and elementary lesions as well as scoring systems, which are now proposed for OMERACT approval for application in clinical trials.

[MRI diagnostics in inflammatory joint and spinal diseases: protocols and special sequences: when and for what?]

Magnetic resonance imaging (MRI) is an important component in rheumatology for imaging diagnostics and therapy monitoring of inflammatory and non-inflammatory diseases of the spine and peripheral joints. The correct selection of suitable and practical MRI protocols and sequences represents a great challenge for physicians with respect to requesting and interpreting the indications for MRI investigations. This review article provides recommendations and suggestions for MRI investigation protocols for clinical utilization and practice. New sequences are evaluated and assessed in order to generate the best possible standardized and comparable examinations for rheumatology in the future and therefore optimize the quality of radiological interventions.

Ultrasound is not associated with the presence of systemic autoimmunity or symptoms in individuals at risk for rheumatoid arthritis

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.

Measuring inflammation in rheumatoid arthritis with a new clinical and ultrasound index: development and initial validation

With the aim to develop and validate a clinical + ultrasound (US) inflammation score in rheumatoid arthritis (RA) for use in clinical practice, a mixed-method study was conducted. The theoretical development of the index was achieved with qualitative methodology (discussion group and Delphi survey). Subsequently, a cross-sectional study was carried out to analyse issues related to scoring and validation of the new index. RA patients underwent clinical [28 swollen and tender joints count, patient and physician global assessment (PhGA), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)], and US assessments [synovitis or tenosynovitis by grey-scale (GS) and power Doppler (PD) of 42 structures]. An index was created based on statistical models and expert interaction. Construct validity was tested by correlation with DAS28, SDAI, CDAI, and PhGA. Reliability was evaluated in a subgroup of patients with the intraclass correlation coefficient (ICC). US assessment, CRP, and swollen joints were the items that passed the prioritization phase (Delphi study). For the cross-sectional study, 281 patients were randomly divided into design (n = 141) and validation samples (n = 140). The combination of US sites chosen (7 bilaterally) detected the maximum proportion of synovitis and PD present. Three scoring methods were tested: semiquantitative (0-3 GS + 0-3 PD), dichotomous (0/1 GS + 0/1 PD), and qualitative (0/1 based on algorithm). All showed strong correlation with activity measures (ρ ≥ 0.60), and reliability (ICC 0.89-0.93). The index with best parameters of validity, feasibility, and reliability was the qualitative. The final index chosen was the sum of swollen joint count, US qualitative score, and CRP. The UltraSound Activity score is a valid and reliable measure of inflammation in RA equal to the sum of 28 SJC, a simplified (0/1) US assessment of 11 structures and CRP. It is necessary further investigation to demonstrate additional value over existing indices.

The "Treat to Target" Approach to Rheumatoid Arthritis

Treatment of rheumatoid arthritis has evolved significantly over the past decades. Therapeutic advances have made clinical remission a feasible goal. Systematic treatment approaches taking into account objective measures of disease activity ("treat-to-target"/"T2T") have been shown to result in better outcomes. This article reviews the latest information regarding T2T in rheumatoid arthritis, including a synopsis of the different disease activity scores available, new definitions of remission used in clinical trials and in routine clinical care, studies supporting a T2T approach, the role of imaging to guide treatment, and areas in which uncertainty remains.

Assessing synovitis in the hands in patients with rheumatoid arthritis by ultrasound: an agreement study exploring the most inflammatory active side from two Norwegian trials

Objective

To assess if the right hand, the dominant hand, or the hand with more clinically swollen joints (SwJ) is per se the most inflamed and exhibits the greatest change during treatment and hence preferred for unilateral scoring of synovitis by ultrasound in rheumatoid arthritis (RA) patients.

Methods

Using data from two previously published Norwegian RA patient cohorts initiating treatment, bilateral metacarpophalangeal joint 1–5, proximal phalangeal joint 2+3, and wrists were evaluated by ultrasound. Using a 0–3 scoring system a grey-scale (GS), power Doppler (PD) and global synovitis score (GLOESS) was calculated for each hand (0–30). For precision, a difference of < ± 3 in sum score was pre-specified as indicating clinically insignificant difference in inflammatory activity for all three scores.

Results

Four hundred thirty-seven RA patients were included. Baseline ultrasound inflammation was statistically significantly higher in hands with more vs fewer SwJ ([mean difference, 95%CI] GS sum score 2.21[1.30 to 3.12], PD sum score 1.70 [0.94 to 2.47] and GLOESS 2.31[1.36 to 3.26]) and also exhibited significantly more change for all sum scores at 3 months follow-up (GS sum score 1.34 [0.60 to 2.08], PD sum score 1.17 [0.44 to 1.91], and GLOESS 1.43 [0.63 to 2.22]). No such differences were found between the dominant and the non-dominant or the right and the left hands at any time points.

Conclusion

The hand with clinically more SwJ is statistically more inflammatory active according to GS, Doppler, and GLOESS sum scores, exhibits a change during treatment, and is potentially the best choice for unilateral scoring systems.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1930-y) contains supplementary material, which is available to authorized users.

Novel Ultrasound Image Acquisition Protocol and Scoring System for the Pediatric Knee

OBJECTIVE

The use of musculoskeletal ultrasound is increasing among pediatric rheumatologists. Reliable scoring systems are needed for the objective assessment of synovitis. The aims of this study were to create a standardized and reproducible image acquisition protocol for B-mode and Doppler ultrasound of the pediatric knee, and to develop a standardized scoring system and determine its reliability for pediatric knee synovitis.

METHODS

Six pediatric rheumatologists developed a set of standard views for knee assessment in children with juvenile arthritis. Subsequently, a comprehensive literature review, practical exercises, and a consensus process were performed. A scoring system for both B-mode and Doppler was then developed and assessed for reliability. Interreader reliability or agreement among a total of 16 raters was determined using 2-way single-score intraclass correlation coefficient (ICC) analysis.

RESULTS

Twenty-one views to assess knee arthritis were initially identified. Following completion of practical exercises and subsequent consensus processes, 3 views in both B-mode and Doppler were selected: suprapatellar longitudinal and medial/lateral parapatellar transverse views. Several rounds of scoring and modifications resulted in a final ICC of suprapatellar view B-mode 0.89 (95% confidence interval [95% CI] 0.86-0.92) and Doppler 0.55 (95% CI 0.41-0.69), medial parapatellar view B-mode 0.76 (95% CI 0.68-0.83) and Doppler 0.75 (95% CI 0.66-0.83), and lateral parapatellar view B-mode 0.82 (95% CI 0.75-0.88) and Doppler 0.76 (95% CI 0.66-0.84).

CONCLUSION

A novel B-mode and Doppler image acquisition and scoring system for assessing synovitis in the pediatric knee was successfully developed through practical exercises and a consensus process. Study results demonstrate overall good-to-excellent reliability.

MR and ultrasound of the hands and wrists in rheumatoid arthritis. Part II. Added clinical value

Advanced imaging has become just as vital for diagnosing, staging, and monitoring disease in rheumatoid arthritis (RA) patients as it is for cancer patients. Part 1 of this review discussed synovitis, tenosynovitis, erosions, and osteitis-key imaging findings that occur in patients with RA. Part 2 will now show how these features, in combination with clinical and serologic data, can assist clinical decision-making at various stages of a patient's disease course. Specifically, assessing current disease activity and prognosticating future aggressiveness inform treatment decisions at initial presentation, during medical treatment, and at clinical remission. In addition to summarizing the current literature on advanced imaging in RA, clinical examples from different stages throughout the disease course will illustrate practical approaches for applying these research results. Last, this review will describe potential future roles of imaging in RA patients.

MRI and ultrasound of the hands and wrists in rheumatoid arthritis. I. Imaging findings

The management of patients with rheumatoid arthritis (RA) has rapidly evolved with the development of newer disease-modifying drugs and the recognition that long-term damage can be mitigated by an earlier and more-informed use of these medications. Historically, radiographs were the mainstay of imaging in RA patients, but radiographic joint narrowing and erosions are late and insensitive findings in the disease. MRI (with intravenous contrast agent) and ultrasound (with power Doppler interrogation) of the hands and wrists are able to demonstrate erosions earlier and with greater sensitivity than radiographs. More importantly, these imaging studies also depict synovitis and active soft-tissue inflammation, which represents a precursor to structural damage. Additionally, MRI can show inflammation within the bones (osteitis), which is proving to be the most important prognosticator of an aggressive disease course. Part I of this review discusses the imaging techniques, pitfalls, definitions, and comparative studies of MRI and ultrasound for identifying and quantifying erosions, synovitis, and osteitis. Part II will demonstrate how these imaging findings influence the clinical management of RA patients throughout their disease course, from presentation through clinical remission.