Radiographic Structural Damage Is Worse in the Dominant than the Non-Dominant Hand in Individuals with Early Rheumatoid Arthritis

Asymmetrical Damage of the Wrist Joint Induces Lateralized Cortical Bone Loss in the Metacarpal Diaphysis in Patients with Rheumatoid Arthritis

Background/Objectives: Osteoporosis is common in rheumatoid arthritis (RA), occurring either systemically or locally around inflamed joints. Decreased metacarpal bone density is a known marker of RA progression and hand function impairment. Although RA is generally characterized by symmetrical arthritis, some patients exhibit asymmetrical joint involvement. This study investigates the frequency of unilateral metacarpal bone density reduction in RA patients and aims to identify associated factors. Methods: This study included 143 RA patients (107 females, mean age 62.4 yrs., mean disease duration 11.1 yrs.). Bilateral hand X-rays were used to measure the cortical thickness rate (CTR) of the 2nd to 4th metacarpals. Unilateral bone density reduction was defined as a thin-to-thick-side CTR ratio (CTRR) < 0.8. Associations between CTR reduction and unilateral wrist joint damage (WJD) were analyzed. Results: Unilateral CTR reduction (CTRR < 0.8) was observed in 16.8% of patients, significantly associated with unilateral WJD. Among patients with unilateral WJD, 50.0% showed CTRR lateral (+) compared to 10.1% without unilateral WJD (p < 0.01). ANCOVA revealed significant effects of WJD laterality on CTRR, with an interaction effect showing greater CTRR laterality when thin-side WJD was present without thick-side WJD. Post-biologic treatment, CTR values decreased in both hands, indicating no improvement in bone density reduction. Conclusions: Approximately 17% of RA patients exhibited unilateral relative metacarpal bone density reduction, closely associated with unilateral WJD. This first detailed report on bone density laterality in RA underscores the need for early intervention and rehabilitation strategies in RA patients with hand involvement.

Biomechanical determinants of rheumatoid arthritis severity and excess cardiovascular disease: common origins of two complex diseases

OBJECTIVES

The determinants of rheumatoid arthritis (RA) severity and excess cardiovascular disease (CVD) are incompletely understood. Biomechanical factors are known to influence RA severity. Articular stiffness correlates with arterial and skin stiffness. This study explored the hypothesis that constitutional stiffness is a common determinant of RA severity and excess CVD.

METHODS

Fifty-eight patients with anti-CCP antibody (ACPA) positive RA and 57 controls were enrolled noting age, sex, body mass index, alcohol and tobacco exposure, Shared Epitope status and in RA disease duration, disease activity, ACPA titre and radiographic damage. Severe RA was defined as radiographic progression >1.3 mSharp points/year or requiring biological disease-modifying antirheumatic drugs (bDMARDs). Articular stiffness (Beighton Score and right 5th metacarpophalangeal (MCP) joint stress-strain responses), carotid-femoral pulse wave velocity and skin extensibility (percent increase distance two dots with manual traction dorsum right hand) were assessed.

RESULTS

Right 5th MCP stiffness correlated with Beighton Score and with arterial and skin stiffness. High radiographic rate was associated with greater MCP articular (t test p 0.014), arterial (p 0.044) and, in RA <5 years duration, greater skin stiffness (p 0.002) with similar trends in subjects requiring bDMARDs. In RA, arterial stiffness correlated with age (ß p<0.005), articular (ß p<0.001) and skin stiffness (ß p 0.037) and inversely with alcohol consumption (p 0.035).

CONCLUSIONS

Articular, arterial and skin stiffness correlated with each other and with RA severity. As skin is not affected by RA, this association suggests that constitutional stiffness might be a common determinant of RA and CVD. Prospective studies of at-risk preclinical and early RA are required to determine if this relationship is causal.

TRIALS REGISTRATION NUMBER

ACTRN12617000170325.

Patterns of Involvement of the Hand Joints in Classical Rheumatoid Arthritis

BACKGROUND

Symmetrical involvement of the hand joints is described as characteristic of rheumatoid arthritis (RA). Quantitative data on specific patterns of involvement are lacking.

OBJECTIVE

The Brigham Rheumatoid Arthritis Sequential Study was created for observational studies of patients with RA and afforded a unique opportunity to answer these questions.

METHODS

Of 1598 subjects in the Brigham Rheumatoid Arthritis Sequential Study cohort, 535 met the following criteria: (1) disease duration of 7 years or greater, (2) seropositive, and (3) hand radiographs available. Patterns in specific hand joints based on physical examination and radiographic findings obtained at entry were identified. The level of symmetry of involvement of the metacarpophalangeal (MCP) and wrist joints was determined, as was the correlation between findings on physical examination and radiographic changes in the hand joints.

RESULTS

The prevalence of joint space narrowing and/or erosions in each proximal interphalangeal (PIP) joints ranged between 11% and 18%. Joint space narrowing and/or erosions in the MCPs increased radially from the fifth to the second finger. Swelling and tenderness on physical examination of both the PIPs and MCPs also increased radially although the positive predictive value of physical examination as an indicator of joint damage decreased radially. The wrist was the most common joint involved both by physical examination (67%) and radiographically (70%). The right side was more involved radiographically. Analysis of radiographic changes in individual patients revealed that symmetrical findings in the wrists and MCPs occurred in only 67% of patients.

CONCLUSIONS

The study describes the pattern of involvement of the hand joints in patients with long standing RA. Findings of interest include symmetrical involvement in only 67% of patients and a discordancy between physical findings and radiographic changes most marked in the more radial PIP joints.

Overload of the Temporomandibular Joints Accumulates γδ T Cells in a Mouse Model of Rheumatoid Arthritis: A Morphological and Histological Evaluation

Recently, it has been reported that γδ T cells are associated with the pathology of rheumatoid arthritis (RA). However, there are many uncertainties about their relationship. In this study, we investigated the morphological and histological properties of peripheral as well as temporomandibular joints (TMJ) in a mouse model of rheumatoid arthritis with and without exposure to mechanical strain on the TMJ. Collagen antibody-induced arthritis (CAIA) was induced by administering collagen type II antibody and lipopolysaccharide to male DBA/1JNCrlj mice at 9-12 weeks of age, and mechanical stress (MS) was applied to the mandibular condyle. After 14 days, 3D morphological evaluation by micro-CT, histological staining (Hematoxylin Eosin, Safranin O, and Tartrate-Resistant Acid Phosphatase staining), and immunohistochemical staining (ADAMTS-5 antibody, CD3 antibody, CD45 antibody, RORγt antibody, γδ T cell receptor antibody) were performed. The lower jawbone was collected. The mandibular condyle showed a rough change in the surface of the mandibular condyle based on three-dimensional analysis by micro-CT imaging. Histological examination revealed bone and cartilage destruction, such as a decrease in chondrocyte layer width and an increase in the number of osteoclasts in the mandibular condyle. Then, immune-histological staining revealed accumulation of T and γδ T cells in the subchondral bone. The temporomandibular joint is less sensitive to the onset of RA, but it has been suggested that it is exacerbated by mechanical stimulation. Additionally, the involvement of γδ T cells was suggested as the etiology of rheumatoid arthritis.

Structural damage in rheumatoid arthritis assessed by musculoskeletal ultrasound: A systematic literature review by the Structural Joint Damage Task Force of the OMERACT Ultrasound Working Group

OBJECTIVES

To identify and synthesize the evidence for the use and measurement properties of musculoskeletal ultrasound in assessing structural joint damage in patients with rheumatoid arthritis (RA).

METHODS

A systematic literature search (SLR) of the PubMed, Embase and Cochrane Library was performed. Original articles were included published in English reporting on ultrasound of bone erosion, cartilage damage and the measurement properties of ultrasound according to the OMERACT filter 2.1.

RESULTS

Of the 1.495 identified articles 149 were included in the final review, most of which reported on cross-sectional studies and used the OMERACT definitions for ultrasonographic pathology. Among these, bone erosions were assessed in 139 (93.3%), cartilage damage in 24 (16.1%), enthesophytes in 8 (5.4%), osteophytes in 15 (10.1%) and malalignment and ankylosis in a single (0.9%) study, respectively. Most studies (126/149, 84.6%) assessed the joints of the hands. The overwhelming majority of studies (127/149, 85.2%) assessed structural joint damage bilaterally. Validity, reliability and responsiveness were assessed in 21 (14.1%), 34 (22.8%) and 17 (11.4%) studies, respectively.

CONCLUSION

While the results of this SLR suggest that ultrasound is a sensitive, reliable and feasible tool to detect damage in RA, they also highlight the need for further research and validation. Findings of this SLR will inform the next steps of the OMERACT Ultrasound Working Group in developing an ultrasound score for assessing structural joint damage in patients with RA.

Nondominant hand computer mouse training and the bilateral transfer effect to the dominant hand

This study explored the effects of training computer mouse use in the nondominant hand on clicking performance of the dominant and nondominant hands. Computer mouse use is a daily operation in the workplace and requires minute hand and wrist movements developed and refined through practice and training for many years. Our study had eleven right-handed computer mouse users train their nondominant hand for 15 min a day, five days per week, for six weeks. This study found improved performance with the computer mouse in the dominant hand following nondominant hand training because of the bilateral transfer effect of training. Additionally, our study showed that the nondominant hand is capable of learning the complex movements that our dominant hand has trained for many years. Last, our research showed that nondominant hand performance decreases when the skill is not trained for over a year, but the performance is significantly higher than that prior to the original training and can be rapidly relearned. Overall, training the nondominant hand on the computer mouse will allow for improved performance in industry while allowing safer, sustainable, and more achievable work in a multitude of economies.

Assessing synovitis in the hands in patients with rheumatoid arthritis by ultrasound: an agreement study exploring the most inflammatory active side from two Norwegian trials

Objective

To assess if the right hand, the dominant hand, or the hand with more clinically swollen joints (SwJ) is per se the most inflamed and exhibits the greatest change during treatment and hence preferred for unilateral scoring of synovitis by ultrasound in rheumatoid arthritis (RA) patients.

Methods

Using data from two previously published Norwegian RA patient cohorts initiating treatment, bilateral metacarpophalangeal joint 1–5, proximal phalangeal joint 2+3, and wrists were evaluated by ultrasound. Using a 0–3 scoring system a grey-scale (GS), power Doppler (PD) and global synovitis score (GLOESS) was calculated for each hand (0–30). For precision, a difference of < ± 3 in sum score was pre-specified as indicating clinically insignificant difference in inflammatory activity for all three scores.

Results

Four hundred thirty-seven RA patients were included. Baseline ultrasound inflammation was statistically significantly higher in hands with more vs fewer SwJ ([mean difference, 95%CI] GS sum score 2.21[1.30 to 3.12], PD sum score 1.70 [0.94 to 2.47] and GLOESS 2.31[1.36 to 3.26]) and also exhibited significantly more change for all sum scores at 3 months follow-up (GS sum score 1.34 [0.60 to 2.08], PD sum score 1.17 [0.44 to 1.91], and GLOESS 1.43 [0.63 to 2.22]). No such differences were found between the dominant and the non-dominant or the right and the left hands at any time points.

Conclusion

The hand with clinically more SwJ is statistically more inflammatory active according to GS, Doppler, and GLOESS sum scores, exhibits a change during treatment, and is potentially the best choice for unilateral scoring systems.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1930-y) contains supplementary material, which is available to authorized users.

Differing X-ray patterns in seronegative and seropositive rheumatoid arthritis

INTRODUCTION

Anti-citrullinated protein antibody (ACPA) and rheumatoid factor (RF) status are important predictors for rheumatoid arthritis (RA) erosivity. Qualitative differences on hand/feet radiographs have been described, indicating more carpal fusion in seronegative RA. This study explores these differences further using the total Sharp/van der Heijde score (TSS), digital X-ray radiogrammetry (DXR), and qualitative description.

METHODS AND MATERIALS

Matched seronegative (ACPA negative, RF negative, snRA) and seropositive (ACPA, RF > 3xULN, spRA) were examined. TSS scores both for erosions and joint space narrowing (JSN) were registered separately and compared for both groups. Joint compartments and single joints were compared, using a heat map. The degree of carpal fusion was quantified 0-5. DXR measurements (bone mineral density, cortical thickness, bone width, metacarpal index) were determined for each hand separately. Finally, selected radiographs were examined unblinded to search for non-quantifiable differences.

RESULTS

A total of 56 snRA and 57 spRA patients were examined. spRA patients had more erosions and joint space narrowing. Erosion load differed significantly between spRA and snRA in the foot and metacarpophalangeal joint, but not in the wrist or proximal interphalangeal joint compartments. Intracompartmental differences were greater in spRA. JSN scores were greater in spRA, in all compartments except wrist. Carpal fusion and DXR scores did not differ between the groups. The qualitative comparison showed that snRA patients displayed periarticular ossifications, carpal shortening, and sparing of the CMC joints, whereas spRA patients had more CMC damage and less shortening.

CONCLUSION

X-ray manifestations in snRA and spRA are qualitatively and quantitatively different. This suggests pathophysiological differences between the two forms. Key Points • Seronegative and seropositive RA display qualitatively and quantitatively different X-ray patterns, suggesting differences in the underlying pathophysiological process. This is the first time that this has been shown in a systematic, quantitative fashion.

Detection of rheumatoid arthritis from hand radiographs using a convolutional neural network

INTRODUCTION

Plain hand radiographs are the first-line and most commonly used imaging methods for diagnosis or differential diagnosis of rheumatoid arthritis (RA) and for monitoring disease activity. In this study, we used plain hand radiographs and tried to develop an automated diagnostic method using the convolutional neural networks to help physicians while diagnosing rheumatoid arthritis.

METHODS

A convolutional neural network (CNN) is a deep learning method based on a multilayer neural network structure. The network was trained on a dataset containing 135 radiographs of the right hands, of which 61 were normal and 74 RA, and tested it on 45 radiographs, of which 20 were normal and 25 RA.

RESULTS

The accuracy of the network was 73.33% and the error rate 0.0167. The sensitivity of the network was 0.6818; the specificity was 0.7826 and the precision 0.7500.

CONCLUSION

Using only pixel information on hand radiographs, a multi-layer CNN architecture with online data augmentation was designed. The performance metrics such as accuracy, error rate, sensitivity, specificity, and precision state shows that the network is promising in diagnosing rheumatoid arthritis.

Assessment of Cortical Interruptions in the Finger Joints of Patients With Rheumatoid Arthritis Using HR-pQCT, Radiography, and MRI

Small cortical interruptions may be the first sign of an erosion, and more interruptions can be found in patients with rheumatoid arthritis (RA) compared with healthy subjects. First, we compared the number and size of interruptions in patients with RA with healthy subjects using high-resolution peripheral quantitative CT (HR-pQCT). Second, we investigated the association between structural damage and inflammatory markers on conventional radiography (CR) and MRI with interruptions on HR-pQCT. Third, the added value of HR-pQCT over CR and MRI was investigated. The finger joints of 39 patients with RA and 38 healthy subjects were examined through CR, MRI, and HR-pQCT. CRs were scored using the Sharp/Van der Heijde method. MRI images were analyzed for the presence of erosions, bone marrow edema, and synovitis. HR-pQCT images were analyzed for the number, surface area, and volume of interruptions using a semiautomated algorithm. Descriptives were calculated and associations were tested using generalized estimating equations. Significantly more interruptions and both a larger surface area and the volume of interruptions were detected in the metacarpophalangeal joints of patients with RA compared with healthy subjects (median, 2.0, 1.42 mm² , and 0.48 mm³ versus 1.0, 0.69 mm² , and 0.23 mm³ , respectively; all p < 0.01). Findings on CR and MRI were significantly associated with more and larger interruptions on HR-pQCT (prevalence ratios [PRs] ranging from 1.03 to 7.74; all p < 0.01) in all subjects, and were consistent in patients with RA alone. Having RA was significantly associated with more and larger interruptions on HR-pQCT (PRs, 2.33 to 5.39; all p < 0.01), also after adjustment for findings on CR or MRI. More and larger cortical interruptions were found in the finger joints of patients with RA versus healthy subjects, also after adjustment for findings on CR or MRI, implying that HR-pQCT imaging may be of value in addition to CR and MRI for the evaluation of structural damage in patients with RA. © 2018 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.

Magnetic Resonance Imaging of Bilateral Hands Is More Optimal Than MRI of Unilateral Hands for Rheumatoid Arthritis

OBJECTIVE

To explore the advantages of magnetic resonance imaging (MRI) of bilateral hands in rheumatoid arthritis (RA).

METHODS

Consecutive patients with active RA were recruited for clinical assessments, radiographs, and MRI of bilateral hands. Bilateral hands were scanned simultaneously on 3.0 T whole-body MRI system and were scored on synovitis, osteitis, and bone erosion according to the RA MRI scoring (RAMRIS) system.

RESULTS

Among 120 patients included, wrist bones and metacarpophalangeal joint (MCPJ) 2 proximal showed bone erosion in early RA. The second to fifth metacarpal bases and the second to fourth MCPJ distal showed more bone erosion in mid-stage or late-stage RA. When MRI of dominant unilateral hand was analyzed, MRI synovitis and osteitis in 5% of wrists and 3 MRI features in 5-14% of MCPJ were misdiagnosed (McNemar test, all p < 0.05). There were 46% wrist synovitis, 29-52% MCPJ2-5 synovitis, 45% wrist osteitis, and 20%-34% MCPJ2-5 osteitis not detected by joint tenderness and/or swelling. When the clinically more severe hand was selected for MRI of unilateral hand according to physical examination, MRI synovitis in 5% of wrists and 3 MRI features in 7-15% of MCPJ were misdiagnosed (all p < 0.05). Scatter plots and linear regression analyses were used to illustrate RAMRIS between dominant or selected hand (Y values) and nondominant or nonselected hand (X values). All linear models were markedly different from a Y = X linear model, indicating the dominant or clinically more severe hand could not represent the contralateral hand to evaluate RAMRIS.

CONCLUSION

MRI of bilateral hands is more optimal than MRI of the unilateral hand in RA.

Association of Low Bone Mineral Density with Anti-Citrullinated Protein Antibody Positivity and Disease Activity in Established Rheumatoid Arthritis: Findings from a US Observational Cohort

Introduction

To assess the relationship between low bone mineral density (BMD), anti-cyclic citrullinated peptide-2 (anti-CCP2) antibodies, and disease activity in patients with established rheumatoid arthritis (RA).

Methods

Patients enrolled in a single-center, observational cohort registry of patients with RA. Eligible patients had known BMD, as measured by digital X-ray radiogrammetry (DXR–BMD), and anti-CCP2 antibody measurements at the same time point or within 6 months. Anti-CCP2–immunoglobulin (Ig)G-positive (+) patients (≥ 20 U/mL) were distributed into three equal groups (Gp1–3), representing increasing anti-CCP2 antibody concentrations. Associations between BMD and anti-CCP2 antibody status and titer were explored in multivariate regression analyses controlling for covariates (including age, duration of RA, use of steroids, use of osteoporosis medication). Association between disease activity (DAS28 [CRP] < 2.6) and bone loss was also explored.

Results

A total of 149 patients (all women) were included (47 anti-CCP2 antibody negative [−], 102 anti-CCP2+ [34\titer group]). Mean disease duration was greater in the three anti-CCP2+ groups vs. the anti-CCP2− group. DXR–BMD was lower in the anti-CCP2+ vs. the anti-CCP2− groups (Gp1–3 vs. anti-CCP2−: P < 0.0001 for left and right hands). DXR–BMD decreased with increasing anti-CCP2 titer (P < 0.001 for left and right hands). Patients with low DXR–BMD were less likely to have a DAS28 (CRP) < 2.6 (P = 0.0181).

Conclusion

Among patients with established RA, data suggest that anti-CCP2+ patients, particularly those with high anti-CCP2 antibody titers, have lower hand BMD, and patients with lower hand BMD are less likely to have low disease activity.

Funding

Bristol-Myers Squibb.

Trial Registration

Clinicaltrials.gov identifier, NCT01793103.

Electronic supplementary material

The online version of this article (10.1007/s12325-017-0657-x) contains supplementary material, which is available to authorized users.

Handgrip strength values of Portuguese older adults: a population based study

Background

Handgrip strength is used to identify sarcopenia and frailty phenotypes, being a potential predictor of mortality in older adults. However, uniformity is lacking in the reference values. This study aimed to describe handgrip strength values of older population aged ≥65 years in Portugal, considering the possible influence of anthropometric parameters.

Methods

A cross-sectional study was conducted in Portugal, among 1500 older adults aged ≥65 years old, according to “The Nutrition UP 65 Study Protocol”. Demographic data were collected and cognitive performance, subjective general health, physical activity, anthropometric parameters and nutritional status were assessed and analysed. Handgrip strength data was obtained with a Jamar dynamometer. A Pubmed/Medline search was carried out to compare handgrip strength data between Portuguese older adults and other older populations.

Results

Handgrip strength was higher among men than among women (30.3 ± 9.2 Kgf vs 18 ± 5.4 Kgf, p < 0.001, respectively). In general, handgrip strength values of Portuguese older adults were lower than other older populations. In our sample, age, cognitive and nutritional status, self-reported sitting time and practice of physical activity were significantly correlated with handgrip strength in both sexes. Concerning anthropometric parameters, height was the most significantly correlated with handgrip strength (r = 0.34, p < 0.001, in women and r = 0.40, p < 0.001, in men).

Conclusion

This study described, for the first time, handgrip strength values of Portuguese population aged ≥65 years, according to age and to sex-specific tertiles of height. The definition of handgrip strength reference values in this age group merits further reflection.

Relationship between handedness and joint involvement in rheumatoid arthritis

Rheumatoid arthritis (RA) is characterized by autoimmune chronic joint inflammation, which is worsened by mechanical stress. It is still inconclusive whether joints on the right side or the dominant side get more damaged in RA since the limited number of patients analyzed in the previous study had made it difficult to separately analyze right-handed and left-handed patients. Here, we enrolled 334 RA patients, the biggest number of patients in studies to address this issue and separately analyzed right-handed and left-handed patients. As a result, we observed that joints on the dominant side got clinically and radiologically more involved in the right-handed patients (p ≤ 0.0030). Importantly, this tendency was also seen in the left-handed patients, while it was not statistically significant due to the small sample size. This tendency was observed in each component of clinical or radiological involvement. Thus, handedness influences the laterality of clinical and radiological joint involvement in RA.