Validity and responsiveness of a self-administered foot evaluation questionnaire in rheumatoid arthritis

Abstract

Objectives. A self-administered foot evaluation questionnaire (SAFE-Q) was developed by the Japanese Society for Surgery of the Foot (JSSF). The aim of this study is to evaluate the validity and responsiveness of the SAFE-Q in patients with rheumatoid arthritis (RA).

Methods. In total, 180 patients with RA answered the SAFE-Q. Of 180 patients, 34 answered the SAFE-Q twice, preoperatively and postoperatively, to assess responsiveness. Construct validity was tested by comparing the 5 SAFE-Q subscales and the JSSF standard rating system for the RA foot and ankle scale (JSSF-RA), a Japanese version of the Health Assessment Questionnaire (JHAQ), disease activity score in 28 joints (DAS28), simplified disease activity index (SDAI), and clinical disease activity index (CDAI). Responsiveness was examined by calculating the standardized response mean (SRM) and effect size (ES) 3 months after surgery.

Results. There were moderate correlations between the SAFE-Q and the JSSF-RA and JHAQ. Conversely, a low correlation was observed between the SAFE-Q and DAS28, SDAI, and CDAI. The responsiveness was high, with an SRM of 0.9 and ES of 0.7 for pain subscales.

Conclusion. SAFE-Q is a useful tool for assessing the foot and ankle in RA patients.     

A novel ultrasonographic synovitis scoring system suitable for analyzing finger joint inflammation in rheumatoid arthritis

OBJECTIVE: To develop an ultrasonographic (US) synovitis scoring system suitable for evaluation of finger joint inflammation in patients with active rheumatoid arthritis (RA) and to compare semiquantitative US scoring with quantitative US measurements. METHODS: US was performed at the palmar and dorsal sides of the second through fifth metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in 10 healthy subjects and in the clinically more affected hand in 46 RA patients. Ten patients additionally underwent magnetic resonance imaging (MRI). Synovitis was measured, standardized, and scored according to a semiquantitative method. The 2 methods (semiquantitative US scoring, quantitative US) were compared and statistical cutoffs were identified using receiver operating characteristic (ROC) curve analysis. MRI results were compared with semiquantitative US scoring and quantitative US results. The optimal US scoring method from 6 joint combinations was identified (ROC curve analysis). RESULTS: Synovitis was most frequently detected in the palmar proximal area (86% of affected joints). We found no significant differences between individual PIP joints or between individual MCP joints, indicating that all fingers within each of these joint groups should be treated equally for statistical calculations, although each joint group as a whole should be treated separately. The optimal cutoff point to distinguish between "health" and "pathology" was 0.6 mm both for MCP joints (sensitivity 94%, specificity 89%) and for PIP joints (sensitivity 90%, specificity 88%). There was no significant difference between semiquantitative US scores and quantitative US measurements. The best results for joint combinations were achieved using the "sum of 4 fingers" (second through fifth MCP and PIP joints) and "sum of 3 fingers" (second through fourth MCP and PIP joints) methods. Comparison of MRI results with semiquantitative US scores revealed high concordance. CONCLUSION: US evaluation of finger joint synovitis can be considerably simplified by focusing on the palmar side and by applying semiquantitative grading instead of quantitative measurements. For evaluation of treatment efficacy based on synovitis in RA patients, we recommend using the "sum of 3 fingers" method in longitudinal trials.     

Standardising joint assessment in rheumatoid arthritis

Summary Evaluating joint involvement in rheumatoid arthritis in a key clinical assessment. We investigated the extent of variation in measurement of joint swelling and tenderness and evaluated the impact of training to standardise methods. Eight observers (medical and nursing staff) examined eight rheumatoid patients for joint swelling and tenderness before and after training in clinical methods. The EULAR handbook for joint evaluation was used for training and assessments were based on the 28 joint count. There was extensive variability in both numbers of swollen and tender joints. Coefficients of variation for articular indices recorded by the 8 observers in individual patients were often high (up to a maximum of 204%), indicating considerable differences between observers. Training had an impact on the assessment of the numbers of swollen joints which increased by a mean of 32% (P<0.05) and the number of tender joints which increased by 41% (p<0.01). Training had only a limited impact on the variation among observers in determining the number of swollen and number of tender joints. After training, the mean coefficients of variation were still 59% for swollen joints and 65% for tender joints. These results highlight the extent of variation in clinical assessment of rheumatoid arthritis and show the advantages of training. It leads to increased sensitivity of measurement. Standardisation appears essential for clinical studies.     

Longitudinal power Doppler ultrasonographic assessment of joint inflammatory activity in early rheumatoid arthritis: predictive value in disease activity and radiologic progression

OBJECTIVE: To evaluate the sensitivity to change of power Doppler ultrasound (PDUS) assessment of joint inflammation and the predictive value of PDUS parameters in disease activity and radiologic outcome in patients with early rheumatoid arthritis (RA). METHODS: Forty-two patients with early RA who started therapy with disease-modifying antirheumatic drugs underwent blinded sequential clinical, laboratory, and ultrasound assessment at baseline, 3 months, 6 months, and 1 year and radiographic assessment at baseline and 1 year. For each patient, 28-joint Disease Activity Score (DAS28) was recorded at each visit. The presence of synovitis was investigated in 28 joints using gray-scale ultrasonography and intraarticular power Doppler signal. Active synovitis was defined as intraarticular synovitis detected with power Doppler signal. The ultrasound joint count for active synovitis and an overall joint index for power Doppler signal were calculated. Sensitivity to change of PDUS variables was assessed by estimating the smallest detectable difference (SDD) from the intraobserver variability. RESULTS: The SDD for ultrasound joint count for active synovitis and ultrasound joint index for power Doppler signal was lower than mean changes from baseline to 3 months, 6 months, and 1 year. Time-integrated values of PDUS parameters demonstrated a highly significant correlation with DAS28 after 1 year (r = 0.63, P < 0.001) and a stronger correlation with radiographic progression (r = 0.59-0.66, P < 0.001) than clinical and laboratory parameters (r < 0.5). CONCLUSION: PDUS is a sensitive and reliable method for longitudinal assessment of inflammatory activity in early RA. PDUS findings may have a predictive value in disease activity and radiographic outcome.     

Screening for rheumatoid arthritis with finger joint power Doppler ultrasonography: quantification of conventional power Doppler ultrasonographic scoring

Abstract

Power Doppler ultrasonography (PD-US) has proved to be a useful technique to measure synovial vascularity due to its capability to provide data that can be used to evaluate the level of joint inflammation and assess rheumatoid arthritis (RA). We have developed a novel PD-US finger joint scoring method that introduces quantitative measurements into the conventional PD-US assessment method. A comparison of the two methods revealed that our novel PD-US method strongly correlates with the conventional method in terms of RA assessment. We performed finger joint PD-US on 69 patients with RA and 70 patients who had multiple joint pain but showed no evidence of inflammatory diseases (non-inflammatory disease, NI) and measured the synovial vascularity of the metacarpophalangeal joints 1–5 and proximal interphalangeal (PIP) joints 1–5 for each patient. We analyzed the data with receiver operating characteristic analysis and, based on the results for the total vascularity of 20 finger joints, defined a cut-off value of 36% as discriminating between RA and NI. This cut-off value was found to be a valuable tool in screening for RA. We conclude that our finger joint PD-US scoring system is both useful and applicable for diagnosing RA.     

Screening for rheumatoid arthritis with finger joint power Doppler ultrasonography: quantification of conventional power Doppler ultrasonographic scoring

Power Doppler ultrasonography (PD-US) has proved to be a useful technique to measure synovial vascularity due to its capability to provide data that can be used to evaluate the level of joint inflammation and assess rheumatoid arthritis (RA). We have developed a novel PD-US finger joint scoring method that introduces quantitative measurements into the conventional PD-US assessment method. A comparison of the two methods revealed that our novel PD-US method strongly correlates with the conventional method in terms of RA assessment. We performed finger joint PD-US on 69 patients with RA and 70 patients who had multiple joint pain but showed no evidence of inflammatory diseases (non-inflammatory disease, NI) and measured the synovial vascularity of the metacarpophalangeal joints 1–5 and proximal interphalangeal (PIP) joints 1–5 for each patient. We analyzed the data with receiver operating characteristic analysis and, based on the results for the total vascularity of 20 finger joints, defined a cut-off value of 36% as discriminating between RA and NI. This cut-off value was found to be a valuable tool in screening for RA. We conclude that our finger joint PD-US scoring system is both useful and applicable for diagnosing RA.     

Sentinel joint scoring in rheumatoid arthritis: an individualized power Doppler assessment strategy

Clinical Rheumatology - Musculoskeletal ultrasound quantifies the total synovial inflammatory burden in rheumatoid arthritis (RA) but is time consuming when scanning numerous joints. This study...     

Inter- and intra-observer agreement of high-resolution ultrasonography and power Doppler in assessment of joint inflammation and bone erosions in patients with rheumatoid arthritis

To assess the inter- and intra-observer reproducibility of musculoskeletal ultrasonography among rheumatologist in detecting inflammatory and morphostructural changes in small joints of the hands in patients with rheumatoid arthritis (RA). Five members of the “Escuela de Ecografía del Colegio Mexicano de Reumatología” tested their inter- and intra-observer reliabilities in the assessment of basic sonographic findings of joint inflammation and bone erosion. Their results were compared to those obtained by a group of international experts from European League Against Rheumatism. A clinical rheumatologist evaluated eight RA patients. Five Siemens Acuson Antares ultrasound machines (7–13 MHz linear probes) were used. The OMERACT preliminary definitions of joint effusion, synovial hypertrophy, bone erosions and tenosynovitis were adopted. Inter-observer and intra-observer agreement was calculated by overall agreement and kappa statistics. Mean kappa value for joint effusion was good, 0.654 (85%); synovial hypertrophy, 0.550 (77.2%); power Doppler signal, 0.550 (82.5%); bone erosions, 0.549 (81%); and tenosynovitis, 0.500 (91.5%). Mean and overall intra-observer agreement for semiquantitative score was good for joint effusion, 0.630 (77.2%) and bone erosions, 0.605 (56.25%); and moderate to synovial hypertrophy, 0.476 (65%) and power Doppler signal, 0.471 (80%). Mean kappa value for joint effusion was 0.381 (95%), synovial hypertrophy, 0.447 (72%); power Doppler signal, 0.496 (81%); bone erosions, 0.294 (81%); and tenosynovitis, 0.030 (66%). Mean and overall inter-observer agreement for semiquantitative score was poor for joint effusion, 0.325 (57%) and bone erosions, 0.360 (43%); and moderate to synovial hypertrophy, 0.431 (55%) and power Doppler signal, 0.496 (81%). Intra-observer variability reached the highest levels of agreement. Factors related to the experience of the rheumatologist, the time spent in each examination and knowledge of the software ultrasound equipment could influence the lower level of inter-observer agreement in this study.     

Comparison of ultrasonographic assessment of synovitis and joint vascularity with radiographic evaluation in a randomized, placebo-controlled study of infliximab therapy in early rheumatoid arthritis

OBJECTIVE: To investigate sensitive ultrasonographic imaging methods for detection of synovial thickness and vascularity to discriminate between patients with early rheumatoid arthritis (RA) receiving infliximab + methotrexate (MTX) versus placebo + MTX over 18 weeks, and to compare the relationship between synovial thickening and vascularity at baseline and radiologic damage to joints of the hands and feet at 54 weeks. METHODS: Patients with early RA (duration <3 years) receiving stable dosages of MTX were randomly assigned to receive blinded infusions of 5 mg/kg infliximab (n = 12) or placebo (n = 12) at weeks 0, 2, 6, and then every 8 weeks until week 46. At baseline and week 18, clinical assessments were performed, and metacarpophalangeal joints were assessed by high-frequency ultrasonography and power Doppler ultrasonography measurements. Radiographs of the hands and feet taken at baseline and at 54 weeks were evaluated using the van der Heijde modification of the Sharp method (vdH-Sharp score). RESULTS: Using changes in the total vdH-Sharp score over 54 weeks and changes in synovial thickening and joint vascularity at 18 weeks, we were able to distinguish those patients receiving infusions of infliximab + MTX from those receiving placebo + MTX. Sonographic measurements of synovial thickening and vascularity at baseline in the placebo + MTX group demonstrated clear relationships with the magnitude of radiologic joint damage at week 54. Infliximab + MTX treatment abolished these relationships. CONCLUSION: The delay or reversal of inflammatory and joint-destructive mechanisms in patients with early RA was already apparent following 18 weeks of treatment with infliximab + MTX and was reflected in radiologic changes at 54 weeks.     

Metalloproteinases, inflammation, and rheumatoid arthritis

Ideally, the inflammatory response occurs rapidly to terminate infection. It also must halt in a timely manner to stop this reaction from inflicting self damage. Such a highly regulated process results from altering balances in pro- and anti-inflammatory signals orchestrated by multiple cell types and factors within the tissue microenvironment. The discovery of new substrates of metalloproteinases within this microenvironment has disclosed a new function in inflammation. The role of these proteases now extends beyond extracellular matrix remodelling enzymes to that of mediators of inflammatory signals involving various chemokines and cytokines. As natural inhibitors of these metalloproteinases, TIMPs have the potential of regulating the inflammatory response and affecting diseases such as rheumatoid arthritis. TIMP-3, in particular, stands out as an important regulator of inflammation with its ability to specifically inhibit proinflammatory cytokines and tissue destruction in the joint.     

Relationship between inflammation and joint destruction in early rheumatoid arthritis: a mathematical description

BACKGROUND: The relationship between inflammation and joint destruction in rheumatoid arthritis (RA) has not been unequivocally characterised. Joint destruction may result from the cumulative inflammatory burden over time, modified by an individual constant factor. OBJECTIVE: To test the hypothesis that the relationship between radiological progression and inflammation can mathematically be expressed as: [equation: see text] where Re is a factor that varies from person to person. METHODS: Clinical data and radiographs of 76 patients with early RA receiving different disease modifying antirheumatic drugs were analysed. Radiographs were quantified using the modified Larsen score and the "X-Ray RheumaCoach" software. The cumulative inflammatory burden was estimated by the time integrated 28 joint Disease Activity Score (DAS28), calculated as the area under the curve. RESULTS: 76 patients with early RA who started treatment with methotrexate (n = 20), sulfasalazine (n = 37), or oral gold (n = 19) monotherapy were evaluated. The mean (SEM) DAS28 decreased from 4.6 (0.1) at baseline to 2.3 (0.1) after 2 years. The mean (SEM) DeltaLarsen score from baseline to year 2 was 10.3 (1.5). Correlation between cumulative inflammation and radiographic change was poor. In contrast, when calculating a person's factor Re in year 1 ( Re 1) and year 2 ( Re 2), a strong and significant correlation (r = 0.58, p<0.000001) was seen between Re 1 and Re 2. CONCLUSIONS: Joint destruction is the result of the cumulative burden of inflammation over time, modified by an individual factor Re that remains relatively constant over the first 2 years of observation. The data support a mathematical model that expresses the interrelationship between inflammation and joint destruction.     

A simplified twenty-eight–joint quantitative articular index in rheumatoid arthritis

We describe a joint index that includes only 28 joints: 10 proximal interphalangeal joints of the fingers, 10 metacarpophalangeal joints, and the wrists, elbows, shoulders, and knees. These joints are evaluated for swelling, tenderness, and limited motion, with the findings scored as abnormal or normal. The 28-joint index is considerably easier to use than traditional methods, and appears to yield as much information in terms of correlation with other measures of clinical status, including hand radiograph scores, American Rheumatism Association functional class, grip strength, walking time, and activities of daily living questionnaire scores (r = 0.25–0.53, P < 0.001). Simplified joint counts might facilitate acquisition of quantitative articular data in research and clinical rheumatologic settings.     

Predicting joint destruction in rheumatoid arthritis with power Doppler,anti-citrullinated peptide antibody,and joint swelling

Objective. To determine combined evaluation of musculoskeletal ultrasonography (MSUS) and power Doppler (PD) signals, anti-citrullinated peptide antibody (ACPA), and other clinical findings improve the prediction of joint destruction in rheumatoid arthritis (RA).

Methods. We performed a retrospective study of 331 RA patients (female n = 280 and male n = 51, mean age: 57.9 ± 13.2 years) who underwent MSUS from 2002 to 2012. Correlations with progression of joint destructions in 1,308 2nd and 3rd metacarpophalangeal (MCP) joints and various factors including PD signals of the same joints, clinical findings, age, disease duration at the study entry, gender, observation period, radiographic bone scores according to modified Sharp–van der Heijde methods, ACPA, and rheumatoid factor (RF) were analyzed in patient- and joint-based fashions, using univariate and multivariate logistic regression analyses and generalized linear mixed model.

Results. Patients’ characteristics were as follows: mean disease duration: 5.7 ± 7.5 years, observation period: 4.6 ± 2.6 years, RF positivity: 79.9%, and ACPA positivity: 77.5%. PD-positive 2nd and 3rd joints showed higher rate of joint destruction, especially in ACPA-positive patients. Moreover, PD-positive joints in ACPA-positive patients showed joint destruction even in joints without swelling. Multivariate analysis determined PD, swollen joint (SJ), observation period, basal radiographic bone scores, and ACPA as independent risks for joint destruction.

Conclusion. PD, SJ, basal radiographic bone scores, and ACPA are independent predictors for the joint destruction of 2nd and 3rd MCPs in RA; thus, considering these factors would be useful in daily practice.     

Comparative assessment of hepatitis C virus-related arthritis and rheumatoid arthritis: Relation to clinical,serologic and ultrasonographic characteristics

BackgroundExtrahepatic manifestations of hepatitis C virus (HCV) infection includes HCV-related arthritis (HCV-A) that may mimic rheumatoid arthritis (RA). Musculoskeletal ultrasound (MSUS) can aid in discriminating both conditions.Aim of the workTo study the clinical, serological and imaging (Xray, MSUS) characteristics of HCV-A and compare them to RA.Patients and methodsThe study included 30 patients with HCV-A and 30 age- and sex-matched RA patients negative for HCV. Ritchie articular index (RAI), tender joint count (TJC) and swollen joint count (SJC) assessed arthritis. Patient global health assessment (PGHA) and modified health assessment questionnaire (MHAQ) were evaluated. The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) and serum cryoglobulins were measured. Radiologic assessment included short Larsen score (SLS) and MSUS using 7-joint ultrasound score (US7).ResultsThe mean age of the HCV-A patients was 45.8 ± 4.7 years; RA was 43.3 ± 5.6 years; F:M was 27:3 in HCV-A patients; 29:1 in RA; HCV-A patients had no subcutaneous nodules, joint deformities or bone erosions. US7 showed that Gray-Scale (GS)/Power Doppler (PD) synovitis and tenosynovitis had higher mean values in RA versus HCV-A patients (p < 0.001; p < 0.001; p = 0.011; p = 0.008 respectively). A significant correlation was found between SJC with GS and PD synovitis in both groups.ConclusionHCV-A differ from RA features as being non nodular, non-deforming, non-erosive and aid in the predilection of HCV-A diagnosis. MSUS can offer a useful imaging modality elucidating inflammatory components of HCV-A and highlighting the spectrum of the condition.     

The assessment of pain in rheumatoid arthritis. Validity of a behavioral observation method

It is difficult to objectively measure pain in rheumatoid arthritis (RA). A behavioral observation method for the assessment of RA pain has been developed. In this study, videotapes were made of 53 RA patients while they performed standardized maneuvers. Trained raters viewed the videotapes and recorded the frequencies of 7 pain behaviors. Clinical and laboratory measures of rheumatoid disease activity also were recorded for each patient. Rheumatology fellows viewed 20 randomly chosen video recordings of the patients and made global estimates of the intensity and unpleasantness of pain. Significant positive correlations were found between total pain behavior scores and measures of disease activity. The fellows' estimates of the intensity and unpleasantness of the patients' pain also were significantly and positively correlated with the total pain behavior scores. The behavioral observation method may be useful in the assessment of RA pain and may be included as an objective outcome measure in clinical trials with RA patients.     

Relation of some clinical composite indices of disease activity in rheumatoid arthritis to a simplified 12 joint power Doppler ultrasound activity index

Aim of the workTo assess the association of some clinical composite disease activity indices with a simplified 12 joint power Doppler ultrasound (PDUS) activity index in rheumatoid arthritis (RA).Patients and methodsOne hundred RA patients who fulfilled the 2010 European league against rheumatism/American college of Rheumatology (EULAR/ACR) classification criteria for RA were recruited from the Rheumatology outpatient clinic, Cairo University Hospitals. Disease activity score (DAS28), the simplified disease activity index (SDAI), clinical disease activity index (CDAI) as well as mean overall index for RA (MOI-RA) were assessed. Grey Scale Ultrasonography (GSUS) and PDUS activity assessment was performed using a simplified 12-joint score.ResultsThe 100 patients were 80 females and 20 males (F:M 4:1). Their mean age was 44.4 ± 10.8 years with disease duration of 6.3 ± 4.7 years. Rheumatoid factor was positive in 77 %. DAS28 was 4.5 ± 1.3, SDAI 27.7 ± 22.7, CDAI 17.5 ± 13.2 and MOI-RA 86.8 ± 25.1. On US, tenosynovitis was present in 10 %, irregularity in 23 % and erosion in 62 %. The mean 12-point PDUS was 3.53 ± 4.16 and the overall US score 10.34 ± 9.3. A significant correlation was found between the US findings of overall synovitis, degree of PD and US score with DAS28 (r = 0.3, p < 0.0001; r = 0.4, p < 0.0001 and r = 0.3, p < 0.0001) with SDAI (r = 0.3, p < 0.0001; r = 0.4,p < 0.0001; r = 0.4, p < 0.0001) and with MOI-RA score (r = 0.3, p < 0.0001; r = 0.4, p < 0.0001 and r = 0.4, p < 0.0001 respectively) but the highest correlations was with CDAI (r = 0.4, p < 0.0001; r = 0.5, p < 0.0001 and r = 0.4, p < 0.0001 respectively).ConclusionSimplified 12 -joint PDUS score is well correlated with activity indices in RA patients.