Interpreting radiographic data in rheumatoid arthritis

Multistage deep learning methods for automating radiographic sharp score prediction in rheumatoid arthritis

The Sharp-van der Heijde score (SvH) is crucial for assessing joint damage in rheumatoid arthritis (RA) through radiographic images. However, manual scoring is time-consuming and subject to variability. This study proposes a multistage deep learning model to predict the Overall Sharp Score (OSS) from hand X-ray images. The framework involves four stages: image preprocessing, hand segmentation with UNet, joint identification via YOLOv7, and OSS prediction utilizing a custom Vision Transformer (ViT). Evaluation metrics included Intersection over Union (IoU), Mean Absolute Error (MAE), Root Mean Squared Error (RMSE), Huber loss, and Intraclass Correlation Coefficient (ICC). The model was trained using stratified group 3-fold cross-validation on a dataset of 679 patients and tested externally on 291 subjects. The joint identification model achieved 99% accuracy. The ViT model achieved the best OSS prediction for patients with Sharp scores < 50. It achieved a Huber loss of 4.9, an RMSE of 9.73, and an MAE of 5.35, demonstrating a strong correlation with expert scores (ICC = 0.702, P < 0.001). This study is the first to apply a ViT for OSS prediction in RA. It presents an efficient and automated alternative for overall damage assessment. This approach may reduce reliance on manual scoring.

Remission versus low disease activity as treatment targets in rheumatoid arthritis: how to strike the right balance between too strict and too lenient targets? A meta-epidemiological study of individual patient data

OBJECTIVES

To evaluate the impact of using Simplified Disease Activity Index (SDAI)-LDA (low disease activity) versus different definitions of remission as a treatment target in established rheumatoid arthritis.

METHODS

A meta-epidemiological study of individual patient data from eight randomised controlled trials was performed. Four definitions of the target were considered at 6 months: (1) SDAI-LDA: SDAI≤11; (2) SDAI-Remission: SDAI≤3.3; (3) 4V-Remission: Tender and swollen 28-joint counts and C reactive protein (mg/dL) all ≤1 and patient global assessment (PGA)≤2 and (4) 3-variable (3V)-Remission: as 4V, excluding PGA. The mean radiographic change in the modified total Sharp-van der Heijde score (mTSS) and the Good Radiographic Outcome rates (defined as a change of ≤0.5 units mTSS) over 2 years were compared among target definitions. Radiographic progression and the distribution of the individual criteria of the Boolean definition in the only LDA subgroup (3.3

RESULTS

In total, 4374 patients (mean disease duration of 5.9 years (95% CI 4.6; 7.1)) were included. The pooled rate of SDAI-LDA at 6 months was 49%, with 13% in SDAI-remission. The 4V-Remission and 3V-Remission were achieved by 16% and 23%, respectively. Mean radiographic progression was 0.55 (0.14; 0.96) units for SDAI-LDA and 0.22 (-0.09; 0.54), 0.28 (-0.07; 0.62), 0.28 (-0.10; 0.65) for SDAI-Remission, 4V-Remission and 3V-Remission states, respectively. Patients with SDAI Pure-LDA presented significantly more radiographic progression than patients in SDAI-Remission (mean 0.72 vs 0.22 units, p<0.05). Over 53% of all patients achieving SDAI-LDA were not in 3V-Remission and had more mean radiographic progression over 2 years than those who met both targets (0.70 vs 0.25 units, p=0.014). Among patients with SDAI-LDA but not in SDAI-Remission, 40% scored PGA>2, reflecting relevant disease impact.

CONCLUSION

SDAI-LDA is associated with more structural damage over 2 years than any of the definitions of remission. It also allows substantial disease impact to go unchecked and uncontrolled. Physicians should strive for remission whenever possible and safe while also taking into account the different individual disease activity parameters included in the adopted definition.

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Key Words

• Outcome Assessment, Health Care
• Patient Reported Outcome Measures
• Rheumatoid Arthritis

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MESH Headings

• Humans
• Arthritis, Rheumatoid/drug therapy
• Remission Induction
• Antirheumatic Agents/therapeutic use
• Treatment Outcome
• Severity of Illness Index
• Disease Progression
• Randomized Controlled Trials as Topic
• Female
• Male
• Middle Aged

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Affiliation(s)

Catia Duarte Rheumatology, ULS de Coimbra EPE, Coimbra, Portugal Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal
Johannes W G Jacobs Rheumatology & Clinical Immunology, UMC, Utrecht, Netherlands
Ricardo J O Ferreira Nursing Research, Innovation and Development Centre of Lisbon (CIDNUR), Higher School of Nursing of Lisbon, Lisboa, Portugal Higher School of Nursing of Coimbra Health Sciences Research Unit Nursing, Coimbra, Portugal
Paco M J Welsing Rheumatology & Clinical Immunology, UMC, Utrecht, Netherlands
Laure Gossec INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, INSERM, Sorbonne Universite, Paris, France APHP, Rheumatology Department, Hopital Universitaire Pitie Salpetriere, Paris, France
Pedro M Machado Department of Neuromuscular Diseases, University College London, London, UK Centre for Rheumatology, University College London, London, UK
Désirée van der Heijde Rheumatology, Leiden University Medical Center, Leiden, Netherlands
Jose Antonio Pereira da Silva Rheumatology, ULS de Coimbra EPE, Coimbra, Portugal Institute for Clinical and Biomedical Research, University of Coimbra, Coimbra, Portugal

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Analysis of synovitis patterns in early RA supports the importance of joint-specific factors

BACKGROUND

Rheumatoid arthritis (RA) is classically considered a systemic disorder, but the role of local factors in driving synovial inflammation is increasingly being recognized. These joint-specific factors may consequently modulate disease phenotype.

OBJECTIVES

Our goal was to study the spatial distribution of swelling, tenderness and erosions in a large cohort of early RA (ERA) patients, to assess for patterns of simultaneously-involved joint clusters. We also aimed to investigate the link between arthritis localization and phenotypic features such as bone erosions and response to methotrexate therapy.

METHODS

DMARD-naive patients from the ERA UCLouvain Brussels cohort were included. Forty-four joints were clinically assessed for swelling and tenderness before treatment, and 6 months later for methotrexate-treated patients. Clusters of joints were identified using Principal component analysis and Cramer's correlation coefficients. Frequency of bone erosions and joint-specific response to methotrexate were compared across different clusters.

RESULTS

452 ERA patients were included. Analysis of the spatial distribution of swelling and tenderness allowed for the identification of 3 joint clusters that showed significant simultaneous involvement: (i) MTP1-5 joints, (ii) hand joints (MCPs and PIPs), and (iii) larger joints. These clusters were associated with different susceptibility to bone erosions and distinct clinical features, but similar local response (joint swelling resolution) to methotrexate.

CONCLUSION

This is the first study investigating the spatial distribution of arthritis in a large cohort of early RA using an unbiased approach. We identify clusters of simultaneously involved joints, supporting the importance of local factors in driving synovitis in RA.

Remission definitions guiding immunosuppressive therapy in rheumatoid arthritis: which is best fitted for the purpose?

OBJECTIVE

To assess which definition of remission best predicts good radiographic outcome (GRO) and good functional outcome (GFO) in rheumatoid arthritis, focusing the updated American College of Rheumatology/European Alliance of Associations for Rheumatology criteria.

MATERIAL AND METHODS

Meta-analyses of individual patient data (IPD) from randomised controlled trials (RCTs). Six definitions of remission were considered: (1) Boolean with Patient Global Assessment (PGA)≤1 (Boolean); (2) Simplified Disease Activity Index (SDAI)≤3.3; (3) Clinical Disease Activity Index (CDAI)≤2.8; (4) Boolean with PGA≤2 (Updated-Boolean); (5) Boolean with Physician Global Assessment (PhGA≤1) replacing PGA (Boolean-PhGA) and (6) Boolean excluding PGA (3VBoolean). GRO was defined as a worsening ≤0.5 units in radiographic score and GFO as a no worsening in Health Assessment Questionnaire (HAQ), that is, ∆HAQ-DI≤0.0 units. Relationships between each remission definition at 6 and/or 12 months and GRO and GFO during the second year were analysed. Pooled probabilities for each outcome for each definition and their predictive accuracy were estimated.

RESULTS

IPD from eight RCTs (n=4423) were analysed. Boolean, SDAI, CDAI, Updated-Boolean, Boolean-PhGA and 3VBoolean were achieved by 24%, 27%, 28%, 32%, 33% and 43% of all patients, respectively. GRO among patients achieving remission ranged from 82.4% (3VBoolean) to 83.9% (SDAI). 3VBoolean showed the highest predictive accuracy for GRO: 51.1% versus 38.8% (Boolean) and 44.1% (Updated-Boolean). The relative risk of GFO ranged from 1.16 (Boolean) to 1.05 (3VBoolean). However, the proportion of GFO correctly predicted was highest for the 3VBoolean (50.3%) and lowest for the Boolean (43.8%).

CONCLUSION

3VBoolean definition provided the most accurate prediction of GRO and GFO, avoiding the risk of overtreatment in a substantial proportion of patients without increment in radiographic damage progression, supporting the proposal that 3VBoolean remission is preferable to guide immunosuppressive treatment. The patient's perspective, which must remain central, is best served by an additional patient-oriented target: a dual-target approach.

Baseline bony erosions and time-averaged DAS28 predict discontinuation of TNF inhibitors in rheumatoid arthritis

The present study evaluated the predictive role of baseline radiographic change and disease activity on drug retention and clinical response in patients with rheumatoid arthritis (RA) treated with tumor necrosis factor inhibitor (TNFi). Korean Observational Study Network for Arthritis (KORONA) registry was evaluated to identify RA patients treated with a TNFi. Disease activity score-28 (DAS28) was evaluated at baseline and 1 year after TNFi initiation or at termination of TNFi due to inefficacy (within 1 year). The retention rate of TNFi was compared in patients with and without bony erosions. The hazard ratio (HR) for drug retention was evaluated by Cox regression analysis, as was the odds ratio (OR) for achieving remission (DAS28 < 2.6). This study included 109 RA patients, including 97 (89%) women and 30 (27.5%) with erosions, who were treated with a TNFi. Higher baseline DAS28 was negatively associated with achievement of remission (OR = 0.56, 95% CI 0.35-0.88). The TNFi retention rate was significantly lower in RA patients with than in those without erosions (p = 0.04). Factors significantly associated with drug discontinuation included the presence of erosions (HR = 2.45, 95% CI 1.08-5.51) and higher time-averaged DAS28 (HR = 2.17, 95% CI 1.47-3.20), whereas concomitant methotrexate was associated with lack of drug discontinuation (HR = 0.40, 95% CI 0.17-0.95). The presence of erosions and high time-averaged disease activity could predict poor retention of TNFi by RA patients. Higher baseline DAS28 was associated with a reduced clinical response in patients with RA.Trial registration Clinical Research Information Service of South Korea https://cris.nih.go.kr : KCT0000086, registered May 26, 2009.

Deep learning-based automatic-bone-destruction-evaluation system using contextual information from other joints

BACKGROUND

X-ray images are commonly used to assess the bone destruction of rheumatoid arthritis. The purpose of this study is to propose an automatic-bone-destruction-evaluation system fully utilizing deep neural networks (DNN). This system detects all target joints of the modified Sharp/van der Heijde score (SHS) from a hand X-ray image. It then classifies every target joint as intact (SHS = 0) or non-intact (SHS ≥ 1).

METHODS

We used 226 hand X-ray images of 40 rheumatoid arthritis patients. As for detection, we used a DNN model called DeepLabCut. As for classification, we built four classification models that classify the detected joint as intact or non-intact. The first model classifies each joint independently, whereas the second model does it while comparing the same contralateral joint. The third model compares the same joint group (e.g., the proximal interphalangeal joints) of one hand and the fourth model compares the same joint group of both hands. We evaluated DeepLabCut's detection performance and classification models' performances. The classification models' performances were compared to three orthopedic surgeons.

RESULTS

Detection rates for all the target joints were 98.0% and 97.3% for erosion and joint space narrowing (JSN). Among the four classification models, the model that compares the same contralateral joint showed the best F-measure (0.70, 0.81) and area under the curve of the precision-recall curve (PR-AUC) (0.73, 0.85) regarding erosion and JSN. As for erosion, the F-measure and PR-AUC of this model were better than the best of the orthopedic surgeons.

CONCLUSIONS

The proposed system was useful. All the target joints were detected with high accuracy. The classification model that compared the same contralateral joint showed better performance than the orthopedic surgeons regarding erosion.

Rheumatoid Arthritis Diagnosis: Deep Learning vs. Humane

Rheumatoid arthritis (RA) is a systemic autoimmune disease that preferably affects small joints. As the well-timed diagnosis of the disease is essential for the treatment of the patient, several works have been conducted in the field of deep learning to develop fast and accurate automatic methods for RA diagnosis. These works mainly focus on medical images as they use X-ray and ultrasound images as input for their models. In this study, we review the conducted works and compare the methods that use deep learning with the procedure that is commonly followed by a medical doctor for the RA diagnosis. The results show that 93% of the works use only image modalities as input for the models as distinct from the medical procedure where more patient medical data are taken into account. Moreover, only 15% of the works use direct explainability methods, meaning that the efforts for solving the trustworthiness issue of deep learning models were limited. In this context, this work reveals the gap between the deep learning approaches and the medical doctors’ practices traditionally applied and brings to light the weaknesses of the current deep learning technology to be integrated into a trustworthy context inside the existed medical infrastructures.

Revisiting the use of remission criteria for rheumatoid arthritis by excluding patient global assessment: an individual meta-analysis of 5792 patients

OBJECTIVES

To determine the impact of excluding patient global assessment (PGA) from the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) Boolean remission criteria, on prediction of radiographic and functional outcome of rheumatoid arthritis (RA).

METHODS

Meta-analyses using individual patient data from randomised controlled trials testing the efficacy of biological agents on radiographic and functional outcomes at ≥2 years. Remission states were defined by 4 variants of the ACR/EULAR Boolean definition: (i) tender and swollen 28-joint counts (TJC28/SJC28), C reactive protein (CRP, mg/dL) and PGA (0-10=worst) all ≤1 (4V-remission); (ii) the same, except PGA >1 (4V-near-remission); (iii) 3V-remission (i and ii combined; similar to 4V, but without PGA); (iv) non-remission (TJC28 >1 and/or SJC28 >1 and/or CRP >1). The most stringent class achieved at 6 or 12 months was considered. Good radiographic (GRO) and functional outcome (GFO) were defined as no worsening (ie, change in modified total Sharp score (ΔmTSS) ≤0.5 units and ≤0.0 Health Assessment Questionnaire-Disability Index points, respectively, during the second year). The pooled probabilities of GRO and GFO for the different definitions of remission were estimated and compared.

RESULTS

Individual patient data (n=5792) from 11 trials were analysed. 4V-remission was achieved by 23% of patients and 4V-near-remission by 19%. The probability of GRO in the 4V-near-remission group was numerically, but non-significantly, lower than that in the 4V-remission (78 vs 81%) and significantly higher than that for non-remission (72%; difference=6%, 95% CI 2% to 10%). Applying 3V-remission could have prevented therapy escalation in 19% of all participants, at the cost of an additional 6.1%, 4.0% and 0.7% of patients having ΔmTSS >0.0, >0.5 and >5 units over 2 years, respectively. The probability of GFO (assessed in 8 trials) in 4V-near-remission (67%, 95% CI 63% to 71%) was significantly lower than in 4V-remission (78%, 74% to 81%) and similar to non-remission (69%, 66% to 72%).

CONCLUSION

4V-near-remission and 3V-remission have similar validity as the original 4V-remission definition in predicting GRO, despite expected worse prediction of GFO, while potentially reducing the risk of overtreatment. This supports further exploration of 3V-remission as the target for immunosuppressive therapy complemented by patient-oriented targets.

Disease‐modifying anti‐rheumatic drugs for rheumatoid arthritis: a systematic review and network meta‐analysis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

The primary objective is to compare the benefits and harms of different disease‐modifying anti‐rheumatic drugs (DMARDs) as initial therapy and after failure of conventional synthetic DMARDs or biologic or targeted synthetic DMARDs in adults with rheumatoid arthritis through a network meta‐analysis (NMA). A secondary objective is to rank the interventions for both benefits and harms.

This protocol describes the approach for separate NMAs for the three populations of interest (described below), which we intend to publish as three separate Cochrane Reviews.

1) Disease‐modifying anti‐rheumatic drugs for rheumatoid arthritis as initial therapy: a systematic review and network meta‐analysis

2) Disease‐modifying anti‐rheumatic drugs for rheumatoid arthritis after failure of conventional synthetic disease‐modifying anti‐rheumatic drugs: a systematic review and network meta‐analysis

3) Disease‐modifying anti‐rheumatic drugs for rheumatoid arthritis after failure of biologic or targeted synthetic therapy: a systematic review and network meta‐analysis

A polymer coated MNP scaffold for targeted drug delivery and improvement of rheumatoid arthritis

DHAA–Fe₃O₄@HA as a nano-carrier was synthesized for targeted sulfasalazine delivery in specific inflammatory joint tissues with improvement in RA disease.

Systematic review of rheumatoid arthritis clinical studies: Suboptimal statistical analysis of radiological data

INTRODUCTION

The distribution of progression scores in rheumatoid arthritis is highly skewed, requiring advanced statistical analysis techniques, with different techniques resulting in different outcomes.

METHODS

Three databases were searched to identify rheumatoid arthritis clinical trials and observational studies that described radiographic analysis techniques, comparing at least two groups.

RESULTS

Of 5980 identified papers, 225 were eligible for data extraction. Parametric techniques (t-tests, ANOVA or linear regression) were used in 39 studies, of which 18% took the skewed distribution into account. In 53 studies, continuous data was categorized and analyzed with binomial or ordinal methods (chi-square tests or logistic regression). Two studies treated the outcome as a 'count' outcome variable (applying a Poisson).

CONCLUSION

There is large heterogeneity in the analysis strategy of radiographic progression in recent rheumatoid arthritis clinical trials and observational studies, with the majority of studies applying simple, suboptimal or inappropriate methods.

Systematic review and network meta-analysis: effect of biologics on radiographic progression in rheumatoid arthritis

AIM

To evaluate the comparative effectiveness of biologics in inhibiting radiographic progression among rheumatoid arthritis (RA) patients.

MATERIALS & METHODS

Bayesian network meta-analysis of published trials investigating the USA FDA approved biologics treatment in RA patients, using methotrexate (MTX) as the reference comparator.

RESULTS

Nine trials met the inclusion criteria for base case analysis. Compared with MTX, most biologics (except golimumab) + MTX had significantly lower rates of radiographic progression at 1 year. Mean difference in radiographic progression rates between MTX monotherapy and biologics + MTX was highest for adalimumab + MTX (-3.8) and lowest for tocilizumab + MTX (-0.7). Inhibition of radiographic progression was sustained.

CONCLUSION

Biologics inhibit radiographic progression in patients with RA at 1 year; however, published evidence beyond 1 year is limited.

A new quantitative 3D approach to imaging of structural joint disease

Imaging of joints with 2D radiography has not been able to detect therapeutic success in research trials while 3D imaging, used regularly in the clinic, has not been approved for this purpose. We present a new 3D approach to this challenge called joint space mapping (JSM) that measures joint space width in 3D from standard clinical computed tomography (CT) data, demonstrating its analysis steps, technical validation, and reproducibility. Using high resolution peripheral quantitative CT as gold standard, we show a marginal over-estimation in accuracy of +0.13 mm and precision of ±0.32 mm. Inter-operator reproducibility bias was near-zero at −0.03 mm with limits of agreement ±0.29 mm and a root mean square coefficient of variation 7.5%. In a technical advance, we present results from across the hip joint in 3D with optimum validation and reproducibility metrics shown at inner joint regions. We also show JSM versatility using different imaging data sets and discuss potential applications. This 3D mapping approach provides information with greater sensitivity than reported for current radiographic methods that could result in improved patient stratification and treatment monitoring.

Is It the Age at Disease Onset or the Disease Radiological Severity That Affects Cervical Spine Involvement in Patients With Rheumatoid Arthritis?

Background:

Cervical spine involvement in patients with rheumatoid arthritis (RA) can cause pain and disability, with a variety of neurologic signs and symptoms.

Objectives:

To investigate the relationship between structural cervical spine involvement in patients with RA with the age at disease onset and the degree of radiologic severity of RA measured by Larsen scoring.

Patients and methods:

This cross-sectional study included 50 adult patients with RA. Patients who complained or not complained from symptoms of cervical spine involvement in RA were included; we did X-ray of the cervical spine, hands, and feet; Larsen scoring method; disease activity score (DAS28); and Neck Disability Index.

Results:

The results revealed that patients with cervical involvement tend to be younger at their disease onset than those with no cervical involvement, as detected by cervical X-ray. The relation was significant P < .05 regarding all cervical involvements except for basilar invagination. Disease radiological severity (measured by Larsen score) significantly increases the risk for subaxial subluxation, P = .040. All other cervical complications of RA tend to have nonsignificant relation with disease severity. Using univariate binary regression analysis for risk factors for cervical involvement showed that the only probable risk factor for cervical involvement (detected by X-ray) in patients with RA is age at disease onset.

Conclusions:

The early age at disease onset tends to affect cervical spine involvement in patients with RA more than the disease radiological severity.

Hypomethylation of CYP2E1 and DUSP22 Promoters Associated With Disease Activity and Erosive Disease Among Rheumatoid Arthritis Patients

Objective

Epigenetic modifications have previously been associated with rheumatoid arthritis (RA). In this study, we aimed to determine whether differential DNA methylation in peripheral blood cell subpopulations is associated with any of 4 clinical outcomes among RA patients.

Methods

Peripheral blood samples were obtained from 63 patients in the University of California, San Francisco RA cohort (all satisfied the American College of Rheumatology classification criteria; 57 were seropositive for rheumatoid factor and/or anti‐cyclic citrullinated protein). Fluorescence‐activated cell sorting was used to separate the cells into 4 immune cell subpopulations (CD14+ monocytes, CD19+ B cells, CD4+ naive T cells, and CD4+ memory T cells) per individual, and 229 epigenome‐wide DNA methylation profiles were generated using Illumina HumanMethylation450 BeadChips. Differentially methylated positions and regions associated with the Clinical Disease Activity Index score, erosive disease, RA Articular Damage score, Sharp score, medication at time of blood draw, smoking status, and disease duration were identified using robust regression models and empirical Bayes variance estimators.

Results

Differential methylation of CpG sites associated with clinical outcomes was observed in all 4 cell types. Hypomethylated regions in the CYP2E1 and DUSP22 gene promoters were associated with active and erosive disease, respectively. Pathway analyses suggested that the biologic mechanisms underlying each clinical outcome are cell type–specific. Evidence of independent effects on DNA methylation from smoking, medication use, and disease duration were also identified.

Conclusion

Methylation signatures specific to RA clinical outcomes may have utility as biomarkers or predictors of exposure, disease progression, and disease severity.

Assessment of 3-month changes in bone microstructure under anti-TNFα therapy in patients with rheumatoid arthritis using high-resolution peripheral quantitative computed tomography (HR-pQCT)

Background

Although one study showed minimal progression of erosions in patients with rheumatoid arthritis (RA) one year after TNFα inhibition therapy, no studies have investigated very early bone changes after initiation of anti-TNFα treatment. We investigated the effects of 3-month anti-TNFα treatment on bone erosion progression and bone microarchitecture in RA patients using high-resolution peripheral quantitative computed tomography (HR-pQCT).

Methods

Patients with RA (n = 27) (17 in the anti-TNFα and 10 in the MTX-only group) underwent assessment of disease activity score in 28 joints (DAS-28), radiographs, 3-T magnetic resonance imaging (MRI) and HR-pQCT of metacarpophalangeal and wrist joints at baseline and 3 months. HR-pQCT-derived erosion volume, joint volume/width and bone microarchitecture were computed and joint destruction was assessed using Sharp and RAMRIS scorings on radiographs and MRI, respectively.

Results

Overall, 73 erosions were identified by HR-pQCT at baseline. Over 3 months, the anti-TNFα group had decreased mean erosion volume; increased erosion volume was observed in one clinical non-responder. The MTX-only group in contrast, trended toward increasing erosion volume despite low disease activity. In the anti-TNFα group, joint-space width and volume of MCP joints decreased significantly and was positively correlated with erosion volume changes (R² = 0.311, p = 0.013; R² = 0.527, p = 0.003, respectively). In addition, erosion volume changes were significantly negatively correlated with changes in trabecular bone mineral density (R² = 0.353, p = 0.020) in this group. We observed significant correlation between percentage change in erosion volume and change in DAS-28 erythrocyte sedimentation rate and C-reactive protein CRP scores (R² = 0.558, p < 0.001; R² = 0.745, p < 0.001, respectively) in all patients.

Conclusions

Using HR-pQCT, our data suggest that anti-TNFα treatment prevents erosion progression and deterioration of bone microarchitecture within the first 3 months of treatment, one patient not responding to treatment, had significant progression of bone erosions within this short time period. Patients with low disease activity scores (<3.2) can have continuous HR-pQCT-detectable progression of erosive disease with MTX treatment only. HR-pQCT can be a sensitive, powerful tool to quantify bone changes and monitor RA treatment short term (such as 3 months).

Standardisation of labial salivary gland histopathology in clinical trials in primary Sjögren's syndrome

Labial salivary gland (LSG) biopsy is used in the classification of primary Sjögren's syndrome (PSS) and in patient stratification in clinical trials. It may also function as a biomarker. The acquisition of tissue and histological interpretation is variable and needs to be standardised for use in clinical trials. A modified European League Against Rheumatism consensus guideline development strategy was used. The steering committee of the ad hoc working group identified key outstanding points of variability in LSG acquisition and analysis. A 2-day workshop was held to develop consensus where possible and identify points where further discussion/data was needed. These points were reviewed by a subgroup of experts on PSS histopathology and then circulated via an online survey to 50 stakeholder experts consisting of rheumatologists, histopathologists and oral medicine specialists, to assess level of agreement (0-10 scale) and comments. Criteria for agreement were a mean score ≥6/10 and 75% of respondents scoring ≥6/10. Thirty-nine (78%) experts responded and 16 points met criteria for agreement. These points are focused on tissue requirements, identification of the characteristic focal lymphocytic sialadenitis, calculation of the focus score, identification of germinal centres, assessment of the area of leucocyte infiltration, reporting standards and use of prestudy samples for clinical trials. We provide standardised consensus guidance for the use of labial salivary gland histopathology in the classification of PSS and in clinical trials and identify areas where further research is required to achieve evidence-based consensus.

Conventional Radiology in Rheumatoid Arthritis

In clinical practice, the conventional radiography is still the radiologic method for the diagnosis of rheumatoid arthritis (RA). Moreover, it provides a quick overview of the symptomatic joints to narrow the differential diagnosis and to evaluate progression. RA is a polyarticular disease with bilateral and symmetric involvement of the peripheral joints, especially small joints, and less frequently, the cervical spine. The radiologic features are soft tissue swelling, periarticular osteoporosis, erosions, loss of joint space, and in advanced disease, osteolysis and typical subluxations or deformities, such as ulnar deviation.

In vivo anti-arthritic efficacy of Camellia sinensis (L.) in collagen induced arthritis model

BACKGROUND

Rheumatoid arthritis (RA), an autoimmune inflammatory disorder with synovial hyperplasia, destruction of cartilage, bone damage is often associated with risk of infections. Such risk could be attributed towards usage of immunosuppressive agents. Thus, the present study was undertaken to evaluate the anti-arthritic efficacy of aquo-alcoholic extract of Camellia sinensis (L.).

MATERIAL AND METHODS

Dried leaves of Camellia sinensis (L.) or Cs were filtered and extracted in 1:1 aqueous: ethanol by Soxhlet apparatus followed by lyophilization and spray drying to develop amorphous powder. Four different oral doses (50, 100, 200, 400mg/kg/body wt.) of aquo-alcoholic extract were evaluated for anti-edematogenic effect in collagen induced arthritis model. The selected anti-arthritic doses of Cs were evaluated for the oxidative stress markers like Glutathione [5-5'dithio-bis-2-nitrobenzoicacid (DTNB)], Superoxide dismutase [Epinephrine], Catalase [Hydrogen peroxide], Lipid peroxidation [Thiobarbituric acid reactive substance (TBARS)], Nitric oxide [Griess reagents:Nitrobluetetrazolium], Articular elastase [N-methoxysuccinyl-Ala-Ala-Pro- Val p-nitroanilide] in joints followed by haematological evaluation including RBC, WBC, Haemoglobin, platelets and haematocrit. To validate these biochemical changes, the radiological and histopathological (Haematoxylin & Eosin) evaluation was also conducted.

RESULTS

The selected anti-arthritic dose of Cs i.e. 400mg/kg/body wt. (∼60% anti-arthritic efficacy on 35th day) could be attributed towards significant (p<0.05) increase in the levels of enzymatic (Superoxide dismutase and Catalase) and non-enzymatic (Glutathione) antioxidants by 34%, 59% and 50% respectively. Simultaneously, the significant (p<0.05) reduction of lipid peroxides, nitrite radical and elastase activity by 32%, 45% & 32% respectively as compare to control indicated overall decrease in oxidative stress. Haematological evaluation revealed restoration of RBC, WBC and platelets level in treatment group. The confirmatory analysis utilizing radiological and histological assessment showed alleviation of joint deformity, tissue swelling, pannus formation and neutrophils infiltration in treatment group as compared to collagen induced arthritis.

CONCLUSION

The analysis showed that Cs can play an effective role in reduction of oxidative stress by modulating levels of antioxidants, reducing levels of free radicals while restoring normal haematopoietic cascade as observed in collagen induced arthritis model. Thus, the cumulative dose impact of 400mg/kg body wt., over a period of 14days also found extremely effective in terms of safeguarding their structural conformity against such auto-immune disorder.

Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying anti-rheumatic drugs for rheumatoid arthritis: A network meta-analysis

BACKGROUND

Methotrexate is considered the preferred disease-modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis, but controversy exists on the additional benefits and harms of combining methotrexate with other DMARDs.

OBJECTIVES

To compare methotrexate and methotrexate-based DMARD combinations for rheumatoid arthritis in patients naïve to or with an inadequate response (IR) to methotrexate.

METHODS

We systematically identified all randomised controlled trials with methotrexate monotherapy or in combination with any currently used conventional synthetic DMARD , biologic DMARDs, or tofacitinib. Three major outcomes (ACR50 response, radiographic progression and withdrawals due to adverse events) and multiple minor outcomes were evaluated. Treatment effects were summarized using Bayesian random-effects network meta-analyses, separately for methotrexate-naïve and methotrexate-IR trials. Heterogeneity was explored through meta-regression and subgroup analyses. The risk of bias of each trial was assessed using the Cochrane risk of bias tool, and trials at high risk of bias were excluded from the main analysis. The quality of evidence was evaluated using the GRADE approach. A comparison between two treatments was considered statistically significant if its credible interval excluded the null effect, indicating >97.5% probability that one treatment was superior.

MAIN RESULTS

158 trials with over 37,000 patients were included. Methotrexate-naïve: Several treatment combinations with methotrexate were statistically superior to oral methotrexate for ACR50 response: methotrexate + sulfasalazine + hydroxychloroquine ("triple therapy"), methotrexate + several biologics (abatacept, adalimumab, etanercept, infliximab, rituximab, tocilizumab), and tofacitinib. The estimated probability of ACR50 response was similar between these treatments (range 56-67%, moderate to high quality evidence), compared with 41% for methotrexate. Methotrexate combined with adalimumab, etanercept, certolizumab, or infliximab was statistically superior to oral methotrexate for inhibiting radiographic progression (moderate to high quality evidence) but the estimated mean change over one year with all treatments was less than the minimal clinically important difference of five units on the Sharp-van der Heijde scale. Methotrexate + azathioprine had statistically more withdrawals due to adverse events than oral methotrexate, and triple therapy had statistically fewer withdrawals due to adverse events than methotrexate + infliximab (rate ratio 0.26, 95% credible interval: 0.06 to 0.91). Methotrexate-inadequate response: In patients with an inadequate response to methotrexate, several treatments were statistically significantly superior to oral methotrexate for ACR50 response: triple therapy (moderate quality evidence), methotrexate + hydroxychloroquine (low quality evidence), methotrexate + leflunomide (moderate quality evidence), methotrexate + intramuscular gold (very low quality evidence), methotrexate + most biologics (moderate to high quality evidence), and methotrexate + tofacitinib (high quality evidence). There was a 61% probability of an ACR50 response with triple therapy, compared to a range of 27% to 64% for the combinations of methotrexate + biologic DMARDs that were statistically significantly superior to oral methotrexate. No treatment was statistically significantly superior to oral methotrexate for inhibiting radiographic progression. Methotrexate + cyclosporine and methotrexate + tocilizumab (8 mg/kg) had a statistically higher rate of withdrawals due to adverse events than oral methotrexate and methotrexate + abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments.

AUTHORS' CONCLUSIONS

We found moderate to high quality evidence that combination therapy with methotrexate + sulfasalazine+ hydroxychloroquine (triple therapy) or methotrexate + most biologic DMARDs or tofacitinib were similarly effective in controlling disease activity and generally well tolerated in methotrexate-naïve patients or after an inadequate response to methotrexate. Methotrexate + some biologic DMARDs were superior to methotrexate in preventing joint damage in methotrexate-naïve patients, but the magnitude of these effects was small over one year.

Methotrexate monotherapy and methotrexate combination therapy with traditional and biologic disease modifying antirheumatic drugs for rheumatoid arthritis: abridged Cochrane systematic review and network meta-analysis

OBJECTIVE

To compare methotrexate based disease modifying antirheumatic drug (DMARD) treatments for rheumatoid arthritis in patients naive to or with an inadequate response to methotrexate.

DESIGN

Systematic review and Bayesian random effects network meta-analysis of trials assessing methotrexate used alone or in combination with other conventional synthetic DMARDs, biologic drugs, or tofacitinib in adult patients with rheumatoid arthritis.

DATA SOURCES

Trials were identified from Medline, Embase, and Central databases from inception to 19 January 2016; abstracts from two major rheumatology meetings from 2009 to 2015; two trial registers; and hand searches of Cochrane reviews.

STUDY SELECTION CRITERIA

Randomized or quasi-randomized trials that compared methotrexate with any other DMARD or combination of DMARDs and contributed to the network of evidence between the treatments of interest.

MAIN OUTCOMES

American College of Rheumatology (ACR) 50 response (major clinical improvement), radiographic progression, and withdrawals due to adverse events. A comparison between two treatments was considered statistically significant if its credible interval excluded the null effect, indicating >97.5% probability that one treatment was superior.

RESULTS

158 trials were included, with between 10 and 53 trials available for each outcome. In methotrexate naive patients, several treatments were statistically superior to oral methotrexate for ACR50 response: sulfasalazine and hydroxychloroquine ("triple therapy"), several biologics (abatacept, adalimumab, etanercept, infliximab, rituximab, tocilizumab), and tofacitinib. The estimated probability of ACR50 response was similar between these treatments (range 56-67%), compared with 41% with methotrexate. Methotrexate combined with adalimumab, etanercept, certolizumab, or infliximab was statistically superior to oral methotrexate for inhibiting radiographic progression, but the estimated mean change over one year with all treatments was less than the minimal clinically important difference of 5 units on the Sharp-van der Heijde scale. Triple therapy had statistically fewer withdrawals due to adverse events than methotrexate plus infliximab. After an inadequate response to methotrexate, several treatments were statistically superior to oral methotrexate for ACR50 response: triple therapy, methotrexate plus hydroxychloroquine, methotrexate plus leflunomide, methotrexate plus intramuscular gold, methotrexate plus most biologics, and methotrexate plus tofacitinib. The probability of response was 61% with triple therapy and ranged widely (27-70%) with other treatments. No treatment was statistically superior to oral methotrexate for inhibiting radiographic progression. Methotrexate plus abatacept had a statistically lower rate of withdrawals due to adverse events than several treatments.

CONCLUSIONS

Triple therapy (methotrexate plus sulfasalazine plus hydroxychloroquine) and most regimens combining biologic DMARDs with methotrexate were effective in controlling disease activity, and all were generally well tolerated in both methotrexate naive and methotrexate exposed patients.

Prediction of Response to Therapy for Autoimmune/Inflammatory Diseases Using an Activated Macrophage-Targeted Radioimaging Agent

The ability to select patients who will respond to therapy is especially acute for autoimmune/inflammatory diseases, where the costs of therapies can be high and the progressive damage associated with ineffective treatments can be irreversible. In this article we describe a clinical test that will rapidly predict the response of patients with an autoimmune/inflammatory disease to many commonly employed therapies. This test involves quantitative assessment of uptake of a folate receptor-targeted radioimaging agent ((99m)Tc-EC20) by a subset of inflammatory macrophages that accumulate at sites of inflammation. Murine models of four representative inflammatory diseases (rheumatoid arthritis, inflammatory bowel disease, pulmonary fibrosis, and atherosclerosis) show markedly decreased uptake of (99m)Tc-EC20 in inflamed lesions upon initiation of successful therapies, but no decrease in uptake upon administration of ineffective therapies, in both cases long before changes in clinical symptoms can be detected. This predictive capability should reduce costs and minimize morbidities associated with failed autoimmune/inflammatory disease therapies.

Imaging of rheumatoid arthritis

Increased awareness of the need for early diagnosis of rheumatoid arthritis and advances in the ability to effectively treat rheumatoid arthritis have made disease remission and maintenance of function a reality for many patients. However, identification of patients who are at risk for erosive disease remains a challenge. As more is learnt about risk factors for disease severity and the role of imaging techniques such as ultrasound and magnetic resonance imaging, the ability to prevent disease progression in the form of joint damage and its attendant deformity and functional limitation will further improve.

Medical imaging in new drug clinical development

Medical imaging can help answer key questions that arise during the drug development process. The role of medical imaging in new drug clinical trials includes identification of likely responders; detection and diagnosis of lesions and evaluation of their severity; and therapy monitoring and follow-up. Nuclear imaging techniques such as PET can be used to monitor drug pharmacokinetics and distribution and study specific molecular endpoints. In assessing drug efficacy, imaging biomarkers and imaging surrogate endpoints can be more objective and faster to measure than clinical outcomes, and allow small group sizes, quick results and good statistical power. Imaging also has important role in drug safety monitoring, particularly when there is no other suitable biomarkers available. Despite the long history of radiological sciences, its application to the drug development process is relatively recent. This review highlights the processes, opportunities, and challenges of medical imaging in new drug development.

Anticitrullinated protein antibodies and radiological progression in juvenile idiopathic arthritis

OBJECTIVE

The aim of the study was to investigate whether determination of anticitrullinated protein antibodies (ACPA) provides predictive information on severity of disease course and joint destruction in children with juvenile idiopathic arthritis (JIA).

METHODS

Sera from 74 children with JIA were examined for ACPA using the ELISA test. To assess joint destruction, plain radiographs of both hands were scored twice according to the Steinbrocker scale: at the beginning of observation and after 8.9 to 15.2 months (median 11.5 months) of the followup. Correlations between ACPA serum levels and the disease characteristics (type of JIA onset, disease activity, disease duration, radiological status) were investigated.

RESULTS

Twenty-six out of 74 examined children with JIA (35.0%) were ACPA-positive [> 5 relative units (RU)/ml]. ACPA were present in all types of JIA onset, including 36.6% of children with early stage JIA (disease duration < 6 months). All of the IgM-rheumatoid factor (RF)-positive children with polyarticular type of JIA onset were simultaneously positive for ACPA. ACPA levels correlated positively with disease activity at the beginning of the study (rho = 0.7196; p < 0.0001) and after followup (rho = 0.2485; p = 0.0486). Disease duration did not significantly affect ACPA serum levels. ACPA levels correlated positively with radiological joint destruction in children with JIA, both at the beginning of the study (rho = 0.4599; p = 0.0004) and after the followup period (rho = 0.5523; p < 0.0001).

CONCLUSION

ACPA were superior to IgM-RF in diagnosing JIA and provided predictive information on severity of disease course and radiological outcome.

Elevated production of galectin-3 is correlated with juvenile idiopathic arthritis disease activity, severity, and progression

OBJECTIVES

Galectin-3 is a carbohydrate-binding protein that plays many important regulatory roles in inflammation, immunity and cancers. Recent studies indicate that galectin-3 plays a role in rheumatoid arthritis (RA) pathogenesis and progression. Therefore, we sought to characterize the expression pattern and role of galectin-3 in juvenile idiopathic arthritis (JIA) and to explore whether galectin-3 investigated in serum and synovial fluid was associated with clinical, laboratory and radiological variables of JIA disease activity and severity.

METHODS

Levels of galectin-3 in serum and synovial fluid from patients with JIA and controls were determined by enzyme-linked immunosorbent assay.

RESULTS

Median (interquartile range) serum galectin-3 concentrations (ng/mL) were increasingly higher across the following groups: healthy controls (8.1 [4.9-16.7]), total JIA children with inactive disease (18.6 [9.7-28.8], P = 0.00039 vs. controls) and active disease (35.8 [15.8-60.8], P = 0.000012 vs. controls) (inactive vs. active, P = 0.00016). Highest serum expression was found in polyarthritic children. Galectin-3 concentrations in paired sera and synovial fluid samples could be related to each other. Serum and synovial concentrations of galectin-3 were positively correlated with total number of joints with active arthritis and with overall articular severity score. Patients with Larsen index and total radiographic score ≥ 1 had significant higher serum galectin-3 levels than patients with indices and scores < 1.

CONCLUSIONS

These results suggest that serum levels of galectin-3 are increased in active JIA children and galectin-3 can be a new biomarker indicating JIA disease activity, severity and progression, although its increment is not disease-specific.

Clinical predictors of erosion-free status in rheumatoid arthritis: a prospective cohort study

OBJECTIVE

Treatment algorithms in RA include factors associated with poor prognosis; however, many patients remain erosion free despite years of disease. Our objective was to characterize the group of RA patients without erosions and identify its clinical predictors.

METHODS

Our study was conducted within a prospective observational cohort of RA patients recruited from the outpatient practice of an academic medical centre. We studied patients with bilateral hand radiographs at cohort baseline and 2-year follow-up assessed with Sharp/van der Heijde scores (SHS). The primary outcome was erosion-free status at baseline and 2-year follow-up. We assessed baseline values of the following as potential correlates: age at RA onset, gender, RA duration, BMI, 28-joint DAS (DAS-28), CRP, anti-CCP status, tender and swollen joint counts, functional status [multidimensional HAQ (MDHAQ)], tobacco use and RA treatments. Variables with P ≤ 0.25 in the univariate analyses were assessed using backward selection in multivariable logistic regression models.

RESULTS

Of the 271 subjects included, 21% (n = 56) were considered erosion free. Forty-six per cent (n = 26) of this group was anti-CCP positive compared with 56% (n = 121) in subjects with erosions present. Mean RA duration for erosion-free subjects was 3.9 years compared with 4.6 years in erosive subjects. Treatments for RA did not differ between the two groups. In the multivariable-adjusted analysis, significant predictors of erosion-free status were younger age at onset and shorter RA duration.

CONCLUSION

In our cohort, 21% of subjects were erosion free at baseline and 2 years. Few baseline clinical characteristics significantly predicted erosion-free status.

An overview of commonly used radiographic scoring methods in rheumatoid arthritis clinical trials

Despite the advent of magnetic resonance imaging and musculoskeletal ultrasound, the plain radiographs of the hands and feet remain an important tool for a practising rheumatologist both in clinical and research settings. This review focuses on providing a historical overview of commonly used methods of scoring radiographs in rheumatoid arthritis and discusses technical issues related to radiographic scoring, limitations and advantages of radiographs, and current recommendations regarding reporting radiographic data in clinical trials.

Equivalent responses to disease-modifying antirheumatic drugs initiated at any time during the first 15 months after symptom onset in patients with seropositive rheumatoid arthritis

OBJECTIVE

To evaluate responses by time to initiation of nonbiologic disease-modifying antirheumatic drugs (DMARD) in a DMARD-naive cohort of patients with early seropositive rheumatoid arthritis (RA).

METHODS

Subjects were categorized by the time from symptom onset to the first DMARD use (median 5.7 months, range 0.6-15.9). Subjects who started their first DMARD within 5 months of symptom onset were compared to subjects who started after 5 months. Disease Activity Scores (DAS-44) and total Sharp Score (TSS) progression rates were analyzed using Wilcoxon rank-sum and chi-square tests; multiple linear regression analysis adjusted for potential covariates. The slope of the least-squares regression line was calculated to estimate the annualized TSS progression rates.

RESULTS

Of 233 RA patients, 76% were female and mean age was 50 (SD 13) years. At DMARD start, DAS-44 was similar in all subsets within the 0.6 to 15 months' duration between symptom onset and DMARD initiation. Erosion scores tended to be higher in those who started DMARD later, but Health Assessment Questionnaire-Disability Index (HAQ-DI) scores were higher in those who started DMARD earlier. During the 2 years after DMARD initiation, improvements in HAQ-DI and DAS-44 were similar in the various duration subsets, with about 25% ever achieving DAS remission (DAS < 1.6). Radiographic progression tended to be numerically but not statistically more rapid in the earlier subsets.

CONCLUSION

Following initiation of nonbiologic DMARD therapy at various times within 15 months of symptom onset, improvements of DAS-44, HAQ-DI, remission rate, and radiographic progression rate were similar, although higher baseline erosion scores were present in those with later initiation of DMARD.

Application of biomarkers in the clinical development of new drugs for chondroprotection in destructive joint diseases: a review

Emerging evidence supports the concept that biochemical markers are clinically useful non-invasive diagnostic tools for the monitoring of changes in cartilage turnover in patients with destructive joint diseases such as osteoarthritis (OA) and rheumatoid arthritis (RA). Epidemiological studies demonstrated that measurements of different degradation products of proteins in the extracellular matrix of hyaline cartilage in urine or serum samples are (1) increased in OA or RA patients compared with healthy individuals, (2) correlate with disease activity, and (3) are predictive for the rate of changes in radiographic measures of cartilage loss. The present review provides an updated list of available biomarkers and summarize the research data arguing for their clinical utility. In addition, it addresses the question whether or not the monitoring of biomarkers during different treatment modalities could be a useful approach to characterize the chondro-protective effects of approved and candidate drugs. Finally, it briefly reviews the in vitro/ex vivo experimental settings - isolated chondrocyte cultures and articular cartilage explants - that can assist in the verification of novel markers, but also studies assessing direct effects of drug candidates on chondrocytes. Collectively, biomarkers may acquire a function as established efficacy parameters in the clinical development of novel chondro-protective agents.

Collagen-induced arthritis in C57BL/6 mice is associated with a robust and sustained T-cell response to type II collagen

Many genetically modified mouse strains are now available on a C57BL/6 (H-2b) background, a strain that is relatively resistant to collagen-induced arthritis. To facilitate the molecular understanding of autoimmune arthritis, we characterised the induction of arthritis in C57BL/6 mice and then validated the disease as a relevant pre-clinical model for rheumatoid arthritis. C57BL/6 mice were immunised with type II collagen using different protocols, and arthritis incidence, severity, and response to commonly used anti-arthritic drugs were assessed and compared with DBA/1 mice. We confirmed that C57BL/6 mice are susceptible to arthritis induced by immunisation with chicken type II collagen and develop strong and sustained T-cell responses to type II collagen. Arthritis was milder in C57BL/6 mice than DBA/1 mice and more closely resembled rheumatoid arthritis in its response to therapeutic intervention. Our findings show that C57BL/6 mice are susceptible to collagen-induced arthritis, providing a valuable model for assessing the role of specific genes involved in the induction and/or maintenance of arthritis and for evaluating the efficacy of novel drugs, particularly those targeted at T cells.

Assessment of foot impairment in rheumatoid arthritis patients by dynamic pedobarography

OBJECTIVES

Impaired foot function may jeopardize the mobility of patients with rheumatoid arthritis (RA). However, there are still no guidelines concerning the adequate early treatment of painful rheumatoid feet which do not yet require surgery. An assessment method for RA feet appears necessary in order to detect foot problems before functional limitations develop. Therefore, the aim of the present study was to evaluate the use of pedobarographic measurements for detecting changes in plantar loading characteristics and their relationship to foot pain in patients with RA.

METHODS

One hundred and twelve patients with RA (55.0+/-11.0 years of age) were divided into three groups according to their Health Assessment Questionnaire (HAQ) Score and compared to a control group of 20 healthy adults (CG). Thirty-six patients with good physical capacity belonged to group 1 (RA1; HAQ-score: 0-1.0), 38 patients with moderate capacity to group 2 (RA2; score: 1.1-2.0) and 38 patients with low capacity to group 3 (RA3; score: 2.1-3.0). Each patient's foot pain was clinically assessed. Pedobarography was used to analyze foot loading parameters while walking barefoot.

RESULTS

In the forefoot, average pressures under the lateral forefoot were higher in RA1 patients than in RA2 patients and controls (p<0.05) despite an inconspicuous clinical examination of the foot in RA1 patients. RA1 patients also demonstrated higher plantar pressures than RA2 under the second metatarsal head (p<0.05). In contrast, no significant differences in maximum force could be demonstrated between patient groups. Furthermore, in RA3 patients with lower physical capacity, foot pain was increased as compared to RA1 and RA2 patients.

CONCLUSION

In RA patients, pedobarographic patterns show specific changes which characterize the level of functional capacity. In patients with foot involvement, pedobarographic measurements can be useful during the earlier stages of the disease, when clinical examination does not yet indicate the need for more aggressive treatment or orthopedic interventions.

The relation of hand functions with radiological damage and disease activity in rheumatoid arthritis

The purpose of this study was to investigate specifically the correlation of hand functions determined by Duruoz hand index (DHI) with radiological findings and disease activity in rheumatoid arthritis (RA) patients. Forty-eight RA patients were evaluated with DHI questionnaire, disease activity score (DAS) 28 and modified Larsen scoring method. Correlation between DAS-28 and DHI was assessed in all the patients. Mean DHI scores were compared between patients in remission (DAS-28 < 2.6) and patients who have more or less disease activity (DAS-28 >or= 2.6). To exclude the probable conflicting effect of disease activity on hand functions, the correlation between radiological scores and DHI was investigated only in patients with remission. There was a positive correlation between DAS-28 and DHI in all patients group (r = 0.434, P < 0.002). No correlation between the radiological scores of any joint groups and DHI could be found in patients with remission. Hand functions seemed to be affected prominently from disease activity. Radiological scores demonstrating joint damage were not in relation with hand functions.

Reporting of radiographic methods in randomised controlled trials assessing structural outcomes in rheumatoid arthritis

BACKGROUND

Because an increasing number of clinical trials evaluating disease-modifying antirheumatic drugs in rheumatoid arthritis (RA) emphasise radiographic outcomes as a primary outcome, using a reproducible radiographic measure should be placed at a premium.

AIM

To evaluate the reporting of radiographic methods in randomised trials assessing radiographic outcomes in RA.

METHODS

Medline was searched for randomised controlled trials assessing radiographic outcomes published between January 1994 and December 2005 in general medical and specialty journals with a high impact factor. One reader extracted data (radiographic acquisition, assessment and reproducibility) using a standardised form.

RESULTS

A total of 46 reports were included in the analysis. The mean (SD) methodological quality scores on the Jadad scale (range 0-5) and the Delphi list (0-9) were 2.9 (1.2) and 6.4 (1.3), respectively. Use of a standardised procedure for the acquisition of the radiographs was reported in 2 (4.3%) articles. 2 (4.3%) reports indicated that the quality of the radiographs was evaluated. In 65.2% of the reports, > or = 2 radiographic scores were used. Reporting of radiographic assessment was well detailed for number of readers (91.3%), information on readers (71.7%), blinding (91.4%) and how films were viewed (74.0%). The reproducibility of the reading was reported in 39.1% of the articles.

CONCLUSION

The reporting of results of randomised controlled trials of radiographic outcomes in RA shows great variability in radiographic scores used. Reporting of radiographic methods could be improved upon, especially the acquisition procedure and the reproducibility of the reading.

Monitoring disease activity of rheumatoid arthritis in clinical practice: contributions from clinical trials

Rheumatoid arthritis is a heterogeneous and progressive autoimmune disease, and patients with this condition show varied responses to treatment. Practical, reliable, individually tailored measures of disease activity and treatment responses are needed. Outcome measures used in randomized, controlled trials, including American College of Rheumatology response criteria and Disease Activity Scores, identify when treatment should be initiated or changed, but can be time consuming and impractical in daily practice. Simplified disease activity indices, abbreviated joint counts and patient-report questionnaires are more-convenient ways to assess therapeutic responses in the clinic. Patient-reported measures of physical function, pain and global disease activity best differentiate the results of active treatment from those of placebo treatment in randomized, controlled trials. Improvements in physical function closely reflect changes in health-related quality of life. Recent trials have demonstrated limited correlations between clinical responses and radiographically demonstrated responses; both should be assessed on a regular basis. It is recommended that three domains be assessed in the clinic for therapeutic responses: patient-reported measures of physical function and/or global disease activity; physician assessment of disease activity; and imaging of the hands and/or feet on a biannual basis. Problematic joints and cervical spine involvement should be followed as clinically indicated. Measures of improvement for individually relevant physical activities need to be defined for each patient.

[Quantitative imaging in rheumatoid arthritis: from scoring to measurement]

The need of clinical sciences to measure therapy effects on chronic illness led to development, evaluation, and publication of several radiological methods to monitor disease progression of rheumatic diseases. This review article explains the basics and background of scoring and measurement. The radiologist thus learns to report more compactly and to communicate the results more specifically.

Medical imaging in pharmaceutical clinical trials: what radiologists should know

The role of medical imaging in pharmaceutical clinical trials includes identification of likely responders; detection and diagnosis of lesions and evaluation of their severity; and therapy monitoring and follow-up. Nuclear imaging techniques such as PET can be used to monitor drug pharmacokinetics and distribution and study specific molecular endpoints. In assessing drug efficacy, imaging biomarkers and imaging surrogate endpoints can not only be more objective and faster to measure than clinical outcomes, but also allow small group sizes, quick results and good statistical power. In this article some basic principles of drug clinical development are explained. Study design, image reading and quantitative image processing in clinical trials with imaging components are discussed.

Differential diagnosis of rheumatic diseases using conventional radiography

The approach to the differential diagnosis of rheumatic diseases using conventional radiography is systematic and module-oriented, which, with respect to future developments, forms the basis for computer-assisted diagnosis (CAD). The indications follow consensus-based referral criteria and attempts should be made to raise the evidence level of the recommendations. Investigation techniques have been improved in the last few years with the use of digital radiography. New imaging technologies may be available in the future that will achieve at least the same quality of images, while exposing patients to a significantly lower radiation dose. The interpretation of radiographical signs could be enhanced through a correlation with other imaging modalities. Computer-assisted techniques with image processing tools for automated measurements, lesion detection and in the form of expert systems are under development. With conventional radiography embedded in CAD systems, promising options will be available to enhance the differential diagnosis of rheumatic diseases.

Quantitative Analysis of Micro-CT Imaging and Histopathological Signatures of Experimental Arthritis in Rats

Micro-computed tomographic (micro-CT) imaging provides a unique opportunity to capture 3-D architectural information in bone samples. In this study of pathological joint changes in a rat model of adjuvant-induced arthritis (AA), quantitative analysis of bone volume and roughness were performed by micro-CT imaging and compared with histopathology methods and paw swelling measurement. Micro-CT imaging of excised rat hind paws (n = 10) stored in formalin consisted of approximately 600 30-mum slices acquired on a 512 x 512 image matrix with isotropic resolution. Following imaging, the joints were scored from H&E stained sections for cartilage/bone erosion, pannus development, inflammation, and synovial hyperplasia. From micro-CT images, quantitative analysis of absolute bone volumes and bone roughness was performed. Bone erosion in the rat AA model is substantial, leading to a significant decline in tarsal volume (27%). The result of the custom bone roughness measurement indicated a 55% increase in surface roughness. Histological and paw volume analyses also demonstrated severe arthritic disease as compared to controls. Statistical analyses indicate correlations among bone volume, roughness, histology, and paw volume. These data demonstrate that the destructive progression of disease in a rat AA model can be quantified using 3-D micro-CT image analysis, which allows assessment of arthritic disease status and efficacy of experimental therapeutic agents.