Clinical features of patients with hands arthralgia referred from primary care physicians to rheumatologists: A cohort study

PURPOSE

Early referral of patients with suspicious of rheumatoid arthritis (RA) has an impact on prognosis. Our study aimed to evaluate the clinical characteristics of patients with hands arthralgia who were referred from primary care physicians (PCP) to the rheumatologist.

METHODS

A descriptive, observational, prospective cohort study was performed. We included patients who visited a PCP for the first time for hands arthralgia. Demographics and the European Alliance of Associations for Rheumatology criteria for arthralgia suspicious for progression to RA plus seven complementary questions, the time to referral, the pressure needed to provoke pain with an automatic squeeze test machine in the metacarpophalangeal joints of both hands, and the diagnoses established at the last review of medical charts from patients on follow-up were documented. The primary outcome was the referral to a rheumatologist.

RESULTS

A total of 109 patients were included. The mean age was 49.9 years, 81.6% were women. 30.3% were referred to the rheumatologist. The time to referral was a median of 38 days. The main clinical characteristics associated with referral to the rheumatologist were the "most severe symptoms are present after midnight" (OR=6.29) and the "difficulty with making a fist" (OR=3.67). An isolated "positive squeeze test of metacarpophalangeal joints" was not associated with a referral to the rheumatologist.

CONCLUSIONS

Among patients with hands arthralgia who attended PCP, those with most severe symptoms after midnight and difficulty making a fist were more likely to be referred to the rheumatology clinic. Isolated positive squeeze tests are not a parameter for referral, it should only be performed if arthralgia is clinically suspected.

Outcomes of undifferentiated peripheral inflammatory arthritis in real-world practice. A longitudinal cohort study

OBJECTIVES

Undifferentiated peripheral inflammatory arthritis (UPIA) may have 3 different courses, including evolution to differentiated arthritis, remaining undifferentiated, and self-limited course. The purpose of this study was to provide a real-world evidence for predictors of outcomes in UPIA in a longitudinal cohort of patients.

METHODS

Patients enrolled in the CTDRC-UA cohort were screened for eligibility. Inclusion criteria were: (i) having synovitis in ≥ 1 joint, (ii) not meeting the criteria of any other rheumatic disease, (iii) having at least 2 visits per year, iv) included in the cohort during the period of 2004 to 2021, and (v) having active disease at cohort entry. Two hundred and three patients who met the inclusion criteria were followed up until January 2023.

RESULTS

Medication-free remissions occurred in 42 (20.7%) cases. In 24 (11.8%) cases, the disease met the criteria of other rheumatic diseases, of which rheumatoid arthritis (RA) was the most common. In addition, joint damage occurred in 33 (16.3%) cases. Predictors of medication-free remissions were absence of comorbidity, starting a sustained remission at ≤ 6 months, and having no flare. Factors associated with disease evolution to RA were anti-citrullinated peptide antibody (ACPA) positivity, non-adherence to therapy, not going into sustained remission and having flare. Delay in treatment for > 3 months and being ACPA positive were the predictors of joint damage.

CONCLUSION

Although the majority of UIPA cases treated with step-up combination therapy with DMARDs do not progress to RA, most require continued treatment and a few achieve medication-free remissions. Key Points • Undifferentiated peripheral inflammatory arthritis (UPIA) can progress to rheumatoid arthritis in 11% of cases; and lack of sustained remission, being anti-citrullinated peptide antibody positive, non-adherence to therapy, and having flare are its predictors. • Medication-free remissions occur in 21% of patients with UPIA; and absence of comorbidity, starting a sustained remission at ≤ 6 months, and having no flare are its predictors. • Initiating treatment in the window of opportunity may lead to a better joint outcome.

Should We Use bDMARDs as an Induction Therapy in Early and Severe Rheumatoid Arthritis? Results at 5 years from the ERA UCLouvain Brussels Cohort

INTRODUCTION

This study sought to analyze the benefit of an early induction therapy with a biological disease-modifying anti-rheumatic drugs (bDMARD) during the first year of treatment with a 5-year follow-up in early rheumatoid arthritis (ERA).

METHODS

We included ERA patients from the UCLouvain Brussels cohort who met the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) 2010 classification criteria and were naïve to DMARDs. ERA patients were divided into two groups according to whether they received an induction bDMARD therapy or a standard therapy with methotrexate (MTX). Clinical response after the induction treatment at 6 and 12 months followed by a MTX maintenance therapy at 36 and 60 months was evaluated.

RESULTS

Data from 470 ERA patients were collected, 189 received a bDMARD and 281 initiated MTX alone. In the bDMARD group, disease activity and HAQ were higher at baseline. A total of 391 patients were followed up to 5 years. We then divided each group into two subgroups according to the last treatment they received at 5 years: bDMARD > MTX (n = 95), bDMARD > bDMARD (n = 59); MTX > MTX (n = 134), MTX > bDMARD (n = 103). During the induction, we observed a clinical response with a large number of patients achieving DAS28-CRP remission. According to a treat-to-target (T2T) approach, remission rate was stable on MTX monotherapy or rescued by the addition or prolongation of a bDMARD. Interestingly, bDMARD followed by a MTX maintenance therapy experienced a stable and sustained DAS28-CRP remission rate in 53% of the ERA patients at year 5.

CONCLUSIONS

Long-term remission is an achievable goal in ERA. Our results suggest that a bDMARD induction therapy followed by MTX maintenance therapy could be an interesting option.

Towards a simplified fluid-sensitive MRI protocol in small joints of the hand in early arthritis patients: reliability between modified Dixon and regular Gadolinium enhanced TSE fat saturated MRI-sequences

OBJECTIVE

MRI of small joints plays an important role in the early detection and early treatment of rheumatoid arthritis. Despite its sensitivity to demonstrate inflammation, clinical use is hampered by accessibility, long scan time, intravenous contrast, and consequent high costs. To improve the feasibility of MRI implementation in clinical practice, we introduce a modified Dixon sequence, which does not require contrast and reduces total acquisition time to 6 min. Because the reliability in relation to conventional MRI sequences is unknown, we determined this.

METHODS

In 29 consecutive early arthritis patients, coronal and axial T2-weighted modified Dixon acquisitions on 3.0 T MRI scanner were acquired from metacarpophalangeal 2-5 to the wrist, followed by the standard contrast-enhanced protocol on 1.5 T extremity MRI. Two readers scored osteitis, synovitis and tenosynovitis (summed as total MRI-inflammation), and erosions (all summed as total Rheumatoid Arthritis MRI Score (RAMRIS)). Intraclass correlation coefficients (ICCs) between readers, and comparing the two sequences, were studied. Spearman correlations were determined.

RESULTS

Performance between readers was good/excellent. Comparing modified Dixon and conventional sequences revealed good/excellent reliability: ICC for total MRI-inflammation score was 0.84 (95% CI:0.70-0.92), for erosions 0.90 (95% CI:0.79-0.96), and for the total RAMRIS score 0.88 (95% CI:0.77-0.94). The scores of total MRI-inflammation, total erosions, and total RAMRIS were highly correlated (ρ = 0.80, ρ = 0.81, ρ = 0.82, respectively).

CONCLUSION

The modified Dixon protocol is reliable compared to the conventional MRI protocol, suggesting it is accurate to detect MRI inflammation. The good correlation may be the first step towards a patient-friendly, short and affordable MRI protocol, which can facilitate the implementation of MRI for early detection of inflammation in rheumatology practice.

Influence of initial glucocorticoid co-medication on mortality and hospitalization in early inflammatory arthritis: an investigation by record linkage of clinical and administrative databases

Background

While low-dose oral glucocorticoids (GCs) are recommended in the management of early arthritis, their impact on mortality is unclear. The aim of this study is to evaluate the effect of GCs on mortality in patients with early arthritis, by linking clinical and administrative databases.

Methods

The study included patients with new-onset rheumatoid arthritis (RA) or undifferentiated arthritis (2005–2010), who received DMARDs (MTX in RA or UA with poor prognosis, hydroxychloroquine in UA) and were alive at the second year of follow-up. Low-dose GCs could be prescribed. Clinical and administrative data were linked from Administrative Health Databases (AHD) of the corresponding province, which provided us with information on drug delivery, comorbidities, hospitalization, and mortality. The effect of GCs in the first year was defined using a dichotomous variable or a 3-level categorization (not delivered, ≤7.5 mg/day, or >7.5 mg/day of prednisone) on all-cause mortality, assessed with Cox regression, either crude or adjusted for age, gender, Charlson Comorbidity Index (CCI) or single comorbidities, ACPA, HAQ, and MTX in the first year. A secondary analysis of the effect of GCs on related hospitalizations (for cardiovascular events, diabetes, serious infections, osteoporotic fractures) was also carried.

Results

Four hundred forty-nine patients were enrolled (mean age 58.59, RA 65.03%) of which 51 (11.36%) died during the study. The median (IQR) follow-up was equal to 103.91 (88.03–126.71) months. Treatments with GCs were formally prescribed to 198 patients (44.10%) at ≤7.5 mg/day, although by the end of the study such treatments were received by 257 patients (57.24%); 88 patients (19.6%) were treated with GCs at >7.5 mg/day. In adjusted analyses, the GC delivery (HR, 95% CI 1.35 (0.74, 2.47)) did not significantly predict mortality — both at a low (HR, 95% CI 1.41 (0.73, 2.71)) and at a high (HR, 95% CI 1.23 (0.52, 2.92)) dosage. When “all-cause hospitalization” was used as an outcome, the analysis did not show a difference between patients receiving GC and patients not receiving GC.

Conclusion

In patients with early inflammatory arthritis, the initial GC dose was higher than that prescribed by rheumatologists; however, on background treatment with DMARDs, GC treatments did not seem to increase mortality and hospitalizations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-022-02824-8.

A multicentre validation study of a smartphone application to screen hand arthritis

BACKGROUND

Arthritis is a common condition, and the prompt and accurate assessment of hand arthritis in primary care is an area of unmet clinical need. We have previously developed and tested a screening tool combining machine-learning algorithms, to help primary care physicians assess patients presenting with arthritis affecting the hands. The aim of this study was to assess the validity of the screening tool among a number of different Rheumatologists.

METHODS

Two hundred and forty-eight consecutive new patients presenting to 7 private Rheumatology practices across Australia were enrolled. Using a smartphone application, each patient had photographs taken of their hands, completed a brief 9-part questionnaire, and had a single examination result (wrist irritability) recorded. The Rheumatologist diagnosis was entered following a 45-minute consultation. Multiple machine learning models were applied to both the photographic and survey/examination results, to generate a screening outcome for the primary diagnoses of osteoarthritis, rheumatoid and psoriatic arthritis.

RESULTS

The combined algorithms in the application performed well in identifying and discriminating between different forms of hand arthritis. The algorithms were able to predict rheumatoid arthritis with accuracy, precision, recall and specificity of 85.1, 80.0, 88.1 and 82.7% respectively. The corresponding results for psoriatic arthritis were 95.2, 76.9, 90.9 and 95.8%, and for osteoarthritis were 77.4, 78.3, 80.6 and 73.7%. The results were maintained when each contributor was excluded from the analysis. The median time to capture all data across the group was 2 minutes and 59 seconds.

CONCLUSIONS

This multicentre study confirms the results of the pilot study, and indicates that the performance of the screening tool is maintained across a group of different Rheumatologists. The smartphone application can provide a screening result from a combination of machine-learning algorithms applied to hand images and patient symptom responses. This could be used to assist primary care physicians in the assessment of patients presenting with hand arthritis, and has the potential to improve the clinical assessment and management of such patients.

Rheumatoid arthritis: Evolving recognition of a common disease

Rheumatoid arthritis (RA) is a highly prevalent autoimmune disease and the most common form of autoimmune inflammatory arthritis. Studies of RA pathogenesis have contributed significantly to understanding the basis for complex immune-mediated disease, identified key steps in the development of autoimmune activation and joint damage in RA, and led to the development of targeted therapies that opened up the era biologic therapy. Current studies are linking differences in gene expression to abnormalities in cellular function that will help optimize therapy for individual patients and advance the goal of personalized medicine. Our evolving understanding and current important issues in RA are highlighted.

A pilot study of a machine-learning tool to assist in the diagnosis of hand arthritis

OBJECTIVE

Arthritis is a common condition, which frequently involves the hands. Patients with inflammatory arthritis have been shown to experience significant delays in diagnosis. We sought to develop and test a screening tool combining an image of a patient's hands, a short series of questions, and a single examination technique, to determine the most likely diagnosis in a patient presenting with hand arthritis. Machine learning techniques were used to develop separate algorithms for each component, which were combined to produce a diagnosis.

METHODS

280 consecutive new patients presenting to a Rheumatology practice with hand arthritis were enrolled. Each patient completed a 9-part questionnaire, had photographs taken of each hand, and had a single examination result recorded. The Rheumatologist diagnosis was recorded following a 45-minute consultation. The photograph algorithm was developed from 1000 previous hand images, and machine learning techniques were applied to the questionnaire results, training several models against the diagnosis from the Rheumatologist.

RESULTS

The combined algorithms in this study were able to predict inflammatory arthritis with an accuracy, precision, recall and specificity of 96·8%, 97·2%, 98·6% and 90·5% respectively. Similar results were found when inflammatory arthritis was subclassified into rheumatoid arthritis and psoriatic arthritis. The corresponding figures for osteoarthritis were 79·6%, 85·9%, 61·9% and 92·6%.

CONCLUSION

This study demonstrates a novel application combining image-processing and a patient questionnaire with applied machine-learning methods, to facilitate the diagnosis of patients presenting with hand arthritis. Preliminary results are encouraging for the application of such techniques in clinical practice. This article is protected by copyright. All rights reserved.

Increased frequency of intermetatarsal and submetatarsal bursitis in early rheumatoid arthritis: a large case-controlled MRI study

Background

The forefoot is a preferential location for joint and tendon sheath inflammation in rheumatoid arthritis (RA). It also contains bursae, of which the intermetatarsal bursae have a synovial lining. Some small imaging studies suggested that intermetatarsal bursitis (IMB) and submetatarsal bursitis (SMB) are involved in RA, but their association has not been thoroughly explored. Healthy control studies suggested that lesion size might be relevant. We studied the relation between IMB and SMB in early RA, compared to other arthritides and healthy controls, and the relevance of lesion sizes.

Methods

Six hundred and thirty-four participants were studied: 157 consecutive patients presenting with early RA, 284 other arthritides, and 193 healthy controls. All underwent unilateral contrast-enhanced MRI of the forefoot at presentation. Two readers independently scored IMB and SMB and measured transverse and dorsoplantar diameters, blinded to clinical data. Subsequently, consensus was reached. Intra-reader ICC was 0.89. Logistic regression models were used, and test characteristics were calculated.

Results

IMB and SMB associated with RA independent of each other (P < 0.001) and independent of age, gender, BMI, RA-MRI inflammation, and anti-CCP-antibodies (P = 0.041). Sensitivity for RA of IMB was 69%, and for SMB 25%. Specificity for IMB was 70% compared to other arthritides, and 84% compared to healthy controls. For SMB, this was 94% and 97% respectively. Regarding lesion size, the groups had considerable overlap: no cut-off size for RA could be distinguished with high sensitivity and specificity.

Conclusion

Intermetatarsal and submetatarsal bursitis associated with early rheumatoid arthritis, contributing to the emerging evidence that inflammation of juxta-articular soft tissues is an early feature of RA.

Reproducibility of Metacarpal Bone Mineral Density Measurements Obtained by Dual-Energy X-Ray Absorptiometry in Healthy Volunteers and Patients With Early Arthritis

Reduction in cortical bone mineral density at diaphysis of metacarpal bones of the hand, evaluated by dual X-ray radiogrammetry, has a bad prognostic value in patients with early arthritis. Nevertheless, this technique is hardly accessible in clinical practice. By contrast, evaluation of cortical bone mineral density at that location has not been previously assessed by conventional dual X-ray absorptiometry. The aim of this study is to evaluate the reproducibility of bone mineral density measurements at diaphysis of metacarpal bones using conventional dual X-ray densitometry in a population of healthy volunteers and patients with early arthritis. Nondominant hand dual X-ray densitometry was performed at three consecutive times with complete hand replacement in 27 subjects: 10 early arthritis and 17 healthy volunteers. Three different evaluators analyzed the 3 measurements of second to fourth metacarpal bones. To assess the reproducibility and accuracy of the measurements, intra- and interobserver agreement degrees, intra- and interclass correlation coefficients, smallest difference detectable assessment, and Bland Altman graphs were calculated. The coefficients of variation obtained for the different metacarpal evaluations were 2.25%, 2.91%, 2.85%, and 2.07% for metacarpal-2, metacarpal-3, metacarpal-4, and mean metacarpal-second to fourth, respectively, with a smallest difference detectable of 0.028, 0.034, 0.028, and 0.03 g/cm², respectively. The mean intra- and interobserver correlation coefficients between of metacarpal second to fourth were 0.990 (95% confidence interval [CI]: 0.982-0.995) and 0.995 (95% CI: 0.991-0.997), respectively. As expected, women had lower bone mineral density at metacarpal bones, especially after menopause. The results obtained in this study show an excellent reproducibility of bone mineral density measurements at diaphysis of metacarpal bones of the hand, measured by conventional dual X-ray densitometry, in a mixed population of healthy subjects and patients with early arthritis. This is of great interest for longitudinal studies in patients with early arthritis.

Profiling of IgG antibodies targeting unmodified and corresponding citrullinated autoantigens in a multicenter national cohort of early arthritis in Germany

OBJECTIVE

To assess the diagnostic potential of IgG antibodies to citrullinated and corresponding native autoantigens in early arthritis.

METHODS

IgG autoantibodies to 390 distinct unmodified and corresponding in vitro citrullinated recombinant proteins were measured by a multiplex assay in baseline blood samples from a German multicenter national cohort of 411 early arthritis patients (56.5 ± 14.6 years, 62.8% female). The cohort was randomly split into a training cohort (n = 329, 28.6% ACPA positive) and a validation cohort (n = 82, 32.9% ACPA pos.). The diagnostic properties of candidate antibodies to predict a subsequent diagnosis of rheumatoid arthritis (RA) as opposed to a non-RA diagnosis were assessed by receiver operating characteristics analysis and generalized linear modeling (GLM) with Bonferroni correction in comparison to clinically determined IgM rheumatoid factor (RF) and citrullinated peptide antibody (ACPA) status.

RESULTS

Of 411 patients, 309 (75.2%) were classified as RA. Detection rates of antibody responses to citrullinated and uncitrullinated forms of the proteins were weakly correlated (Spearman's r = 0.13 (95% CI 0.029-0.22), p = 0.01). The concentration of 34 autoantibodies (32 to citrullinated and 2 to uncitrullinated antigens) was increased at least 2-fold in RA patients and further assessed. In the training cohort, a significant association of citrullinated "transformer 2 beta homolog" (cTRA2B)-IgG with RA was observed (OR 5.3 × 103, 95% CI 0.8 × 103-3.0 × 106, p = 0.047). Sensitivity and specificity of cTRA2B-IgG (51.0%/82.9%) were comparable to RF (30.8%/91.6%) or ACPA (32.1%/94.7%). Similar results were obtained in the validation cohort. The addition of cTRA2B-IgG to ACPA improved the diagnostic performance over ACPA alone (p = 0.026 by likelihood ratio test).

CONCLUSIONS

cTRA2B-IgG has the potential to improve RA diagnosis in conjunction with RF and ACPA in early arthritis.

The relation between physical joint examination and MRI-depicted inflammation of metatarsophalangeal joints in early arthritis

BACKGROUND

The relationship between physical joint examination (PE) and MRI-detected inflammation in early inflammatory arthritis has mostly been studied in the hands. Physical examination of MTP joints is considered difficult, and for these joints, this relationship is unknown. Therefore, we studied the concordance of PE with MRI inflammation in MTP joints. Metacarpophalangeal (MCP) joints were included for comparison.

METHODS

One thousand seven hundred fifty-nine MTP(2-5) and 1750 MCP(2-5) joints of 441 consecutive patients with early arthritis underwent PE (for joint swelling) and MRI, all evaluated by two assessors. MRI was scored for synovitis, tenosynovitis, and osteitis (summed MRI inflammation). Synovial intermetatarsal bursae may enlarge upon inflammation and become palpable and were therefore also assessed. Analyses (frequencies, GEE) were performed on joint level.

RESULTS

PE and MRI were concordant in 79% of MTP joints. Of 1606 non-swollen MTP joints, 83% showed no MRI inflammation and 17% showed subclinical MRI inflammation. Of 153 swollen MTP joints, 48% had MRI inflammation and 52% (79 MTP joints) did not. Of these 79 swollen MTP joints without MRI inflammation, 31 showed intermetatarsal bursitis and 48 joints had none of these MRI abnormalities (this concerned 31% of swollen MTP joints). MTP swelling was statistically independently associated with tenosynovitis (OR 2.21, 95% CI 1.1-4.3) and intermetatarsal bursitis (OR 2.91, 95% CI 1.8-4.8). MTP joints showed subclinical inflammation less often than MCP joints (17% vs. 34%, P < 0.001). Swollen MTP joints showed MRI inflammation less often than swollen MCP joints (48% vs. 88%, P < 0.001).

CONCLUSIONS

The absence of swelling of MTP joints in early arthritis is mostly accompanied by the absence of MRI-detected inflammation. Swollen MTP joints are, in addition to synovitis, also explained by tenosynovitis and intermetatarsal bursitis and partly unexplained by MRI. Their clinical relevance must be determined in longitudinal studies.

Improved RA classification among early arthritis patients with the concordant presence of three RA autoantibodies: analysis in two early arthritis clinics

Background

The patients with RA benefit from early identification soon after the first clinical symptoms appear. The 2010 ACR/EULAR classification criteria were developed to fulfill this need and their application has been demonstrated to be effective. However, there is still room for improvement. Therefore, we aimed to evaluate the potential of the concordant presence of RF, anti-CCP and anti-carbamylated protein antibodies to improve current RA classification among early arthritis (EA) patients.

Methods

Data from the first visit of 1057 patients in two EA prospective cohorts were used. The serological scores from the 2010 ACR/EULAR criteria and the concordant presence of the three RA autoantibodies were assessed relative to a gold standard consisting of the RA classification with the 1987 ACR criteria at the 2 years of follow-up.

Results

The concordant presence of three antibodies showed predictive characteristics allowing for direct classification as RA (positive predictive value = 96.1% and OR = 80.9). They were significantly better than the corresponding to the high antibody titers defined as in the 2010 classification criteria (PPV = 88.8%, OR = 26.1). In addition, the concordant presence of two antibodies was also very informative (PPV = 82.3%, OR = 15.1). These results allowed devising a scoring system based only on antibody concordance that displayed similar overall performance as the serological scoring system of the 2010 criteria. However, the best classification was obtained combining the concordance and 2010 serological systems, a combination with a significant contribution from each of the two systems.

Discussion

The concordant presence of RA autoantibodies showed an independent contribution to the classification of EA patients that permitted increased discrimination and precision.

[Higher prevalence of depressive and anxiety symptoms in early arthritis patients in comparison to the normal population]

BACKGROUND

Many studies and registry data confirm that depression, often associated with anxiety disorders is very often found in patients with rheumatoid arthritis (RA). To what extent these psychiatric disorders are already relevant at a very early stage of the disease, has currently not been adequately investigated.

METHODS

In this study 176 patients with early joint symptoms (<1 year) were surveyed in an early arthritis consultation (EAC). The hospital anxiety and depression scale (HADS) was completed by the patients to examine the prevalence of depressive and anxiety symptoms. The results were compared to normative data of the general German population and between the diagnosis groups.

RESULTS

With 47.7% the prevalence of global distress for EA patients was almost twice as high compared to the corresponding group from the general population. This was also confirmed for depressive and anxiety symptoms. The EA patients without confirmed evidence of musculoskeletal inflammatory rheumatic disease (RD) showed nearly the same point prevalence as patients with confirmed RD. In multiple logistic regression the health assessment questionnaire (HAQ) was positively associated with global distress (odds ratio, OR 3.63) while the visual analogue scale (VAS) for global disease activity was positively associated with symptoms of depression (OR 1.03). Female EA patients (OR 5.45) appear to have a higher probability for experiencing corresponding symptoms, whereas patients over 60 years old appear to have less anxiety than younger patients (OR 0.11).

CONCLUSION

The high prevalence of symptoms of depression and anxiety in EA patients compared to the general population is a challenge for rheumatologists, orthopedists and general practitioners, particularly with respect to the differentiation of possible psychosomatic components in noninflammatory joint complaints. The results suggest that screening for psychiatric problems in patients with rheumatism should be evaluated as soon as possible as these can have a great impact on the perception of pain and physical functional status from the very beginning.

Early rheumatoid arthritis is characterised by a distinct and transient synovial fluid cytokine profile of T cell and stromal cell origin

A study by Raza et al., published in this journal in 2005, identified that RA patients, within 3 months of symptom onset, had a synovial fluid cytokine profile that was distinct from that of patients with other inflammatory arthritides of similarly short duration. This profile, which was transient, was characterised by cytokines of stromal and T cell origin. These findings suggested that the first few months after symptom onset were associated with changes in the early RA joint that differed from those operating at later stages. The significance of this paper's methodological approach and its findings, and how they relate to subsequent literature, are discussed.

The impact of gender on time to rheumatoid arthritis classification: a retrospective analysis of a population-based cohort

The objective is to compare the time to fulfillment of 1987 and 2010 ACR/EULAR classification criteria between female and male patients with rheumatoid arthritis (RA) and to assess the potential impact of gender on the time to DMARD therapy. Time from first provider-documented joint swelling to fulfillment of 1987 and 2010 ACR/EULAR criteria was measured in a population-based cohort of adults with incident RA, who were stratified by male or female gender. Disease characteristics, time to start of DMARD therapy, and choice of initial DMARD were compared between groups. The study included 214 patients with RA (148 females and 66 males). Median times from first joint swelling to fulfillment of 1987 (6.5 vs 2.5 days, p = 0.48) and 2010 (1 vs 0 days, p = 0.34) classification criteria were not different between female and male patients overall. There was no difference in time to first DMARD therapy in female vs male patients (15.5 vs 16 days, p = 0.90), and methotrexate was used most frequently as first DMARD in both genders (61% female vs 64% male, p = 0.76). Among the 49 female and 20 male RF/ACPA-negative patients, females experienced a higher median time from first joint swelling to fulfillment of the 1987 (65 vs 11 days, p = 0.063) and 2010 (65 vs 0 days, p = 0.035) classification criteria. Overall, there was no significant delay in meeting 1987 and 2010 ACR/EULAR classification criteria between female and male RA patients, though time to meeting both 1987 and 2010 criteria was slightly longer in males compared with females. Among seronegative patients, females experienced a significant delay to meeting 2010 criteria from first clinically detected synovitis.

Outcome of patients with early arthritis without rheumatoid factor and ACPA and predictors of rheumatoid arthritis in the ESPOIR cohort

OBJECTIVE

To describe the disease course of patients with early arthritis without rheumatoid factor (RF) and anti-citrullinated protein auto-antibodies (ACPA) in an inception cohort. To determine baseline predictors of fulfilling 2010 ACR/EULAR criteria for rheumatoid arthritis (RA) for these patients within 3 years.

METHOD

Patients included in the multicenter ESPOIR cohort were compared at baseline and 3 years by whether they were negative for RF and ACPA ("seronegative") or positive for RF and/or ACPA ("seropositive"). Univariate analysis was used to determine the association between baseline variables in seronegative patients and RA classification. Stepwise multiple logistic regression was used to identify predictors of RA classification within 3 years, estimating odds ratios (ORs).

RESULTS

Among 354 seronegative patients, 224/340 with available data (65.9%) fulfilled RA classification at baseline and 189/233 (81.1%) at 3 years. As compared with seropositive patients, seronegative patients had lower DAS28 (p = 0.002) and lower modified total Sharp score (mTSS; p = 0.026) at baseline; DAS28 remission was similar (p = 0.634), but radiographic progression rate was lower in seronegative patients (p <  0.001) at 3 years. In seronegative patients, factors predicting RA classification within 3 years were additive (OR = 3.61), bilateral (OR = 2.59) and hand, wrist or forefeet involvement (OR = 3.87); presence of a trigger event (OR = 3.57); pain at rest (OR = 2.76); morning stiffness (OR = 2.62); number of tender joints (OR = 23.73); and mTSS (OR = 2.56).

CONCLUSION

"Seronegative" patients have less active disease at baseline and less radiographic progression during follow-up than "seropositive" patients. With inflammatory pain, symmetric involvement of numerous small joints and erosive disease, a classification of RA is likely.

Early arthritis clinic is cost-effective, improves outcomes and reduces biologic use

There is good evidence that dedicated early arthritis clinics (EACs) improve referral lag time and reduce delay in establishing disease-modifying therapy. However, it remains arguable whether such clinics improve relevant disease outcomes. Nationally, only 57% of units have dedicated EACs. Our rheumatology department established a centralised, patient-focused and multidisciplinary EAC to achieve key financial and clinical outcome targets the department was failing to meet. The EAC aimed to increase the department's capacity to accommodate referrals from general practitioners (GPs) and other sources, decrease the time between diagnosis and starting therapy, establish standardised treatment algorithms and reduce biologic use. The EAC was established in January 2016 and comprised the introduction of a dedicated referral pro forma and an EA educational programme for GPs, pooling of all sources of referral, running of six EACs per week with availability of ultrasound and introduction of a standardised approach to the early initiation of therapy and timely review of treatment outcomes. The introduction of the EAC was associated with improved clinical outcomes (EA patients achieving a Disease Activity Score 28 (DAS28) < 3.2 in 2015, 38.0% [N = 113] vs. 78.5% [N = 220] in 2016) and overall patient experience (mean waiting time for EA patients' first appointment in 2015: 12 weeks vs. 2.5 weeks in 2016; 94% [N = 167] of patients recommended the rheumatology service in 2016 vs. 74% [N = 100] in 2015). The total costs associated with introducing the EAC were ~ £201,362. Use of biologics decreased from 26.0 to 5.6% between 2015 and 2016, resulting in a cost saving of ~ £394,942. Other cost savings associated with the EAC included reductions in the overall cost/patient seen (2015, £198.88; 2016, £74.98) and not running any premium rate initiative clinics (saving ~ £26,500 in 2016) to meet waiting list targets. Efficiency gains from the introduction of the EACs have improved patients' health and overall satisfaction with their treatment, whilst saving costs for healthcare.

Similar alteration for mental and physical aspects in health-related quality of life over 5 to 8 years in 1347 patients with early arthritis and early inflammatory back pain

Introduction

Health-related quality of life (HRQoL) is a priority for patients. The objectives were to describe the changes in HRQoL over 5–8 years in patients with early arthritis (EA) or early inflammatory back pain (IBP) and to explore factors associated to HRQoL.

Patients and methods

In 2 prospective observational French cohorts (ESPOIR for EA patients and DESIR for early IBP patients), HRQoL was assessed regularly over 5–8 years, using the SF36 physical and mental composite scores (PCS and MCS, range 0–100). Disease activity was assessed by DAS28-ESR and ASDAS-CRP. Univariate and multivariate linear mixed-effect models and trajectory-based mapping were applied.

Results

In all, 1347 patients (701 EA and 646 early IBP) were analysed: mean age 48.4 ± 12.2 and 33.9 ± 8.7 years respectively; mean disease duration 3.4 ± 1.7 and 18.2 ± 10.8 months; and 76.3% and 55.0% females. At baseline, in EA, mean PCS and MCS were respectively 40.2 ± 9.1 and 40.4 ± 11.2 and, in early IBP, were respectively 38.5 ± 8.5 and 39.8 ± 10.9. Over follow-up, HRQoL mean levels improved mostly over the first 6 months (p <  0.001). Two trajectories were evidenced in both diseases. The ‘good HRQoL’ trajectory groups, i.e. 54–61% of patients, reached levels of HRQoL close to population norms. DAS28-ESR and ASDAS-CRP over time were related to PCS (range of explained variance 9–43%, p <  0.001 in the mixed models) but not to MCS.

Conclusion

HRQoL was altered similarly for both physical and mental aspects in EA and early IBP. Disease activity only partly explained HRQoL: the drivers of HRQoL should be further explored.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1841-y) contains supplementary material, which is available to authorized users.

Early arthritis clinic is effective for rheumatoid and psoriatic arthritides

INTRODUCTION

Early arthritis clinics (EACs) have been well established since 1980s. Most of the data for their effectiveness comes from rheumatoid arthritis (RA) management and is largely limited to process outcomes. There is little evidence that such clinics improve clinical outcomes particularly for psoriatic arthritis (PsA). We examined whether EACs provide better outcomes irrespective of final arthritis diagnosis.

METHODS

A 52-week prospective observational study of all inflammatory arthritis patients presenting to early arthritis service at our secondary care hospital in 2016 was undertaken. A protocolised approach to the early initiation of therapy (within 3 weeks) and 6-weekly review of treatment outcomes was embedded irrespective of the arthritis diagnosis. Statistical analysis was undertaken using Mann-Whitney U test for disease activity scores to ascertain the significance of outcomes.

RESULTS

Of 1884 patients referred, 482 (25.5%) were triaged into EACs based on set criteria. 159 (64.3%) had RA, 55 (22%) with PsA and 33 had other inflammatory arthritides. Mean DAS28 for RA at first visit was 4.65 (0.6-8.0). Treating to target achieved DAS28 remission for 84 (53.5%) and low disease activity (LDA) for a further 44 (34%). Median time to achieve remission or LDA was 20 weeks (0-52 weeks). Mean tender (TJ) and swollen joint (SJ) counts for PsA at first visit were 8.2 (1-35) and 3.5 (0-14), respectively [n = 55]. The patient (PtGA) and physician (PhGA) global assessments mean were 3.0 and 2.9 (1-5). Target [TJ and SJ ≤ 2] was achieved for 38 patients (69%) and good PsARC response for a further four (7%). Median time to achieve the target or good response was 22 weeks (0-48 weeks). Final TJ and SJ mean was significantly better at 1.2 (0-4) and 0.3 (0-2) [p < 0.0001] with similar improvement in PtGA [mean 1.8 (1-4)] and PhGA [mean 1.6 (1-3)].

CONCLUSION

Dedicated EACs help achieve good clinical outcomes in majority of patients with RA and PsA. Nearly 80% of our cohort attained the target or good disease response in less than 6 months. This was despite a significant delay in patients presenting to their GPs and moderately high disease activity.

Do musculoskeletal ultrasound and magnetic resonance imaging identify synovitis and tenosynovitis at the same joints and tendons? A comparative study in early inflammatory arthritis and clinically suspect arthralgia

Objective

Ultrasound (US) and magnetic resonance imaging (MRI) are recommended in the diagnostic process of rheumatoid arthritis. Research on its comparability in early disease phases is scarce. Therefore, we compared synovitis and tenosynovitis detected by US and MRI on joint/tendon level.

Methods

Eight hundred forty joints and 700 tendons of 70 consecutive patients, presenting with inflammatory arthritis or clinically suspect arthralgia, underwent US and MRI of MCP (2–5), wrist and MTP (1–5) joints at the same day. Greyscale (GS) and power Doppler (PD) synovitis were scored according to the modified Szkudlarek method (combining synovial effusion and hypertrophy) and the recently published EULAR-OMERACT method (synovial hypertrophy regardless of the presence of effusion) on static images. US-detected tenosynovitis was scored according to the OMERACT. MRI scans were scored according to the RAMRIS. Test characteristics were calculated on joint/tendon level with MRI as reference. Cut-off for US scores were ≥ 1 and ≥ 2 and for MRI ≥ 1.

Results

Compared to MRI, GS synovitis according to EULAR-OMERACT (cut-off ≥ 1) had a sensitivity ranging from 29 to 75% for the different joint locations; specificity ranged from 80 to 98%. For the modified Szkudlarek method, the sensitivity was 68–91% and specificity 52–71%. PD synovitis had a sensitivity of 30–54% and specificity 97–99% compared to MRI. The sensitivity to detect GS tenosynovitis was 50–78% and the specificity 80–94%. For PD tenosynovitis, the sensitivity was 19–58% and specificity 98–100%.

Conclusion

Current data showed that US is less sensitive than MRI in the early detection of synovitis and tenosynovitis, but resulted in only few non-specific findings. The higher sensitivity of MRI is at the expense of less accessibility and higher costs.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1824-z) contains supplementary material, which is available to authorized users.

Frequency of human leukocyte antigens class II-DR alleles (HLA-DRB1) in Argentinian patients with early arthritis

Patients with rheumatoid arthritis (RA) or undifferentiated arthritis (UA) in the CONAART database (Argentine Consortium for Early Arthritis) were assessed for genetic risk factors for RA, specifically for HLA-DRB1 alleles and the PTPN22 rs2476601 polymorphism associated with progression to RA. This is a case-control study. Blood samples were obtained to determine HLA-DRB1 genotypes by PCR-SSO Luminex and PTPN22 (rs2476601) polymorphism by allelic discrimination. A control group of individuals from the general Argentinian population were obtained from the national register of cadaveric organ donors. A total of 1859 individuals were included in this analysis: 399 patients from the CONAART database (347 patients with RA at study end and 52 patients with UA at study end, mean follow-up time 25 ± 18 months) and 1460 individuals from the general Argentinian population. Compared with the controls, the HLA-DRB1*04 and DRB1*09 alleles were more commonly detected in patients with RA diagnosis (OR (95% CI) 2.23 (1.74-2.85) and 1.89 (1.26-2.81)) respectively. Both patients with UA and the general population showed higher frequency of DRB1*07, DRB1*11 and DRB1*15 alleles than patients with RA. PTPN22 rs2476601 polymorphism frequency was higher in RA and UA vs the general population; however, this was significantly different only for RA vs control group (OR [95% CI] = 1.81 [1.10-3.02], P = 0.018. HLA-DRB1 typing and PTPN22 allelic discrimination could distinguish between patients with UA, patients with early RA, and the general population in Argentina. This is the first study of HLA-DRB1 alleles and PTPN22 polymorphism associations with progression to early RA in an Argentinian population.

Induction of sustained remission in early inflammatory arthritis with the combination of infliximab plus methotrexate: the DINORA trial

BACKGROUND

In the present study, we explored the effects of immediate induction therapy with the anti-tumour necrosis factor (TNF)α antibody infliximab (IFX) plus methotrexate (MTX) compared with MTX alone and with placebo (PL) in patients with very early inflammatory arthritis.

METHODS

In an investigator-initiated, double-blind, randomised, placebo-controlled, multi-centre trial (ISRCTN21272423, http://www.isrctn.com/ISRCTN21272423 ), patients with synovitis of 12 weeks duration in at least two joints underwent 1 year of treatment with IFX in combination with MTX, MTX monotherapy, or PL randomised in a 2:2:1 ratio. The primary endpoint was clinical remission after 1 year (sustained for at least two consecutive visits 8 weeks apart) with remission defined as no swollen joints, 0-2 tender joints, and an acute-phase reactant within the normal range.

RESULTS

Ninety patients participated in the present study. At week 54 (primary endpoint), 32% of the patients in the IFX + MTX group achieved sustained remission compared with 14% on MTX alone and 0% on PL. This difference (p < 0.05 over all three groups) was statistically significant for IFX + MTX vs PL (p < 0.05), but not for IFX + MTX vs MTX (p = 0.10), nor for MTX vs PL (p = 0.31). Remission was maintained during the second year on no therapy in 75% of the IFX + MTX patients compared with 20% of the MTX-only patients.

CONCLUSIONS

These results indicate that patients with early arthritis can benefit from induction therapy with anti-TNF plus MTX compared with MTX alone, suggesting that intensive treatment can alter the disease evolution.

TRIAL REGISTRATION

The trial was registered at http://www.isrctn.com/ISRCTN21272423 on 4 October 2007 (date applied)/12 December 2007 (date assigned). The first patient was included on 24 October 2007.

Symptoms in individuals at risk of rheumatoid arthritis

An increasing interest in treating individuals at risk of rheumatoid arthritis (RA) to prevent the development of this chronic condition has focussed attention on the identification of risk factors of this disease. Most patients who develop RA progress through a preceding symptomatic phase that may take the form of arthralgia, palindromic rheumatism or unclassified arthritis before a disease currently classifiable as RA is established. An understanding of symptoms that identify individuals as being at risk of RA is a critical issue. Constellations of relevant symptoms could (1) form the basis of public health campaigns to encourage rapid consultation, (2) inform primary health care providers regarding which patients to perform additional tests in or whom to refer to a rheumatologist and (3) be included in algorithms to predict RA development. In this review, we present qualitative and quantitative data summarising current understanding of the symptoms experienced by individuals at risk of RA.

Severity indices in rheumatoid arthritis: A systematic review

OBJECTIVE

To identify tools designed to evaluate the severity of patients with rheumatoid arthritis (RA) in order to use them in the investigation of prognostic markers in early arthritis.

METHODS

We conducted a systematic review of studies that developed/validated an index for RA disease severity. They were analyzed using the COSMIN checklist to assess their methodological quality. In addition, all the variables included were evaluated for their clarity of definition, feasibility and probability of being present in each outcome during the first 2 years of the disease course. To estimate redundancy, variables were grouped by domains.

RESULTS

After reviewing 3,519 articles, 3 studies were included. The first study, the PAS, assessed whether current and lifetime treatment with disease-modifying antirheumatic drugs and/or biologics accurately predicted RA severity, as measured by the patient-reported PAS. Treatment variables did not fully distinguish patients in the highest and lowest quartiles of PAS scores. Another severity index, the Claims-Based Index for RA Severity (CIRAS), included the variables age, sex, Felty's syndrome, number of rehabilitation and rheumatology visits, test for inflammatory markers, number of chemistry panels/platelet counts ordered and rheumatoid factor test. The correlation was low (r=0.56) with an index previously validated by the same research group, the RA medical records-based index of severity (RARBIS), with Disease Activity Score-C-reactive protein (DAS28-PCR) (r=0.07) and Multidimensional Health Assessment Questionnaire (MD-HAQ) (r=0.008). Finally, the RARBIS, used to validate the CIRAS, was devised as an RA severity index based on medical records. It includes as domains surgery, radiology, extra-articular manifestations, clinical and laboratory variables, previously chosen by an expert panel. RARBIS had a weak correlation with treatment intensity (r=0.35) and with DAS28 (r=0.41).

CONCLUSION

There is no index to assess the severity of RA based on the course of the first 2 years of follow-up that is adapted to the current strategy of therapeutic management of this disease. Therefore, we believe it is reasonable to develop a new ad hoc severity index for patients with early arthritis.

Psychosocial predictors of DMARD adherence in the first three months of treatment for early arthritis

OBJECTIVES

To induce disease remission, early arthritis patients should adhere to their disease-modifying antirheumatic drugs (DMARD) in the first months after diagnosis. It remains unknown why some patients are non-adherent. We aimed to identify patients at risk for non-adherence in the first 3 months of treatment.

METHODS

Adult DMARD-naive early arthritis patients starting synthetic DMARDs filled out items on potential adherence predictors at baseline. Adherence was measured continuously. Non-adherence was defined as not opening the electronically monitored pill bottle when it should have been. Items were reduced and clustered using principal component analysis. The most discriminating items were identified with latent trait models. We used a multivariable logistic regression model to find non-adherence predictors.

RESULTS

301 patients agreed to participate. Adherence was high and declined over time. Principal component analysis led to 7 dimensions, while subsequent latent trait models analyses led to 15 dimensions. Two dimensions were associated with adherence, one dimension was associated with non-adherence.

CONCLUSIONS

Information seeking behavior and positive expectations about the course of the disease are associated with adherence. Patients who become passive because of pain are at risk for non-adherence.

PRACTICE IMPLICATIONS

Rheumatologists have cues to identify non-adherence, and may intervene on non-adherence through implementing shared decision making techniques.

Self-limiting arthritis among patients fulfilling the 2010 ACR/EULAR classification criteria for rheumatoid arthritis in a very early arthritis cohort

OBJECTIVES

To study occurrence of and factors associated with self-limiting arthritis among patients fulfilling the 2010 ACR/EULAR classification criteria for rheumatoid arthritis (RA) (2010 RA criteria) in patients with ≤16 weeks׳ duration of joint swelling.

METHODS

We applied the 2010 RA criteria in 1118 patients included in a 2-year longitudinal cohort. In all, 256 patients fulfilled the 2010 RA criteria at baseline; outcome was defined as either "self-limiting arthritis" (no DMARD use during follow-up, no swollen joints at last assessment, and no final clinical diagnosis of RA) or "persistent disease." The associations between baseline characteristics, including the components of the 2010 RA criteria score, and outcomes were studied.

RESULTS

In total, 36 of 256 patients (14.1%) classified as having RA had self-limiting arthritis. These patients differed from patients with persistent disease according to ACPA positivity (11.1% vs. 65.0%, p < 0.001), duration of joint swelling (median = 47.5 vs. 66.0 days, p = 0.002), 2010 RA criteria points (median = 6.0 vs. 7.0, p < 0.001), and ever smoking (52.8% vs. 74.5%, p = 0.01). Having no serology points and no duration points were independent predictors of self-limiting arthritis. The rate of self-limiting arthritis was 2.7% vs. 29.4% among ACPA positive vs. ACPA negative patients (p < 0.001), and 32.5% when duration of joint swelling was <4 weeks vs. 10.6% with longer duration (p < 0.001).

CONCLUSIONS

Negative ACPA status, short duration of joint swelling and being a never smoker were factors associated with self-limiting arthritis in early arthritis patients classified as having RA at presentation. Our findings contribute to identify patients who potentially do not need DMARDs and who should not be included in early RA clinical drug trials.

Validation of Leiden Score in Predicting Progression of Rheumatoid Arthritis in Undifferentiated Arthritis in Indian Population

Background:

Leiden Score, is a very useful tool for predicting future development of rheumatoid arthritis (RA), among undifferentiated arthritis (UA) patients. This score has been validated in various western studies but rarely among south east Asian patients.

Aims:

To validate the Leiden early arthritis prediction rule in an Indian cohort of patients for predicting rheumatoid arthritis (RA) in undifferentiated arthritis (UA) patients and to formulate any simpler version of prediction score taking only clinical variables of original Leiden prediction rule.

Subjects and Methods:

In a group comparative longitudinal study model, 58 patients with early symmetrical polyarthritis were enrolled and baseline evaluation was done according to Leiden prediction rule and then 3 monthly. After 1 year, Leiden prediction score and chance of evolving into RA were calculated. Patients were divided into two groups: Those who developed RA and who did not. They were selected on random sampling process. Tender joint count (TJC), duration of morning stiffness, and duration of arthritis were selected as clinical variables for linear discriminant analysis with disease outcome being the dependent variable. Discriminant scores (D) for each patient was calculated. A receiver operating characteristic (ROC) curve was constructed with the discriminant score and compared with Leiden prediction score.

Results:

About 54% (27/50) of patients were diagnosed with RA and 46% (23/50) developed other rheumatologic condition or viral inflammatory arthritis or remained undifferentiated or attained complete remission. None of the patients with UA, who scored the regression coefficients 4 or less progressed to RA, and those who scored 7 or more, almost certainly progressed to RA. Unstandardized canonical discriminant coefficients for TJC (T), duration of morning stiffness (M), and duration of arthritis (A) were calculated. ROC curve was plotted with the formula: D = 0.164 × T + 0.066 × M + 0.012 × A − 2.838. Area under curve (AUC) at 95% confidence interval for our discriminant function was 0.845 (standard error [SE] 0.054). In comparison, AUC of Leiden prediction score was 0.897 (SE 0.043).

Conclusions:

Leiden prediction rule is highly applicable to UA patients to predict progression of RA in Indian patients and larger multi-center study with larger cohorts is needed to validate the formulation we derived to predict RA.

US Guided Treat-to-Target Approach in Early RA: Implications for Uncoupling of Disease Activity and Structural Joint Damage

OBJECTIVE

To assess the relationship between disease activity, measured by DAS28, and radiographic progression, using X-Ray and US as tools to evaluate structural joint damage and residual inflammation, in early RA patients.

METHODS

Changes from baseline to week 52 in clinical variables and measures of radiographic progression were compared between early RA patients who received anti-TNF biologic therapy (192 patients), and those who received synthetic DMARD therapy (288 patients). Patients were stratified into: in remission, low (LDA), moderate (MDA) and high (HDA) disease activity at 52-weeks of treatment according to DAS-28 score. Radiographic progression was assessed both at baseline and at 52-weeks using modified Total Sharp Score (mTSS). In addition, US scores for number of erosions, synovial hypertrophy and vascularity were recorded.

RESULTS

Whilst there was no significant radiologic progression in the patients who achieved remission, whether treated with synthetic DMARD or biologic therapy; on the other hand, there was a steady increase of joint damage in those who did not achieve remission, mainly in those treated with synthetic DMARD and in favor of the biologic therapy. On comparing the MSS scores at 52-weeks, the biologic therapy cohort who showed LDA (DAS-28: 2.6-3.1), MDA (DAS-28 score > 3.2-5.1) and HDA (>5.1) had significantly (p< 0.001) less number of erosions and joint space narrowing (P< 0.001) as well as US-GS and US-PD scores in comparison to the synthetic DMARD therapy cohort. X-Ray and US parameters showed a discriminating value regarding joint damage particularly in the patients who did not achieve remission, with US parameter showing accurate 95% CI estimate.

CONCLUSION

Using US as a sensitive tool for joint affection assessment, the combination of biologic and DMARDs therapies retards joint damage, independently of its effects on disease activity, contrasting synthetic DMARDs monotherapy.

Early lessons from the recent-onset rheumatoid arthritis cohort ESPOIR

ESPOIR is a French multicenter cohort of patients with undifferentiated arthritis enrolled within six months of symptom onset, naive to disease-modifying antirheumatic drugs and corticosteroid therapy, and either having rheumatoid arthritis (RA) or being at risk for progression to RA. The cohort is sponsored by the French Society for Rheumatology (Société française de rhumatologie [SFR]). Between December 2002 and March 2005, 813 patients were enrolled at 14 regional university hospitals, with the participation of a network of community-based rheumatologists. The objective was to establish a database on recent-onset inflammatory joint disease and, more specifically, on RA to serve for scientific research in the clinical, epidemiological, pathophysiological, and healthcare-cost fields. Ten years after enrolment were started, the cohort still has about 500 patients. The scientific committee has approved 104 clinical research projects, of which many are ongoing, and 54 original articles written by numerous French and international groups have been published. These projects cover a vast spectrum of topics including environmental factors, diagnosis, outcomes, prognosis, disease evaluation, imaging, genetics, biomarkers, costs, and RA management strategies.