双重滤过血浆置换联合免疫抑制剂治疗对重度活动性类风湿关节炎患者磁共振成像的影响

目的 探讨双重滤过血浆置换(DFPP)联合免疫抑制剂(来氟米特+甲氨蝶呤)治疗对重度活动性类风湿关节炎(RA)患者磁共振成像(MRI)的影响.方法 纳入58例RA患者,病程6个月至12年,采用计算机自动生成的随机号,将患者随机分为治疗组和对照组.对照组予以来氟米特10 mg,每日2次,甲氨蝶呤15 mg,每周1次;治疗组在对照组治疗的基础上予以DFPP治疗3～4次,每次问隔7～14 d.随访至6个月.通过右腕关节MRI平扫加增强观察基线和治疗1、6个月时滑膜炎、关节腔积液及骨髓水肿的变化,应用RA磁共振评分标准(RAMRIS)判断对MRI滑膜炎的影响.组内比较采用配对t检验,组间比较采用独立样本t检验.结果 治疗组6个月时滑膜、血管翳、骨髓水肿计分分别为(1.4±1.6)、(0.13±0.35)、(5±4),显著低于对照组[分别为(7.9±1.3)、(2.76±0.43)、(16±12),P均<0.01];治疗组30例(100%)关节腔积液均消失,对照组无一例消失(P<0.01).治疗组达到MRI滑膜炎完伞缓解(滑膜、血管翳见强化,关节腔无积液)+疾病活动指数(DAS)28缓解标准的为16例(53%),对照组无一例达到此标准(P<0.01).1个月时治疗组DAS28、健康评估问卷(HAQ)分别由(7.5±1.0)、(2.23±0.58)下降至(3.5±1.2)、(0.50±0.73),差异有统计学意义(P<0.01);MRI影像滑膜、血管翳、关节腔积液、骨髓水肿无明显变化(P>0.05).结论 DFPP联合免疫抑制剂治疗对重度活动性RA MRI滑膜炎症有明显缓解作用.MRI对疾病活动的判断及治疗方案的选择可作为必要的手段之一.     

Evaluation of a new erosion score by musculoskeletal ultrasound in patients with rheumatoid arthritis

The objectives of this study are to evaluate a new semi-quantitative (0–5) musculoskeletal ultrasound (US) erosion score in patients with rheumatoid arthritis (RA) and to prove its usefulness in the detection of disease activity and success of therapy. Thirty-eight patients with RA (mean disease duration 10.1?±?11.9 years) were enrolled. Start or change of therapy (DMARD/biologics) was an inclusion criterion. DAS28, laboratory (ESR and CRP) and US data were evaluated before new therapy initiation and after 1, 3, 6 and 12 months. Thirteen joints of the clinically more affected hand and forefoot (wrist and MCP, PIP, MTP joints 2–5) were analyzed for synovitis in grayscale (GS) and power Doppler (PD) US, tenosynovitis/paratenonitis in GS/PDUS (wrist, MCP level) and for erosions. Erosions were analyzed by a new semi-quantitative score (grade 0, no erosion; grade 1, <1 mm, grade 2, 1 to <2 mm; grade 3, 2 to ≤3 mm; grade 4, >3 mm; grade 5, multiple bone erosions). After 12 months, DAS28 decreased from 4.5 to 3.4 (p?p?=?0.001) and the synovitis score in PDUS from 10.6 to 4.1 (p?p?=?0.046). There were longitudinal significant correlations between the new erosion score and both the DAS28 (r?=?0.368; p?=?0.025) and the synovitis score in PDUS (r?=?0.365; p?=?0.026) over a 1-year follow-up period. The new erosion score might be a useful tool for the evaluation of erosive changes by US in RA patients. In the course of DMARD and biologic therapy, it was responsive under 1-year follow-up examination.     

Magnetic resonance imaging in early rheumatoid arthritis: a multicenter,prospective study

To identify the magnetic resonance imaging (MRI) features of hands and wrists in early rheumatoid arthritis (RA). A total of 129 early arthritis patients (≤1 year) were enrolled in the study. At presentation, MRI of the hands was performed, with clinical and laboratory analyses. After a 1-year follow-up, clinical diagnosis of early RA or non-RA was confirmed by two rheumatologists. The characteristics of MRI variables at baseline in RA patients not fulfilling ACR 1987 criteria [RA-87(?)] were compared with those fulfilling ACR1987 criteria [RA-87(+)] and non-RA. In the 129 early arthritis patients, 90 were diagnosed with RA in a 1-year follow-up. There were 47.8 % (43/90) of the RA patients not fulfilling ACR 1987 criteria [RA-87(?)]. The scores of synovitis in RA-87(?) patients were similar with those in RA-87(+) [Synovitis score, 14.0 (IQR, 4.0–25.0) vs. 14.0 (IQR, 10.0–25.0), p?>?0.05]. Compared with those in non-RA, RA-87(?) patients had higher synovitis scores and occurrence of synovitis in proximal interphalangeal (PIP) joints [synovitis score, 14.0 (IQR, 4.0–25.0) vs. 6.0 (IQR, 2.0–14.5), p?=?0.046; occurrence of PIP synovitis: 53.5 vs. 27.3 %, p?=?0.02]. There was no significant difference of bone marrow edema, bone erosion, and tenosynovitis between RA-87(?) and non-RA. Synovitis in PIP joints was independent predictor for RA-87(?) [OR, 3.1 (95 %CI 1.2–8.1)]. High synovitis scores and synovitis in PIP joints on MRI were important in early RA, especially those not fulfilling ACR 1987 criteria.     

Bone erosions and bone marrow edema as defined by magnetic resonance imaging reflect true bone marrow inflammation in rheumatoid arthritis

OBJECTIVE: To investigate the pathologic nature of features termed "bone erosion" and "bone marrow edema" (also called "osteitis) on magnetic resonance imaging (MRI) scans of joints affected by rheumatoid arthritis (RA). METHODS: RA patients scheduled for joint replacement surgery (metacarpophalangeal or proximal interphalangeal joints) underwent MRI on the day before surgery. The presence and localization of bone erosions and bone marrow edema as evidenced by MRI (MRI bone erosions and MRI bone marrow edema) were documented in each joint (n=12 joints). After surgery, sequential sections from throughout the whole joint were analyzed histologically for bone marrow changes, and these results were correlated with the MRI findings. RESULTS: MRI bone erosion was recorded based on bone marrow inflammation adjacent to a site of cortical bone penetration. Inflammation was recorded based on either invading synovial tissue (pannus), formation of lymphocytic aggregates, or increased vascularity. Fat-rich bone marrow was replaced by inflammatory tissue, increasing water content, which appears as bright signal enhancement on STIR MRI sequences. MRI bone marrow edema was recorded based on the finding of inflammatory infiltrates, which were less dense than those of MRI bone erosions and localized more centrally in the joint. These lesions were either isolated or found in contact with MRI bone erosions. CONCLUSION: MRI bone erosions and MRI bone marrow edema are due to the formation of inflammatory infiltrates in the bone marrow of patients with RA. This emphasizes the value of MRI in sensitively detecting inflammatory tissue in the bone marrow and demonstrates that the inflammatory process extends to the bone marrow cavity, which is an additional target structure for antiinflammatory therapy.     

A multicenter reliability study of extremity-magnetic resonance imaging in the longitudinal evaluation of rheumatoid arthritis

There are limited data on the reliability of extremity magnetic resonance imaging (E-MRI) in the longitudinal evaluation of rheumatoid arthritis (RA). Our aim was to assess the interreader reliability of the OMERACT RA MRI score in the assessment of change in disease activity and bone erosion scores using 0.2 T E-MRI hand and wrist images from 2 timepoints, evaluated by 3 readers at different international centers. The intraclass correlation coefficients and smallest detectable difference results for the change scores were generally good for erosions and synovitis, but were not acceptable for bone edema. Overall, E-MRI demonstrated ability to detect change comparable to that reported for high-field MRI for erosion and synovitis.     

Elucidation of the relationship between synovitis and bone damage: a randomized magnetic resonance imaging study of individual joints in patients with early rheumatoid arthritis

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.     

Magnetic resonance imaging versus musculoskeletal ultrasonography in detecting inflammatory arthropathy in systemic sclerosis patients with hand arthralgia

The aim of the study was the detection of inflammatory arthropathy in patients with systemic sclerosis (SSc) with arthralgia using musculoskeletal ultrasonography (MSUS) and magnetic resonance imaging (MRI) and to compare between MRI versus MSUS detecting musculoskeletal abnormalities and find out its relation with other clinical and laboratory parameters. Sixteen SSc patients with hand arthralgia had a baseline MSUS for their hands. Six months later, patients had a second MSUS and MRI with gadolinium of their most symptomatic hand. Of the 16 patients examined by MSUS, it was found that on baseline and second examination, tenosynovitis was seen in 8 (50 %) and 7 (43.7 %) patients and synovitis was seen in 4 (25 %) and 5 (31 %) patients, respectively, indicating persistence synovial inflammation, and erosion was seen in only 1 (6.3 %) patient on baseline and second examination. Regarding MRI, 81.3 % (13) patients had tenosynovitis, 87.5 % (14) patients had synovitis, and 62.5 % (10) patients had erosions. Applying the RAMRIS system (a semiquantitative MRI scoring system used in RA), the mean values for synovitis, bone marrow edema, and erosions fell within the range seen in RA. Systemic sclerosis patients with arthralgia that have no obvious clinical inflammatory arthritis were found to have persistent inflammatory erosive arthropathy in their hands and wrists using MSUS and MRI. 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 on larger number of SSc patients with arthralgia and a control group consisting of SSc patients without arthralgia to better establish the clinical and radiological findings in SSc.     

Treatment of early rheumatoid arthritis: a randomized magnetic resonance imaging study comparing the effects of methotrexate alone, methotrexate in combination with infliximab, and methotrexate in combination with intravenous pulse methylprednisolone

OBJECTIVE: To compare the effects of methotrexate (MTX), alone or in combination with intravenous (IV) methylprednisolone (MP) or infliximab, on magnetic resonance imaging (MRI)-detected synovitis, bone edema, and erosive changes in patients with early rheumatoid arthritis (RA). METHODS: Forty-four patients with early RA were randomized to receive MTX alone (MTX group), MTX plus IV MP (IV MP group), or MTX plus infliximab (infliximab group), infused on day 0 and weeks 2, 6, 14, 22, 30, 38, and 46. Gadolinium-enhanced MRI scans of the metacarpophalangeal joints, wrists, and metatarsophalangeal joints were performed at baseline, week 18, and week 52. RESULTS: Scores for MRI-detected synovitis and bone edema improved over time in the 3 groups, with significantly lower synovitis scores in the infliximab group compared with the MTX group and significantly lower bone edema scores in the infliximab group compared with the MTX and the IV MP groups. Scores for MRI-detected erosion significantly increased over time in all groups. There were no differences in erosion scores between the MTX group and the other groups. It is of note that patients treated with IV MP showed more significant progression in MRI-detected erosions compared with patients treated with infliximab. At week 22, response rates according to the American College of Rheumatology 20% improvement criteria (ACR20), the ACR50, and the ACR70 were significantly higher in both the IV MP group and the infliximab group compared with the MTX group. At week 52, remission was achieved in 40% of patients in the MTX group and in 70% of patients in the IV MP and infliximab groups. Health Assessment Questionnaire scores improved significantly over time in all groups, with patients receiving IV MP experiencing significantly more improvement compared with patients treated with MTX alone. No severe side effects were observed, except 1 case of MTX-related pneumonitis. CONCLUSION: The combination of MTX and infliximab is superior to MTX alone for reducing MRI-detected signs of synovitis and bone edema in patients with early RA. Progression of MRI-detected erosion was greater in patients treated with MTX plus IV MP compared with that in patients who received MTX plus infliximab.     

The evidence for magnetic resonance imaging as an outcome measure in proof-of-concept rheumatoid arthritis studies

Magnetic resonance imaging (MRI) has now been used extensively in cross-sectional and observational studies as well as in controlled clinical trials to assess disease activity and joint damage in rheumatoid arthritis (RA). MRI measurements or scores for erosions, bone edema, and synovitis have been developed and validated by several groups. The OMERACT criteria require that outcome measures demonstrate adequate validity, discriminative power, and feasibility if they are to be useful in clinical trials. Specific performance targets for these criteria depend on the scientific, regulatory, logistical, and financial context of the study in question. We review the extent to which MRI assessments of joint erosion, bone edema, and synovitis fulfil these criteria, particularly as they relate to proof-of-concept RA clinical trials.     

Evidence for a different anatomic basis for joint disease localization in polymyalgia rheumatica in comparison with rheumatoid arthritis

OBJECTIVE: The anatomic basis for joint disease localization in polymyalgia rheumatica (PMR) is poorly understood. This study used contrast-enhanced and fat suppression magnetic resonance imaging (MRI) to evaluate the relationship between synovial and extracapsular inflammation in PMR and early rheumatoid arthritis (RA). METHODS: Ten patients with new-onset PMR and 10 patients with early RA underwent dynamic contrast-enhanced MRI and conventional MRI of affected metacarpophalangeal (MCP) joints. Synovitis and tenosynovitis were calculated based on the number of enhancing voxels, initial rate of enhancement, and maximal enhancement of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Periarticular bone erosion and bone edema were scored according to the OMERACT (Outcome Measures in Rheumatology Clinical Trials) scoring system in both groups. The degree of extracapsular Gd-DTPA enhancement was assessed in both conditions using semiquantitative scoring. RESULTS: No significant differences were seen in the volume of synovitis (P = 0.294), degree of flexor tenosynovitis (P = 0.532), periarticular erosions (P = 0.579), or degree of bone edema (P = 0.143) between RA and PMR joints. However, despite comparable degrees of synovitis, the proportion of MCP joints showing extracapsular enhancement was higher in the PMR group (100%) than in the RA group (50%) (P = 0.030). One PMR patient, but none of the RA patients, had bone edema at the capsular insertion. CONCLUSION: Despite degrees of synovitis and tenosynovitis comparable with those in RA, PMR-related hand disease is associated with prominent extracapsular changes, suggesting that inflammation in these tissues is more prominent than joint synovitis, which is common in both conditions. This suggests that the anatomic basis for joint disease localization differs between RA and PMR.     

Comparison of MRI and X-ray in detection of erosions in RA

ObjectiveTo compare magnetic resonance imaging (MRI) of hands with conventional radiographs in detection of erosions in rheumatoid arthritis (RA) patients.MethodsThe study was conducted on 42 RA patients. X-ray and MRI of both hands were done and findings were compared.ResultsOut of 42 patients, MRI detected erosions in 41 patients (97.6%). However, X-ray detected erosions only in 19 patients (45.2%). No patient had erosion detected on X-ray, which was not visualized by MRI. Mean numbers of erosions detected by X-rays were 2.09 ± 2.97 and by MRI were 11.30 ± 10.03 (P < 0.0001). In early RA (disease duration less than 3 months), MRI could detect erosions in some patients, whereas X-rays were unable to detect erosions in any.ConclusionsIn RA, MRI is superior to conventional radiographs in detecting erosions, especially in patients with early disease.     

Risk of cervical myelopathy in rheumatoid arthritis patients with neck pain

BackgroundCervical spine (CS) evaluation in rheumatoid arthritis (RA) is challenging since subtle neurological insult is usually masked by the severe peripheral joint affection or muscle atrophy. Neglected CS lesions could end up with cervical myelopathy. Magnetic resonance imaging (MRI) has been the modality of choice in assessing CS in RA.Aim of the workTo evaluate CS in RA using MRI and detect the risk factors for its involvement.Patients and methodsForty RA patients with neck pain were assessed using disease activity score (DAS28), Ranawat classification of rheumatoid myelopathy, simple erosion narrowing score (SENS), bilateral hand and wrist musculoskeletal ultrasound (MSKUS) for early erosion detection and CS MRI.ResultsThe mean age of patients was 44.3 ± 10.1 years, disease duration 7.9 ± 6.6 years and the DAS28 was 4.8 ± 1.6. 70% of patients were in Ranawat class I, 30% in class II, and none in class III. 70% of patients had CS lesions where synovitis occurred in 67.5% of patients, odontoid erosions in 15%, atlanto-axial marrow edema in 5%, atlanto-occipital marrow edema in 5% and none had atlanto-axial subluxation (AAS), subaxial subluxation (SAS), spinal cord/brain stem compression. CS involvement was significantly related to peripheral joint erosion, high SENS and positive RF (p = 0.01, p < 0.0001, p < 0.0001 respectively).ConclusionCS involvement is remarkable in RA especially in those with peripheral joint erosions, high SENS and positive RF. RA patients with persistent neck pain, even in absence of objective neurological deficit should be evaluated early for detection and management of CS lesions before irreversible neurological damage takes place.     

Bone edema determined by magnetic resonance imaging reflects severe disease status in patients with early-stage rheumatoid arthritis

OBJECTIVE: To determine the significance of bone edema, detected by magnetic resonance imaging (MRI), in early-stage rheumatoid arthritis (RA). METHODS: We simultaneously examined serologic variables, MRI of wrist sites and finger joints of both hands, clinical disease activity score (DAS), and HLA-DR typing at entry in 80 patients with early-stage RA. RESULTS: The number of bones scored as positive for bone edema correlated with the number of sites scored as positive for MRI synovitis and MRI bone erosion, rate of enhancement (E-rate), and serum C-reactive protein (CRP), matrix metalloproteinase 3 (MMP-3), and interleukin 6 (IL-6). Findings for MRI synovitis and MRI bone erosion, E-rate, CRP, MMP-3, IL-6, seropositivity, and titer of anti-cyclic citrullinated peptide antibody (anti-CCP antibody), DAS28-CRP and HLA-DRB1*0405 allele carriership, were significantly higher in the positive versus the negative bone edema group. CONCLUSION: Bone edema based on our scoring system may reflect severe disease status in patients with early-stage RA. However, its clinical value at entry in prognostication of RA should be examined through prospective clinical followup studies.     

Comparison of OMERACT-RAMRIS scores and computer-aided dynamic magnetic resonance imaging findings of hand and wrist as a measure of activity in rheumatoid arthritis

The purpose of this study was to compare the value of conventional magnetic resonance imaging (MRI) finding of rheumatoid arthritis (RA) and computer-aided dynamic MRI measurements in predicting the activity of disease. The activity of the disease in 40 RA patients was evaluated by the disease activity score in 28 joints (DAS28). The conventional MRI of the wrists of all patients were scored for bone edema, synovitis and erosions, according to the criteria of RA-MRI scoring system (RAMRIS) developed by Outcome measures in rheumatology clinical trials (OMERACT) MR Imaging Group. Synovitis was also quantified by dynamic postcontrast MRI imaging using color coded maximum slope of increase maps and measurements of early enhancement rate (EER) and relative enhancement (RE). Twenty-two (55 %) patients with a score higher than 5.1 constituted the high disease activity group, 18 (45 %) patients with a score of 5.1 or less constituted moderate disease activity group. The dynamic MRI-EER score was the most significant parameter to differentiate between the groups (p = 0.001). Among OMERACT scores, only bone edema [p = 0.020 for wrist and p = 0.037 for metacarpophalangeal joints (MCP)] had a significant difference between the two groups. Dynamic MRI RE score and OMERACT scores for erosions and synovitis for both the wrist and MCP joints did not differ significantly between the two groups. Computer-aided dynamic MRI is a reliable, noninvasive method of evaluating the RA patients, which correlates with the DAS28 scores, at a higher significance than the OMERACT-RAMRIS scores.     

Treatment discontinuation in patients with very early rheumatoid arthritis in sustained simplified disease activity index remission after synthetic disease-modifying anti-rheumatic drug administration

We aimed to identify whether drug-free remission could be achieved in patients with very early rheumatoid arthritis (RA) with poor prognosis factors by treatment with synthetic disease-modifying antirheumatic drugs (DMARDs). Thirteen patients with very early RA, whose disease was considered to have highly erosive potential, were included. Magnetic resonance imaging (MRI)-proven bone edema and autoantibodies were determined in these patients. A treat-to-target strategy initiated with synthetic DMARDs was employed for 12 months. If the patients achieved simplified disease activity index (SDAI) remission along with a reduction of the RA MRI scoring bone edema score to <33% as compared with baseline at 12 months, DMARD treatment was stopped and the clinical status was further observed for the following 12 months. Synthetic DMARDs were stopped at 12 months in 5 patients. One of the 5 was lost to follow-up because of sustaining an injury that required orthopedic surgery. Three of the remaining 4 patients showed continued SDAI remission that was DMARD-free without any evidence of radiographic progression for the following 12 months. Although this was a small clinical trial, we have shown-for the first time-that true remission of very early RA with poor prognosis factors can be achieved by treatment with synthetic DMARDs.     

Treatment discontinuation in patients with very early rheumatoid arthritis in sustained simplified disease activity index remission after synthetic disease-modifying anti-rheumatic drug administration

Abstract

We aimed to identify whether drug-free remission could be achieved in patients with very early rheumatoid arthritis (RA) with poor prognosis factors by treatment with synthetic disease-modifying antirheumatic drugs (DMARDs). Thirteen patients with very early RA, whose disease was considered to have highly erosive potential, were included. Magnetic resonance imaging (MRI)-proven bone edema and autoantibodies were determined in these patients. A treat-to-target strategy initiated with synthetic DMARDs was employed for 12 months. If the patients achieved simplified disease activity index (SDAI) remission along with a reduction of the RA MRI scoring bone edema score to <33% as compared with baseline at 12 months, DMARD treatment was stopped and the clinical status was further observed for the following 12 months. Synthetic DMARDs were stopped at 12 months in 5 patients. One of the 5 was lost to follow-up because of sustaining an injury that required orthopedic surgery. Three of the remaining 4 patients showed continued SDAI remission that was DMARD-free without any evidence of radiographic progression for the following 12 months. Although this was a small clinical trial, we have shown–for the first time–that true remission of very early RA with poor prognosis factors can be achieved by treatment with synthetic DMARDs.     

Evaluation of changes in magnetic resonance images following 24 and 52 weeks of treatment of rheumatoid arthritis with infliximab,tocilizumab, or abatacept

Objectives. To compare MRI findings in rheumatoid arthritis (RA) patients treated with biologic disease-modifying anti-rheumatic drugs (DMARDs).

Methods. The study subjects were 43 RA patients treated with biologic DMARDs (13 with infliximab, 15 with tocilizumab, and 15 with abatacept). They were evaluated using Simplified Disease Activity Index (SDAI) and low-field extremity MRI at baseline, and at 24 weeks and 52 weeks of treatment.

Results. Synovitis scores were significantly lower by 24 weeks in all groups, compared with baseline (P < 0.05). Significant improvement in bone marrow edema (BME) scores were noted from baseline to 24 weeks in infliximab and abatacept groups (P < 0.05), but from 24 weeks to 52 weeks in tocilizumab group (P < 0.01). No significant change was found in erosion score. The synovitis score at baseline correlated significantly with SDAI at 24 weeks (P < 0.05), and the score at 24 weeks correlated significantly with SDAI at 52 weeks (P < 0.05).

Conclusions. The results suggest that the inflammatory improvement by infliximab and abatacept may express earlier than those by tocilizumab, despite similar improvement in SDAI. MRI-detected synovitis could be a useful predictor of SDAI at 24 weeks of treatment. The MRI remains the best tool to detect and assess the effects of biologic DMARDs in RA.     

Magnetic resonance imaging of the knee: a tool for prediction of joint damage in early rheumatoid arthritis?

OBJECTIVE: To evaluate the usefulness of magnetic resonance imaging (MRI) in predicting destructive rheumatoid arthritis (RA) in the knee joint, and to compare this method with clinical examination and conventional radiography (CR). METHODS: Clinical evaluations of the knee joint, followed by MRI and CR examinations were performed in 30 patients with early RA. The MRI examination included evaluation of inflammation using a synovitis score and evaluation of destruction with an erosion score. The first examinations were performed within 14 months from disease onset. Twenty-eight patients were re-examined after 1 year, and 23 patients after 3 years. 'Disease activity score' (DAS), using a 28 joints score (DAS28); health assessment questionnaire (HAQ); rheumatoid factor (RF); and C-reactive protein (CRP) were also analysed. RESULTS: At baseline, MRI found synovitis in 29 patients, of whom 18 also had clinical synovitis. At baseline five patients had 17 MRI erosions, whereas on CR two patients had one erosion each. After 1 year 17 of 35 and after 3 years 28 of 55 MRI erosions were detected also on CR. In only one case CR showed an erosion that was not visible on MRI. The MRI synovitis score (reflecting the extent of the synovitis) at baseline correlated significantly with the number of erosions on MRI both at year 1 and 3, and with the number of erosions on CR at 3 years. In logistic multiple regression analyses the MRI-synovitis score proved to be the best independent predictor of erosiveness. CONCLUSION: MRI was superior to clinical examination and CR in detecting erosions. MRI synovitis score was the best independent predictor of erosiveness in the knee joint in patients with early RA.     

Persistent low grade synovitis without erosive progression in magnetic resonance imaging of rheumatoid arthritis patients treated with infliximab over 1?year

Disease remission is only reached by a minority of rheumatoid arthritis (RA) patients treated with infliximab. Radiological assessment reported in clinical trials support the view that even under persistent inflammatory activity there is no further structural damage. Magnetic resonance imaging (MRI) allows a highly accurate detection of synovitis, bone edema, and erosions, constituting the ideal instrument for the evaluation of treatment response. The goal of this study was to evaluate MRI changes over 1 year in RA patients treated with infliximab. Four RA patients refractory to methotrexate (MTX) therapy were treated with infliximab 3 mg/kg 8/8 weeks and followed up for 1 year. Disease Activity Score (DAS28) was measured in the day of each infliximab administration. MRI was performed at baseline, 3 months, and 1 year. A simplified OMERACT RA MRI scoring (RAMRIS) was applied to the dominant wrist: synovitis (0–3) was measured in the intercarpal–carpometacarpal joints (CMTJ); bone edema (0–39) and erosions (0–130) in the base of the metacarpal and wrist bones. Baseline DAS28 was superior to 3.2 in all patients (ranging from 4.8 up to 6.2). At 14 weeks, DAS28 was still superior to 3.2 (ranging from 3.5 up to 4.6) and at 46 weeks all patients have responded, however without having achieved clinical remission, as DAS28 was still above 2.6 (ranging from 2.6 up to 3.4). MRI showed that synovitis was reduced in all patients to a score of 1, bone edema was slightly reduced (10% reduction), and erosive score was unchanged (baseline values ranging from 2 up to 20). Despite persistent low disease activity, these four RA patients treated with infliximab had stable simplified RAMRIS erosive scores over 1 year. These results support the view that there might be an uncoupling process between inflammation and bone erosions when tumor necrosis factor alpha is targeted in RA.