A diagnostic algorithm for persistence of very early inflammatory arthritis: the utility of power Doppler ultrasound when added to conventional assessment tools

What is the place of ultrasound in MSK imaging?

During the past four decades, ultrasound has become popular as an imaging modality applied to the musculoskeletal (MSK) system, particularly outside the USA, due to its low cost, accessibility, and lack of ionizing radiation. A basic requirement in performing these examinations is to have a core group of radiologists and ultrasound technologists with expertise in MSK ultrasound. The extent to which ultrasound will be part of the imaging offered by a particular radiology practice or in an academic institution will vary according to expertise, availability, and reimbursements. A brief discussion of the technical capabilities of the current generation of ultrasound scanners will be followed by a description of some of the more prevalent MSK ultrasound imaging applications. The extent to which training to perform these exams within and outside of Radiology plays a role is discussed. Applications that are unique to ultrasound, such as dynamic evaluation of musculoskeletal anatomy and some, US-guided interventions are an important part of MSK imaging. Ultrasound is increasingly important in the assessment of superficial structures, such as tendons, small joints, and peripheral nerves. These applications help to establish the place of ultrasound as an important part of the Radiologists approach to MSK imaging. Outside of radiology, for a variety of clinical subspecialties, ultrasound already plays an integral role in MSK imaging.

When Autoantibodies Are Missing: The Challenge of Seronegative Rheumatoid Arthritis

Seronegative rheumatoid arthritis (SNRA) is characterized by the absence of both rheumatoid factor (RF) and antibodies against the cyclic citrullinated protein (ACPA) in serum. However, the differences between the two forms of RA are more complex and have not yet been definitively characterized. Several lines of evidences support the idea that there are specific elements of the two forms, including genetic background, epidemiology, pathogenesis, severity of progression over time, and response to therapy. Clinical features that may differentiate SNRA from SPRA are also suggested by data obtained from classical radiology and newer imaging techniques. Although new evidence seems to provide additional help in differentiating the two forms of RA, their distinguishing features remain largely elusive. It should also be emphasized that the distinctive features of RA forms, if not properly recognized, can lead to the underdiagnosis of SNRA, potentially missing the period called the "window of opportunity" that is critical for early diagnosis, timely treatment, and better prognosis. This review aims to summarize the data provided in the scientific literature with the goal of helping clinicians diagnose SNRA as accurately as possible, with emphasis on the most recent findings available.

The value of ultrasound-defined tenosynovitis and synovitis in the prediction of persistent arthritis

OBJECTIVES

The value of US-defined tenosynovitis in predicting the persistence of inflammatory arthritis is not well described. In particular, the predictive utility of US-defined tenosynovitis of larger tendons is yet to be reported. We assessed the value of US-defined tenosynovitis alongside US-defined synovitis and clinical and serological variables in predicting persistent arthritis in an inception cohort of DMARD-naïve patients with early arthritis.

METHODS

One hundred and fifty DMARD-naïve patients with clinically apparent synovitis of one or more joints and a symptom duration of ≤3 months underwent baseline clinical, laboratory and US (of 19 bilateral joints and 16 bilateral tendon compartments) assessments. Outcomes were classified as persistent or resolving arthritis after 18 months' follow-up. The predictive value of US-defined tenosynovitis for persistent arthritis was compared with those of US-defined synovitis, and clinical and serological variables.

RESULTS

At 18 months, 99 patients (66%) had developed persistent arthritis and 51 patients (34%) had resolving disease. Multivariate logistic regression analysis showed that US-detected digit flexor tenosynovitis [odds ratio (OR): 6.6, 95% CI: 2.0 , 22.1, P = 0.002] provided independent predictive data for persistence over and above the presence of US-detected joint synovitis and RF antibodies. In the RF/ACPA-negative subcohort, US-defined digit flexor tenosynovitis remained a significant predictive variable (OR: 4.7, 95% CI: 1.4, 15.8, P = 0.012), even after adjusting for US-defined joint synovitis.

CONCLUSION

US-defined tenosynovitis provided independent predictive data for the development of persistent arthritis. The predictive role of US-defined digit flexor tenosynovitis should be further assessed; investigators should consider including this tendon site as a candidate variable when designing imaging-based predictive algorithms for persistent inflammatory arthritis development.

When and how should we use imaging in individuals at risk of rheumatoid arthritis?

In recent years rheumatologists have begun to shift focus from early rheumatoid arthritis (RA) to studying individuals at risk of developing the disease. It is now possible to use blood, clinical and imaging biomarkers to identify those at risk of progression before the onset of clinical synovitis. The use of imaging, in particular ultrasound (US) and magnetic resonance imaging (MRI), has become much more widespread in individuals at-risk of RA. Numerous studies have demonstrated that imaging can help us understand RA pathogenesis as well as identifying individuals at high risk of progression. In addition, imaging techniques are becoming more sophisticated with newer imaging modalities such as high-resolution peripheral quantitative computed tomography (HR-pQRCT), nuclear imaging and whole body-MRI (WB-MRI) starting to emerge. Imaging studies in at risk individuals are heterogeneous in nature due to the different at-risk populations, imaging modalities and protocols used. This review will explore the available imaging modalities and the rationale for their use in the main populations at risk of RA.

VEGF Profile in Early Undifferentiated Arthritis Cohort

Background and Objectives: Early undifferentiated arthritis (UA) is a group of inflammatory joint diseases that are not classified under any specific rheumatic or connective tissue disorder and might evolve into chronic inflammatory arthritis or may be a self-limiting condition. Early recognition and treatment are crucial for the future course of the disease. Vascular endothelial growth factor (VEGF) is an angiogenic regulator that induces the growth of new capillary blood vessels, which are important in joint invasion and destruction during the progression of chronic inflammatory arthritis. The aim of this study was to assess VEGF levels associated with sociodemographic, clinical, laboratory, and ultrasound findings in the early UA patient cohort as well as to evaluate VEGF as a potential prognostic marker for arthritis outcomes. Materials and Methods: Seventy-six patients with inflammatory arthritis in at least one joint, with a duration of arthritis <12 months at the study entry that did not meet any rheumatic disease classification criteria, were enrolled after informed consent was obtained. Patient’s sociodemographic, laboratory data, and clinical disease characteristics were recorded, VEGF levels were measured, and ultrasound (US) of tender and swollen joints was performed. Results: VEGF levels had positive correlation with conventional rheumatic disease activity and diagnostic markers: erythrocyte sedimentation rate (ESR), C−reactive protein (CRP), and rheumatoid factor (RF) (p < 0.05). RF-positive patients had higher VEGF values (p = 0.024). A statistically higher number of patients whose VEGF levels were below the median value presented with active infection (p = 0.046). In patients with a higher number of swollen joints, and a higher score of synovitis and power doppler (PD) seen on US, VEGF levels were statistically significantly higher. Patients who after 12-month follow-up developed rheumatoid arthritis (RA) had statistically higher VEGF levels at baseline compared with those who developed spondyloarthropathies (p = 0.028). Conclusions: This study demonstrated that VEGF levels significantly represented inflammatory processes that were present in the joints (number of swollen joints, synovitis, and PD changes) of the early UA cohort.

Systematic review of imaging tests to predict the development of rheumatoid arthritis in people with unclassified arthritis

OBJECTIVE

To estimate and compare the diagnostic accuracy of magnetic resonance imaging (MRI) and ultrasound, for the prediction of rheumatoid arthritis (RA) in unclassified arthritis (UA).

METHODS

MEDLINE, Embase and BIOSIS were searched from 1987 to May 2019. Studies evaluating any imaging test in participants with UA were eligible. Reference standards were RA classification criteria or methotrexate initiation. Two authors independently extracted data and assessed validity using QUADAS-2. Sensitivities and specificities were calculated for each imaging characteristic and joint area. Summary estimates with 95% confidence intervals (CI) were estimated where possible.

RESULTS

Nineteen studies were included; 13 evaluated MRI (n=1,143; 454 with RA) and 6 evaluated ultrasound (n=531; 205 with RA). Studies were limited by unclear recruitment procedures, inclusion of patients with RA at baseline, differential verification, lack of blinding and consensus grading. Study heterogeneity largely precluded meta-analysis, however summary sensitivity and specificity for MRI synovitis in at least one joint were 93% (95% CI 88%, 96%) and 25% (95% CI 13%, 41%) (3 studies). Specificities may be higher for other MRI characteristics but data are limited. Ultrasound results were difficult to synthesise due to different diagnostic thresholds and reference standards.

CONCLUSION

The evidence for MRI or ultrasound as single tests for predicting RA in people with UA is heterogeneous and of variable methodological quality. Larger studies using consensus grading and consistently defined RA diagnosis are needed to identify whether combinations of imaging characteristics, either alone or in combination with other clinical findings, can better predict RA in this population.

EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis

BACKGROUND

Despite growing interest, there is no guidance or consensus on how to conduct clinical trials and observational studies in populations at risk of rheumatoid arthritis (RA).

METHODS

An European League Against Rheumatism (EULAR) task force formulated four research questions to be addressed by systematic literature review (SLR). The SLR results informed consensus statements. One overarching principle, 10 points to consider (PTC) and a research agenda were proposed. Task force members rated their level of agreement (1-10) for each PTC.

RESULTS

Epidemiological and demographic characteristics should be measured in all clinical trials and studies in at-risk individuals. Different at-risk populations, identified according to clinical presentation, were defined: asymptomatic, musculoskeletal symptoms without arthritis and early clinical arthritis. Study end-points should include the development of subclinical inflammation on imaging, clinical arthritis, RA and subsequent achievement of arthritis remission. Risk factors should be assessed at baseline and re-evaluated where appropriate; they include genetic markers and autoantibody profiling and additionally clinical symptoms and subclinical inflammation on imaging in those with symptoms and/or clinical arthritis. Trials should address the effect of the intervention on risk factors, as well as progression to clinical arthritis or RA. In patients with early clinical arthritis, pharmacological intervention has the potential to prevent RA development. Participants' knowledge of their RA risk may inform their decision to participate; information should be provided using an individually tailored approach.

CONCLUSION

These consensus statements provide data-driven guidance for rheumatologists, health professionals and investigators conducting clinical trials and observational studies in individuals at risk of RA.

A core set of risk factors in individuals at risk of rheumatoid arthritis: a systematic literature review informing the EULAR points to consider for conducting clinical trials and observational studies in individuals at risk of rheumatoid arthritis

BACKGROUND

There is significant interest in determining risk factors in individuals at risk of rheumatoid arthritis (RA). A core set of risk factors for clinical arthritis development has not been defined.

METHODS

A literature search and systematic literature review (SLR) was conducted to identify risk factors in individuals at risk of RA using Medline, Embase, PubMed and Central databases.

RESULTS

3854 articles were identified by the literature search. After screening of titles, 138 abstracts were reviewed and 96 articles finally included. Fifty-three articles included data on risk factors including autoantibodies, subclinical inflammation on imaging, clinical features, serum and cellular biomarkers and genetic markers. Risk factors were dependent on the at-risk population. There was good evidence for serum anticitrullinated protein antibodies (ACPA) levels, as risk factors for arthritis in all at-risk populations (n=13 articles). Subclinical inflammation on ultrasound (n=12) and MRI (n=6) was reported as a risk factor in multiple studies in at-risk individuals with musculoskeletal (MSK) symptoms and undifferentiated arthritis (UA). Clinical features were reported as a risk factor in at-risk individuals with MSK symptoms and UA (n=13). Other risk factors, including serum and cellular markers were less frequently reported.

CONCLUSIONS

Risk factors for arthritis development in RA are specific to the at-risk population. Serum ACPA confers risk in all populations; subclinical inflammation on imaging and clinical features confer risk in at-risk individuals with MSK symptoms. This SLR informed the EULAR taskforce for points to consider on conducting clinical trials and studies in individuals at risk of RA.

What Is the Value of Ultrasound in Individuals 'At-Risk' of Rheumatoid Arthritis Who Do Not Have Clinical Synovitis?

The identification of biomarkers that help identify individuals at imminent risk of progression to rheumatoid arthritis (RA) is of crucial importance for disease prevention. In recent years, several studies have highlighted the value of musculoskeletal (MSK) ultrasound (US) in predicting progression to inflammatory arthritis (IA) in individuals ‘at-risk’ of RA. These studies have highlighted the following main aspects: first, in RA-related autoantibody-positive individuals, MSK symptoms seem to develop before ‘sub-clinical’ joint inflammation occurs on US. Second, the detection of ‘sub-clinical’ synovitis (and/or bone erosions) greatly increases the risk of IA development in these ‘at-risk’ individuals. US has a potential key role for better understanding the ‘pre-clinical’ stages in individuals ‘at-risk’ of RA, and for the early identification of those individuals at high risk of developing IA. Further research is needed to address questions on image analysis and standardization. In this review, we provide an overview of the most relevant studies which have investigated the value of US in the prediction of RA development in individuals ‘at-risk’ of RA who have MSK symptoms, but no clinical evidence of IA. We highlight recent insights, limitations, and future perspectives of US use in this important population.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Bone Erosions Detected by Ultrasound Are Prognostic for Clinical Arthritis Development in Patients With ACPA and Musculoskeletal Pain

Anti-citrullinated protein antibodies (ACPA) often precede onset of rheumatoid arthritis (RA) by years, and there is an urgent clinical need for predictors of arthritis development among such at-risk patients. This study assesses the prognostic value of ultrasound for arthritis development among ACPA-positive patients with musculoskeletal pain. We prospectively followed 82 ACPA-positive patients without clinical signs of arthritis at baseline. Ultrasound at baseline assessed synovial hypertrophy, inflammatory activity by power Doppler, and erosions in small joints of hands and feet. We applied Cox regression analyses to examine associations with clinical arthritis development during follow-up (median, 69 months; range, 24–90 months). We also compared the ultrasound findings among the patients to a control group of 100 blood donors without musculoskeletal pain. Clinical arthritis developed in 39/82 patients (48%) after a median of 6 months (range, 1–71 months). One or more ultrasound erosions occurred in 13/82 patients (16%), with none in control subjects (p < 0.001). Clinical arthritis development was more common among patients with baseline ultrasound erosions than those without (77 vs. 42%, p = 0.032), and remained significant in a multivariable Cox regression analysis that included previously described prognostic factors (HR 3.9, 95% CI 1.6–9.4, p = 0.003). Ultrasound-detected tenosynovitis was more frequent among the patients and associated with clinical arthritis development in a univariable analysis (HR 2.5, 95% CI 1.1–5.7, p = 0.031), but did not remain statistically significant in multivariable analysis. Thus, bone erosions detected by ultrasound are independent predictors of clinical arthritis development in an ACPA-positive at-risk population.

Trial Registration: Regional Ethics Committee in Linköping, Sweden, Dnr M220-09. Registered 16 December 2009, https://etikprovningsmyndigheten.se/.

The Role of Ultrasound Across the Inflammatory Arthritis Continuum: Focus on "At-Risk" Individuals

In individuals at-risk of developing inflammatory arthritis, the value of an ultrasound (US) scan assessment to predict progression has been demonstrated repeatedly. However, depending on recruitment criteria, these individuals may be at different stages in the arthritis development continuum, therefore representing a heterogeneous population. As a consequence, the predictive value of ultrasound results may differ between cohorts. As other reviews have focused on the challenges in population recruitment or have combined biomarkers predicting value according to one recruitment pathway, we wanted to focus on the sole use of ultrasound assessment and its variation according to population recruitment criteria. In this review, we discuss the use of ultrasound in the different at-risk populations across the inflammatory arthritis disease continuum. This review demonstrates that although some sub-population data is scarce, ultrasound is best predictive in three at-risk populations: those with a positive ACPA test in the context of non-specific MSK symptoms, those with clinically suspect arthralgia and those with palindromic rheumatism. We consider that ultrasound assessment will be a cornerstone in prediction risk modeling and prevention studies of the preclinical phases of IA in the future.

Effective Treatment with Tocilizumab in a Rheumatoid Arthritis Patient Complicated with Human T-cell Leukemia Virus Type 1-associated Myelopathy

A 61-year-old woman with human T-cell leukemia virus type 1 (HTLV-1)-associated myelopathy (HAM)/tropical spastic paraparesis (TSP) and interstitial pneumonia (IP) was admitted to our hospital. She complained of sicca symptoms, polyarthralgia, and swollen joints. She was diagnosed with rheumatoid arthritis (RA) and Sjögren's syndrome. Methotrexate and anti-tumor necrosis factor therapy were not utilized because of the inclusion of severe respiratory disorders among the complications and the neurological symptoms of HAM/TSP. Tocilizumab monotherapy improved the RA disease activity without exacerbating HAM/TSP. The present case suggests that tocilizumab might be a suitable treatment option in patients with RA and HAM/TSP.

The changing role of ultrasonography examination in patients with rheumatoid arthritis in light of recent studies

For many years, ultrasonography (US) has been a widely accepted modality used for joint assessment in patients with rheumatoid arthritis (RA). Given the efficacy of present day therapies, there is scepticism whether it is required in the first place. The most recent clinical Targeting synovitis in Early Rheumatoid Arthritis (TaSER) and Clinical Tight Control Therapy (ARCTIC) trials’ results appear to contradict it, yet this does not necessarily mean ultrasound has no place in modern rheumatology. The possibility of detecting inflammation at a subclinical level carries a tremendous predictive value, enabling identification of patients likely to experience an exacerbation in the coming months. Therefore, US should be a part of the decision-making process regarding treatment modification or introduction of any additional interventions, such as glucocorticosteroid injections.

The results of the most recent clinical trials do not negate the usefulness of US, but merely suggest that it ought to be used in moderation.

Ultrasonography in Early Rheumatoid Arthritis of Hand and Wrist Joints: Comparison with Magnetic Resonance Imaging

BACKGROUND

The aim of the study was to evaluate the use of ultrasonography (USG) including power Doppler in detecting hand and wrist joint changes in early rheumatoid arthritis (RA) and to compare USG findings with magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Thirty-four patients diagnosed as RA by 2010 ACR/EULAR criteria; with the onset of symptoms within last one year, were included in the study after institute ethical clearance and informed consent to undergo USG and contrast-enhanced MRI of the dominant affected hand. Second to fifth metacarpophalangeal (MCP) joints, second to fifth proximal interphalangeal (PIP) joints and wrist joints (total nine joints) were evaluated for synovitis, erosions along with tenosynovitis. USG and MRI features were compared; agreement on the two imaging modalities as well as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of ultrasonography compared to MRI (gold standard) was calculated.

RESULTS

One hundred thirty-six MCP, 136 PIP and 34 wrist joints (total 306 joints) and 136 flexor tendons were evaluated. The sensitivity, specificity, PPV, NPV and diagnostic accuracy of USG for diagnosing synovitis was 78.6%, 91.1%, 86.1%, 85.8%, 86.3%; for erosions 67.2%, 97.5%, 84.8%, 90.5%, 91.5%; for tenosynovitis 86.5%, 100%, 100%, 92.3% and 94.8% respectively. The overall agreement between USG and MRI for detection of synovitis was achieved in 83% joints and for erosions in 89.5% joints.

CONCLUSION

In early RA, USG was nearly as effective in diagnosing features of joint and tendon sheath involvement, with relatively better performance of USG for tenosynovitis. The performance of USG in diagnosing erosions was limited likely due to difficult access of three-dimensional joint structure.

The Role of Musculoskeletal Ultrasound in the Rheumatoid Arthritis Continuum

PURPOSE OF REVIEW

Rheumatoid arthritis (RA) is no longer considered a fixed phenotype but rather a disease continuum. This review outlines the current and potential value of applying ultrasound (US) along this continuum: from the prediction of progression to RA in at-risk individuals, to confirmation of the early diagnosis of RA, as well as the consideration of differential diagnoses, and the use in disease monitoring and defining remission.

RECENT FINDINGS

In individuals at-risk of RA (i.e., positive autoantibodies with symptoms but without synovitis), US has shown a promising predictive value for the development of clinical arthritis, providing the opportunity to improve risk stratification (and disease prevention) of these individuals. The detection of inflammation on US in patients with early undifferentiated arthritis, in which a definite diagnosis cannot be reached, could predict evolution to persistent arthritis, mostly RA. This, in addition to the US potential ability to identify disease specific patterns for different rheumatic conditions, might facilitate early diagnosis and, therefore, improve the management of patients with RA, or other types of inflammatory arthritides. US has also demonstrated the capability to predict radiographic progression, and relapse risk after treatment discontinuation, in RA patients in remission according to the clinical instruments, raising implications in the management, including therapy discontinuation, of these patients. US has an undeniable value in the management of patients at different stages along the RA continuum. Further research is needed to identify which groups of patients benefit the most from US imaging.

Treatment-resistant synovitis and radiographic progression are increased in elderly-onset rheumatoid arthritis patients: findings from a prospective observational longitudinal early arthritis cohort study

BACKGROUND

Clinical outcomes in elderly-onset rheumatoid arthritis (EORA), starting after the age of 60, are conflicting. Thus, we aimed to investigate in a unique biopsy-driven, treatment-naïve early arthritis cohort, the relationship between synovial pathobiology of elderly- (EORA) and younger-onset rheumatoid arthritis (YORA) patients through clinical, imaging and treatment response outcome-measures.

METHODS

Patients (n = 140) with early RA (<12months) starting before (YORA, n = 99) or after (EORA, n = 41) age 60 had an ultrasound-guided synovial biopsy prior to conventional immunosuppressive therapy and after 6 months. Clinical, ultrasound and radiographic data were collected prospectively and compared between groups and against immunohistological features. Using multivariate logistic regression, we determined predictors of clinical response (disease activity score-28-erythrocyte sedimentation rate [DAS28-ESR]<3.2) at 6 months and radiographic progression (≥1-unit-increase in Sharp van der Heijde [SvdH] score) at 12 months.

RESULTS

EORA patients were more frequently male and presented most commonly with an abrupt, polymyalgia rheumatica-like onset and extra-articular features. Both before and after treatment, DAS28-ESR was similar but ultrasound synovial-thickening (p<0.05) and power-Doppler (p<0.01) synovitis and SvdH (p<0.001) scores were higher in EORA patients. EORA was independently associated with poor treatment response at 6 months (OR=0.28, p = 0.047) and radiographic progression at 12 months (OR=4.08, p = 0.029). Synovial pathotype, synovitis scores and cellular infiltration were similar before treatment, but a pauci-immune-fibroid pathotype tended to be more common in YORA at 6 months (p = 0.093). Moreover, YORA patients had a marked improvement of all synovitis parameters (p<0.001), whereas EORA presented only mild decreases in synovitis (p<0.05), sublining macrophage (p<0.05) and T cell scores (p<0.05), with no significant changes in lining macrophages, B cells or plasma cells.

CONCLUSION

Early EORA presents differently and has a worse overall prognosis than YORA, with poorer clinical, histological, ultrasonographic and radiographic outcomes.

Lack of association between clinical and ultrasound measures of disease activity in rheumatoid arthritis remission

OBJECTIVES

The objective of this study was to assess the prevalence of ultrasound (US) abnormalities and association with clinical parameters in rheumatoid arthritis (RA) clinical remission.

METHODS

Patients with established RA in clinical remission (DAS28-CRP < 2.4) taking conventional synthetic disease-modifying anti-rheumatic drugs were recruited as part of the Biomarkers of Remission in Rheumatoid Arthritis (BioRRA) Study. In addition, patients from the Newcastle Early Arthritis Clinic (NEAC) with early active RA (DAS28-CRP > 2.4) or seronegative non-inflammatory arthralgia (NIA) were studied as positive and negative controls, respectively. The association between individual dependent variables (synovial power Doppler and greyscale, tenosynovial greyscale, and erosions) and clinical parameters was assessed by multivariate ordinal logistic regression, with adjustment for multiple testing.

RESULTS

A total of 294 patients were included: 66 RA in remission, 146 active RA, and 82 NIA. Within the active RA group, significant associations were observed between swollen joint count and higher total synovial greyscale score (OR 1.17 95% CI 1.08-1.26, p < 0.001) and higher total synovial power Doppler score (OR 1.20, 95% CI 1.12-1.30, p < 0.001). No significant associations were observed for the NIA group. In the RA remission group, US abnormalities were frequently observed and comparable for both DAS28-CRP and 2011 ACR/EULAR Boolean remission, with no significant association with clinical parameters identified.

CONCLUSION

We observed widespread subclinical US findings in RA patients in clinical remission, even when remission is defined using the stringent ACR/EULAR Boolean criteria. In contrast to active disease, synovial power Doppler failed to show significant association with any of the clinical parameters in RA remission. Our results suggest that clinical and US examinations are non-overlapping in evaluating RA remission, challenging the proposition of US-driven management strategies in this setting.

Routine musculoskeletal ultrasound findings impact diagnostic decisions maximally in autoantibody-seronegative early arthritis patients

OBJECTIVE

The diagnostic value added by musculoskeletal ultrasound (MSUS) over standard clinical and laboratory parameters has proved difficult to quantify. The additive contribution to diagnostic classification of a pragmatic, 15 min MSUS protocol was appraised in a large, unselected cohort of early arthritis clinic attendees.

METHODS

Detailed baseline characteristics were recorded. Semi-quantitative MSUS scoring of the most symptomatic wrist, second/third MCPs and PIPs and second/fifth MTPs was recorded, along with the sonographer's scan impression (definitely inflammatory, possibly inflammatory or non-inflammatory). MSUS findings were available to rheumatologist diagnosticians during subsequent consultations. Persistent inflammatory arthritis (PIA) was classified only where patients were started on ≥1 DMARD. Multivariate and receiver operating characteristic (ROC) curve analyses were used to identify independent discriminators of PIA, and the added value of MSUS parameters.

RESULTS

Eight hundred and thirty-one patients were enrolled, of whom 31.3% acquired a PIA diagnosis. Swollen joint count, CRP, age and ACPA status were non-redundant clinical/laboratory predictors of a PIA diagnosis by consulting rheumatologists, with good discriminatory utility (area under the ROC curve, AUROC, 0.88). While the additive contribution of summed parameters from the seven-joint MSUS protocol to this model was statistically significant (P = 0.004), it was numerically small (ΔAUROC 0.02). However, the additive contribution to diagnostic outcome of sonographer's scan impression over clinical parameters alone became substantial in the sub-cohort of ACPA-negative patients, increasing the AUROC by 9% from 0.81 to 0.90 (P < 0.0001).

CONCLUSION

The clinical utility of a 15-min MSUS screen for diagnosing PIA requiring DMARDs is most evident among ACPA-negative patients attending an early arthritis clinic.

EULAR definition of "arthralgia suspicious for progression to rheumatoid arthritis" in a large cohort of patients included in a program for rapid diagnosis: role of auto-antibodies and ultrasound

OBJECTIVES

To evaluate the performance of the European League Against Rheumatism (EULAR) definition of arthralgias suspicious for progression to RA in patients with hand arthralgias and to estimate the added value of both auto-antibodies and ultrasound (US) with power Doppler (PD).

METHODS

Consecutive patients admitted for hand arthralgias to "Reuma-check" ® program were included. This program includes the following at baseline: clinical assessment, laboratory tests, US with PD of both hands, and radiography of both hands and feet. All patients were followed-up after baseline evaluation by their treating rheumatologists, and a definitive diagnosis of RA (ACR/EULAR 2010 criteria) was established or not.

RESULTS

A total of 465 consecutive patients were included. During follow-up, 44 (9.4%) were diagnosed with RA. Mean of baseline EULAR features describing arthralgia suspicious for progression to RA was 4.1 in patients with final diagnosis of RA vs 2.3 in non-RA patients (p < 0.0001). The AUC for the EULAR defined features describing arthralgia suspicious for progression to RA for the final diagnosis of RA was 0.7827, while adding US with PD, rheumatoid factor (RF), and anti-cyclic citrullinated peptide antibodies (ACPA) data, the AUC was 0.9172 (p < 0.0001). In the multivariate regression logistic analysis, baseline features associated with a final diagnosis of RA were difficulty with making a fist, RF, ACPA, and US with PD.

CONCLUSIONS

EULAR definition of arthralgia suspicious for progression to RA had an acceptable performance to predict the future development of RA and improves adding information of both RF, ACPA and US with PD data.Key Points• Clinically suspect arthralgia may trigger rheumatologists to monitor patients closely for an early diagnosis.• EULAR definition of arthralgia suspicious for progression to RA predicts future development of arthritis.• Auto-antibodies and ultrasound improve EULAR definition of arthralgia suspicious for progression to RA.

Should ultrasound be used routinely in the diagnosis of rheumatoid arthritis?

INTRODUCTION

A growing body of evidence indicates the benefits of early diagnosis of rheumatoid arthritis (RA) and prompt treatment with disease-modifying anti-rheumatic drugs (DMARDS) in terms of relieving symptoms, improving prognosis, and reducing long-term complications. There is however some controversy over the most beneficial method of imaging in providing accurate early diagnosis. Though current practice favours clinical and radiological assessment, this is increasingly supplemented by ultrasound techniques (and, to a lesser extent, CT and MRI scanning). While EULAR and ESSR favour the use of ultrasonography (US) as the first-line investigation in cases of suspected RA, a recent NICE review upholds the traditional place of plain film radiographs of hands and feet to detect erosions as early signs of synovitis. This review considers the evidence for US in the early diagnosis of RA and the case for it becoming the primary assessment modality in rheumatology clinics.

AIMS

This paper aims to assess the current literature on the efficacy of ultrasonography in diagnosing early RA, by comparing US with alternative imaging modalities. The goal is to propose the most appropriate method of diagnosis to improve early initiation of DMARD treatment for optimum disease outcomes.

METHODS

Searches for related studies and review articles were carried out using electronic databases and hand searches. Additional references were gleaned from the bibliographies of included papers. Related articles and pop-outs from PubMed were also used. The search was refined in PubMed, by only using reviews which were written in English and published in past 10 years and had full free text available.

RESULTS

This review confirms that US has a high level of sensitivity in diagnosing RA (and hence a low risk of missing cases of RA which might benefit from early treatment with DMARDs). It also has a high level of specificity (and hence a low risk of falsely diagnosing somebody with RA who may suffer adverse effects of DMARD therapy). US is already widely available and well accepted by clinicians and patients. It does not involve exposure to radiation and can be readily delivered by appropriately trained staff.

CONCLUSION

This review of relevant studies indicates that US should become accepted as the investigation with the most favourable balance of benefits to risks in the early diagnosis of RA. Given the continuing controversy surrounding studies of different imaging techniques in RA, further research into the diagnostic role of US in RA is indicated.

Rheumatoid arthritis-like active synovitis with T-cell activation in a case of idiopathic multicentric Castleman disease: A case report

RATIONALE

Idiopathic multicentric Castleman disease (iMCD) is a systemic disease with multiple regions of lymphadenopathy and systemic symptoms and associated with rheumatoid arthritis (RA) and collagen diseases. However, few reported have described the coexistence of iMCD and RA and the mechanisms by which iMCD induces arthritis remain elusive. We experienced a rare case of iMCD, wherein the patient exhibited symptoms of polyarthritis with high-grade fever.

PATIENT CONCERNS

A 34-year-old woman was admitted to our hospital for further evaluation of a high fever with polyarthritis. The levels of both rheumatoid factor and anticitrullinated protein antibody were negative. F-fluorodeoxyglucose/positron emission tomography-computed tomography showed lymphadenopathy with increased fluoro-2-deoxy-D-glucose uptake. Magnetic resonance imaging and musculoskeletal ultrasonography revealed active synovitis in the hands which was consistent with RA.

DIAGNOSES

We diagnosed iMCD based on human herpesvirus 8 negativity, HIV negativity, systemic lymphadenopathy, and pathologic findings of the lymph nodes. The patient did not satisfy the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for RA. Cytokine assay showed elevated serum levels of interleukin-17 and CXCL10, comparable to those in patients with RA.

INTERVENTIONS

We administered 15 mg/d of predonisolone.

OUTCOMES

After this treatment, the patient's symptoms showed improvement. As of this writing, we tapered the prednisolone to 7.5 mg/d, and the patient's remission has been maintained for >4 months.

LESSONS

The present case suggests that RA-like active synovitis may coexist in iMCD, resulting from aberrant T-cell activation and histologic examination using lymph node biopsy may help enable early diagnosis of iMCD.

Real benefits of ultrasound evaluation of hand and foot synovitis for better characterisation of the disease activity in rheumatoid arthritis

Objectives

Optimal management of rheumatoid arthritis (RA) depends on accurate evaluation of disease activity. Foot synovitis is not included in the most used RA outcome measure (DAS-28 score). The aim of this study was to investigate how musculoskeletal ultrasound (MSK-US) examination of hand and feet correlate with the disease activity score (DAS-28 score). We also explored whether performing MSK-US assessments of hands alone compared with hands and feet underestimates the disease activity in RA.

Methods

This is a real-life cross-sectional study of 101 patients (51 with RA and 50 with other musculoskeletal conditions) with inflammatory small joint pain, who underwent MSK-US examination of hands and feet.

Results

MSK-US-detected hand synovitis was found in 18/51 (35.3%) RA patients and 16/50 (32%) of those with other musculoskeletal conditions (p = 0.96), while foot synovitis was detected in 18/51 (35.3%) and 12/50 (24%) patients, respectively (p = 0.78). DAS-28 did not correlate with any of the US outcome measures in patients with RA. Six out of 13 (46.1%) RA patients in remission, 7/14 (50%) with low disease activity and 18/32 (56.2%) with moderate disease activity (according to DAS-28 definition) had active synovitis as assessed by the MSK-US examination of their hands and feet. MSK-US-detected synovitis led to treatment escalation in 26/51 (51%) RA patients.

Conclusion

This study emphasises that MSK-US examination of hands and feet has led to optimised management of the majority of RA patients, which would have not been possible otherwise, because of the lack of correlation between DAS-28 assessment and MSK-US outcomes.

Key Points

• The most used disease activity score in rheumatoid arthritis (DAS-28) did not correlate with US outcome measures derived from hands and feet examination.

• DAS-28 did not differentiate between RA patients with subclinical active synovitis versus well-controlled disease on US.

• As a result of US examination of the hands and feet, 51% RA patients had their immunosuppressive treatment optimised.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06187-8) contains supplementary material, which is available to authorized users.

Reliability of Ultrasound for the Detection of Rheumatoid Arthritis

The aim of this review article was to investigate the pooled sensitivity and specificity of musculoskeletal ultrasound (MSUS) for the detection of synovitis and early bone erosion in the small joint in rheumatoid arthritis (RA). In addition, investigate the pooled sensitivity and specificity of Power Doppler ultrasonography (PDUS) for the detection of synovial hypervascularity in small joints in RA. A systematic literature search of PubMed, Wiley online library, Google Scholar, Research gate, E-book, BioMed Central, the Journal of Rheumatology and Springer Link were investigated from 2001 to 2017. Original researches related to the article written in English including RA, synovitis, bone erosion, grayscale, and PDUS were included in this study. The sample size, study design, sensitivity, and specificity were analyzed. The review summarizes the value of MSUS for the detection of RA as it is the first choice of modality. Results show the acceptable reliability of US for the diagnosis of early bone erosions, synovitis, and synovial hypervascularity.

The importance of ultrasound examination in early arthritis

Objectives

To assess the importance of ultrasound (US) examination of joints in hands and feet in patients with early arthritis and perform comparative analysis of the diagnostic value of US examination for 8, 12 and 52 selected joints.

Material and methods

123 patients (87 women, 36 men) with arthritis lasting less than 12 months, naive to disease-modifying anti-rheumatic drugs and glucocorticosteroids. Necessary differential diagnostics was performed for each patient. After the preliminary analysis, 72 patients met the classification criteria for rheumatoid arthritis (RA) according to ACR/EULAR of 2010, and undifferentiated arthritis (UA) was diagnosed in 51 patients. UA patients were followed up after 6 and 12 months, and verification of the initial diagnosis yielded the following groups of patients: patients meeting classification criteria for RA, patients with maintained diagnosis of UA, patients in remission, and patients with other diagnoses. Ultrasound examination was performed considering the volume of joint effusion (JE), synovial membrane hypertrophy (GS), and synovial membrane hyperaemia assessed by power Doppler (PD). Results were assessed using the semi-qualitative scale. Coefficients being the sum of US scores for the assessment of JE, GS and PD for 52 and 12 joints in hands and feet, and 8 joints in hands were determined for the purpose of the study.

Results

In patients meeting classification criteria for RA during the initial assessment the US examination yielded significantly higher PD-52I, PD-12I and PD-8I coefficients. In UA patients who were diagnosed with RA after 12 months, the GS-8I coefficient was significantly higher.

Conclusions

Ultrasonography is a valuable tool in diagnostics of early arthritis. The GS assessment has prognostic value for UA patients. The assessment of 8 or 12 selected joints is often sufficient for the diagnostics of patients with early arthritis.

The value of joint ultrasonography in predicting arthritis in seropositive patients with arthralgia: a prospective cohort study

BACKGROUND

The value of joint ultrasonography (US) in the prediction of clinical arthritis in individuals at risk of developing rheumatoid arthritis (RA) is still a point of debate, due to varying scanning protocols and different populations. We investigated whether US abnormalities assessed with a standard joint protocol can predict development of arthritis in seropositive patients with arthralgia.

METHODS

Anti-citrullinated protein antibodies and/or rheumatoid factor positive patients with arthralgia, but without clinical arthritis were included. US was performed at baseline in 16 joints: bilateral metacarpophalangeal 2-3, proximal interphalangeal 2-3, wrist and metatarsophalangeal (MTP) joints 2-3 and 5. Images were scored semi-quantitatively for synovial thickening and for positive signs on power Doppler (PD). Association between US abnormalities and arthritis development at the joint and at the patient level was evaluated. Also, we investigated the added value of US over clinical parameters.

RESULTS

Out of 163 patients who underwent US examination, 51 (31%) developed clinical arthritis after a median follow-up time of 12 (interquartile range 5-24) months, of which 44 (86%) satisfied the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA. US revealed synovial thickening and PD in at least one joint in 49 patients (30%) and 7 patients (4%), respectively. Synovial thickening was associated with both development and timing of clinical arthritis in any joint (patient level) when MTP joints were excluded from the US assessment (odds ratio 6.6, confidence interval (CI) 1.9-22), and hazard ratio 3.4, CI 1.6-6.8, respectively, with a mean time to arthritis of 23 versus 45 months when synovial thickening was present versus not present). There was no association between US and arthritis development at the joint level. Predictive capacity was highest in the groups with an intermediate and high risk of developing arthritis based on a prediction rule with clinical parameters.

CONCLUSIONS

Synovial thickening on US predicted clinical arthritis development at the patient level in seropositive patients with arthralgia when MTPs were excluded from the US assessment. Positive PD signs were infrequently seen in these at-risk individuals and was not predictive. In patients at intermediate risk of RA, US may help to identify those at higher risk of developing arthritis.

Identification of a distinct imaging phenotype may improve the management of palindromic rheumatism

Objectives

To use high-resolution imaging to characterise palindromic rheumatism (PR) and to compare the imaging pattern observed to that seen in new-onset rheumatoid arthritis (NORA).

Methods

Ultrasound (US) assessment of synovitis, tenosynovitis and non-synovial extracapsular inflammation (ECI) was performed during and between flares in a prospective treatment-naive PR cohort. MRI of the flaring region was performed where possible. For comparison, the same US assessment was also performed in anticyclic citrullinated peptide (CCP) positive individuals with musculoskeletal symptoms (CCP+ at risk) and patients with NORA.

Results

Thirty-one of 79 patients with PR recruited were assessed during a flare. A high frequency of ECI was identified on US; 19/31 (61%) of patients had ECI including 12/19 (63%) in whom ECI was identified in the absence of synovitis. Only 7/31 (23%) patients with PR had synovitis (greyscale ≥1 and power Doppler ≥1) during flare. In the hands/wrists, ECI was more prevalent in PR compared with NORA and CCP+ at risk (65% vs 29 % vs 6%, p<0.05). Furthermore, ECI without synovitis was specific for PR (42% PR vs 4% NORA (p=0.003) and 6% CCP+ at risk (p=0.0012)). Eleven PR flares were captured by MRI, which was more sensitive than US for synovitis and ECI. 8/31 (26%) patients with PR developed RA and had a similar US phenotype to NORA at progression.

Conclusion

PR has a distinct US pattern characterised by reversible ECI, often without synovitis. In patients presenting with new joint swelling, US may refine management by distinguishing relapsing from persistent arthritis.

The ability of rheumatologists blinded to prior workup to diagnose rheumatoid arthritis only by clinical assessment: a cross-sectional study

Objectives

We aimed to study the ability of board-certified rheumatologists, blinded to all prior diagnostic test results, to establish the presence/absence of an inflammatory rheumatic disease (IRD) or RA among polyarthralgia or arthritis patients, solely relying on clinical assessment.

Methods

We performed a prospective, examiner-blinded, cross-sectional study documenting the diagnostic work in four sequential steps (medical history, physical examination, musculoskeletal ultrasonography and laboratory tests) of board-certified rheumatologists in a convenience cohort of 100 patients referred for inpatient diagnostic workup to a tertiary care rheumatology centre.

Results

The ability to correctly identify patients with or without an IRD (diagnostic accuracy) increased from 27% after the clinical assessment to 53% after the ultrasonography and to 70% after taking laboratory test results into account. The corresponding values for correctly identifying patients with or without RA were 19, 42 and 60%, respectively. Therefore the diagnostic accuracy of solely clinical assessment for determining the diagnosis of IRD or RA compared with the diagnosis established by a consecutive thorough in-patient workup was only 27 and 19% in our cohort, respectively. Pretreatment with corticosteroids (in the prior 7 days) vs none did not alter these results substantially (20 vs 29% for IRD, 15% vs 20% for RA).

Conclusion

Experienced rheumatologists, if deprived of information on prior external imaging and laboratory workup by blinding, were not able to correctly classify the majority of patients presenting with polyarthralgia or arthritis symptoms for inpatient workup, relying only on a brief symptom-focused medical history and physical examination.

Synovial Predictors of Differentiation to Definite Arthritis in Patients With Seronegative Undifferentiated Peripheral Inflammatory Arthritis: microRNA Signature, Histological, and Ultrasound Features

Objectives: To examine synovial tissue (ST) predictors of clinical differentiation in patients with seronegative undifferentiated peripheral inflammatory arthritis (UPIA).

Methods: Fourty-two patients with IgA/IgM-Rheumatoid Factor and anti-citrullinated peptide antibodies negative UPIA, naive to Disease-Modifying Anti-Rheumatic Drugs, underwent Gray Scale (GSUS) and power Doppler (PDUS) evaluation and Ultrasound (US) guided ST biopsy. CD68, CD3, CD21, CD20, and CD31 synovial expression was evaluated by immunohistochemistry. Whole ST microRNA expression was assessed using miScript miRNA PCR Array. Peripheral blood (PB) and synovial fluid (SF) IL-6, VEGF-A, and VEGF-D levels were measured by ELISA and ST TNF expression was assessed by RT-PCR. Each patient was prospectively monitored and classified at baseline and within 1 year as UPIA, Rheumatoid Arthritis (RA), Spondyloarthritis (SpA) or Psoriatic Arthritis (PsA), respectively.

Results: At baseline, CD68⁺ cells were the most common cells within the lining layer (p < 0.001) in seronegative UPIA, directly correlating with GSUS (R = 0.36; p = 0.02) and PDUS (R = 0.55; p < 0.001). Synovial CD31⁺ vessels count directly correlated with GSUS (R = 0.41; p = 0.01) and PDUS (R = 0.52; p < 0.001). During the follow-up, 6 (14.3%) UPIA reached a definite diagnosis (2 RA, 2 SpA and 2 PsA, respectively). At baseline, UPIA who differentiated had higher GSUS (p = 0.01), PDUS scores (p = 0.02) and higher histological scores for CD68⁺ (p = 0.005 and p = 0.04 for lining and sublining respectively), sublining CD3⁺ cells (p = 0.002), CD31⁺ vessels count (p < 0.001) and higher IL-6 PB levels (p = 0.01) than patients who remained as UPIA. MiRNA PCR Array showed that among the 86 tested miRNA species, at baseline, miR-346 and miR-214 were significantly down-regulated (p = 0.02 for both) in ST of UPIA who differentiated than in patients who remained as UPIA, inversely correlating with the lining CD68⁺ cells IHC score (R = −0.641; p = 0.048) and CD31⁺ vessels count (R = −0.665; p = 0.036) and with higher baseline ST expression of TNF (p = 0.014). Finally, logistic regression analysis demonstrated that baseline GSUS and PDUS scores ≥1.5 [OR:22.93 (95%CI:0.98–534.30)] and CD31⁺ vessels count ≥24.3 [OR:23.66 (95%CI:1.50–373.02)] were independent factors associated with the development of definite arthritis.

Conclusions: MiRNA signature, histological and US features of ST may help in the identification of seronegative UPIA with high likelihood of clinical differentiation toward definite seronegative arthritis.

The role of ultrasound-defined tenosynovitis and synovitis in the prediction of rheumatoid arthritis development

OBJECTIVES

Tenosynovitis (TS) is common in early arthritis. However, the value of US-defined TS in predicting RA development is unclear. We assessed the predictive utility of US-defined TS alongside US-defined synovitis and clinical and serological variables in a prospective cohort of early arthritis patients.

METHODS

One hundred and seven patients with clinically apparent synovitis of one or more joint and symptom duration ⩽3 months underwent baseline clinical, laboratory and US assessment of 19 bilateral joint sites and 16 bilateral tendon compartments. Diagnostic outcome was determined after 18 months, applying the 2010 ACR/EULAR classification criteria for RA. The predictive values of US-defined TS for persistent RA were compared with those of US-defined synovitis, clinical and serological variables.

RESULTS

A total of 4066 US joint sites and 3424 US tendon compartments were included in the analysis. Forty-six patients developed persistent RA, 17 patients developed non-RA persistent disease and 44 patients had resolving disease at follow-up. US-defined TS in at least one tendon compartment at baseline was common in all groups (RA 85%, non-RA persistent disease 71% and resolving 70%). On multi-variate analysis, US-defined digit flexor TS provided independent predictive data over and above the presence of ACPA and US-defined joint synovitis.

CONCLUSION

US-defined digit flexor TS provided independent predictive data for persistent RA development in patients with early arthritis. The predictive utility of this tendon site should be further assessed in a larger cohort; investigators designing imaging-based predictive algorithms for RA development should include this tendon component as a candidate variable.

The role of imaging in early diagnosis and prevention of joint damage in inflammatory arthritis

INTRODUCTION

Inflammatory arthritis is characterized by chronic inflammation in the synovium, associated with degradation of cartilage and erosion of juxta-articular bone. The bone loss and joint destruction mediated by aberrant immunological responses resulting in proinflammatory cytokine release and various immune cell activation are known as osteoimmunology. Areas covered: A structured literature search including Medline and PubMed, Cochrane meta-analyses and abstracts of international congresses was performed to review joint damage in inflammatory arthritis in terms of pathogenesis, novel imaging assessment, and prevention. Expert commentary: Deeper understanding of the integration of the skeletal and immune as well as inflammatory system is paving the way to prevent bone loss and bone destruction in inflammatory arthritis. With the availability of various imaging modalities such as ultrasound, magnetic resonance imaging (MRI) and high-resolution peripheral quantitative computed tomography (HR-pQCT), we are now able to detect early joint damage, early diagnosis of inflammatory arthritis, monitor the progression or even ascertain whether the inflammatory process is effectively suppressed to allow repair of joint damage by novel therapeutic agents.

ACR Appropriateness Criteria® Chronic Extremity Joint Pain-Suspected Inflammatory Arthritis

Evaluation for suspected inflammatory arthritis as a cause for chronic extremity joint pain often relies on imaging. This review first discusses the characteristic osseous and soft tissue abnormalities seen with inflammatory arthritis and how they may be imaged. It is essential that imaging results are interpreted in the context of clinical and serologic results to add specificity as there is significant overlap of imaging findings among the various types of arthritis. This review 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 American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

The impact of rheumatologist-performed ultrasound on diagnosis and management of inflammatory arthritis in routine clinical practice

Background

Rheumatologists increasingly perform ultrasound (US) imaging to aid diagnosis and management decisions. There is a need to determine the role of US in facilitating early diagnosis of inflammatory arthritis. This study describes the impact of US use by rheumatologists on diagnosis and management of inflammatory arthritis in routine UK clinical practice.

Methods

We conducted a prospective study in four secondary care rheumatology clinics, each with one consultant who routinely used US and one who did not. Consenting patients aged > 18, newly referred with suspected inflammatory arthritis were included. Data were collected both retrospectively from medical records and via a prospectively-completed physician questionnaire on US use. Analyses were stratified by US/non-US groups and by sub-population of rheumatoid arthritis (RA)-diagnosed patients.

Results

258 patients were included; 134 US and 124 non-US. 42% (56/134) of US and 47% (58/124) of non-US were diagnosed with RA. Results described for US and non-US cohorts, respectively as follows. The proportion of patients diagnosed at their first clinic visit was 37% vs 19% overall (p = 0.004) and 41% vs 19% in RA-diagnosed patients (p = 0.01). The median time to diagnosis (months) was 0.85 vs 2.00 (overall, p = 0.0046) and 0.23 vs 1.38 (RA-diagnosed, p = 0.0016). Median time (months) to initiation on a DMARD (where initiated) was 0.62 vs 1.41 (overall, p = 0.0048) and 0.46 vs 1.81 (RA-diagnosed, p = 0.0007).

Conclusion

In patients with suspected inflammatory arthritis, routine US use in newly referred patients seems to be associated with significantly earlier diagnosis and DMARD initiation.

Electronic supplementary material

The online version of this article (10.1186/s12891-017-1850-4) contains supplementary material, which is available to authorized users.

Role of ultrasound imaging in individuals at risk of RA

Early diagnosis and treatment improves outcomes for patients with rheumatoid arthritis (RA). Studies have shown that musculoskeletal ultrasound is more sensitive than clinical examination in identifying synovitis. This review aims to address the role of ultrasound in identifying (1) patients with early inflammatory arthritis (IA) at risk of progression to RA and (2) those without clinical synovitis at risk of progression to early IA and therefore early RA.

Absence of ultrasound inflammation in patients presenting with arthralgia rules out the development of arthritis

BACKGROUND

To decrease the burden of disease of rheumatoid arthritis (RA), patients at risk for RA need to be identified as early as possible, preferably when no clinically apparent synovitis can be detected. Up to now, it has been fairly difficult to identify those patients with arthralgia who develop inflammatory arthritis (IA), but recent studies using ultrasound (US) suggest that earlier detection is possible. We aimed to identify patients with arthralgia developing IA within 1 year using US to detect subclinical synovitis at first consultation.

METHODS

In a multi-centre cohort study, we followed patients with arthralgia with at least two painful joints of the hands, feet or shoulders without clinical synovitis over 1 year. Symptom duration was < 1 year, and symptoms were not explained by other conditions. At baseline and at 6 and 12 months, data were collected for physical examinations, laboratory values and diagnoses. At baseline, we examined 26 joints ultrasonographically (bilateral metacarpophalangeal joints 2-5, proximal interphalangeal joints 2-5, wrist and metatarsophalangeal joints 2-5). Scoring was done semi-quantitatively on greyscale (GS; 0-3) and power Doppler (PD; 0-3) images. US synovitis was defined as GS ≥ 2 and/or PD ≥ 1. IA was defined as clinical soft tissue swelling. Sensitivity and specificity were used to assess the diagnostic value of US for the development of IA. Univariate logistic regression was used to analyse the association between independent variables and the incidence of IA. For multivariate logistic regression, the strongest variables (p < 0.157) were selected. Missing values for independent variables were imputed.

RESULTS

A total of 196 patients were included, and 159 completed 12 months of follow-up. Thirty-one (16%) patients developed IA, of whom 59% showed US synovitis at baseline. The sensitivity and specificity of US synovitis were 59% and 68%, respectively. If no joints were positive on US, negative predictive value was 89%. In the multivariate logistic regression, age (OR 1.1), the presence of morning stiffness for > 30 minutes (OR 3.3) and PD signal (OR 3.4) were associated with incident IA.

CONCLUSIONS

The presence of PD signal, morning stiffness for > 30 minutes and age at baseline were independently associated with the development of IA. Regarding the value of US in the diagnostic workup of patients with early arthralgia at risk for IA, US did perform well in ruling out IA in patients who did not have US synovitis.

Can Synovial Pathobiology Integrate with Current Clinical and Imaging Prediction Models to Achieve Personalized Health Care in Rheumatoid Arthritis?

Although great progress has been made in the past decade toward understanding the pathogenesis of rheumatoid arthritis (RA), clinicians remain some distance from a goal of personalized health care. The capacity to diagnose RA early, predict prognosis, and moreover predict response to biologic therapies has been a research focus for many years. How currently available clinical prediction models can facilitate such goals is reviewed in this article. In addition, the role of current imaging techniques in this regard is also discussed. Finally, the authors review the current literature regarding synovial biomarkers and consider whether integration of synovial pathobiology into clinical prediction algorithms may enhance their predictive value.

Ultrasound-detectable grey scale synovitis predicts future fulfilment of the 2010 ACR/EULAR RA classification criteria in patients with new-onset undifferentiated arthritis

Objective

To determine the clinical outcomes for patients with new-onset undifferentiated arthritis (UA), not fulfilling the 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) rheumatoid arthritis (RA) classification criteria, and the clinical and imaging predictors of disease progression in these patients.

Methods

A prospective observational study was conducted in treatment-naïve UA patients. Baseline ultrasound involved semiquantitative assessment of grey scale (GS) synovitis and power Doppler activity (PD) at 26 joints. Outcomes were fulfilment of 2010 RA criteria (joint involvement determined clinically) and initiation of methotrexate over 12 months. Cox proportional hazards analysis was used to investigate predictors of outcome.

Results

Of 60 patients, 13(22%) progressed to RA and 32(53%) ever received methotrexate. Analyses of predictors of outcome were conducted in the subgroup (n=41) of patients with complete baseline data. The presence of GS was associated with progression to RA and methotrexate use: HRs (95% CI) were 1.25(1.07 to 1.45) and 1.16(1.02 to 1.32), respectively, for the number of joints with GS≥ grade 2 after adjustment for swollen joints. PD was not predictive in the low levels at which it was observed. Progression to RA was also associated with fulfilment of the 2010 criteria using ultrasound synovitis for enumerating joint involvement, higher baseline disability and radiographic erosion.

Conclusions

This is the first report of ultrasound findings in early UA (defined by presence of clinical synovitis and non-fulfilment of 2010 RA criteria). A significant proportion of patients with UA progressed to RA and/or required methotrexate. GS synovitis was predictive of disease progression.

Diagnosis and management of rheumatoid arthritis; What is the current role of established and new imaging techniques in clinical practice?

Ultrasound and magnetic resonance imaging (MRI) have become established imaging techniques for the management of rheumatoid arthritis. Several publications have pointed out the advantages of these techniques for a more complete evaluation of the inflammation and structural damage at joint level. Recently new imaging techniques as the positron emission tomography (PET) associated with computed tomography (CT) or MRI scan, and the optical imaging have been introduced in the panorama. This article presents the advantages and limitations of each imaging techniques in light with the recent publications.

Recommendations for the use of ultrasound and magnetic resonance in patients with rheumatoid arthritis

OBJECTIVE

To develop evidence-based recommendations on the use of ultrasound (US) and magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA).

METHODS

Recommendations were generated following a nominal group technique. A panel of experts, consisting of 15 rheumatologists and 3 radiologists, was established in the first panel meeting to define the scope and purpose of the consensus document, as well as chapters, potential recommendations and systematic literature reviews (we used and updated those from previous EULAR documents). A first draft of recommendations and text was generated. Then, an electronic Delphi process (2 rounds) was carried out. Recommendations were voted from 1 (total disagreement) to 10 (total agreement). We defined agreement if at least 70% of experts voted ≥7. The level of evidence and grade or recommendation was assessed using the Oxford Centre for Evidence-based Medicine Levels of Evidence. The full text was circulated and reviewed by the panel. The consensus was coordinated by an expert methodologist.

RESULTS

A total of 20 recommendations were proposed. They include the validity of US and MRI regarding inflammation and damage detection, diagnosis, prediction (structural damage progression, flare, treatment response, etc.), monitoring and the use of US guided injections/biopsies.

CONCLUSIONS

These recommendations will help clinicians use US and MRI in RA patients.