Relevance of Grade 1 Gray‐Scale Ultrasound Findings in Wrists and Small Joints to the Assessment of Subclinical Synovitis in Rheumatoid Arthritis

Witt, Matthias; Mueller, Felix; Nigg, Axel; Reindl, Christiane; Leipe, Jan; Proft, Fabian; Stein, Nicola; Hammitzsch, Ariane; Mayer, Stefan; Dechant, Claudia; Schulze‐Koops, Hendrik; Grünke, Mathias

doi:10.1002/art.37954

Cited by 87 publications

(72 citation statements)

References 27 publications

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“…Low level of imaging activity was defined less strictly, allowing gradually 1 to maximum 2 joints or tendons with positive synovitis or tenosynovitis, binary graded (GS and PD global scores for binary evaluation of synovitis and tenosynovitis≤1 or ≤2). GS and PD synovitis detected with US in patients in remission according to clinical scores was named subclinical synovitis [20]. GS and PD tenosynovitis detected with US in the same group of patients was named in our study subclinical tenosynovitis.…”

Section: Us Examinationmentioning

confidence: 74%

Tenosynovitis US scoring systems follow synovitis and clinical scoring systems in RA and are responsive to change after biologic therapy

Vlad

Berghea

Micu³

et al. 2015

Med Ultrason

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Aims: To investigate by ultrasonography (US) in a cohort of active RA patients starting biologic therapy the responsiveness of tenosynovitis of wrist and hands compared to the responsiveness of synovitis in a 6 month period follow-up, to compare the responsiveness of finger flexor tenosynovitis with the responsiveness of wrist extensor tenosynovitis and to describe the subclinical synovitis and tenosynovitis in RA patients in clinical remission. Material and methods: Fifty seven patients with active RA starting biologic therapy were included. Clinical, laboratory, and US evaluations were performed at baseline, 1, and 6 months. US evaluation included wrist and MCPs 2-5 joints, bilaterally for synovitis and extensor tendons compartments 2, 4, and 6 and finger flexors 2-5 for tenosynovitis. Eighteen US scores based on semiquantitative or binar grades were calculated at each visit. Responsiveness of synovitis and tenosynovitis scores was calculated using the standardized response mean (SRM). Results: The responsiveness of US tenosynovitis was lower comparing with the responsiveness of US synovitis but both showed large effect of therapy. Furthermore, tenosynovitis responsiveness was similar to CRP responsiveness (SRM -0.90). Finger flexors tenosynovitis showed a higher responsiveness than extensor tenosynovitis on GS (-0.94 compared to -0.63) and a lower SRM on PD (-0.56 compared to -0.85). Tenosynovitis scores remission was overlapping clinical remission according to CDAI and SDAI in 100% of cases. Overall there was less subclinical tenosynovitis than subclinical synovitis at final visit according to clinical activity indices. Conclusion: Tenosynovitis US scoring in RA may be as good as synovitis scoring for characterization of disease activity and responsiveness.

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Section: Us Examinationmentioning

confidence: 74%

Tenosynovitis US scoring systems follow synovitis and clinical scoring systems in RA and are responsive to change after biologic therapy

Vlad

Berghea

Micu³

et al. 2015

Med Ultrason

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“…The authors do not mention the sides were the PD was found but they published an US image with a PD signal from the dorsal side of the joint. Probably the same explanation is valuable for the grade 1 synovitis, due to its incipient pathologic vascularization: in the presence of grade 1synovitis the PD signal was much frequent detected in the dorsal side (28.1%) comparing with palmar side (3.7%) [12]. Also, Witt et al [24] found in patients with newly diagnosed rheumatoid arthritis (RA) more pathologic findings in grey-scale US from the palmar approach and more frequent PD signals from the dorsal approach of the finger joints.…”

Section: Discussionmentioning

confidence: 90%

“…For these reasons the term of "synovitis" should be reserved only for cases with proved inflammation by using color/power Doppler [9]. The correct interpretation of the grade 1 grey-scale US aspect of the MCP (normal or minimal synovial thickening) is one of the most debated subjects [9][10][11][12] concerning US criteria for early inflammatory arthritis.…”

mentioning

confidence: 99%

Ultrasonography of the metacarpophalangeal joints in healthy subjects using an 18 MHz transducer.

Fodor

Felea²,

Popescu³

et al. 2015

Med Ultrason

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Aim: To evaluate the metacarpophalangeal (MCP) joints (MCP2 and 5) in healthy subjects by ultrasonography (US) using a high frequency transducer (18 MHz) and to verify the interobserver agreement. Material and methods: We enrolled 50 healthy volunteers (37 women, age between 30-58 years, mean age 41.7 years, divided into 3 groups according to age: 30-39, 40-49, and 50-58 years). The subjects were successively evaluated by 4 rheumatologists: 2 experienced (team A) and 2 beginners (team B) in US. Seven dorsal and palmar longitudinal scanning positions and a supplementary scan for MCP cartilage were performed. The bone surface (erosions, osteophytes), the intra-articular content (synovial thickening and vascularization, 4 grade scale), and the aspect of the metacarpal head cartilage were analyzed. The anterior palmar recess was measured. The time for examination was recorded. Results: Erosions were detected in 7% of joints by team A and 2% by team B (p<0.05, kappa agreement 0.567) in subjects over 40 years. The agreement by team A in the detection of the erosions was very good (kappa value 0.83). A moderate positive correlation was obtained between the presence of erosions and age (r= 0.401, p=0.004). Osteophytes were identified only on the dorsal scan in subjects over 50 years (in 3.5% of joints team A, 1.5% team B, p>0.05, kappa value 0.421). No grade 1 synovitis was observed by team A but 4 joints with grade 1 synovitis were identified by team B (p<0.05) from the dorsal scan. The dimensions of the palmar recess had large distribution (MCP 2 between 0.55-1.3 mm; MCP 5 between 0.6-1.2 mm). No statistical significant differences were obtained when comparing the dimensions of the two hands or the values obtained in agegroups (all p>0.05). No statistical significant correlations were obtained between the dimensions of palmar recess and the body mass index or dominant hand (all p>0.05). No pathological findings were found in the examination of the metacarpal head cartilage. Power Doppler investigation found the presence of grade 1 signal in 2.5% joints by team A and 1.5% by team B (p>0.05) only in the dorsal scans. The mean time for examination was 7.8±1.74 min in team A and 13.78±2.96 min in team B (p<0.05). Conclusions: In healthy subjects pathological findings are occasionally encountered, especially erosions and osteophytes. Using an 18 MHz transducer the aspect of grade 1 synovitis was not encountered in healthy non-inflammatory MCP joints. There is a permanent need for standardized training and examination in musculoskeletal US.

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“…Because of the uncertainties that still exist when integrating US into clinical decision making, and because our patients had severe longstanding disease, we adopted a cautious approach defining US remission as PDUS 0 in all joints, even though the significance of grade 1 change is uncertain and can occur in patients with osteoarthritis (31) and a proportion of healthy volunteers (32). We elected to make treatment decisions on the basis of PDUS only and ignored grayscale changes because their significance in later RA remains uncertain (33). Following anti-TNF dose reduction, 8 patients were identified as having subclinical synovitis despite DAS28 remission using US at routine …”

Section: Discussionmentioning

confidence: 99%

Does Combined Clinical and Ultrasound Assessment Allow Selection of Individuals With Rheumatoid Arthritis for Sustained Reduction of Anti–Tumor Necrosis Factor Therapy?

Marks

Holroyd

Dimitrov

et al. 2015

Arthritis Care & Research

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Objective. To investigate whether a strategy combining clinical and ultrasound (US) assessment can select individuals with rheumatoid arthritis (RA) for sustained dose reduction of anti-tumor necrosis factor (anti-TNF) therapies. Methods. As part of a real-world approach, patients with RA receiving anti-TNF therapies were reviewed in a dedicated biologic therapy clinic. Patients not taking oral corticosteroids with both Disease Activity Score in 28 joints (DAS28) remission (£2.6) and absent synovitis on power Doppler US (PDUS 0) for >6 months were invited to reduce their anti-TNF therapy dose by one-third. Results. Between January 2012 and February 2014, a total of 70 patients underwent anti-TNF dose reduction. Combined DAS28 and PDUS remission was maintained by 96% of patients at 3 months followup, 63% at 6 months, 37% at 9 months, and 34% at 18 months followup. However, 88% of patients maintained at least low disease activity (LDA) with DAS28 <3.2 and PDUS £1 at 6 months. The addition of PDUS identified 8 patients (25% of those that flared) in DAS28 remission, with subclinically active disease. Those who maintained dose reduction were more likely to be rheumatoid factor (RF) negative (46% versus 17%; P 5 0.03) and have lower DAS28 scores at biologic therapy initiation (5.58 versus 5.96; P 5 0.038). Conclusion. Combined clinical and US assessment identifies individuals in remission who may be suitable for anti-TNF dose reduction and enhances safe monitoring for subclinical disease flares. Despite longstanding severe RA, a subset of our cohort sustained prolonged DAS28 and PDUS remission. LDA at biologic therapy initiation and RF status appeared predictive of sustained remission.

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Relevance of Grade 1 Gray‐Scale Ultrasound Findings in Wrists and Small Joints to the Assessment of Subclinical Synovitis in Rheumatoid Arthritis

Cited by 87 publications

References 27 publications

Tenosynovitis US scoring systems follow synovitis and clinical scoring systems in RA and are responsive to change after biologic therapy

Tenosynovitis US scoring systems follow synovitis and clinical scoring systems in RA and are responsive to change after biologic therapy

Ultrasonography of the metacarpophalangeal joints in healthy subjects using an 18 MHz transducer.

Does Combined Clinical and Ultrasound Assessment Allow Selection of Individuals With Rheumatoid Arthritis for Sustained Reduction of Anti–Tumor Necrosis Factor Therapy?

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