Mechanism of berbamine-mediated DNA damage in synovial fibroblasts to alleviate rheumatoid arthritis

Rheumatoid arthritis (RA) is a common chronic autoimmune disease characterised by the proliferation and infiltration of fibroblast-like synoviocytes (FLS). However, pharmaceutical approaches to inhibit FLS in the treatment of RA are limited. Berbamine (BBM), a natural compound extracted from Phellodendron chinense Schneider, has demonstrated anti-tumour and anti-inflammatory effects. This study aimed to investigate the inhibitory effect of BBM on FLS in RA and to delineate the specific mechanisms involved, thereby proposing a novel therapeutic strategy for RA. Using the cell counting kit 8 assay and flow cytometry, we found that BBM reduced the proliferative ability of MH7A rheumatoid arthritis fibroblast-like synoviocytes by blocking the cell cycle and inducing apoptosis. In addition, BBM led to a decrease in the mitochondrial membrane potential and an increase in reactive oxygen species (ROS) and DNA damage. To explore the explicit mechanism of BBM, we used the ROS inhibitor N-acetyl-L-cysteine and the anti-apoptotic drug Z-VAD-FMK to rescue the effects of BBM. BBM effectively inhibited joint inflammation in RA cells in vivo. Regarding the safety confirmation, BBM does not damage the liver, spleen, and kidneys of collagen-induced arthritis mice. In summary, we found that the traditional Chinese medicine extract BBM alleviated RA by promoting ROS production and DNA damage in rheumatoid arthritis fibroblast-like synoviocytes providing new ideas for the clinical treatment of RA with traditional Chinese medicine.

Reliability and Availability of the 2017 EULAR-OMERACT Scoring System for Ultrasound Synovitis Assessment: Results From a Training and Reading Exercise

OBJECTIVE

To evaluate the availability and reliability of the European League Against Rheumatisms Outcome Measures in Rheumatology Synovitis (EULAR-OMERACT) scoring system among radiologists with different levels of musculoskeletal ultrasound (US) experience in assessing synovitis in patients with rheumatoid arthritis (RA).

METHOD

The patients with RA were retrospectively recruited from January 2020 to March 2022. Five radiologists with different levels of US experience were recruited for the reader study (R1-5), which included two parts. The participating radiologists first read 120 gray-scale (GS) and 120 Doppler US images twice, before and after a standard training program. In the first part, they semi-quantitatively scored the images from 0 to 3 based on the EULAR-OMERACT scoring system. In the second part, they read and scored 165 paired GS and Doppler images two times in 1 month using the EULAR-OMERACT scoring system. The correlation between the sum of the GSUS and power Doppler US (PDUS) image scores and the clinical scores was assessed.

RESULT

The intra-rater agreement of the five radiologists was good for the EULAR-OMERACT scoring system, with κ ranging from 0.72 to 0.94 for GSUS and from 0.81 to 0.97 for PDUS. The inter-rater agreement among the experts was good to very good in the EULAR-OMERACT scoring system (κ: 0.76-0.94 for GSUS and 0.80-0.96 for PDUS). The sum of the GSUS and PDUS scores in the EULAR-OMERACT scoring system was moderate to highly positively correlated with the clinical scores (ρ of GSUS: 0.58-0.79, ρ of PDUS: 0.57-0.70 for disease activity score in 28 joints C-reactive protein) after training.

CONCLUSION

The EULAR-OMERACT scoring system is a reliable method for evaluating synovitis in RA and shows potential for disease assessment and follow-up in patients with RA.

Sonographic and Disease Activity Findings Related With Medication Change in JIA: A Historical Cohort Study

BACKGROUND

Musculoskeletal ultrasound (MSUS) is increasingly used to evaluate pediatric inflammatory arthritis. This study aimed to explore the relationship between MSUS findings with medication modifications in patients with juvenile idiopathic arthritis (JIA) and clinical disease activity measurements (clinical Juvenile Arthritis Disease Activity Score [cJADAS-10], active joint count [AJC], patient/parent global assessment [PPGA], and physician global assessment [PGA]).

METHODS

Data from patients with JIA who underwent a 12-joint (bilateral second and third metacarpophalangeal, wrist, elbow, knee, and ankle) MSUS examination during a 57-month period were collected. Patients were categorized into 2 groups: a medication change group and a control group (patients without medication change). A pediatric-specific MSUS scoring system was used to assess MSUS findings. The association between clinical and MSUS findings was examined for the study groups.

RESULTS

A total of 38 patients, 23 in the medication change group and 15 in the control group were included. The medication change group had higher AJC, PGA, and cJADAS-10. These patients also had a statistically significant presence of abnormal knee MSUS findings. For other joints, the frequency of abnormal MSUS findings was slightly higher in patients with a medication change, but the difference was not statistically significant. No strong correlation was observed between MSUS findings and clinical disease activity measurements.

CONCLUSIONS

Abnormal MSUS findings were not observed to be higher in patients with a change in medication except for the involvement of the knee joint. Further longitudinal studies are needed to understand the role of MSUS in the medical decision-making process in JIA.

Joint swelling in the hand in rheumatoid arthritis: agreement between clinical evaluation, ultrasonography, magnetic resonance imaging and patient self-evaluation

OBJECTIVE

To describe agreement in detection of joint swelling as the mandatory key of the diagnostic algorithm used in rheumatoid arthritis (RA). This was done by comparing clinical examinations, ultrasonography (US), Magnetic Resonance Imaging (MRI) and patient self-evaluation of the joints in the wrist and fingers (metacarpophalangeal joints (MCP) and proximal interphalangeal joints (PIP)) in an early untreated RA cohort.

METHODS

14 patients (8 women and 6 men, mean age ± standard deviation: 54.9 ± 14.5 years, range: 34-81 years) with symptom duration of less than six months, steroid and DMARD naïve at the time of examination and no previous history of arthritis were included in the study. US techniques included B mode and Color Doppler while MRI included a variety of imaging sequences (STIR, T1W TSE and T1W VIBE).

RESULTS

Overall, there was good agreement between clinical evaluation, evaluation by US, by MRI or patients' own evaluation of joint swelling. Patient self-evaluation converged with the clinical evaluation in 12 cases (86%).

CONCLUSION

Agreement was good among the applied imaging modalities and patient self-evaluation when compared to the clinical evaluations. Adding MRI to the US examination did not provide further diagnostic information.

Self-immunological disease aid diagnosis with ConvSANet and Eu-clidean distance

BACKGROUND

Ankylosing spondylitis (AS), Osteoarthritis (OA), and Sjögren's syndrome (SS) are three prevalent autoimmune diseases. If left untreated, which can lead to severe joint damage and greatly limit mobility. Once the disease worsens, patients may face the risk of long-term disability, and in severe cases, even life-threatening consequences.

RESULT

In this study, the Raman spectral data of AS, OA, and SS are analyzed to auxiliary disease diagnosis. For the first time, the Euclidean distance(ED) upscaling technique was used for the conversation from one-dimensional(1D) disease spectral data to two-dimensional(2D) spectral images. A dual-attention mechanism network was then constructed to analyze these two-dimensional spectral maps for disease diagnosis. The results demonstrate that the dual-attention mechanism network achieves a diagnostic accuracy of 100 % when analyzing 2D ED spectrograms. Furthermore, a comparison and analysis with s-transforms(ST), short-time fourier transforms(STFT), recurrence maps(RP), markov transform field(MTF), and Gramian angle fields(GAF) highlight the significant advantage of the proposed method, as it significantly shortens the conversion time while supporting disease-assisted diagnosis. Mutual information(MI) was utilized for the first time to validate the 2D Raman spectrograms generated, including ED, ST, STFT, RP, MTF, and GAF spectrograms. This allowed for evaluation of the similarity between the original 1D spectral data and the generated 2D spectrograms.

SIGNIFICANT

The results indicate that utilizing ED to transform 1D spectral data into 2D images, coupled with the application of convolutional neural network(CNN) for analyzing 2D ED Raman spectrograms, holds great promise as a valuable tool in assisting disease diagnosis. The research demonstrated that the 2D spectrogram created with ED closely resembles the original 1D spectral data. This indicates that ED effectively captures key features and important information from the original data, providing a strong descript.

Multimodal PA/US imaging in Rheumatoid Arthritis: Enhanced correlation with clinical scores

BACKGROUND

Accurate assessment of Rheumatoid Arthritis (RA) activity remains a challenge. Multimodal photoacoustic/ultrasound (PA/US) joint imaging emerges as a novel imaging modality capable of depicting microvascularization and oxygenation levels in inflamed joints associated with RA. However, the scarcity of large-scale studies limits the exploration of correlating joint oxygenation status with disease activity.

OBJECTIVE

This study aimed to explore the correlation between multimodal PA/US imaging scores and RA disease activity, assessing its clinical applicability in managing RA.

METHODS

In this study, we recruited 111 patients diagnosed with RA and conducted examinations of seven small joints on their clinically dominant side using a PA/US imaging system. The PA and power Doppler ultrasound (PDUS) signals were semi-quantitatively assessed using a 0-3 grading system. The cumulative scores for PA and PDUS across these seven joints (PA-sum and PDUS-sum) were calculated. Relative oxygen saturation (So2) values of inflamed joints on the clinically dominant side were measured, and categorized into four distinct PA+So2 patterns. The correlation between PA/US imaging scores and disease activity indices was systematically evaluated.

RESULTS

Analysis of 777 small joints in 111 patients revealed that the PA-sum scores exhibited a strong positive correlation with standard clinical scores for RA, including DAS28 [ESR] (ρ = 0.682), DAS28 [CRP] (ρ = 0.683), CDAI (ρ = 0.738), and SDAI (ρ = 0.739), all with p < 0.001. These correlations were superior to those of the PDUS-sum scores (DAS28 [ESR] ρ = 0.559, DAS28 [CRP] ρ = 0.555, CDAI ρ = 0.575, SDAI ρ = 0.581, p < 0.001). Significantly, in patients with higher PA-sum scores, notable differences were observed in the erythrocyte sedimentation rate (ESR) (p < 0.01) and swollen joint count 28 (SJC28) (p < 0.01) between hypoxia and intermediate groups. Notably, RA patients in the hypoxia group exhibited higher clinical scores in certain clinical indices.

CONCLUSION

Multi-modal PA/US imaging introduces potential advancements in RA assessment, especially regarding So2 evaluations in synovial tissues and associated PA scores. However, further studies are warranted, particularly with more substantial sample sizes and in multi-center settings.

SUMMARY

This study utilized multi-modal PA/US imaging to analyze Rheumatoid Arthritis (RA) patients' synovial tissues and affected joints. When juxtaposed with traditional PDUS imaging, the PA approach demonstrated enhanced sensitivity, especially concerning detecting small vessels in thickened synovium and inflamed tendon sheaths. Furthermore, correlations between the derived PA scores, PA+So2 patterns, and standard clinical RA scores were observed. These findings suggest that multi-modal PA/US imaging could be a valuable tool in the comprehensive assessment of RA, offering insights not only into disease activity but also into the oxygenation status of synovial tissues. However, as promising as these results are, further investigations, especially in larger and diverse patient populations, are imperative.

KEY POINTS

⸸ Multi-modal PA/US Imaging in RA: This novel technique was used to assess the So2 values in synovial tissues and determine PA scores of affected RA joints.⸸ Correlation significantly with Clinical RA Scores: Correlations significantly were noted between PA scores, PA+So2 patterns, and standard clinical RA metrics, hinting at the potential clinical applicability of the technique.

Diagnostic values of different musculoskeletal ultrasound signs, serum uric acid, and their combined detection for gouty arthritis

Objectives

The study aimed to investigate the diagnostic values of different musculoskeletal ultrasound (MSUS) signs, serum uric acid (SUA), and their combined detection for gouty arthritis (GA).

Patients and methods

In this retrospective study, 70 patients (62 males, 8 females; mean age: 46.1±14.1 years; range, 25 to 86 years) diagnosed with GA (the GA group) between August 2022 and March 2023 and 70 patients (54 females, 16 males; mean age: 49.0±14.1 years; range, 21 to 75 years) diagnosed with rheumatoid arthritis and osteoarthritis during the same period (the non-GA group) were included. The positive rate of MSUS signs and SUA in both groups was recorded to compare the differences. The correlations of MSUS signs and SUA with GA were analyzed using Spearman's rank correlation analysis. The diagnostic values of different MSUS signs, SUA, and their combined detection for GA were analyzed using a receiver operating characteristic, the area under the curve (AUC), sensitivity, specificity, and the Youden index.

Results

The positive rate of the double contour (DC) sign (chi-squared [χ2 ]=102.935, p<0.001), hyperechoic spots (χ2=56.395, p<0.001), bone erosions (χ2 =10.080, p<0.001), and SUA (χ2 =41.117, p <0.001) were higher in the GA group than in the non-GA group. The positive rate of the DC sign (rs=0.829, p=0.001), hyperechoic spots (rs=0.631, p<0.001), bone erosion (rs=0.268, p=0.001), and SUA (rs=0.542, p<0.001) were positively correlated with GA. Among the single-indicator measures, the DC sign exhibited the highest diagnostic value (AUC=0.907, sensitivity=81.4%, specificity=100%, p<0.001). Among the combined-indicator measures, the DC sign combined with SUA exhibited the highest diagnostic value (AUC=0.929, sensitivity=91.4%, specificity=94.3%, p<0.001), higher than DC sign detection alone.

Conclusion

The DC sign combined with SUA yielded a high diagnostic value and can thus provide a reliable basis for effectively and efficiently diagnosing GA.

Association of dietary inflammatory index with immune-inflammatory biomarkers in rheumatoid arthritis patients: results from NHANES 1999-2018

Background

Synovial inflammation is the main reason for joint damage in patients with rheumatoid arthritis (RA). Diet is recognized as one of the therapeutic strategies to control the inflammatory activity in RA. However, few studies have investigated the association between diet and immune-inflammatory biomarkers in RA patients. Our study aims to examine the correlation between dietary inflammatory potential and systemic immune-inflammation Index (SII), neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR) in the RA population.

Materials and methods

The National Health and Nutrition Examination Survey (NHANES) was the data source utilized in this study, spanning from 1999 to 2018. The study encompassed 2,500 RA participants in total. The dietary inflammatory potential was calculated by the dietary inflammation index (DII) score based on dietary recall interviews. The generalized multiple linear regression analyses were used to evaluate the relationship between DII and immune-inflammatory markers. Furthermore, subgroup analyses and restricted cubic spline models were performed.

Results

After full adjustments, there were significant positive correlations between DII levels and SII/NLR in RA patients (SII, β: 14.82, 95% CI: 5.14-24.50, p = 0.003; NLR, β: 0.04, 95% CI: 0.01-0.08, p = 0.005). It was noteworthy that inconsistent results were observed in the association between DII and SII as well as NLR in subgroups of red blood cell levels (Interaction p-value <0.001).

Conclusion

Pro-inflammatory dietary status in the RA population is significantly positively correlated with SII and NLR, influenced by variations in red blood cell levels.

Identification of serum exosomal miRNA biomarkers for diagnosis of Rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is an autoimmune disorder characterized by inflammation-induced joint damage, which can cause lasting disability. Therefore, early diagnosis and treatment of RA are crucial. Herein, we evaluated whether exosomal microRNAs (miRNAs) could be served as promising biomarkers that can accelerate the diagnosis of RA and development of therapies for RA.

METHODS

First, we performed small RNA sequencing to determine the miRNA profiles of serum exosomes within a screening cohort comprised of 18 untreated active RA patients, along with 18 age and gender-matched healthy controls (HCs). Subsequently, the miRNA profiles were then validated in a training cohort consisting of 24 RA patients and 24 HCs by RT-qPCR. Finally, the selected exosomal miRNAs were validated in a larger cohort comprising 108 RA patients and 103 HCs. The diagnostic efficacy of the exosomal miRNAs was evaluated by receiver operating characteristic (ROC) curve analysis. Biological functions of the miRNAs were determined by Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses.

RESULTS

Our results first demonstrated a noteworthy upregulation of three candidate miRNAs (miR-885-5p, miR-6894-3p, and miR-1268a) in the RA patients' serum exosomes compared to HCs. The combination of three miRNAs along with anti- citrullinated peptide antibodies (ACPA) exhibited excellent diagnostic accuracy, yielding an area under the curve (AUC) of 0.963 (95 % CI : 0.941-0.984), sensitivity of 87.96 %, and specificity of 93.20 %. Notably, miR-885-5p exhibited remarkable discriminatory capacity by itself in indistinguishing ACPA- negative RA patients from HCs, with an AUC of 0.993 (95 % CI : 0.978-1.000), sensitivity of 96.67 %, and specificity of 100 %. Moreover, the expression of miR-1268a in the assessment of therapeutic effectiveness displayed significant reduction on 29th day of Methotrexate (MTX) treatment in RA patients. This decreased expression paralleled with trends observed in tender 28-joint count (TJC28), swollen 28-joint count (SJC28), and disease activity score with 28-joint count using C-reactive protein (DAS28-CRP), all of which are indicative of RA disease activity. Finally, predictive analysis indicated that, these three exosomal miRNAs target pivotal signaling molecules involved in inflammatory pathways, thereby demonstrating effective modulation of the immune system.

CONCLUSIONS

In this study, we successfully demonstrated the promising potential for serum exosomal miRNAs, particularly miR-885-5p, miR-6894-3p and miR-1268a as biomarkers for early diagnosis and prediction of RA for the first time.

Diagnostic Accuracy of Ultrasound for Assessment of Synovial Abnormalities Among Patients With Knee Pain: A Meta-Analysis

OBJECTIVE

Synovial abnormalities, which are modifiable treatment targets for knee pain, affect ~25% of adults. Ultrasound is a safe, inexpensive, and easily accessible imaging modality for assessing synovial abnormalities, but its diagnostic accuracy is still controversial. We conducted a meta-analysis by comparing ultrasound with the "reference standard" method, ie, magnetic resonance imaging (MRI), in assessing synovial abnormalities among patients with knee pain.

METHODS

PubMed, Embase, and Web of Science were searched from inception to January 7, 2022, to retrieve studies including patients with knee pain for evaluating 1) the diagnostic accuracy of ultrasound versus MRI for synovial abnormalities (synovitis and synovial effusion) and 2) the correlations of synovial abnormalities assessed by ultrasound and MRI. The summary of diagnostic accuracy was analyzed using the bivariate model, and the correlation coefficients were pooled using the random effects model.

RESULTS

Fourteen studies were included, representing a total of 755 patients. The pooled sensitivity, specificity, and area under the curve were 0.88 (95% confidence interval [95% CI] 0.65-0.96), 0.70 (95% CI 0.51-0.84), and 0.81 (95% CI 0.77-0.84) for synovitis and 0.90 (95% CI 0.81-0.95), 0.86 (95% CI 0.77-0.92), and 0.94 (95% CI 0.91-0.96) for synovial effusion, respectively. Strong correlations between ultrasound- and MRI-diagnosed synovitis (r = 0.64, 95% CI 0.56-0.71) and synovial effusion (r = 0.63, 95% CI 0.52-0.73) were observed.

CONCLUSION

Ultrasound demonstrated a promising accuracy in detecting synovial abnormalities among patients with knee pain. The use of ultrasound provides equivalent synovial information to MRI but is less expensive and more accessible. Therefore, it is recommended as an adjuvant for managing patients with knee pain during diagnostic strategy and individualized treatment decision-making.

Diagnostic Accuracy Study of the Pediatric-Specific Ultrasound Scoring System for the Knee Joint in Children With Juvenile Idiopathic Arthritis

OBJECTIVE

We undertook this study to validate the Pediatric Arthritis Ultrasound Scoring System for the knee joint (PAUSS-knee) in children with juvenile idiopathic arthritis (JIA).

METHODS

Children with JIA were enrolled to prospectively receive a musculoskeletal ultrasound (MSUS) examination of the knee and a physical examination to determine presence/absence of clinical arthritis. MSUS images were scored using the PAUSS-knee, a semiquantitative MSUS scoring system (0-3, normal to severe) for B-mode and power Doppler mode. In addition to MSUS, a subset of participants also received magnetic resonance imaging (MRI) of the knee, which was scored according to the combined Juvenile Arthritis MRI Scoring (JAMRIS) system. Spearman's correlations (rs ) were used to calculate associations between variables. Test characteristics of the PAUSS-knee were calculated with MRI as the reference standard. Inflammatory biomarkers were assessed in synovial fluid from involved knees.

RESULTS

Eighty children with JIA contributed 112 MSUSs and 25 MRIs of the knee. Of the knees, 41% (n = 46) had clinical evidence of arthritis. The B-mode PAUSS-knee score moderately correlated with clinically determined arthritis (rs = 0.54, P < 0.001) and strongly correlated with the JAMRIS score (rs = 0.75, P < 0.001). Compared with MRI, the area under the curve for the B-mode PAUSS-knee was 0.92. For a cutoff of >1, the B-mode PAUSS-knee had a sensitivity of 83% and specificity of 82%. Biomarker analysis indicates that interleukin-2R levels correlate with PAUSS score.

CONCLUSION

Our data indicate that the PAUSS-knee has excellent accuracy for the diagnosis of arthritis when compared with MRI. The PAUSS-knee has the potential to effectively inform JIA medical decision-making in real time.

Rapid screening for autoimmune diseases using Fourier transform infrared spectroscopy and deep learning algorithms

Introduce

Ankylosing spondylitis (AS), rheumatoid arthritis (RA), and osteoarthritis (OA) are three rheumatic immune diseases with many common characteristics. If left untreated, they can lead to joint destruction and functional limitation, and in severe cases, they can cause lifelong disability and even death. Studies have shown that early diagnosis and treatment are key to improving patient outcomes. Therefore, a rapid and accurate method for rapid diagnosis of diseases has been established, which is of great clinical significance for realizing early diagnosis of diseases and improving patient prognosis.

Methods

This study was based on Fourier transform infrared spectroscopy (FTIR) combined with a deep learning model to achieve non-invasive, rapid, and accurate differentiation of AS, RA, OA, and healthy control group. In the experiment, 320 serum samples were collected, 80 in each group. AlexNet, ResNet, MSCNN, and MSResNet diagnostic models were established by using a machine learning algorithm.

Result

The range of spectral wave number measured by four sets of Fourier transform infrared spectroscopy is 700-4000 cm-1. Serum spectral characteristic peaks were mainly at 1641 cm-1(amide I), 1542 cm-1(amide II), 3280 cm-1(amide A), 1420 cm-1(proline and tryptophan), 1245 cm-1(amide III), 1078 cm-1(carbohydrate region). And 2940 cm-1 (mainly fatty acids and cholesterol). At the same time, AlexNet, ResNet, MSCNN, and MSResNet diagnostic models are established by using machine learning algorithms. The multi-scale MSResNet classification model combined with residual blocks can use convolution modules of different scales to extract different scale features and use resblocks to solve the problem of network degradation, reduce the interference of spectral measurement noise, and enhance the generalization ability of the network model. By comparing the experimental results of the other three models AlexNet, ResNet, and MSCNN, it is found that the MSResNet model has the best diagnostic performance and the accuracy rate is 0.87.

Conclusion

The results prove the feasibility of serum Fourier transform infrared spectroscopy combined with a deep learning algorithm to distinguish AS, RA, OA, and healthy control group, which can be used as an effective auxiliary diagnostic method for these rheumatic immune diseases.

Evolution and impact of a dedicated ultrasound clinic on clinical rheumatology practice at an academic medical center

BACKGROUND

Rheumatologic ultrasonography (RhUS) has grown in scope and application over the past 20 years. While many studies have shown the benefits of RhUS, few have investigated the efficacy of a dedicated clinic. This study explores the impact of a dedicated ultrasound clinic on patients and rheumatologists at an academic medical center (AMC).

METHODS

We analyzed claims data for patient visits, X-rays (XR), magnetic resonance imaging (MRI), and RhUS from an AMC with an established RhUS clinic, alongside two affiliated community medical practices (CMPs) without RhUS. We also analyzed RhUS clinic records on referral indication, procedures, results, and follow-up treatment changes. Pre- and post-RhUS visit patient surveys and referring physician (RP) surveys assessed experience and impact of the RhUS clinic.

RESULTS

From 2018 to 2021, referrals to the RhUS clinic substantially increased. In parallel, XR and MRI orders changed by -76 % and -43 % respectively, compared with 163 % and -24 % at CMPs. Discordance between RP pre-RhUS assessments and RhUS results were common. Patient surveys showed RhUS led to increased disease understanding and impacted thoughts and decisions about their therapy. RPs found utility in RhUS across a range of indications and were confident with RhUS results.

CONCLUSIONS

These findings suggest a dedicated RhUS clinic can be a valuable resource in clinical rheumatology practice. Implementation of a RhUS clinic at this AMC spurred rapid adoption of RhUS into clinical decision-making with notable benefits for patients and physicians alike. This may serve as a model for implementation of similar clinics at other institutions.

Added value of high-resolution ultrasound and MRI in the evaluation of rheumatologic diseases

Rheumatologic diseases are a widespread group of disorders affecting the joints, bones, and connective tissue, and leading to significant disability. Imaging is an indispensable component in diagnosing, assessing, monitoring, and managing these disorders, providing information about the structural and functional alterations occurring within the affected joints and tissues. This review article aims to compare the utility, specific clinical applications, advantages, and limitations of high-resolution ultrasound and magnetic resonance imaging in the context of rheumatologic diseases. It also provides insights into the imaging features of various types of inflammatory arthritis with clinical relevance and a focus on high-resolution ultrasound and magnetic resonance imaging. By understanding the comparative aspects of high-resolution ultrasound and magnetic resonance imaging, it is easier for the treating physicians to make informed decisions when selecting the optimal imaging modality for specific diagnostic purposes, effective treatment planning, and improve patient outcomes. The patterns of soft tissue and joint involvement; bony erosion and synovitis help in differentiating between various type of arthritis. Involvement of various small joints of the hands also gives an insight into the type of arthritis. We also briefly discuss the potential applications of emerging techniques, such as ultrasound elastography, contrast-enhanced ultrasound, and dual-energy CT, in the field of rheumatology.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis, Crystalline Arthritis, or Erosive Osteoarthritis: 2022 Update

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity because there is significant overlap of imaging findings among the various types of arthritis. This document provides recommendations for imaging evaluation of specific types of inflammatory arthritis, including rheumatoid arthritis, seronegative spondyloarthropathy, gout, calcium pyrophosphate dihydrate disease (or pseudogout), and erosive osteoarthritis. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Ultrasound and magnetic resonance imaging of hands in systemic sclerosis: A cross-sectional analytical study of prevalence of inflammatory changes in patients with subclinical arthropathy

Objectives

Prevalence of synovitis, tenosynovitis, erosions, acro-osteolysis and bone marrow edema in systemic sclerosis is not extensively reported. We aimed to estimate the prevalence of changes in individual joints of hands in systemic sclerosis patients.

Method

A cross-sectional analytical study consisting of 34 adults (females, n = 32) with systemic sclerosis. Patients with clinical synovitis were excluded. All patients underwent ultrasound (US) and magnetic resonance imaging of bilateral hands.

Results

On US, synovitis, tenosynovitis, erosions, and acro-osteolysis were detected in 97%, 94%, 97%, and 29% patients. Grade I synovitis observed in 67% joints-first carpometacarpal joint (55%), first metacarpophalangeal joint (54%), distal radioulnar joint (50%), and intercarpal joints (47%) were commonly affected. Erosions were common in distal phalanges (first DP72% to fifth DP39%). On magnetic resonance imaging, synovitis, tenosynovitis, erosions, and bone edema were observed in 91%, 85%, 97%, and 85% patients. Grade I synovitis was seen in 70% joints, affecting intercarpal joint (70.6%) and third metacarpophalangeal joint (52.9%) commonly. Grade I erosions were seen in 61%, affecting distal phalanges (55.8%), capitate (60.3%), and lunate (55.8%). Grade I edema was commonly affecting lunate (39%) and capitate (26%). On magnetic resonance imaging, acro-osteolysis was present in 28% (97/340) distal phalanges. Fair agreement (0.21-0.40) was noted between US and magnetic resonance imaging for synovitis and erosions.

Conclusion

High prevalence of low-grade inflammation is found in systemic sclerosis patients on US and magnetic resonance imaging. Distal joint assessment in addition to proximal joints improves accurate estimation of prevalence of early arthropathy.

Synovial Oxygenation at Photoacoustic Imaging to Assess Rheumatoid Arthritis Disease Activity

Background Synovial hypoxia is a hallmark of rheumatoid arthritis (RA). Photoacoustic (PA) imaging, based on the use of laser-generated US, can detect the oxygenation status of tissue in individuals with RA. However, large studies are lacking, with few investigating the correlation between oxygenation status and disease activity. Purpose To measure synovial oxygenation status in participants with RA by using a multimodal PA US imaging system and to determine the correlation between PA imaging-measured oxygen saturation (SO₂) and disease activity. Materials and Methods In this prospective observational cohort study, multimodal PA US imaging examinations were performed on small joints of consecutive participants with RA, who were treated at two outpatient rheumatology clinics from 2019 to 2021, and healthy controls. The SO₂ values of the synovium were measured with dual-wavelength PA imaging and classified into three categories-hyperoxia, intermediate oxygenation status, or hypoxia-based on the signal coloration and clustering analysis of the SO₂ values. The correlations of oxygenation status with power Doppler US (PDUS) scoring and clinical disease activity index were evaluated with one-way analysis of variance and the Kruskal-Wallis test with Bonferroni correction. Results A total of 118 participants with RA (median age, 55 years [IQR, 41-62 years]; 92 women) and 15 healthy control participants (median age, 37 years [IQR, 33-41 years]; 11 women) were included. The wrist synovium was categorized as hyperoxic in 36 participants with RA, of intermediate oxygenation status in 48 participants, and hypoxic in 34 participants. All control participants had hyperoxic synovial tissues. For participants with RA, hyperoxic synovium had more affluent Doppler US-depicted vasculature than those with hypoxia and intermediate oxygenation status (mean PDUS grade: hyperoxia, 2.7 ± 0.6 [SD]; intermediate, 1.3 ± 0.7; hypoxia, 1.1 ± 0.8; P < .001). Participants with intermediate status synovium had a lower clinical disease activity index than those with hypoxia (intermediate, 11.0 [IQR, 5.0-21.5] vs hypoxia, 26.0 [IQR, 18.0-39.0]; P = .001). Conclusion Photoacoustic imaging-detected hypoxia in thickened synovium correlated with less vascularization and higher disease activity in participants with rheumatoid arthritis. Clinical trial registration no. NCT04297475 © RSNA, 2022 Online supplemental material is available for this article.

Biomarkers (mRNAs and non-coding RNAs) for the diagnosis and prognosis of rheumatoid arthritis

In recent years, diagnostic and therapeutic approaches for rheumatoid arthritis (RA) have continued to improve. However, in the advanced stages of the disease, patients are unable to achieve long-term clinical remission and often suffer from systemic multi-organ damage and severe complications. Patients with RA usually have no overt clinical manifestations in the early stages, and by the time a definitive diagnosis is made, the disease is already at an advanced stage. RA is diagnosed clinically and with laboratory tests, including the blood markers C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) and the autoantibodies rheumatoid factor (RF) and anticitrullinated protein antibodies (ACPA). However, the presence of RF and ACPA autoantibodies is associated with aggravated disease, joint damage, and increased mortality, and these autoantibodies have low specificity and sensitivity. The etiology of RA is unknown, with the pathogenesis involving multiple factors and clinical heterogeneity. The early diagnosis, subtype classification, and prognosis of RA remain challenging, and studies to develop minimally invasive or non-invasive biomarkers in the form of biofluid biopsies are becoming more common. Non-coding RNA (ncRNA) molecules are composed of long non-coding RNAs, small nucleolar RNAs, microRNAs, and circular RNAs, which play an essential role in disease onset and progression and can be used in the early diagnosis and prognosis of RA. In this review of the diagnostic and prognostic approaches to RA disease, we provide an overview of the current knowledge on the subject, focusing on recent advances in mRNA-ncRNA as diagnostic and prognostic biomarkers from the biofluid to the tissue level.

A Scoping Review of the Use of Pioglitazone in the Treatment of Temporo-Mandibular Joint Arthritis

Thiazolidinediones (TZDs) are a group of diabetes medications currently being investigated for anti-arthritis effectiveness, one of which is pioglitazone. The purpose of this scoping review is to evaluate the potential use of pioglitazone in the treatment of temporomandibular joint (TMJ) arthritis. The criteria of eligibility were studies with the diagnosis of arthritis and pioglitazone treatment with a change in any inflammation index as an outcome. Of the 1169 records initially identified following the selection process, two animal studies and four clinical studies were included in the review. Improvements from the baseline were observed in each treatment group for each inflammation indicator. The results of the animal studies on the temporomandibular joints and on patients with rheumatoid and psoriatic arthritis indicate that the drug in question may have potential to treat arthritis, including within the temporomandibular joint.

Prediction of Radiographic Progression During a Treat-to-Target Strategy by the Sequential Application of MRI-Proven Bone Marrow Edema and Power-Doppler Grade ≥2 Articular Synovitis in Rheumatoid Arthritis: Retrospective Observational Study

OBJECTIVES

To investigate the appropriate timing, useful findings and combination of magnetic resonance imaging (MRI) and ultrasound (US) for predicting the radiographic progression in early rheumatoid arthritis (RA).

METHODS

Forty-four active RA patients, who examined by both of MRI and US in the symptomatic wrist and finger joints, were recruited in Nagasaki University Hospital from 2010 to 2017 and treated by the T2T therapeutic strategy for 1 year. MRI was evaluated by RA MRI scoring and US by Outcomes Measures in Rheumatology Clinical Trial, respectively. Plain radiographs were assessed by the Genant-modified Sharp score for the symptomatic side in the same manner as MRI and US. Radiographic progression was defined as an annual increase ≥0.75 at 1 year. Factors associated with radiographic progression were analyzed. Also, the optimal combination of MRI and US at each timepoint was considered.

RESULTS

Logistic regression model revealed that MRI-proven BME at baseline and 6 month and joint counts of PD grade ≥2 articular synovitis at 3 or 6 month were significantly associated with radiographic progression at 1 year.

CONCLUSION

This study may suggest the favorable timing and combination of MRI and US at each point to predict radiographic progression in patients with early-stage RA.

The correlation of ultrasound-detected synovitis in an individual small joint with overall clinical disease activity in patients with rheumatoid arthritis

OBJECTIVES

To explore the correlation between the ultrasound-detected synovitis in each individual joint at metacarpophalangeal (MCP), proximal interphalangeal (PIP), and metatarsophalangeal (MTP) regions and the clinical disease activity in patients with rheumatoid arthritis (RA).

METHODS

Clinical disease activity was assessed by disease activity score (DAS) based on 28-joint count and erythrocyte sedimentation rate (DAS28-ESR), C-reactive protein (DAS28-CRP), Simplified Disease Activity Index (SDAI), and Clinical Disease Activity Index (CDAI). Gray scale (GS) and power Doppler (PD) synovitis was assessed by ultrasound semi-quantitatively. The correlation between clinical disease activity indices and synovitis score in each joint was assessed using Spearman's rank correlation test.

RESULTS

211 RA patients were included in this study. The whole GS scores of all MCP joints showed the highest correlation with each Clinical Disease Activity Index (r = 0.403-0.452, p < 0.01). Likewise, the whole PD scores of all MCP joints also showed the highest correlation with clinical disease activity (r = 0.332-0.396, p < 0.01). At individual joint level, the highest correlation of GS score with DAS28-ESR (r = 0.411, p < 0.01), DAS28-CRP (r = 0.459, p < 0.01), and SDAI (r = 0.444, p < 0.01) was observed in MCP3 joint while with CDAI (r = 0.421, p < 0.01) in MCP2 joint. The highest correlation of PD score with DAS28-ESR (r = 0.353, p < 0.01), DAS28-CRP (r = 0.399, p < 0.01), CDAI (r = 0.368, p < 0.01), and SDAI (r = 0.377, p < 0.01) was observed in MCP5 joint.

CONCLUSIONS

The ultrasound-detected synovitis at MCP joints, especially MCP2, MCP3, and MCP5 joints, was best correlated with clinical disease activity in most RA cases, in contrast to PIP and MTP joints. Key Points • The correlation of ultrasound-detected synovitis in each individual joint with the clinical disease activity in RA patients is diverse among joint regions. MCP joints showed the best, in contrast to PIP and MTP joints.

Seronegative rheumatic arthritis has milder inflammation and bone erosion in an ultrasound study of disease-modifying anti-rheumatic drugs (DMARDs)-naïve Chinese cohort

Background

Compared with the seropositive rheumatic arthritis (sp-RA), seronegative rheumatic arthritis (sn-RA) lacks ultrasound (US) research. It is unknown whether sn-RA patients had more severe synovitis than sp-RA ones at the same level of swollen joint counts (SJCs). We designed the US study to find out the answers.

Methods

All cases satisfied the 2010 classification criteria, first diagnosed and disease-modifying anti-rheumatic drugs (DMARDs) naïve with the characteristics of abnormal swelling or pain in the wrist, proximal interphalangeal (PIPs), and metacarpophalangeal (MCPs) joints. Demographic data was collected. US examinations, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), visual analogue scale scores (VASs), patient global assessment (PGA), physician’s global assessment (PhGA), disease activity score of 28 joints (DAS28), and van der Heijde-modified Sharp score (vdHSS) were used to evaluate the disease activity among these groups. Anticitrullinated peptide antibody (ACPA), rheumatoid factor (RF) and SJCs were used to divide the patients into 3 groups, which were defined as follows: Group A, sp-RA (positive RF and/or ACPA) with SJC >10; Group B, sp-RA with SJC ≤10; and Group C, sn-RA (all negative RF and ACPA with SJC >10 due to the criteria).

Results

A total of 139 cases were recruited. Fifty-six were Group A, 54 were Group B, and 29 were Group C. All indexes above and the total US scores were significantly lower in Group C than Group A (both groups with SJC >10) (ESR, CRP, VASs, PGA, PhGA, DAS28, vdHSS, US total score respectively: 58.8 vs. 37.5, P=0.009; 37.5 vs. 17.8, P=0.008; 61.7 vs. 52.8, P=0.032; 62.2 vs. 53.9, P=0.031; 59.8 vs. 48.3, P=0.029; 6.92 vs. 5.56, P=0.000; 61.7 vs. 44.5, P=0.023; 31.4 vs. 20.9, P=0.000). The difference of the total US scores above was mostly contributed by the symptoms of synovitis. The total US scores were prominently lower in Group C with the duration over 2 years (2–5 years, >5 years, respectively compared to <2 years: 16.3 vs. 27.4, P=0.044; 16.5 vs. 27.4, P=0.048), and vdHSS were remarkably higher in almost all groups with a duration of over 5 years. For the patients with a duration over 2 years, bone erosions occurred earlier in sp-RA than in sn-RA patients.

Conclusions

Sn-RA patients had milder synovitis than sp-RA ones at the same extent of disease activity. In addition, sn-RA had delayed progress of bone erosion than the sp-RA group.

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.

The naturally-occurring flavonoid nobiletin reverses methotrexate resistance via inhibition of P-glycoprotein synthesis

Methotrexate (MTX) is the first-line treatment for rheumatoid arthritis (RA). However, after long-term treatment, some patients develop resistance. P-glycoprotein (P-gp), as an indispensable drug transporter, is essential for mediating this MTX resistance. In addition, nobiletin (NOB), a naturally occurring polymethoxylated flavonoid, has also been shown to reverse P-gp–mediated MTX resistance in RA groups; however, the precise role of NOB in this process is still unclear. Here, we administered MTX and NOB alone or in combination to collagen II-induced arthritic (CIA) mice and evaluated disease severity using the arthritis index, synovial histopathological changes, immunohistochemistry, and P-gp expression. In addition, we used conventional RNA-seq to identify targets and possible pathways through which NOB reverses MTX-induced drug resistance. We found that NOB in combination with MTX could enhance its performance in synovial tissue and decrease P-gp expression in CIA mice compared to MTX treatment alone. In vitro, in MTX-resistant fibroblast-like synoviocytes from CIA cells (CIA-FLS/MTX), we show that NOB treatment downregulated the PI3K/AKT/HIF-1α pathway, thereby reducing the synthesis of the P-gp protein. In addition, NOB significantly inhibited glycolysis and metabolic activity of CIA-FLS/MTX cells, which could reduce the production of ATP and block P-gp, ultimately decreasing the efflux of MTX and maintaining its anti-RA effects. In conclusion, this study shows that NOB overcomes MTX resistance in CIA-FLS/MTX cells through the PI3K/AKT/HIF-1α pathway, simultaneously influencing metabolic processes and inhibiting P-gp–induced drug efflux.

The EANM guideline for radiosynoviorthesis

PURPOSE

Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain.

METHODS

The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed.

CONCLUSION

These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

Diagnostic Utility of Ultrasound Versus Physical Examination in Assessing Knee Effusions: A Systematic Review and Meta-analysis

Knee effusion can be detected by physical examination, ultrasound and MRI, but the utility of each test is unclear. This study aimed to analyze the diagnostic value of physical examination and ultrasound for knee effusion. A systematic literature search of electronic databases was completed. Bivariate mixed-effects regression modelling was used to estimate sensitivity, specificity and diagnostic odds ratio of physical examination and ultrasound diagnosis of knee effusion. Sensitivity of ultrasound diagnosis of knee effusion was higher than the bulge sign and patellar tap, leading to improved positive and negative predictive values.

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.

Serum etanercept concentrations in relation to disease activity and treatment response assessed by ultrasound, biomarkers and clinical disease activity scores: results from a prospective observational study of patients with rheumatoid arthritis

Objectives

To identify the therapeutic range for etanercept and to assess the incidence of anti-etanercept antibody formation.

Methods

Associations between etanercept serum concentration and disease activity as well as treatment response were examined in a longitudinal observational study of rheumatoid arthritis patients starting etanercept. Disease activity was assessed by ultrasound (grey scale and power Doppler), 28-joint Disease Activity Score (DAS28), Simplified Disease Activity Index, plasma calprotectin and C reactive protein. Etanercept concentration and anti-etanercept antibodies were analysed using automated in-house fluorescence assays.

Results

A total of 89 patients were included, whereof 66% were biological disease-modifying antirheumatic drug (DMARD) naïve and 91% used concomitant synthetic DMARD. At 3 months, the median etanercept concentration was 1.8 (IQR 1.1–2.5) mg/L. Longitudinal associations were found between etanercept concentration and disease activity assessed by plasma calprotectin, C reactive protein and DAS28, but not between etanercept concentration and improvement in disease activity by any of the parameters at 3, 6 or 12 months of treatment. Etanercept concentrations were not significantly different among patients who achieved response or remission, compared with non-response or non-remission. Hence, no therapeutic range could be identified. None of the patients developed anti-etanercept antibodies.

Conclusion

Despite the use of sensitive and objective markers of inflammation, a therapeutic range could not be identified for etanercept. Hence, this study suggests that proactive therapeutic drug monitoring is unlikely to benefit rheumatoid arthritis patients treated with etanercept, but a potential benefit in certain clinical situations cannot be excluded.

Synovitis and Tenosynovitis on Ultrasound as Predictors of DMARD Tapering Failure in Patients with Long-Standing Rheumatoid Arthritis in Clinical Remission or Low Disease Activity

OBJECTIVES

This study aimed to investigate the predictive value of synovitis and tenosynovitis detected by grayscale (GS) and by power Doppler (PD) ultrasound (US) in relation to failure of tapering disease-modifying antirheumatic drugs (DMARD) in rheumatoid arthritis (RA) patients.

METHODS

Long-standing RA patients who de-escalated treatment were included in this prospective cohort study. All patients underwent 3 ultrasonographic and clinical assessments, at baseline and every 3 or 4 months, over a period of 6-8 months. US investigation of 32 joints was performed. Synovitis was assessed by GS and PD semiquantitative scoring (0-3) and a global score was calculated for each individual by summing single joint scores. The presence of tenosynovitis was recorded whenever detected during ultrasound assessment.

RESULTS

Thirty-three patients completed the follow-up period (29 women; 4 men). Eight patients (25%) relapsed. Using the optimal cutoff values determined by receiver operating characteristic curve, patients with a PD synovitis ≥1 at baseline had significantly greater chances to relapse than those without PD activity. During follow-up, GS tenosynovitis was detected in 6 patients (5 with PD) who failed and in 3 patients (1 with PD) who succeeded in tapering therapy. Having at least 1 joint with PD synovitis resulted in a relative risk of 3.14 and having GS tenosynovitis resulted in a relative risk of 11.4 (95% CI: 1.03-9.60 and 2.82-45.9, respectively) for relapse in the multivariate Poisson model.

CONCLUSIONS

PD synovitis and GS tenosynovitis may be useful to identify RA patients in risk of relapse after DMARD tapering.

Fatigue Is Not Associated With Objective Assessments of Inflammation During Tocilizumab Treatment of Patients With Rheumatoid Arthritis

Objective

In patients with rheumatoid arthritis (RA), the relation between fatigue and disease activity is not established, and our objective was to explore in post hoc analyses the associations between fatigue and subjective as well as objective assessments of inflammation during follow‐up of patients with RA initiating biologic treatment.

Methods

In a Nordic multicenter study, patients with RA starting tocilizumab were examined for fatigue (Functional Assessment of Chronic Illness Therapy–Fatigue sum score) as well as patient‐reported outcome measures (PROMs) (patient's global disease activity, joint pain, and Health Assessment Questionnaire Disability Index), clinical examinations (examiner's global disease activity, 28 tender/swollen joint counts), laboratory variables (erythrocyte sedimentation rate, C‐reactive protein), and ultrasound assessments (semiquantitative scoring [0‐3]) of gray scale and Doppler of 36 joints and 4 tendons) at baseline and 4, 12, and 24 weeks. The associations were explored by using nonparametric tests, including the Wilcoxon rank test, the Mann–Whitney U test, Spearman correlations, and a linear regression and linear mixed model.

Results

One hundred ten patients were included (83% female, mean [SD] age 55.6 [12.1] years, mean [SD] RA duration 8.7 [9.5] years, 81% anti–cyclic citrullinated peptide positive). Fatigue, PROMs, and clinical, laboratory, and ultrasound variables all decreased significantly during follow‐up, already at 4 weeks (P < 0.001). Fatigue was both cross‐sectionally and longitudinally associated with PROMs, whereas there were no or low associations with clinical, laboratory, or ultrasound assessments of inflammation. Baseline fatigue was predictive of PROMs at 12 and 24 weeks (P < 0.05 and P < 0.001, respectively) but not of any objective assessments.

Conclusion

Fatigue was primarily associated with subjective assessments of disease activity. Thus, the present study supports fatigue to reflect other aspects of RA disease activity than inflammation.

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.

Ultrasound Imaging and Guidance in Common Wrist/Hand Pathologies

ABSTRACT

Wrist/hand pain is a prevalent musculoskeletal condition with a great spectrum of etiologies (varying from overuse injuries to soft tissue tumors). Although most of the anatomical structures are quite superficial and easily evaluated during physical examination, for several reasons, the use of ultrasound imaging and guidance has gained an intriguing and paramount concern in the prompt management of relevant patients. In this aspect, the present review aims to illustrate detailed cadaveric wrist/hand anatomy to shed light into better understanding the corresponding ultrasonographic examinations/interventions in carpal tunnel syndrome, trigger finger, de Quervain tenosynovitis, rhizarthrosis, and the radiocarpal joint arthritis. In addition, evidence from the literature supporting the rationale why ultrasound guidance is henceforth unconditional in musculoskeletal practice is also exemplified.

Musculoskeletal ultrasound for ankylosing spondylitis: A systematic review and meta-analysis

OBJECTIVE

To clarify if musculoskeletal ultrasound (US) would give additional information for the clinical examination to diagnose and evaluate the activity of ankylosing spondylitis (AS).

METHODS

A literature search was performed in PubMed, Embase, Web of Science, the Cochrane Library, Sinomed, Chinese National Knowledge Infrastructure (CINK), and Wanfang databases from their inceptions to May 15, 2020. Studies that examined the musculoskeletal US, which detected sacroiliac joints in people with AS were included. The pooled analyses were performed using Meta Disc version 1.4 software.

RESULTS

A total of 9 studies encompassing 984 participants were included. Statistical analysis suggested an area under the curve (AUC) of 0.9259 (sensitivity 0.86, specificity 0.54) indicating that US had excellent diagnostic test accuracy for AS, an AUC of 0.6441 (sensitivity 0.87, specificity 0.51) indicating that the US did not have a good diagnostic test accuracy for AS activity. A subgroup analysis revealed that the AUC of power Doppler US (PDUS) and color Doppler US (CDUS) was 0.5000 and 0.9274, respectively, indicating that CDUS was superior to PDUS.

CONCLUSION

US, especially CDUS, is a valid and reproducible technique for the diagnosis of AS. While the accuracy of AS activity evaluation of the US is not ideal. It may be considered for routine use as part of the standard diagnostic tools in AS.

[Joint DGN, OGNMB and SGNM S1 guideline for radiosynoviorthesis]

This recommendation is intended to provide a guideline for radiosynoviorthesis (RSO) in the effective local treatment of chronic inflammatory (non-infectious) joint diseases. It was developed in an interdisciplinary manner and describes the general objectives, definitions, clinical background information, indication and contraindications of this radionuclide therapy. The requirements to be met by a treatment center, the results of pretherapeutic examinations as well as recommendations on how the treatment should be carried out. Here, organizational and technical issues have been considered. Furthermore, information on the surveillance and follow-up of the treated patients can be found. In general, treatment and follow-up should be done in in close cooperation of the participating disciplines.

Major reduction of ultrasound-detected synovitis during subcutaneous tocilizumab treatment: results from a multicentre 24 week study of patients with rheumatoid arthritis

Objective: Few studies have investigated the efficacy of subcutaneous tocilizumab (TCZ-SC) on ultrasound-detected inflammation. This study aimed to explore the clinical efficacy of TCZ-SC treatment in rheumatoid arthritis (RA) patients and to evaluate the response by ultrasound compared to Composite Disease Activity Scores (CDAS).Method: This open-label, single-arm study enrolled RA patients with inadequate response to conventional synthetic disease-modifying anti-rheumatic drugs initiating TCZ-SC 162 mg once weekly for 24 weeks, with clinical assessments at baseline, 2, 4, 8, 12, 16, 20, and 24 weeks. Ultrasound examinations [semi-quantitative score (0-3) of 36 joints and four tendons] were performed at baseline, 4, 12, and 24 weeks. CDAS and American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) response, and sum scores of ultrasound grey scale/Doppler were calculated. Changes during follow-up were explored by the Mann-Whitney test and correlations by Spearman's rho.Results: In total, 133 patients (mean ± sd age 55.9 ± 12.0 years) were assessed clinically and 110 patients were also examined with ultrasound. All clinical and ultrasound scores decreased significantly after 4 weeks (p < 0.001). At 24 weeks there was EULAR good response in 87.7% and ACR 70% response in 47.4%. Ultrasound scores had no or low correlations with patient-reported outcomes. At 24 weeks, CDAS remission was achieved in 27.4-83.5% and a sum score Doppler of 0 was found in 53.3%.Conclusions: Clinical and ultrasound scores decreased rapidly. Ultrasound scores were not associated with patient-reported variables. Half of the patients reached ultrasound remission, while there were large discrepancies in the percentage of patients reaching remission based on different CDAS.Trial registration: Study ML28691, registered 28 January 2014, ClinicalTrials.gov identifier: NCT02046616.

The effects of drug transporters on the efficacy of methotrexate in the treatment of rheumatoid arthritis

The ATP-binding cassette (ABC) and solute carrier (SLC) transporter families consist of common drug transporters that mediate the efflux and uptake of drugs, respectively, and play an important role in the absorption, distribution, metabolism and excretion of drugs in vivo. Rheumatoid arthritis (RA) is an autoimmune disease characterized by erosive arthritis, and there are many RA patients worldwide. Methotrexate (MTX), the first-choice treatment for RA, can reduce the level of inflammation, prevent joint erosion and functional damage, and greatly reduce pain in RA patients. However, many patients show resistance to MTX, greatly affecting the efficacy of MTX. Many factors, such as irrational drug use and heredity, are associated with drug resistance. Considering the effect of drug transporters on drugs, many studies have compared the expression of drug transporters in drug-resistant and drug-sensitive patients, and abnormal transporter expression and transport activity have been found in patients with MTX resistance. Thus, drug transporters are involved in drug resistance. This article reviews the effects of transporters on the efficacy of MTX in the treatment of RA.

Fatigue is cross-sectionally not associated with objective assessments of inflammation, but changes in fatigue are associated with changes of disease activity assessments during biologic treatment of patients with established rheumatoid arthritis

Objective

The associations between fatigue and disease activity in patients with rheumatoid arthritis (RA) have not been defined. The present objectives were to explore in RA patients the cross-sectional and longitudinal relation of fatigue with subjective as well as objective assessments of disease activity.

Methods

RA patients were consecutively included when initiating biologic disease-modifying anti-rheumatic drugs (DMARDs) and assessed at baseline, 1, 2, 3, 6, and 12 months with investigation of fatigue, patient-reported outcome measures (PROMs; joint pain and patient’s global disease activity, MHAQ, pain catastrophizing, Mental Health score), clinical examinations (examiner’s global disease activity, 28 tender and swollen joint counts), and laboratory variables (ESR, CRP, calprotectin). Ultrasound examinations (semi-quantitative scoring (0–3)) with grey scale and power Doppler were performed of 36 joints and 4 tendons. Statistics included one-way analysis of variance, Pearson’s correlations, and multiple linear and logistic regression analysis.

Results

A total of 208 RA patients (mean (SD) age 53.2 (13.2) years, disease duration 9.8 (8.5) years) were included. Fatigue levels diminished during follow-up (mean (SD) baseline/12 months; 4.8 (2.8)/3.0 (2.5) (p < 0.001)). Substantial correlations were cross-sectionally found between fatigue and PROMs (median (IQR) r=0.61 (0.52-0.71)) but not with the objective inflammatory assessments. During follow-up, baseline fatigue was associated with PROMs (p < 0.001) but not with objective inflammatory assessments. However, change of fatigue was associated with change in all variables. Higher baseline fatigue levels were associated with lower clinical composite score remission rates.

Conclusion

Fatigue was cross-sectionally associated to subjective but not to objective disease assessments. However, change of fatigue during treatment was associated to all assessments of disease activity.

Trial registration number

Anzctr.org.au identifier ACTRN12610000284066, Norwegian Regional Committee for Medical and Health Research Ethics South East reference number 2009/1254

Key Points • In this longitudinal study of patients with established RA, fatigue was associated with patient reported outcome measures at each visit, but not with objective assessments of inflammation including calprotectin and comprehensive ultrasound examinations. • Changes in fatigue during biological treatment were associated with changes in patient reported outcome measures, clinical, laboratory and ultrasound assessments. • Baseline fatigue was associated with all patient reported outcome measures, but not objective assessments of inflammation at all the prospective visits. • Higher baseline fatigue levels were associated with lower remission rates as assessed by clinical composite scores.

Contemporary imaging of rheumatoid arthritis: Clinical role of ultrasound and MRI

Magnetic resonance imaging (MRI) and musculoskeletal ultrasound (MSUS) are sensitive imaging modalities used by clinicians to assist in decision-making in the management of rheumatoid arthritis (RA). This review will examine the utility of MRI and MSUS in diagnosing RA, predicting RA flares, tapering therapy, assessing remission, and examining difficult periarticular features. We will also outline the strengths and weaknesses of utilizing MRI and MSUS as outcome measures in the management of RA.

Ultrasound Imaging in Psoriatic Arthritis: What Have We Learnt in the Last Five Years?

Psoriatic arthritis (PsA) is a complex heterogeneous disease with multiple inter-related pathologies such as synovitis, enthesitis, tendinopathy, and dactylitis. Clinical assessment is limited in its detail to assess pathology, thus in recent years, ultrasound (US) has become more popular, given its high sensitivity to detect inflammatory arthritis and ability to inform clinical decisions. Although a qualitative technique, US findings can be graded semi-quantitatively for grayscale (GS) and power Doppler (PD). Synovitis is frequently present in inflammatory arthritis pathologies, and in PsA, recent evidence shows a propensity for tendon and entheseal lesions. The presence of flexor tenosynovitis and flexor tendon insertional enthesopathy at accessory pulleys is supportive of the “Deep Koebner” concept. Peri-tendinous inflammation—mutual to PsA or rheumatoid arthritis (RA), is associated with soft tissue oedema with PD signal frequently at the flexor tendon compartments in PsA. Research on enthesitis in PsA/PsO has improved understanding in subclinical and clinical PsA, explored associations with progression to PsA, and investigated links to prognosis assessment. Dactylitis is a pathognomonic PsA lesion where US has enhanced knowledge of the disease course and pathology of lesions such as: flexor tenosynovitis; synovitis; and soft tissue oedema. Increased US sensitivity has also brought innovation including promising automated ultrasound scanning techniques. So, what have we learnt in recent years and what are the unmet needs to focus future research initiatives in this disabling disease? This narrative review article assesses the neoteric evidence, bringing into context the knowledge gained and highlighting potential areas of research.

Update on the Pathomechanism, Diagnosis, and Treatment Options for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is an autoimmune disease that involves multiple joints bilaterally. It is characterized by an inflammation of the tendon (tenosynovitis) resulting in both cartilage destruction and bone erosion. While until the 1990s RA frequently resulted in disability, inability to work, and increased mortality, newer treatment options have made RA a manageable disease. Here, great progress has been made in the development of disease-modifying anti-rheumatic drugs (DMARDs) which target inflammation and thereby prevent further joint damage. The available DMARDs are subdivided into (1) conventional synthetic DMARDs (methotrexate, hydrochloroquine, and sulfadiazine), (2) targeted synthetic DMARDs (pan-JAK- and JAK1/2-inhibitors), and (3) biologic DMARDs (tumor necrosis factor (TNF)-α inhibitors, TNF-receptor (R) inhibitors, IL-6 inhibitors, IL-6R inhibitors, B cell depleting antibodies, and inhibitors of co-stimulatory molecules). While DMARDs have repeatedly demonstrated the potential to greatly improve disease symptoms and prevent disease progression in RA patients, they are associated with considerable side-effects and high financial costs. This review summarizes our current understanding of the underlying pathomechanism, diagnosis of RA, as well as the mode of action, clinical benefits, and side-effects of the currently available DMARDs.

Diagnostic test accuracy of magnetic resonance imaging and ultrasound for detecting bone erosion in patients with rheumatoid arthritis

OBJECTIVE

To evaluate and compare the diagnostic test accuracy of magnetic resonance imaging (MRI) and ultrasound (US) for bone erosion in rheumatoid arthritis (RA) patients for a specific and efficient diagnostic recommendation.

METHOD

To evaluate the diagnostic accuracy, the sensitivity, specificity, area under the summary receiver operating characteristic curve, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of MRI and US for detecting bone erosion were calculated. Subgroup analyses were conducted to evaluate the performance of these values with different standard references when compared with types of machines and scanning positions.

RESULTS

Data from 26 articles were extracted for calculation. The comprehensive values of sensitivity and specificity were 0.77 (95% CI 0.63, 0.87)/0.89 (95% CI 0.80, 0.95) and 0.61 (95% CI 0.43, 0.77)/0.95 (95% CI 0.88, 0.98) for MRI and US, respectively. The 1.5-T Signa MRI system, General Electric© (sensitivity 0.66; specificity 0.90), and different models of LOGIQ US units and General Electric© (sensitivity 0.66; specificity 0.91) had better diagnostic capability to detect bone erosion, while the 2nd metacarpophalangeal joint (sensitivity 0.70; specificity 0.98) showed the best diagnostic performance among the hand joints with US.

CONCLUSIONS

Neither MRI nor US showed satisfactory diagnostic test accuracy in detecting bone erosion. However, the 1.5-T Signa MRI system, General Electric©, and different models of LOGIQ US units and General Electric© showed similarly good performance in detecting bone erosion in RA patients, while the 2nd metacarpophalangeal joint is the best recommended scanning position during US.

KEY POINTS

• In this study, we evaluated the diagnostic accuracy of US and MRI for bone erosion in RA patients, neither MRI nor US showed perfect diagnostic test accuracy.• 1.5-T Signa system and the LOGIQ units both from General Electric© are the machine types of MRI and US with the greatest performance, respectively.• The 2nd MCP joint is the scanning position recommended during US test.• Different reference standards will greatly influence the judgment of the results.

Considerations for Optimal Trial Design for Rheumatoid Arthritis Prevention Studies

The field of rheumatology has made major contributions to medicine through the identification of cellular and molecular targets and with the development of therapies for the treatment of an impressive range of immune-mediated rheumatic diseases. In recent years new milestones have been achieved. These include the recognition of an "at risk" state, defined by distinct clusters of characteristics, including disease-specific autoantibodies in serum and symptom complexes that include inflammatory joint pain. Studies seeking to prevent high-risk individuals from progressing to a state of clinically apparent arthritis have been initiated. Here, exploiting the current evidence base, an experimental framework to inform trial design is described, taking into consideration study patient phenotypes and highlighting the impact of risk stratification and the options available for therapeutic intervention according to the different phases of the preclinical syndrome. Pragmatic primary end points and suggestions for a set of risk-focused trial outcome measures are proposed, including both clinical assessments and patient-reported outcome measures. Rheumatoid arthritis prevention studies provide an important experimental framework for generating deeper insights into risk stratification and for refining trial design in the future. To this end, a research agenda is suggested, together with some considerations for imaging and for biological sampling. This commentary concludes with some of the operational issues that arise from such studies and addresses some of the challenges associated with recruitment and retention of the at-risk trial participant.

The correlation between interleukin-34 and bone erosion under ultrasound in rheumatoid arthritis

Background: Rheumatoid arthritis (RA) is a chronic inflammatory arthropathy characterized by excessive synovial hyperplasia and progressive joint destruction. Pro-inflammatory cytokines play major roles in the regulation of synovial inflammation. The contribution of interleukin-34 (IL-34) in RA pathogenesis has been strongly suggested in clinical studies.Aim: To investigate the correlation between plasma IL-34 and disease parameters in RA patients including disease activity score (DAS28), receptor activator of NF-[Formula: see text]B ligand (RANKL) concentration, synovitis and bone erosions under ultrasound.Methods: 60 RA patients and 20 healthy controls were from Huashan Hospital, patient's medical history, physical examination, laboratory examination and ultrasound data were collected and recorded, respectively. Blood samples of all participants were collected and the levels of IL-34 and RANKL were tested. The levels of IL-34 and RANKL in RA patients were compared with those of healthy controls. Furthermore, the correlation between IL-34, RANKL and disease parameters in RA patients was analyzed.Results: Both plasma levels of IL-34 and RANKL in RA patients were significantly higher than the healthy controls (p < .05). IL-34 was significantly related to disease activity scores (r = 0.43, p = .001); RANKL (r = 0.46, p = .0003) and bone erosions by ultrasound (r = 0.38, p = .002).Conclusions: The plasma IL-34 concentration in RA was significantly higher than the healthy controls and was significantly correlated with RANKL, as well as disease activity score and bone erosions by ultrasound. The IL-34 may be a new biological marker for disease activity and predictor for bone erosions in RA. Targeting IL-34 holds promise in the management of RA and, potentially, other osteoclasts driven diseases (erosive osteoarthritis and psoriatic arthritis for example).

Can optical spectral transmission assess ultrasound-detected synovitis in hand osteoarthritis?

Objective

To determine whether optical spectral transmission (OST) can be used to assess synovitis in hand and wrist joints of patients with hand osteoarthritis (OA).

Design

Hand and wrist joints of 47 primary hand OA patients with at least one clinically inflamed hand or wrist joint were assessed for synovitis by OST and ultrasound (US). Associations between standardized OST and US synovitis were studied in linear mixed effects models, across all joint types together and individually for wrist, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints, and were adjusted for OA features that showed associations with US synovitis. Diagnostic performance was determined using receiver operator characteristic (ROC) curves analysis, with US as reference standard.

Results

Altogether, 6.7% of joints showed US synovitis. Statistically significant associations between OST scores and US synovitis were found for all joints combined (Δ0.37SD, p<0.001) and PIP joints (Δ0.81SD, p<0.001), but not for DIP (Δ0.14SD, p = 0.484) or wrist joints (Δ0.37SD, p = 0.178). All associations were independent of other OA features, i.e. osteophytes and dorsal vascularity. Analysis of diagnostic performance of OST, revealed an area under the ROC curve (AUC-ROC) of 0.74 for all joints together (p<0.001), 0.69 for PIP joints (p<0.001), 0.54 for DIP joints (p = 0.486), and 0.61 for wrist joints (p = 0.234).

Conclusions

OST scores and US synovitis are statistically significantly associated, independent of osteophytes and dorsal vascularity. At this stage, OST performs fair in the assessment of synovitis in PIP joints of hand OA patients.

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.

MRI of synovitis and joint fluid

Synovitis and joint effusion are common manifestations of rheumatic disease and play an important role in the disease pathophysiology. Earlier detection and accurate assessment of synovial pathology, therefore, can facilitate appropriate clinical management and hence improve prognosis. Magnetic resonance imaging (MRI) allows unparalleled assessment of all joint structures and associated pathology. It has emerged as a powerful tool, which enables not only detection of synovitis and effusion, but also allows quantification, detailed characterization, and noninvasive monitoring of synovial processes. The purpose of this article is to summarize the pathophysiology of synovitis and to review the role of qualitative, semiquantitative, and quantitative MRI in the assessment of synovitis and joint fluid. We also discuss the utility of MRI as an outcome measure to assess treatment response, particularly with respect to osteoarthritis and rheumatoid arthritis. Emerging applications such as hybrid positron emission tomography / MRI and molecular imaging are also briefly discussed. Level of Evidence: 5 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2019.

Comparison of Ultrasound, Radiography, and Clinical Investigations in the Diagnosis of Early Rheumatoid Synovitis in Patients with Nonspecific Musculoskeletal Symptoms: A Multicenter Cross-Sectional Study

BACKGROUND Early diagnosis and treatment of rheumatoid synovitis can reduce the progression of rheumatoid arthritis (RA). However, in the early stages of rheumatoid synovitis, patients may only have non-specific musculoskeletal symptoms, and plain film radiographs may not detect early synovial changes. The aim of this study was to compare the sensitivity and specificity of ultrasound with radiography, and clinical investigations in the detection of rheumatoid synovitis in patients presenting with nonspecific musculoskeletal symptoms. MATERIAL AND METHODS This was a non-randomized, cross-sectional, clinical study that included 189 patients who had nonspecific musculoskeletal symptoms. All patients underwent clinical investigations, postero-anterior and dorsal radiographic imaging, and bilateral grey-scale ultrasound examinations of the third and second metacarpophalangeal (MCP) joints, the third and the second proximal interphalangeal (PIP) joints, the second and the fifth metatarsophalangeal (MTP) joints, and the wrist. RESULTS There was no clear predictive value for detection of early synovitis by clinical investigations alone. Plain film radiography of patients only provided accurate information of joint erosions but less information for synovitis. Grey-scale ultrasound was more effective at detecting early synovitis compared with clinical investigations (p=0.00015; q=4.548) and compared with plain film radiography (p=0.0002; q=4.537), and quantified the synovial changes. The predictive values of plain film radiography and clinical investigations had 0.43 and 0.24 sensitivity and 0 specificity compared with ultrasound. CONCLUSIONS The findings of this study support the use of grey-scale ultrasound in the detection of early rheumatoid synovitis of the fingers and the wrist.