Sonography and subclinical synovitis

Evaluating the sound of silence The approach to the treatment of rheumatoid arthritis (RA) has changed substantially in recent years.1 Firstly, it is now common practice to introduce conventional disease modifying antirheumatic drugs (DMARDs) such as methotrexate, and even targeted biological therapies, within months of the onset of symptoms.2 One reason for this change is the growing appreciation that irreversible structural damage can occur very early in the course of inflammatory arthritis.3 Secondly, the establishment of dedicated early arthritis clinics facilitates early referral of patients with recent onset inflammatory arthritis for specialist evaluation and management.4 Thirdly, rheumatologists now have access to targeted therapies that greatly reduce the rate of progressive joint damage.5–7 Finally, it has been established that DMARDs reduces the rate of progressive joint damage most effectively when introduced within 6 months of symptom onset.8 In this context, the achievement of a sustained clinical remission in RA, the complete and permanent resolution of synovial inflammation, could become a realistic therapeutic goal. The same should be true of other inflammatory arthropathies. ### Ultrasonography demonstrates subclinical synovitis The advances in rheumatology practice have depended on carefully validated measures of the clinical course and outcome. Rheumatologists employ clinical criteria that include quantifying the number of inflamed joints to define diagnostic categories,9 disease activity,10 response to treatment,11 and remission.12 In addition, it has …