Objective. To assess the value of gray-scale (GS) and power Doppler (PD) ultrasound (US) in detecting inflammatory/ destructive changes and for prediction of necessity of re-therapy with rituximab (RTX) in patients with rheumatoid arthritis (RA) over 1 year of followup. Methods. GSUS and PDUS were performed to assess synovitis, tenosynovitis, and erosions on the clinically dominant hand and forefoot of 20 patients with RA before and after therapy with RTX. US parameters were compared with clinical (Disease Activity Score in 28 joints, tender/swollen joint counts, and patients' visual analog scale of disease activity) and laboratory parameters (C-reactive protein level and erythrocyte sedimentation rate). Results were compared for patients with and without re-therapy with RTX. Results. Significant decreases in clinical and laboratory parameters were observed after 6 and 12 months. US synovitis scores significantly decreased after 6 and 12 months (P < 0.05 for each). Regarding patients who received re-therapy between 6 and 9 months after the start of therapy (n ‫؍‬ 9), a fair therapy response was still detectable before re-therapy. In these patients, PD-positive synovitis was the only parameter that increased up to the 6-month examination. All patients negative for rheumatoid factor and anti-cyclic citrullinated peptide (n ‫؍‬ 4) were in the group of patients receiving a second course of treatment. Seropositive patients showed a better response to treatment with less need for re-therapy. Conclusion. Response to therapy was measurable by clinical and laboratory parameters as well as by US. Since PDUS was able to detect the onset of disease activity before worsening of clinical symptoms occurred, PDUS is most helpful in evaluating disease activity and making earlier therapy decisions.

Objective. The main objective of this study was to evaluate the 7-joint ultrasound (US7) score by detailed joint region analysis of an arthritis patient cohort. Methods. The US7 score examines the clinically most affected wrist, MCP and PIP II, III, MTP II, and V joints for synovitis, tenosynovitis/paratenonitis, and erosions. Forty-five patients with rheumatoid arthritis (RA) (84.4%) and spondyloarthritis with polyarticular peripheral arthritis (PsA 13.3%; AS 2.2%) with a median disease duration of 6.5 yrs (range 7.5 mths–47.6 yrs) were included and examined at baseline and 3, 6, and 12 months after starting or changing therapy (DMARD/biologic). In this study, detailed US7 score joint region analysis was firstly performed. Results. The joint region analysis performed at baseline disclosed synovitis in 95.6% of affected wrists in the dorsal aspect by greyscale (GS) US where Grade 2 (moderate) was most often (48.9%) detected. Palmar wrist regions presented Grade 1 (minor) capsule elevation in 40% and Grade 2 (moderate synovitis) in 37.8%. Tenosynovitis of the extensor carpi ulnaris (ECU) tendon was found in 40%, with PD activity in 6.6%. Most of the erosions in MCP II were detected in the radial (68.9%), followed by the dorsal (48.9%) and palmar (44.4%) aspects. In MTP V, erosions were seen in 75.6% from lateral. Conclusions. Synovitis in GSUS was more often detected in the wrist in the dorsal than in the palmar aspect. ECU tendon involvement was frequent. Most erosions were found in the lateral scan of MTP V and the medial (radial) scan of MCP II.

Objective. To assess the inter-and intraobserver reliability of 26 rheumatologists when performing the 7-joint ultrasound score (US7). Methods. Six patients with rheumatoid arthritis were examined by 26 sonographers in 12 rater groups who performed the US7 score. The US7 score includes the clinically dominant wrist, the second and third metacarpophalangeal (MCP) and proximal interphalangeal joints, and the second and fifth metatarsophalangeal (MTP) joints, which were evaluated for synovitis, tenosynovitis/paratenonitis, and erosions from the dorsal side and palmar/plantar aspects by gray-scale and power Doppler (PD) ultrasound. Additional lateral scans were performed at the MCP2 and MTP5 joints. All of the groups repeated the examination in 4 patients in order to calculate the intraobserver reliability. The results of one group that included 2 expert sonographers were considered as the reference standard. Kappa values, median agreement rates (interobserver), and P values (intraobserver evaluation) were calculated. Results. The median overall kappa value for detecting synovitis was 0.51, for tenosynovitis/paratenonitis was 0.57, and for erosions was 0.45. In detail, the best interobserver results were found for the detection of erosions in the MTP2 joint from the plantar aspect ( ‫؍‬ 1; median agreement rate 89.4%) and for PD signal detection in the palmar wrist region ( ‫؍‬ 0.79; median agreement rate 78.8%). Good agreement was found for detecting erosions in the MCP2 joint from the radial side ( ‫؍‬ 0.67; median agreement rate 77.3%). Conclusion. The inter-and intraobserver reliability of the US7 score shows moderate to substantial kappa values and good agreements. Therefore, this ultrasound score has the potential to be an important imaging tool, including multicenter analysis to assess structural changes.

The objectives of this study are to evaluate a new semi-quantitative (0-5) musculoskeletal ultrasound (US) erosion score in patients with rheumatoid arthritis (RA) and to prove its usefulness in the detection of disease activity and success of therapy. Thirty-eight patients with RA (mean disease duration 10.1 ± 11.9 years) were enrolled. Start or change of therapy (DMARD/biologics) was an inclusion criterion. DAS28, laboratory (ESR and CRP) and US data were evaluated before new therapy initiation and after 1, 3, 6 and 12 months. Thirteen joints of the clinically more affected hand and forefoot (wrist and MCP, PIP, MTP joints 2-5) were analyzed for synovitis in grayscale (GS) and power Doppler (PD) US, tenosynovitis/paratenonitis in GS/PDUS (wrist, MCP level) and for erosions. Erosions were analyzed by a new semi-quantitative score (grade 0, no erosion; grade 1, <1 mm, grade 2, 1 to <2 mm; grade 3, 2 to ≤3 mm; grade 4, >3 mm; grade 5, multiple bone erosions). After 12 months, DAS28 decreased from 4.5 to 3.4 (p < 0.001), the synovitis score in GSUS from 26.3 to 12.8 (p = 0.001) and the synovitis score in PDUS from 10.6 to 4.1 (p < 0.001). The erosion score decreased from 21.5 to 18.1 (p = 0.046). There were longitudinal significant correlations between the new erosion score and both the DAS28 (r = 0.368; p = 0.025) and the synovitis score in PDUS (r = 0.365; p = 0.026) over a 1-year follow-up period. The new erosion score might be a useful tool for the evaluation of erosive changes by US in RA patients. In the course of DMARD and biologic therapy, it was responsive under 1-year follow-up examination.

Background Fluorescence optical imaging (FOI) is a novel imaging technology. It detects hypervascularisation of inflamed joints and tissues in both hands using indocyanine green (ICG) as fluorophore. Objectives In this study, FOI was compared to low-field MRI and musculoskeletal ultrasound (US) in patients with early rheumatoid arthritis (RA). Methods Thirteen patients (9 female; mean age 54±15 yrs, range 26-75) with the diagnosis of early RA were enrolled. Low-field MRI (under application of 0.2 mmol/kg BW Dotarem®) and US (grey-scale (GSUS) as well as power-Doppler (PDUS) mode) of the clinically more affected hand were performed. Both methods were evaluated according to the OMERACT criteria. After informed consent, all patients were examined by the FOI device Xiralite© (mivenion GmbH, Berlin) using ICG as fluorophore (ICG-Pulsion® 0.1 mg/kg BW bolus I.V., 6 minutes examination time). Images were interpreted in three defined phases of increased signal intensity (ISI) in the finger tips: early (P1, prior to strong ISI in the finger tips), intermediate (P2, during ISI in the finger tips), and late phase (P3, after decreasing of ISI in the finger tips) [1]. Sensitivity and specificity for synovitis were calculated using MRI as reference. Furthermore, interclass correlation coefficients (ICC) were calculated between all three imaging methods. Results In total, 104 joints (MCP n=52, PIP n=52) were evaluated. For all finger joints, FOI reached a sensitivity of 88% and specificity of 57% using MRI as reference. In detail, sensitivity of 70% and specificity of 81% was calculated for the MCPs (n=52), and sensitivity of 96% and specificity of 41% for the PIPs (n=52) (Table 1). The ICCs between MRI and FOI were 0.77 for the MCPs and 0.79 for the PIPs. The ICCs between US and FOI were 0.79 for the MCPs and 0.73 for the PIPs (Table 2). Table 1. Sensitivity and specificity for FOI with MRI as reference method MRI FOI (P1)Sensitivity (%)Specificity (%) All joints (n=104)8857 MCP (n=52)7081 PIP (n=52)9641 Table 2. Interclass correlation coefficients (ICCs) between the three imaging methods Interclass correlation coefficients (ICC)MCP (n=52)PIP (n=52) FOI (P1) vs. MRT0.770.79 FOI (P1) vs. US0.790.73 Conclusions With MRI as reference, the novel FOI method seems to be very sensitive in the detection of synovitis, but not very specific. There was a high sensitivity especially for the PIP joint evaluation, with poor specificity, though. In contrast, MCP joint evaluation by FOI was much more specific. There were comparable good correlations between FOI and MRI as well as between FOI and US. Hence, FOI might be a helpful tool in the screening of patients with suspected early RA. References Werner SG, Langer EH, Ohrndorf S, et al. Inflammation assessment in patients with arthritis using a novel in vivo fluorescence optical imaging technology.Ann Rheum Dis. 2011 Oct 12. [Epub ahead of print] Disclosure of Interest S. Ohrndorf Grant/Research support from: Arthromark Research Support, M. Krohn: None Declared, S. Werner Grant/R...