Whole-body MRI for the investigation of joint involvement in inflammatory arthritis

OBJECTIVES

This study aimed to develop a novel whole-body MRI protocol capable of assessing inflammatory arthritis at an early stage in multiple joints in one examination.

MATERIALS AND METHODS

Forty-six patients with inflammatory joint symptoms and 9 healthy volunteers underwent whole-body MR imaging on a 3.0 T MRI scanner in this prospective study. Image quality and pathology in each joint, bursae, entheses and tendons were scored by two of three radiologists and compared to clinical joint scores. Participants were divided into three groups based on diagnosis at 1-year follow-up (healthy volunteers, rheumatoid arthritis and all other types of arthritis). Radiology scores were compared between the three groups using a Kruskal-Wallis test. The clinical utility of radiology scoring was compared to clinical scoring using ROC analysis.

RESULTS

A protocol capable of whole-body MR imaging of the joints with an image acquisition time under 20 min was developed with excellent image quality. Synovitis scores were significantly higher in patients who were diagnosed with rheumatoid arthritis at 12 months (p < 0.05). Radiology scoring of bursitis showed statistically significant differences between each of the three groups-healthy control, rheumatoid arthritis and non-rheumatoid arthritis (p < 0.05). There was no statistically significant difference in ROC analysis between MRI and clinical scores.

CONCLUSION

This study has developed a whole-body MRI joint imaging protocol that is clinically feasible and shows good differentiation of joint pathology between healthy controls, patients with rheumatoid arthritis and patients with other forms of arthritis.

Real-world experience of IL-17Ai drug survival in a large cohort of axial spondyloarthritis and psoriatic arthritis

Objective

The aim was to assess the use and drug survival of IL-17Ai in a real-world cohort of axial SpA (axSpA) and PsA patients.

Methods

Patients ever commenced on an IL-17Ai (secukinumab or ixekizumab) for axSpA or PsA at the Leeds Specialist Spondyloarthritis Service were identified. Demographics, IL-17Ai treatment length and reason for cessation were collected. Drug survival data were plotted as a Kaplan-Meier curve, with log rank test of median survival compared between axSpA and PsA. Cox regression analysis was performed to investigate the relationship between diagnosis and length of drug survival.

Results

In total, 228 patients (91 axSpA and 137 PsA) were exposed to IL-17Ai. Drug survival for all patients at 12 months was 69% (95% Confidence Interval (CI) 63, 75%) and at 24 months 60% (95% CI 54, 67%). In axSpA and PsA, drug survival at 12 months was 63% (CI 54, 74%) and 73% (CI 66, 81%), respectively, and at 24 months it was 53% (CI 44, 65%) and 65% (CI 57, 75%), respectively. Median survival did not differ significantly between both diseases (log rank test 0.65). There was no association between diagnosis and survival (hazard ratio 0.92, 95% CI 0.63, 1.33), including when adjusting for age, previous biologic DMARD usage and sex (hazard ratio 0.89, 95% CI 0.61, 1.13).

Conclusion

This is the first study, to our knowledge, to analyse and compare real-world IL-17Ai drug survival in patients with axSpA and PsA from a single centre. We demonstrate that there is no difference in IL-17Ai survival rates and no relationship between diagnosis and drug survival. These results contribute to the body of real-world evidence confirming the role of IL-17Ai in the management of axSpA and PsA.

Regulation of entheseal IL-23 expression by IL-4 and IL-13 as an explanation for arthropathy development under dupilumab therapy

OBJECTIVES

Dupilumab blocks the IL-4 receptor (IL-4R) and thus signalling of the 'Th2' cytokines IL-4 and IL-13. It has a license to treat atopic eczema and was recently linked to emergent enthesitis and psoriasis. We investigated the cellular and functional basis for how IL-4/IL-13 regulates the IL-23-IL-17 axis in entheseal stromal, myeloid and lymphocyte cells.

METHODS

Immunohistochemistry was performed on healthy enthesis samples from patients undergoing elective spinal surgery to investigate entheseal tissue IL-4R expression and cytokine expression by intracellular flow cytometry for IL-4 and IL-13. Digested human enthesis samples were stimulated with lipopolysaccharide (LPS) for IL-23 induction, either alone or with IL-4 or IL-13. Enthesis fibroblasts were stimulated with TNF and IL-17 with and without IL-4 or IL-13 to assess the effect on CCL20 secretion. Synovial fluid samples from PsA patients were also analysed by ELISA for levels of IL-4 and IL-13.

RESULTS

The IL-4/IL-13 receptor was present in both the peri-entheseal bone and enthesis soft tissue, and entheseal-derived T cells produced basal levels of IL-4, but not IL-13. Both IL-4 and IL-13 attenuated LPS-induced entheseal IL-23 production. IL-4 also downregulated secretion of TNF/IL-17A-induced CCL20 from entheseal fibroblasts. Both IL-13 and IL-4 were also detectable in the synovial fluid of PsA patients. We also noted a seronegative inflammatory oligoarthritis whilst under dupilumab therapy.

CONCLUSION

Our findings suggest a previously unknown protective role for IL-4/IL-13 in entheseal induction of the IL-23-IL-17 axis. These findings point towards a novel explanation for IL-13 pathway single nucleotide polymorphisms in PsA and also a molecular explanation for why anti-IL-4/IL-13 therapy may induce musculoskeletal entheseal pathology as recently reported.

Long-term follow-up of patients in the TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) trial

OBJECTIVES

The TIght COntrol of inflammation in early Psoriatic Arthritis (TICOPA) study was the first strategy trial in psoriatic arthritis using an early treat-to-target strategy to improve clinical outcomes. The current study aimed to review a cohort of patients who had completed TICOPA to judge if the clinical advantage gained by participants in the tight control (TC) arm was sustained, and to explore subsequent therapy.

METHODS

A case note review was conducted for a cohort of patients who had participated in TICOPA. Current drug use and clinical status were obtained, with low disease activity judged as no tender or swollen joints, no dactylitis and enthesitis, and no change in treatment required.

RESULTS

Approximately five years after completion of the TICOPA study, notes were reviewed for 110 patients [TC, n = 54; standard care (StdC), n = 56]. Disease activity was found to be similar in both groups (current low disease activity: TC 69%, StdC 76%). Biologic use at the end of the study was higher in the TC arm (TC 33%, StdC 9%), but at review a similar percentage in both groups were taking biologic drugs (TC 54%, StdC 52%), whereas MTX use diminished.

CONCLUSION

After several years, clinical outcomes and therapeutic drug use were similarly good for patients in both arms of the TICOPA study, with no obvious clinical advantage after TC ended. Notably, TC did not result in greater biological use long term, and MTX use decreased in both arms of the study.

P83 Improving patient care through a collaborative effort in the Leeds Combined Psoriatic Service: an effective provision of multi-specialty input

Background

NICE guidance (NG65) endorses the need for a multi-specialist approach in spondyloarthritis. The Leeds Combined Psoriatic Service has been running rheumatology and dermatology clinics in parallel since 2011, where patients with psoriatic arthritis (PsA) and psoriasis from both services are reviewed on request by both teams.

Methods

Prospective survey to assess the potential benefits of the current combined review over a 17-month period (May 2018-September 2019). In addition, a patient satisfaction survey was performed in the rheumatology setup.

Results

In a standard month, 120 patients with PsA and 180 with psoriasis are reviewed in each clinic. A total of 136 combined consultations took place during this study period with dermatologists reviewing rheumatology patients on 87 occasions and rheumatology reviewing dermatology patients on 49 occasions. Overall, the combined review had a direct impact on the other specialty’s clinical treatment plan in 32% (44/136). This included altering csDMARDs (16%; 7/44), switching or starting a TNF inhibitor (20%; 9/44), new IL-17 inhibition (41%; 18/44); IL-23 inhibition (19%; 8/44), apremilast (5%; 2/44). Furthermore, 12 Rheumatology patients with PsA were able to access a biological medication for which they didn't fulfil NICE criteria or which is not yet approved for use in PsA, based on their skin involvement (1 secukinumab, 2 ixekizumab, 3 adalimumab, 1 rizankizumab, 5 guselkumab); 2 dermatology patients were able to access biological medication prescribed by rheumatology (1 adalimumab, 1 apremilast). Objectively, combined reviews avoided a separate out-patient appointment on 82 occasions averaging a saving of £21,080 to the CCG. A new rheumatological diagnosis was given to 18 people attending the dermatology clinic (4 spondyloarthritis; osteoarthritis, gout, fibromyalgia or mechanical joint pains) and 34 people were given a new skin diagnosis (3 new psoriasis, 9 fungal rash or possible psoriasis, 2 vasculitis, 17 eczema, rosacea or other). During the past year, 196 patients were recruited to clinical trials in rheumatology and 170 in dermatology conducted studies. The patient satisfaction survey was returned by 108 rheumatology patients. In total, 24% (26 of 108) reported benefitting from a dermatologist’s review whilst attending a rheumatology appointment. 70% of rheumatology patients with psoriasis, who were not already under dermatology, had either seen or would like to have seen a dermatologist whilst attending rheumatology clinic.

Conclusion

Combined clinics give clear patient benefits, with improved clinical decision making, enhanced diagnosis and access to therapies. In addition, they carry substantial savings for the CCGs and lead to high patient satisfaction. These specialised services support pioneering clinical practice and deliver cutting-edge care acting as hubs for translational research within the NHS, and as such should be eligible for high tariff commissioning to allow for fine tuning on the delivery of quality of care and cost control.

Disclosures

C. Vandevelde: None. K. Harnden: None. J. Freeston: None. A. Barr: None. K. Shams: None. P. Laws: None. H. Marzo-Ortega: None.

Validity of a two-component imaging-derived disease activity score for improved assessment of synovitis in early rheumatoid arthritis

OBJECTIVES

Imaging of joint inflammation provides a standard against which to derive an updated DAS for RA. Our objectives were to develop and validate a DAS based on reweighting the DAS28 components to maximize association with US-assessed synovitis.

METHODS

Early RA patients from two observational cohorts (n = 434 and n = 117) and a clinical trial (n = 59) were assessed at intervals up to 104 weeks from baseline; all US scans were within 1 week of clinical exam. There were 899, 163 and 183 visits in each cohort. Associations of combined US grey scale and power Doppler scores (GSPD) with 28 tender joint count and 28 swollen joint count (SJC28), CRP, ESR and general health visual analogue scale were examined in linear mixed model regressions. Cross-validation evaluated model predictive ability. Coefficients learned from training data defined a re-weighted DAS28 that was validated against radiographic progression in independent data (3037 observations; 717 patients).

RESULTS

Of the conventional DAS28 components only SJC28 and CRP were associated with GSPD in all three development cohorts. A two-component model including SJC28 and CRP outperformed a four-component model (R2 = 0.235, 0.392, 0.380 vs 0.232, 0.380, 0.375, respectively). The re-weighted two-component DAS28CRP outperformed conventional DAS28 definitions in predicting GSPD (Δtest log-likelihood <-2.6, P < 0.01), Larsen score and presence of erosions.

CONCLUSION

A score based on SJC28 and CRP alone demonstrated stronger associations with synovitis and radiographic progression than the original DAS28 and should be considered in research on pathophysiological manifestations of early RA. Implications for clinical management of RA remain to be established.

Effect of Fatigue, Older Age, Higher Body Mass Index, and Female Sex on Disability in Early Rheumatoid Arthritis in the Treatment-to-Target Era

OBJECTIVE

To compare disease activity and disability over 2 years in early rheumatoid arthritis (RA) before and after implementation of treat-to-target therapy and identify predictors of adverse outcome.

METHODS

The Yorkshire Early Arthritis Register (YEAR) recruited 725 patients with early RA between 2002 and 2009, treated with a step-up approach. The Inflammatory Arthritis Continuum study (IACON) recruited cases between 2010 and 2014 and treated to target. A total of 384 IACON cases met 2010 American College of Rheumatology/European League Against Rheumatism criteria. Latent growth curves of change in Disease Activity Score in 28 joints (DAS28) and the Health Assessment Questionnaire (HAQ) were compared between YEAR and IACON. Latent class growth analysis identified trajectories of change. Baseline predictors of trajectories were identified using logistic regression.

RESULTS

The mean DAS28 over 2 years was lower in IACON than in YEAR. Latent trajectories of HAQ change in YEAR were high stable (21% of cohort), moderate reducing (35%), and low reducing (44%). Only moderate reducing (66%) and low reducing (34%) were seen in IACON. In both cohorts, female sex and fatigue predicted adverse HAQ trajectories (high stable and moderate reducing). Odds ratios (ORs) for moderate reducing compared to low reducing for women were 2.58 (95% confidence interval [95% CI] 1.69, 4.49) in YEAR and 5.81 (95% CI 2.44, 14.29) in IACON. ORs per centimeter fatigue visual analog score were 1.13 (95% CI 1.07, 1.20) in YEAR and 1.16 (95% CI 1.12, 1.20) in IACON.

CONCLUSION

Treat-to-target therapy gave more favorable trajectories of change in DAS28 and HAQ, but adverse HAQ trajectory was more likely in women with greater fatigue, suggesting such patients would benefit from interventions to improve function as well as reduce inflammation.

Whole-body Magnetic Resonance Imaging in Inflammatory Arthritis: Systematic Literature Review and First Steps Toward Standardization and an OMERACT Scoring System

OBJECTIVE

Whole-body magnetic resonance imaging (WB-MRI) is a relatively new technique that can enable assessment of the overall inflammatory status of people with arthritis, but standards for image acquisition, definitions of key pathologies, and a quantification system are required. Our aim was to perform a systematic literature review (SLR) and to develop consensus definitions of key pathologies, anatomical locations for assessment, a set of MRI sequences and imaging planes for the different body regions, and a preliminary scoring system for WB-MRI in inflammatory arthritis.

METHODS

An SLR was initially performed, searching for WB-MRI studies in arthritis, osteoarthritis, spondyloarthritis, or enthesitis. These results were presented to a meeting of the MRI in Arthritis Working Group together with an MR image review. Following this, preliminary standards for WB-MRI in inflammatory arthritides were developed with further iteration at the Working Group meetings at the Outcome Measures in Rheumatology (OMERACT) 2016.

RESULTS

The SLR identified 10 relevant original articles (7 cross-sectional and 3 longitudinal, mostly focusing on synovitis and/or enthesitis in spondyloarthritis, 4 with reproducibility data). The Working Group decided on inflammation in peripheral joints and entheses as primary focus areas, and then developed consensus MRI definitions for these pathologies, selected anatomical locations for assessment, agreed on a core set of MRI sequences and imaging planes for the different regions, and proposed a preliminary scoring system. It was decided to test and further develop the system by iterative multireader exercises.

CONCLUSION

These first steps in developing an OMERACT WB-MRI scoring system for use in inflammatory arthritides offer a framework for further testing and refinement.

The new ACR/EULAR criteria for rheumatoid arthritis can identify patients with same disease activity but less damage by ultrasound

OBJECTIVE

We aimed to compare the ultrasound findings of patients fulfilling the 1987 ACR [OLD-rheumatoid arthritis (RA)] and the new ACR/EULAR (NEW-RA) classification criteria to examine the impact of the new criteria on disease characteristics, particularly disease duration.

MATERIAL AND METHODS

A total of 2730 hands, wrists, elbows, knees, ankles, and foot joints of 105 consecutive patients with inflammatory arthritis, i.e., 82 patients fulfilling the RA criteria (60 patients, OLD-RA; 22 patients, NEW-RA alone) and 23 patients with undifferentiated arthritis, were scanned using ultrasound. Synovitis, erosions, and power Doppler (PD) findings were scored using a scale of 0-3 and scores form each joint were added up to calculate synovitis, PD and erosion scores for each patient.

RESULTS

OLD-RA and NEW-RA patients had similar swollen joint count, tender joint count, acute-phase response, patient global, and disease activity assessment 28 scores. The disease duration was longer in OLD-RA patients [30 (3-179) months] than in NEW-RA patients [16 (0-45) months; p=0.009]. Both the groups had similar synovitis and PD scores, whereas erosion scores were higher in OLD-RA patients than in NEW-RA patients (p=0.009). Patients with undifferentiated arthritis were older than those with RA and had fewer swollen joints than NEW-RA patients [0 (0-4) vs. 2 (0-9); p=0.017]. All other disease activity parameters were similar in both NEW-RA and OLD-RA patients. Both the synovitis (p=0.006) and erosion (p=0.007) scores were lower in patients with undifferentiated arthritis than in OLD-RA patients, despite the scores being similar to those in NEW-RA patients.

CONCLUSION

The new ACR/EULAR RA criteria enabled the classification of patients with similar disease activity (by clinical assessment and ultrasound) but with less damage. A similar disease activity should ensure suitability for an intervention, and a shorter duration and less damage should improve the outcome with patient benefit.

Whole-body MRI of patients with polymyalgia rheumatica identifies a distinct subset with complete patient-reported response to glucocorticoids

OBJECTIVES

To determine whether whole-body MRI defines clinically relevant subgroups within polymyalgia rheumatica (PMR) including glucocorticoid responsiveness.

METHODS

22 patients with PMR and 16 with rheumatoid arthritis (RA), untreated and diagnosed by consultant rheumatologists, underwent whole-body, multiple-joint MRI, scored by two experts. Patients with PMR reported whether they felt 'back to normal' on glucocorticoid therapy and were followed for a median of 2 years.

RESULTS

All patients with PMR were deemed to respond to glucocorticoids clinically. A characteristic pattern of symmetrical, extracapsular inflammation, adjacent to greater trochanter, acetabulum, ischial tuberosity and/or symphysis pubis, was observed in 14/22 of the PMR cases. In PMR, this pattern was associated with complete glucocorticoid response (p=0.01), higher pretreatment C-reactive protein (CRP) and serum interleukin-6 (IL-6), and better post-treatment fatigue and function. Only 1/14 in the extracapsular group could stop glucocorticoids within 1 year, compared with 4/7 of the others. A score derived from the five sites discriminating best between PMR and RA correlated with IL-6 (p<0.002). IL-6 levels ≥16.8 pg/mL had 86% sensitivity and 86% specificity for the extracapsular MRI pattern.

CONCLUSIONS

A subset of patients with rheumatologist-diagnosed PMR had a characteristic, extracapsular pattern of MRI inflammation, associated with elevated IL-6/CRP and with complete patient-reported glucocorticoid responsiveness.

Update on the OMERACT Magnetic Resonance Imaging Task Force: Research and Future Directions

Magnetic resonance imaging (MRI) provides an important biomarker across a range of rheumatological diseases. At the Outcome Measures in Rheumatology (OMERACT) 11 meeting, the MRI task force continued its work of developing and improving the use of MRI outcomes for use in clinical trials. The breadth of pathology in the Rheumatoid Arthritis MRI Score has been strengthened with further work on the development of a joint space narrowing score, and a series of exercises presented at OMERACT 11 demonstrated good reliability and construct validity for this assessment. Understanding the importance of residual inflammation after RA treatment remains a major focus of the group’s work. Analyses were presented on defining the level of synovitis (using MRI scores of a single hand) that would predict absence of erosion progression. The development of the OMERACT Hand Osteoarthritis MRI score has continued with substantial work presented on its iterative development, including pathology definition, scaling, and subsequent reliability of the score. Optimizing the role of MRI as a robust biomarker and surrogate outcome remains a priority for this group.

Which knee and probe position determines the final diagnosis of knee inflammation by ultrasound? Results from a European multicenter study

PURPOSE

To investigate which knee and probe position best identifies knee inflammation and to determine a cut-off level for abnormal synovial effusion.

MATERIALS AND METHODS

18 experienced sonographers (all rheumatologists) performed ultrasound examinations of the knee joint in patients with knee symptoms and in healthy controls. Each sonographer performed longitudinal suprapatellar ultrasound scans using 9 different configurations at each knee: Midline, parapatallar lateral and parapatellar medial from midline in neutral position (0°) with and without quadriceps muscle contraction and in 30° flexion of the knee. The presence of synovial effusion (SE), the effusion measured in millimeters and the presence of synovial hypertrophy (SH) was noted.

RESULTS

A total of 298 knees of 149 subjects (129 patients and 20 controls) were examined. The detection of SH is more sensitive and specific than the detection of SE, independently of the knee and probe position, for the final diagnosis of abnormality. The detection of both synovial hypertrophy and effusion in the knee in neutral position (0°) with quadriceps contraction and with the probe in the midline position, are the best independent predictors for knee abnormalities. Knee effusion > 3.2 mm measured with the probe in the lateral aspect of the knee is the best diagnostic characteristics for predicting pathological SE.

CONCLUSION

The best combination for detecting SH and SE is obtained by placing the probe in the midline position with the knee in 0° with quadriceps contraction. A cut-off value for pathological effusion may be obtained in the lateral aspect of the knee.

Update on research and future directions of the OMERACT MRI inflammatory arthritis group

The OMERACT Magnetic Resonance Imaging (MRI) Task Force has developed and evolved the psoriatic arthritis MRI score (PsAMRIS) over the last few years, and at OMERACT 10, presented longitudinal evaluation by multiple readers, using PsA datasets obtained from extremity MRI magnets. Further evaluation of this score will require more PsA imaging datasets. As well, due to improved image resolution since the development of the original rheumatoid arthritis MRI scoring system (RAMRIS), the Task Force has worked on semiquantitative assessment of joint space narrowing, and developed a reliable method as a potential RAMRIS addendum, although responsiveness will need to be evaluated. One of the strengths of MRI is the ability to detect subclinical synovitis, so the group worked on obtaining low disease activity/clinical remission datasets from a number of international centers and presented cross-sectional findings. Subsequent longitudinal evaluation of this unique resource will be a major continuing focus for the group.

Ultrasound evaluation of fluid in knee recesses at varying degrees of flexion

OBJECTIVE

Various methods are utilized in daily practice to obtain optimal information on effusion in the knee. Our aim is to investigate which scanning position provides the best information about synovial fluid in the knee by using ultrasound and to evaluate the magnitude of difference for measuring synovial fluid in 3 major recesses (suprapatellar, medial parapatellar, and lateral parapatellar) of the knee according to various degrees of flexion.

METHODS

Sonographers in 14 European centers documented bilateral knee joint ultrasound examinations on a total of 148 knee joints. The largest sagittal diameter of fluid was measured in scans corresponding to the 3 major recesses at different (0°, 15°, 30°, 45°, 60°, and 90°) degrees of flexion of the knee. The difference of measurement of effusion according to transducer position, knee position, and the interaction between them was investigated by analysis of variance followed by Tukey's test.

RESULTS

No correlation was noted between patient characteristics and ultrasound detection of effusion. The sagittal diameter of synovial fluid in all 3 recesses was greatest at 30° flexion. Analysis of variance and Tukey's test revealed that the suprapatellar scan and 30° flexion is the best combination for detecting effusion as confirmed by receiver operator characteristic curve analysis.

CONCLUSION

The suprapatellar scan of the knee in 30° flexion was the most sensitive position to detect fluid in knee joints. Sagittal diameter of fluid in all 3 recesses increased with the knee in the 30° flexed position as compared to the extended position.

Development and preliminary validation of a magnetic resonance imaging joint space narrowing score for use in rheumatoid arthritis: potential adjunct to the OMERACT RA MRI scoring system

OBJECTIVE

To develop and validate a magnetic resonance imaging (MRI) method of assessment of joint space narrowing (JSN) in rheumatoid arthritis (RA).

METHODS

Phase A: JSN was scored 0-4 on MR images of 5 RA patients and 3 controls at 15 wrist sites and 2nd-5th metacarpophalangeal (MCP) joints by 8 readers (7 once, one twice), using a preliminary scoring system. Phase B: Image review, discussion, and consensus on JSN definition, and revised scoring system. Phase C: MR images of 15 RA patients and 4 controls were scored using revised system by 5 readers (4 once, one twice), and results compared with radiographs [Sharp-van der Heijde (SvdH) method].

RESULTS

Phase A: Intraobserver agreement: intraclass correlation coefficient (ICC) = 0.99; smallest detectable difference (SDD, for mean of readings) = 2.8 JSN units (4.9% of observed maximal score). Interobserver agreement: ICC = 0.93; SDD = 6.4 JSN units (9.9%). Phase B: Agreement was reached on JSN definition (reduced joint space width compared to normal, as assessed in a slice perpendicular to the joint surface), and revised scoring system (0-4 at 17 wrist sites and 2nd-5th MCP; 0: none; 1: 1-33%; 2: 34-66%; 3: 67-99%; 4: ankylosis). Phase C: Intraobserver agreement: ICC = 0.90; SDD = 6.8 JSN units (11.0%). Interobserver agreement: ICC = 0.92 and SDD = 6.2 JSN units (8.7%). The correlation (ICC) with the SvdH radiographic JSN score of the wrist/hand was 0.77. Simplified approaches evaluating fewer joint spaces demonstrated similar reliability and correlation with radiographic scores.

CONCLUSION

An MRI scoring system of JSN in RA wrist and MCP joints was developed and showed construct validity and good intra- and interreader agreements. The system may, after further validation in longitudinal data sets, be useful as an outcome measure in RA.

Can early diagnosis and management of costochondritis reduce acute chest pain admissions?

OBJECTIVE

We identified patients presenting with chest pain diagnosed as costochondritis by a consultant rheumatologist. The time taken to diagnosis was determined and the influence of diagnosis on subsequent management was assessed. We then estimated any cost benefits that early diagnosis and treatment of costochondritis might confer. Finally, we evaluated our current experience of sulfasalazine as a treatment for recurrent costochondritis.

METHODS

This was a retrospective observational study of 25 consecutive patients (17 female), mean age 50 years (range 26-75), with costochondritis who initially presented with acute chest pain.

RESULTS

The mean time to diagnosis was 9.4 (0-57) months. The total number of chest pain admissions pre-review was 39 compared with 6 post-review (p < 0.0001). The number of minor investigations was 169 pre-review compared with 17 post-review (p < 0.0001), and major investigations 30 compared with 0 (p < 0.01). All 13 patients treated with corticosteroid injections reported symptomatic improvement, and 10 of the 11 whose symptoms recurred responded to sulfasalazine.

CONCLUSION

Patients with costochondritis frequently present with acute chest pain, often resulting in multiple admissions and investigations. In this study admission and investigation rates were significantly reduced following rheumatological review. How much of this reduction is directly a result of rheumatological intervention is unclear, given the limitations of the study. The findings suggest early review may improve patient care and reduce expenditure; in recurrent cases of costochondritis, sulfasalazine may be of additional longterm benefit.