Abstract Objective To simultaneously image bone and synovium in the individual joints characteristically involved in early rheumatoid arthritis (RA). Methods Forty patients with early, untreated RA underwent gadolinium‐enhanced magnetic resonance imaging (MRI) of the second through fifth metacarpophalangeal joints of the dominant hand at presentation, 3 months, and 12 months. In the first phase (0–3 months), patients were randomized to receive either methotrexate alone (MTX) or MTX and intraarticular corticosteroids (MTX + IAST) into all joints with clinically active RA. The MTX‐alone group received no further corticosteroids until the second phase (3–12 months), when both groups received standard therapy. Results In the first phase, MTX + IAST reduced synovitis scores more than MTX alone. There were significantly fewer joints with new erosions on MRI in the former group compared with the latter. During the second phase, the synovitis scores were equivalent and a similar number of joints in each group showed new erosions on MRI. In both phases, there was a close correlation between the degree of synovitis and the number of new erosions, with the area under the curve for MRI synovitis the only significant predictor of bone damage progression. In individual joints, there was a threshold effect on new bone damage related to the level of synovitis; no erosions occurred in joints without synovitis. Conclusion In early RA, synovitis appears to be the primary abnormality, and bone damage occurs in proportion to the level of synovitis but not in its absence. In the treatment of patients with RA, outcome measures and therapies should focus on synovitis.
Arthropathy, particularly synovial inflammation in SSc, is not well characterized. We explored the role of MRI and musculoskeletal ultrasonography (MSUS) in detecting and characterizing synovial inflammation in SSc patients with arthralgia while comparing the two imaging modalities.Seventeen SSc patients with arthralgia and no overt inflammatory arthritis had a baseline MSUS of their hands. Six months later, 13 unselected patients had a second MSUS and 8 of these 13 patients also had MRI with gadolinium of their most symptomatic hand.Of the eight patients undergoing MRI scan, all (100%) patients had synovitis and 88% of patients had tenosynovitis. MRI also showed erosions in 75% of patients. On MSUS, on baseline and second scans, tenosynovitis was seen in 46% and 47% of the patients and synovitis in 6% and 23%, respectively. No erosions were identified. Applying the RAMRIS system (a semi-quantitative MRI scoring system used in RA), the mean values for synovitis, oedema and erosions fell within the range seen in RA.This study demonstrates the presence of a persistent inflammatory, erosive, peripheral arthropathy, similar to that seen in RA, in SSc patients with arthralgia without overt inflammatory joint disease. While both MRI and MSUS are useful in characterizing synovial inflammation in SSc, MRI is clearly more sensitive than MSUS in this setting. Further studies to establish the clinical and radiological musculoskeletal outcomes over time in this group of patients are required in order to identify the appropriate management of arthralgia in SSc.
Myopathy is a recognised but less investigated symptom of rheumatoid arthritis (RA) compared to other extra-articular manifestations. To date, the documentation of myopathic features in RA is poorly detailed. No studies have yet utilised a non-invasive quantitative method to define and investigate these features. Shear wave elastography (SWE), a novel ultrasound technology, can measure muscle stiffness to provide insight into the biomechanical properties of skeletal muscle.
Objectives
1- To investigate muscle stiffness (using SWE) and strength in three cohorts of RA patients compared to healthy controls. 2- To study the association between muscle strength and stiffness in RA.
Methods
Shear wave velocity (SWV), as a measure of muscle stiffness, was evaluated in the quadriceps, hamstrings and biceps brachii in 80 RA patients from three disease activity groups newly diagnosed treatment naïve RA [n=29; mean age 56.8 ± 10.6 years], persistent active RA for at least 1 year [n=18; 60.9 ± 15.9 years] and remission RA for at least 1 year [n=33; 65.9 ± 11.6 years], and compared them to 40 healthy controls (56.8 ± 10.6 years). The participants performed various muscle tests (handgrip strength, expanded timed get up and walk test (ETGUG), chair stand and isokinetic knee extension/flexion) to assess their strength and physical performance. One-way ANOVA was used to compare SWV and muscle assessment results, and Pearson's correlation was used to evaluate the correlation between muscle stiffness and strength.
Results
Mean SWV was not significantly different amongst the RA groups or compared to the healthy controls (p>0.05). For example, the rectus femoris SWV was 1.69±0.15 m/s for healthy controls, 1.68±0.18 m/s for new RA, 1.70±0.16 m/s for active RA and 1.68±0.14 m/s for remission RA (p=0.96). The muscle assessment results are presented in table 1 and compared to healthy controls in figure 1. Overall, the active and new RA groups showed significant muscle weakness compared to healthy controls. The remission RA group did not show a significant difference except in the isokinetic knee strength (-21%; p=0.027). The correlations between SWE and the muscle assessment results were weak and insignificant (r<0.30; p>0.05).
Conclusion
Muscle stiffness, as determined using SWE, does not appear to be altered or associated with muscle weakness in RA patients. The remission RA group showed significantly better strength and physical performance compared to new untreated or persistently active RA groups. Future research should investigate the significant muscle weakness in RA in addition to developing prevention and therapeutic strategies.
Disclosure of Interests
Abdulrahman M. Alfuraih: None declared, Ai Lyn Tan: None declared, Philip O'Connor: None declared, Paul Emery Grant/research support from: Pfizer, MSD, AbbVie, Bristol-Myers Squibb, Roche, Consultant for: Pfizer, MSD, AbbVie, Bristol-Myers Squibb, UCB, Roche, Novartis, Gilead,Samsung, Sandoz and Lilly, Richard Wakefield: None declared
The rise and proliferation of artificial intelligence (AI) has the potential to influence and disrupt many aspects of society as we currently know it. While it has been a long-held belief that robots are limited to physical tasks and therefore only capable of replacing blue collar workers, many concerns exist that continued developments will yield artificial minds capable of replacing knowledge workers. These advancements have led people to ask the question, "What will our society look like when AI is everywhere?" [1].
Abstract Objective Anti–tumor necrosis factor α agents are among the most effective therapies for rheumatoid arthritis (RA). However, their optimal use is yet to be determined. This 12‐month double‐blind study attempted remission induction using standard therapy with or without infliximab in patients with early, poor‐prognosis RA. The primary end point was synovitis (measured by magnetic resonance imaging [MRI]). Clinical observations continued to 24 months. Methods All patients had fewer than 12 months of symptoms. Assessments included full metrologic evaluation, laboratory tests, radiographs, functional evaluation using the Health Assessment Questionnaire (HAQ), and quality of life measurement using the RA Quality of Life (RAQoL) questionnaire. MRI was performed at 0, 4, 14, and 54 weeks; MR images were scored blindly. Patients received methotrexate (MTX) and were randomized to receive either infliximab or placebo for 12 months. Results Twenty patients were recruited (mean age 52 years, mean symptom duration 6 months, mean C‐reactive protein level 42 mg/liter, and 65% rheumatoid factor positive). At 1 year, all MRI scores were significantly better, with no new erosions in the infliximab plus MTX group; a greater percentage of infliximab plus MTX–treated patients fulfilled the American College of Rheumatology (ACR) 50% and 70% improvement criteria (78% versus 40% in the placebo plus MTX group and 67% versus 30%, respectively) and had a greater functional benefit ( P < 0.05 for all comparisons). Importantly, at 1 year after stopping induction therapy, response was sustained in 70% of the patients in the infliximab plus MTX group, with a median Disease Activity Score in 28 joints (DAS28) of 2.05 (remission range). At 2 years, there were no significant between‐group differences in the DAS28, ACR response, or radiographic scores, but differences in the HAQ and RAQoL scores were maintained ( P < 0.05). Conclusion Remission induction with infliximab plus MTX provided a significant reduction in MRI evidence of synovitis and erosions at 1 year. At 2 years, functional and quality of life benefits were sustained, despite withdrawal of infliximab therapy. These data may have significant implications for the optimal use of expensive biologic therapies.
Abstract Background Myositis is an autoimmune disease which can cause a decrease in quality of life and increased mortality, presenting with muscle weakness, raised muscle enzymes and myalgia. Diagnosis is reliant on subjective clinical examinations, blood tests, conventional MRI and invasive muscle biopsies. Quantitative T2 MRI offers a non-invasive measurement of muscle oedema which could help improve the understanding of muscle pathology and potentially inform diagnosis. The aim of this study was to evaluate whether quantitative T2 MRI of muscles is sensitive enough to detect differences in myositis patients compared to healthy controls, and how it compares with current radiologist scoring methods. Methods 16 myositis patients were recruited (10/16 female, 10 polymyositis, 6 dermatomyositis, mean age 50 ± 26), median CK 1000IU/L ± 3100IU/L, and 16 age and gender matched healthy controls were recruited. MRI of the dominant thigh were performed. Imaging was performed using a fat-suppressed turbo-spin echo sequence. Quantitative T2 measurements were obtained from regions of interest (ROI) drawn manually within the individual muscles that make up the quadriceps and hamstrings with no distinction made between affected and unaffected muscles. A mono-exponential fit was used to obtain an estimate of the T2 from each ROI. Two radiologists blinded to the diagnosis, semi-quantitatively scored by consensus the muscles on a 4-point visual scale as either no oedema (0), mild oedema (1), moderate oedema (2) or severe oedema (3). Muscle strength was assessed using an isokinetic dynamometer. Results T2 values were higher in myositis patients compared to healthy controls [mean (SD) hamstring myositis 47.8ms (7.7ms), healthy 39.9ms (1.5ms), p < 0.001; quadriceps myositis 53.8ms (12.1ms), healthy 42.1ms (2.1ms), p < 0.001]. Quantitative T2 correlated with the radiologists’ oedema scores with rs=0.7 in the hamstrings (p < 0.001) and rs=0.6 in the quadriceps (p < 0.001), with an upward trend in T2 as radiologist scored visible oedema increased. Patients who had been classified as normal by the radiologists were compared with matched healthy controls (n = 8), T2 values for patients with ‘normal muscle’ were still higher than those for healthy controls: mean T2 in the hamstrings (myositis 42.2ms, healthy controls 38.7ms, p = 0.004); mean T2 in the quadriceps (myositis 43.9ms, healthy controls 40.1ms, p = 0.001). T2 was inversely correlated with muscle strength in all participants. Conclusion Quantitative T2 measurements can detect muscle differences between myositis patients and healthy control groups, which suggests that this measurement could be used as an objective method to monitor muscles. They are also sensitive to differences that may not be detected by radiologists. This suggests that subtle systemic changes in muscle in myositis patients, which go undetected in semi-quantitative visual scoring, can be detected using quantitative T2 measurements. This shows the potential for T2 measurements to be a diagnostic measure in the diagnosis and management of myositis. Disclosures M. Farrow None. J. Biglands None. A. Grainger None. E. Hensor None. P. O'Connor None. A. Ladas None. S. Tanner None. A. Aslam None. P. Emery None. A. Tan None.
Abstract Purpose There is currently no standardized method for muscle shear wave elastography (SWE). The objective of this study was to investigate the effect of unit of measurement, depth, and probe load on the reliability of muscle SWE. Methods The vastus lateralis, biceps femoris, biceps brachii, and abductor digiti minimi muscles were scanned on 20 healthy participants. The SWE readings were measured in shear wave velocity (m/s) and Young's modulus (kPa). Three acquisitions of varying depths were acquired from vastus lateralis. Minimal probe load was compared with the use of a standoff gel layer. Three repeated measurements were acquired to assess reliability using intraclass correlations (ICC). Results The mean elasticity varied across muscle groups and ranged from 1.54 m/s for biceps femoris to 2.55 m/s for abductor digiti minimi (difference = 1.01 m/s [95% confidence interval, CI = 0.92, 1.10]). Reporting readings in meters per second resulted in higher ICC of 0.83 (0.65, 0.93) in comparison to 0.77 (0.52, 0.90) for kilopascal for the vastus lateralis muscle only. Variance increased proportionally with depth reaching 0.17 (equivalent to ±0.82 m/s) at 6 cm. Using a standoff gel decreased ICC to 0.63 (0.20, 0.84) despite similar mean elasticity readings to minimal probe load. Conclusions Different acquisition and technical factors may significantly affect the reliability of SWE in skeletal muscles. Readings acquired in the unit of shear wave velocity (m/s) from depths less than 4 cm using a minimal probe load without a standoff gel yielded the best reliability.
Abstract Rheumatology is one of the last remaining imaging areas in which new applications are currently being developed. The ability of ultrasound (US) to image both soft tissues and the bone surface at high resolution lends itself well to the assessment of musculoskeletal conditions. For both radiologists and clinicians highresolution US is an increasingly popular imaging tool for the management of musculoskeletal conditions. Technological improvements in image quality and user interface have facilitated this growth in clinical interest.
Rotator cuff tears are the most likely source of shoulder pain in adults and may cause protracted disability. Management of rotator cuff tears is associated with considerable costs. Accurate diagnosis can guide surgical planning and help achieve a favorable clinical outcome. Although radiography remains the initial imaging test for shoulder injury, the roles of MRI and ultrasound (US) as first-line imaging after radiography are evolving. This article leverages current literature and the practical experience of subspecialty musculoskeletal radiologists from different institutions in describing a practical approach to imaging rotator cuff pathology. Both MRI and US are accurate for identifying rotator cuff tears, but each has advantages and shortcomings. As both modalities currently represent reasonable first-line approaches, considerable practice variation has evolved. Given the low cost of US, imagers should strive to optimize the quality of shoulder US examinations and to build referrer confidence in this modality. The roles of direct CT and MR arthrography as well as imaging evaluation of the postoperative rotator cuff are also considered. Through careful selection among the available imaging modalities and optimal performance and interpretation of such examinations, radiologists can positively contribute to the diagnosis and treatment of patients with rotator cuff injuries.
Objective. The ability to make an early, accurate diagnosis of rheumatoid arthritis (RA) has become increasingly important with the availability of new, expensive, and targeted therapies. However, plain radiography, the traditional method of detecting the characteristic bone erosions and an important adjunct in establishing a diagnosis of RA, is known to be insensitive. This study compared sonography, a modern imaging technique, with conventional radiography for the detection of erosions in the metacarpophalangeal (MCP) joints of patients with RA. Methods. One hundred RA patients (including 40 with early disease) underwent posteroanterior radiography and sonography of the MCP joints of the dominant hand. Twenty asymptomatic control subjects also underwent sonography. Erosion sites were recorded and subsequently compared using each modality. Magnetic resonance imaging (MRI) was performed on the second MCP joint in 25 patients with early RA to confirm the pathologic specificity of sonographic erosions. Intraobserver reliability of sonography readings was assessed using video recordings of 55 MCP joint scans of RA patients, and interobserver reliability was assessed by comparing 160 MCP joint scans performed sequentially by 2 independent observers. Results. Sonography detected 127 definite erosions in 56 of 100 RA patients, compared with radiographic detection of 32 erosions (26 [81%] of which coincided with sonographic erosions) in 17 of 100 patients (P < 0.0001). In early disease, sonography detected 6.5-fold more erosions than did radiography, in 7.5-fold the number of patients. In late disease, these differences were 3.4-fold and 2.7-fold, respectively. On MRI, all sonographic erosions not visible on radiography (n = 12) corresponded by site to MRI abnormalities. The Cohen-kappa values for intra- and interobserver reliability of sonography were 0.75 and 0.76, respectively. Conclusion. Sonography is a reliable technique that detects more erosions than radiography, especially in early RA. Sonographic erosions not seen on radiography corresponded to MRI bone abnormalities. This technology has potential in the management of patients with early RA/inflammatory arthritis and is likely to have major implications for the future practice of rheumatology.
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