Radiographic assessment of disease progression in rheumatoid arthritis

The role that radiography plays in the assessment of disease has been a subject of controversy over the last two decades. Significant problems continue to exist with radiographic assessment. These include (1) technical variables, (2) interpretational variables, (3) clinical variables, and (4) pathophysiologic variables. Unless these problems are recognized and fully understood by the interpreting physician, the "gold standard" quickly can become "fool's gold."     

Radiographic assessment of disease progression in rheumatoid arthritis patients treated with methotrexate or minocycline

Radiographic studies of methotrexate (MTX) treated and minocycline treated patients with rheumatoid arthritis (RA) are reviewed. A formal metaanalysis of publications of RA treated with MTX was undertaken at the time when MTX was used for patients with established RA. Thus the conclusions of that metaanalysis may not be applicable to patients treated with MTX earlier in the course of their disease. On the other hand, there are no sufficient data to conduct a formal metaanalysis of patients with RA treated with minocycline.     

Radiographic assessment of osteoarthritis: analysis of disease progression

Osteoarthritis (OA) is one of the most prevalent and disabling chronic conditions affecting older adults, and is a significant public health problem among adults of working age. The knee is the most frequently involved joint site associated with disability in OA. Diagnosis of OA is primarily based on history and physical examination, but radiographic findings, including asymmetric joint space narrowing (JSN), subchondral sclerosis, osteophyte formation, subluxation, and distribution patterns of osteoarthritic changes are all helpful when diagnosis is uncertain. Structural morphological changes on X-rays are also considered the primary outcome variables for assessing the progression of OA. The development of new methods for prevention and treatment of OA requires improved understanding of the factors that influence its progression. The ability to assess progression quantitatively is a necessary first step in understanding factors that influence the disease process. Depending on the joint studied, several indices are currently used for assessing radiological progression of OA, including individual radiographic features (e.g., marginal osteophytes), composite indices (e.g., Kellgren and Lawrence scoring systems), and quantitative measures (e.g., joint space width measurement). Unfortunately, the review of studies evaluating the longitudinal rate of JSN indicates that the yearly change may be very small and of doubtful clinical significance. This emphasizes the need for further refinement in the definition of radiographic outcomes in prospective clinical trials. This review focuses on the available scoring methods used for the sites most frequently involved in OA (hand, knee, hip) and their various advantages and disadvantages.     

Radiographic progression in children with polyarticular juvenile rheumatoid arthritis: a pilot study

OBJECTIVE: To assess disease progression on hand/wrist x rays from children with polyarticular juvenile rheumatoid arthritis. METHODS: Initial and subsequent films of 13 white children (10 girls) were read blind by a paediatric radiologist for the presence of joint space narrowing (JSN), erosions, and relative carpal length (RCL). RESULTS: One child had subcutaneous nodules; one (of 11) was rheumatoid factor positive; six were ANA positive. Median age at diagnosis was 10.7 years (2.5 to 15.9). Median number of involved joints (swelling, pain, or decreased range of motion) at diagnosis was 16 (6 to 33). Four initial x rays had either erosions or JSN. Subsequent x rays were done at (median) 13.3 (8.3 to 24.9) months after initial x rays. One of 10 subsequent x rays had shortened RCL, and six of 13 were worse than the initial ones. Four of these developed new erosions, one had increased number of erosions, and one developed new JSN. CONCLUSIONS: About half the children with polyarticular juvenile rheumatoid arthritis will have evidence of radiographic progression within two years after diagnosis. Thus newly diagnosed children are at high risk of substantial joint destruction and potential disability, emphasising the need for prompt treatment.     

Radiographic progression in weight-bearing joints of patients with rheumatoid arthritis after TNF-blocking therapies

The aim of the present study was to assess the influence of tumor necrosis factor (TNF)-blocking therapies on weight-bearing joints in patients with rheumatoid arthritis. Changes in clinical variables and radiological findings in 213 weight-bearing joints (69 hip joints, 63 knee joints, and 81 ankle joints) of 42 consecutive patients were investigated at baseline and at 1 year of TNF-blocking therapies. Structural damage to the weight-bearing joints was assessed using the Larsen scoring method. Detailed comparisons of the sizes and locations of erosions were performed for each set of radiographs of the respective joints. Assessment of radiographs of the 213 weight-bearing joints indicated progression of the Larsen grade in eight joints. Another five joints without Larsen grade progression showed apparent radiographic progression of joint damage based on increases in bony erosions. Overall, 13 joints (6%) of eight patients (19%) showed progression of joint damage after 1 year of TNF-blocking therapies. Analysis of each baseline grade indicated that radiographic progression of joint damage was inhibited in most grade 0–II joints. On the other hand, all hip and knee joints with pre-existing damage of grade III/IV showed apparent progression even in patients with good response. The results further suggested that radiographic progression may occur in less damaged joints when the patients were non-responders to the therapy. Among the weight-bearing joints, ankle joints showed different radiographic behavior and four ankle joints displayed improvement of radiographic damage. Early initiation of anti-TNF therapy should be necessary especially when the patients are starting to show early structural damage in weight-bearing joints.     

Radiographic progression of cervical lesions in patients with rheumatoid arthritis receiving infliximab treatment

We evaluated radiographic change in the cervical lesions of 47 RA patients receiving continuous infliximab therapy for at least 1 year. Infliximab treatment had been initiated between November 2003 and December 2007. Patients who were progressive and non-progressive in terms of RA cervical lesions were compared. Matrix metalloproteinase 3 (MMP3) values improved significantly only in non-progressive patients within the 1-year treatment window. Cervical lesion progression was suppressed in 19 of the 23 patients (83%) showing a good response to infliximab treatment and occurred in 16 of the 24 patients (67%) showing a moderate response. This difference was shown to be significant by the Fisher’s exact test (p = 0.002). In the well-responding patients (n = 23) and moderately responding patients (n = 24), the respective changes in the cervical lesion parameters within 1 year were: atlanto-dental interval, 0.17 ± 0.49 and 0.54 ± 0.58 mm (p = 0.013); spinal cord, −0.17 ± 0.49 and −0.54 ± 0.59 mm (p = 0.025); Ranawat value, −0.09 ± 0.29 and −0.42 ± 0.65 mm (p = 0.032). Based on these results, we conclude that infliximab treatment can be used to suppress the progression of rheumatoid arthritis (RA) cervical lesions. It is possible that response to infliximab and MMP3 values can be used to predict the progression of these cervical lesions.     

Radiographic assessment in relation to clinical and biochemical variables in rheumatoid arthritis

Radiographs of hands and feet were obtained from 125 consecutive patients with rheumatoid arthritis (RA) and the degree of destruction was assessed numerically on a 200-point scale using Larsen's standard radiographs as reference. The method is shown to possess a satisfactory degree of reproducibility. In 96 of these 125 patients, values of another 15 simultaneously determined clinical and biochemical variables were obtained. On applying linear and quadratic multiple regression analysis to this set as well as to the male and female subsets, an 'automatic' selection procedure (stepwise regression) proved duration of disease to be the most important factor relating to the 'Larsen index'. The 96 patients were therefore ranked with respect to duration of disease and divided into 4 subsets of equal magnitude. In the 3 subsets with duration of disease less than 21 years, stepwise regression produced in the final step linear or quadratic combinations not containing duration of disease but correlating quite well with the 'Larsen index' (R = 0.64-0.96). A similar result was obtained upon performing an analogous procedure in the female subset. In all instances, positive contributions of varying degree were obtained from Ritchie's index, ESR, a-antitrypsin (A1-AT), orosomucoid, fibrinogen, and IgM, while negative correlations were associated with ceruloplasmin, IgG, and IgA.     

Malnutrition and disease progression in patients with rheumatoid arthritis

Abstract

To examine the changes in nutritional status during the progression of rheumatoid arthritis (RA), we studied anthropometric and biochemical variables in 97 Japanese patients with RA. Anthropometric data included body mass index (BMI), triceps skinfold thickness (TSF), and arm muscle area (AMA). Levels of albumin and cholesterol in serum, and lymphocyte count were studied as biochemical variables. The prevalence of malnutrition defined as hypoalbuminemia less than 3.4?g/dl was 24.7%, similar to the reports in other countries. Analysis of the data according to disease stage showed that malnutrition in RA was characterized by a progressive reduction in body protein. Body mass index and TSF were increased in patients with stage 1 disease, whereas serum albumin and AMA were within normal range. Stage 2 patients had normal BMI with decreased body protein, albumin, and AMA. Progression to stages 3 and 4 was associated with a stepwise decrease in AMA; serum albumin and BMI remained in the same range as stage 2. Albumin values and AMA were significantly lower in patients with poor functional class and high C-reactive protein. The characteristic progression of malnutrition in RA is attributed to excessive protein catabolism evoked by inflammatory cytokines and by disuse atrophy due to functional impairment.     

Malnutrition and disease progression in patients with rheumatoid arthritis

To examine the changes in nutritional status during the progression of rheumatoid arthritis (RA), we studied anthropometric and biochemical variables in 97 Japanese patients with RA. Anthropometric data included body mass index (BMI), triceps skinfold thickness (TSF), and arm muscle area (AMA). Levels of albumin and cholesterol in serum, and lymphocyte count were studied as biochemical variables. The prevalence of malnutrition defined as hypoalbuminemia less than 3.4g/dl was 24.7%, similar to the reports in other countries. Analysis of the data according to disease stage showed that malnutrition in RA was characterized by a progressive reduction in body protein. Body mass index and TSF were increased in patients with stage 1 disease, whereas serum albumin and AMA were within normal range. Stage 2 patients had normal BMI with decreased body protein, albumin, and AMA. Progression to stages 3 and 4 was associated with a stepwise decrease in AMA; serum albumin and BMI remained in the same range as stage 2. Albumin values and AMA were significantly lower in patients with poor functional class and high C-reactive protein. The characteristic progression of malnutrition in RA is attributed to excessive protein catabolism evoked by inflammatory cytokines and by disuse atrophy due to functional impairment.     

MRI of rheumatoid arthritis image quantitation for the assessment of disease activity, progression and response to therapy

Magnetic resonance imaging (MRI) allows the direct visualization of many bone and soft tissue changes in rheumatoid arthritis. Synovitis volume, bone marrow oedema and bone erosions are suitable for serial measurement. The outcome measures in rheumatoid arthritis clinical trials (OMERACT) rheumatoid arthritis magnetic resonance imaging (RAMRIS) system is designed to allow straightforward, reproducible scoring of all these features. Alternatively, synovial volumes may be directly and quickly measured using semi-automated techniques. There is the potential for similar systems for measuring erosions. Dynamic contrast enhanced MRI depends on the rate of enhancement of the synovium after intravenous contrast agent. Measurements depend on the underlying physiology of the inflamed synovium, in particular the vascularity and capillary permeability which are expected to closely mirror inflammatory activity in the joint. Measurements from MRI have been shown to correlate with clinical, laboratory, imaging and histological measures of inflammation, predict erosive progression and respond rapidly to various types of treatment. They are, therefore, expected to be good measures of disease activity, progression and response to therapy.     

Radiographic assessment of progression in osteoarthritis

We evaluated methods of grading radiologic progression of osteoarthritis (OA). Sets of radiographs were assessed separately by 8 readers who were blinded to the time sequence. Included were radiographs of patients with OA of the hands (24 pairs), hips (40 pairs), and knees (32 pairs). Most films were taken 12-60 months apart. The relative contribution of individual joints (such as particular interphalangeal joints), of observations (such as narrowing or spurs), and of a single joint compartment (such as the medial or lateral compartment of the knee) toward evidence of OA progression was evaluated, as well as the reliability and concordance of scoring, and the sensitivity in detecting change. In assessing OA of the hand, the greatest sensitivity was achieved by reading a single posteroanterior bilateral hand radiograph for narrowing, spurs, and erosions, and scoring 10 joints (second and third distal interphalangeal, second and third proximal interphalangeal, and trapeziometacarpal joints, bilaterally), using a scale of 0-3. In OA of the hip, a single anteroposterior radiograph assessed for joint space narrowing and cyst formation yielded the greatest sensitivity. In OA of the knee, an anteroposterior radiograph, with weight-bearing, assessed for narrowing, spurs, and sclerosis in both the medial and lateral compartments yielded the greatest sensitivity. These techniques will be useful to the investigator in designing experimental studies and to the clinician in determining the rate of disease progression in an individual patient.