Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset

OBJECTIVES—To evaluate the role of magnetic resonance imaging (MRI) of the wrist in detecting early joint damage in patients with rheumatoid arthritis (RA).
METHODS—MRI was performed on 42 patients with early RA (median symptom duration of four months). Scans were scored separately by two musculoskeletal radiologists using a newly devised scoring system, which was validated. MRI findings were compared with plain radiography, clinical measures, and HLA-DRB*01/04 genotyping.
RESULTS—Interobserver reliability for the overall MRI score was high (r = 0.81) as was intraobserver reliability (r = 0.94 for observer 1 and 0.81 for observer 2). There was more variation in scoring synovitis (interobserver reliability: r = 0.74). Erosions were detected in 45% of scans (19 of 42), compared with 15% of plain radiographs. The most common site for erosions was the capitate (39%), for synovitis the ulnar aspect of the radiocarpal joint, and for tendonitis, the extensor carpi ulnaris tendon. The total MRI score and MRI synovitis score correlated most significantly with C reactive protein (r = 0.40 and 0.42 respectively, p<0.01). The MRI erosion score was highly correlated with MRI bone marrow oedema (r = 0.83) as well as the Ritchie score and disease activity score (r = 0.32, p<0.05). HLA-DRB1*04 or *01 (shared epitope +ve) was found in 76% of patients; 84% of those with MRI erosions and 69% of those without (NS, p = 0.3).
CONCLUSIONS—A high proportion of RA patients develop MRI erosions very early in their disease, when plain radiography is frequently normal. MRI of the dominant wrist may identify those requiring early aggressive treatment.

Keywords: magnetic resonance imaging; carpus; rheumatoid arthritis     

Association between hypoxanthine concentration in synovial fluid and joint destruction in patients with rheumatoid arthritis

To evaluate the significance of augmented levels of hypoxanthine in synovial fluids in patients with rheumatoid arthritis (RA), the hypoxanthine level in the synovial fluid was investigated in association with joint damage. Concentrations of hypoxanthine, xanthine and uric acid in synovial fluids from knee joints of 45 patients with RA, six patients with gout and five patients with osteoarthritis were determined by high performance liquid chromatography. Relationships between these oxypurines and markers for joint inflammation or Larsen grade of knee joint X-ray film were analyzed. Hypoxanthine levels were significantly elevated in patients with RA and with gout but not in those with osteoarthritis. In RA patients, levels of synovial fluid hypoxanthine were correlated with matrix metalloproteinases MMP-3 (r=0.510), but not with C-reactive protein nor synovial fluid cytokines. Among various biological factors in synovial fluid (including cytokines and metalloproteinases) only hypoxanthine levels were significantly (P<0.05) positively correlated with Larsen’s grade of knee joint. In conclusion, augmented levels of synovial hypoxanthine can indicate joint damage in patients with RA and might be a useful marker in a clinical context.     

Association between hypoxanthine concentration in synovial fluid and joint destruction in patients with rheumatoid arthritis

Abstract

To evaluate the significance of augmented levels of hypoxanthine in synovial fluids in patients with rheumatoid arthritis (RA), the hypoxanthine level in the synovial fluid was investigated in association with joint damage. Concentrations of hypoxanthine, xanthine and uric acid in synovial fluids from knee joints of 45 patients with RA, six patients with gout and five patients with osteoarthritis were determined by high performance liquid chromatography. Relationships between these oxypurines and markers for joint inflammation or Larsen grade of knee joint X-ray film were analyzed. Hypoxanthine levels were significantly elevated in patients with RA and with gout but not in those with osteoarthritis. In RA patients, levels of synovial fluid hypoxanthine were correlated with matrix metalloproteinases MMP-3 ( r=0.510), but not with C-reactive protein nor synovial fluid cytokines. Among various biological factors in synovial fluid (including cytokines and metalloproteinases) only hypoxanthine levels were significantly ( P<0.05) positively correlated with Larsen’s grade of knee joint. In conclusion, augmented levels of synovial hypoxanthine can indicate joint damage in patients with RA and might be a useful marker in a clinical context.     

Managing comorbidity in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease that decreases physical function and imposes substantial medical costs. Comorbid conditions are common in patients with RA and they adversely affect quality of life and RA‐related outcomes such as work disability and mortality. Rheumatologists have the important responsibility to consider comorbidities and their risks when treating patients and to adapt therapies to the specific situation of individual patients. This paper discusses the common comorbidities in patients with RA and management approaches.     

No erosive progression revealed by MRI in rheumatoid arthritis patients treated with etanercept,even in patients with persistent MRI and clinical signs of joint inflammation

The aim of this study is to investigate the course of magnetic resonance imaging (MRI) signs of inflammatory and destructive changes in rheumatoid arthritis (RA) wrist and metacarpophalangeal (MCP) joints during etanercept treatment. MRI of the non-dominant wrist and second to fifth MCP joints was performed in five clinical active RA patients before and 4 and 16 weeks after initiation of etanercept treatment. MRI was evaluated according to the EULAR–OMERACT RA MRI reference image atlas. The median 28-joint count disease activity score (DAS28; erythrocyte sedimentation rate based) was 5.6 (range 5.0–6.8) at baseline and 3.5 (1.5–4.1) at week 16 (decreased in all patients compared to baseline, Wilcoxon–Pratt, p < 0.05). The median MRI synovitis score was 18 (14–21), 18 (10–20) and 16 (10–20) at baseline, week 4 and 16, respectively (decreased in all patients compared to baseline, Wilcoxon–Pratt, p < 0.05), while corresponding MRI bone oedema scores were 4 (0–13), 3 (0–9) and 1 (0–3; NS). The median MRI bone erosion score was 27 (11–111; NS) at all time points. Four patients had identical total bone erosion scores at baseline and week 16, whereas one patient showed a reduced score. In conclusion, one patient showed erosive regression, while no patient showed erosive progression on MRI during 16 weeks of etanercept therapy; even though clinical and MRI signs of joint inflammation remained. This small study supports that erosive progression judged by MRI is minimal in RA patients treated with etanercept, even in joints with persistent inflammation.     

Teaching medical students about chronic disease: patient‐led teaching in rheumatoid arthritis

Objectives: To evaluate the effectiveness of patient‐led teaching compared with doctor‐led teaching, regarding the impact of chronic disease (rheumatoid arthritis [RA]). Methods: A set of learning objectives regarding the impact of RA on patient and family was designed. Students (n = 42) attached to the academy for their musculoskeletal diseases module were randomized to teaching either by a doctor or a patient. Outcome was assessed using a knowledge test, feedback forms and qualitative written interview. Results: In the knowledge test, the groups performed equally. The patient‐taught group scored 24.5 ± 3.5 (max 35); the doctor‐taught group scored 24.6 ± 4.1 (p > 0.05; NS). Feedback was completed by 40/42 students. Mean scores for the overall grading of teaching (1–5, where 1 = worst, 5 = best) were: patient teaching 4.36 (95% confidence interval [CI] 4.11, 4.61); doctor teaching 3.69 (95% CI 3.52, 3.92).The difference between the average scores was 0.42 (p = 0.005). Qualitative feedback showed recurring themes that students appreciated the personal nature of the patient's teaching, enabling them to understand the impact of the disease on patients and their families. The doctors' teaching was also appreciated, particularly the interactive style and opportunity to participate in role play. Conclusions: We have demonstrated that our patient was at least as good as a doctor at teaching about the impact of chronic disease on patients. Furthermore, this experience is valued by students who appreciate the personal insight that a patient can offer. Copyright © 2010 John Wiley & Sons, Ltd.     

Ultrasonography‐detected subclinical inflammation in patients with hand osteoarthritis and established rheumatoid arthritis: a comparison between two different pathologies using the same ultrasound examination protocol

Objectives

A recent review of ultrasound (US) studies in osteoarthritis (OA) showed very limited data about hand OA. Previous US studies in patients with OA described a degree of overlap between the US appearance of rheumatoid arthritis (RA) and OA joints. The present study aimed to assess the US features of subclinical inflammation in RA and hand OA, using the same US examination protocol.

Methods

A retrospective, cohort study compared patients with established RA (n = 224) and hand OA (n = 73), with respect to several demographic, clinical, laboratory and US parameters. We used a 22‐hand joint US examination protocol (wrists, metacarpophalangeal and proximal interphalangeal joints bilaterally – Outcome Measures in Rheumatology Clinical Trials [OMERACT] scoring system) for all patients.

Results

Subclinical joint inflammation in the context of equivocal clinical examination was found in 9.6% of OA patients compared with 46.4% of RA patients (p = 0.0001), despite the fact that there was no significant difference between the degree of chronic joint swelling (synovial hypertrophy grades 2 and 3; p = 0.75 and p = 0.11, respectively). The presence of osteophytes was more common in patients with hand OA, as expected (p = 0.0001).

Conclusions

Our study findings reflected differences between the incidence and characteristics of subclinical inflammation in patients with RA and OA, which could be helpful in patients with an equivocal clinical examination or history of both diseases. Almost one in 10 patients with hand OA had active synovitis, while almost one in two patients with RA had uncontrolled inflammation in at least one joint.     

Assessing joint destruction in the knees of patients with rheumatoid arthritis by using a semi-automated software for magnetic resonance imaging: therapeutic effect of methotrexate plus etanercept compared with methotrexate monotherapy

Objectives: To evaluate the prevention of knee joint destruction and clinical efficacy of methotrexate (MTX) plus etanercept (ETN) compared with MTX monotherapy in patients with rheumatoid arthritis (RA) by using semi-automated software for magnetic resonance imaging (MRI) scan analysis.

Materials and methods: This study enrolled patients with active moderate-to-severe RA who displayed an inadequate response to oral MTX at screening. Patients were assigned to receive either MTX plus ETN or MTX monotherapy (≥10?mg/week). The primary endpoint was the quantitative knee cartilage volume using our software developed for MRI scan analysis.

Results: A total of 18 female patients were enrolled in this study and allocated to the MTX?+?ETN group (n?=?9) or the MTX monotherapy group (n?=?9). At 52 weeks, the quantitative knee cartilage volume was significantly reduced compared with baseline in both groups (MTX plus ETN group: 2.3?±?2.3?cm³; MTX monotherapy group: 2.4?±?1.6?cm³); however, the difference was not significant.

Conclusion: The semi-automated software for MRI scan analysis can reveal useful and potentially clinically important information about the characteristics of knee joint destruction in patients with RA.