Comparisons of 7- to 78-joint ultrasonography scores: all different joint combinations show equal response to adalimumab treatment in patients with rheumatoid arthritis

Introduction The primary objectives were to explore the associations between a comprehensive ultrasonographic (US) assessment of joints, tendons and bursae and previously described reduced joint counts (7-, 12-, 28- and 44-joint score) as well as to assess the sensitivity to change of these different US joint combinations during biological treatment. Methods Twenty patients with rheumatoid arthritis (RA) were examined by US (B-mode (BM) and power Doppler (PD)) with use of a semi-quantitative (0 to 3) score of 78 joints, 36 tendons/tendon groups and two bursae (hereafter described as the 78-joint score) at baseline and 1, 3, 6 and 12 months after initiating treatment with adalimumab. BM and PD scores for the different joint combinations were generated. Results The reduced joint scores had high correlation coefficients with the 78-joint score at all examinations (range 0.79 to 0.99 for BM and 0.77 to 0.99 for PD, each P < 0.001) and sum BM and PD scores of all the different joint combinations improved significantly during follow-up (P ≤ 0.05 to 0.001). Conclusions The reduced joint combinations were highly associated to the 78-joint score. Furthermore, all the joint combinations presently explored responded well to biological treatment. This indicates that an approach focusing on few joints and tendons gives equivalent information about the inflammatory activity in RA patients as a comprehensive US examination. The optimal combination of joints and tendons for a valid, reliable and feasible US measurement should be further explored to define a US score for follow-up of RA patients on biological treatment

Is synovial hypertrophy without Doppler activity sensitive to change? Post-hoc analysis from a rheumatoid arthritis ultrasound study

Abstract Background To explore to what extent synovial hypertrophy in joints without Doppler activity is a sign of active disease, we investigated the sensitivity to change of synovial hypertrophy without Doppler activity during biological disease-modifying antirheumatic drug (bDMARD) treatment in rheumatoid arthritis (RA) patients. Method RA patients initiating or switching bDMARD treatment had ultrasound (US) performed on 36 joints at baseline, and at 3 and 6 months. Synovial hypertrophy by grayscale US and Doppler activity were graded separately from 0 to 3 at the joint level for all time points. Changes in synovial hypertrophy in joints without Doppler activity during treatment were assessed and compared with changes in synovial hypertrophy in joints with Doppler activity. Results We included 151 patients (82.8% women, 80.1% seropositive for anticyclic citrullinated peptide) with a mean ± standard deviation age of 51.4 ± 13.2 years, a disease duration of 9.9 ± 7.9 years, and baseline Disease Activity Score 28-joint count C-reactive peptide (DAS28-CRP) of 4.14 ± 1.32. At baseline, 44.8% of all joints examined (n = 5225) had synovial hypertrophy ≥ 1 and 50.7% of these had synovial hypertrophy without Doppler activity. The improvement in synovial hypertrophy was similar in joints with and without Doppler activity but, when adjusting for the baseline score of synovial hypertrophy, joints with synovial hypertrophy without Doppler had a higher tendency towards a decrease than joints with synovial hypertrophy with Doppler activity independent of grade (3 months: p < 0.0001; 6 months: p = 0.0003). Conclusion Joints with synovial hypertrophy without Doppler activity improve during treatment, independent of the grade. Thus, SH without Doppler activity is not a sign of inactive disease. These findings indicate that joints with synovial hypertrophy without Doppler activity should also be taken in to account when assessing disease activity by US

Fluctuation and change of serum urate levels and flares in gout: results from the NOR-Gout study

A gout attack may evolve after a purine-rich diet or alcohol and after starting urate-lowering therapy (ULT). The relationships between fluctuation and change in serum urate (SU) with the occurrence of flares were investigated in this study. In the prospective NOR-Gout study, gout patients with increased SU and a recent flare were treated to target with ULT over 1 year, with follow-up at year 2 with SU and flare as outcomes. SU and flares were assessed at both monthly and 3-monthly intervals until target SU was reached. Fluctuation over periods and changes in SU between two time points were assessed and compared in patients with and without flares. At year 1, 186 patients completed follow-up (88.2%) and 173 (82.0%) at year 2. Mean age (SD) at baseline was 56.4 (13.7) years, disease duration was 7.8 (7.6) years, and 95.3% were men. The first-year SU fluctuation and change were related to flare occurrence during year 1 (both p 360 mu mol/l were not related to flares. Fluctuation and change in SU were related to flare occurrence during the first year of ULT, while changes between visits and reaching SU levels > 360 mu mol/L were not related to flares.Open access funding provided by University of Oslo (incl Oslo University Hospital)

One- and 2-year flare rates after treat-to-target and tight-control therapy of gout: results from the NOR-Gout study

[EN] OBJECTIVES: To explore the frequency and predictors of flares over 2years during a treat-to-target strategy with urate-lowering therapy (ULT) in patients with gout. METHODS: In the treat-to-target, tight control NOR-Gout study patients started ULT with escalating doses of allopurinol. Flares were recorded over 2years. Baseline predictors of flares during months 9-12 in year 1 and during year 2 were analyzed by multivariable logistic regression. RESULTS: Of 211 patients included (mean age 56.4years, disease duration 7.8years, 95% males), 81% (150/186) of patients experienced at least one gout flare during the first year and 26% (45/173) during the second year. The highest frequency of flares in the first year was seen during months 3-6 (46.8% of patients). Baseline crystal depositions detected by ultrasound and by dual-energy computed tomography (DECT) were the only variables which predicted flares both during the first period of interest at months 9-12 (OR 1.033; 95% CI 1.010-1.057, and OR 1.056; 95% CI 1.007-1.108) and also in year 2. Baseline subcutaneous tophi (OR 2.42, 95% CI 1.50-5.59) and prior use of colchicine at baseline (OR 2.48, 95% CI 1.28-4.79) were independent predictors of flares during months 9-12, whereas self-efficacy for pain was a protective predictor (OR 0.98 per unit, 95% CI 0.964-0.996). CONCLUSIONS: In patients with gout, flares remain frequent during the first year of a treat-to-target ULT strategy, especially during months 3-6, but are much less frequent during year 2. Baseline crystal depositions predict flares over 2years, supporting ULT early during disease course.The study was funded by Diakonhjemmet Hospital and was performed by employees at National Advisory Unit on Rehabilitation in Rheumatology (NKRR) and Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway

Ultrasound assessment of degenerative muscle sarcopenia: the University of Barcelona ultrasound scoring system for sarcopenia

AimThis study aimed to (1) determine the intraobserver and interobserver reliability of ultrasonographic measurement of muscle thickness (MT) and cross-sectional area (CSA) of the rectus femoris and biceps brachii, correlating these values with manual measurements on dissected cadavers and (2) develop the first semiquantitative musculoskeletal ultrasound (MSUS) scoring system of muscle morphology in sarcopenia and assess its intraobserver and interobserver reliability. In addition, the MSUS morphology score was compared with the corresponding histological images to verify concurrent validity.MethodsTen cryopreserved limbs of 10 cadavers aged 68-91 years were evaluated. The MSUS scoring system was based on the severity of muscle degeneration on a 3-point qualitative scale: grade 1 (normal), grade 2 (moderate changes) and grade 3 (severe changes). Reliability was assessed with intraclass correlation coefficient (ICC) for the MT and CSA and with Cohen's kappa coefficients (& kappa;) for the MSUS scoring system. Concurrent validity was analysed with ICC.ResultsThe results showed excellent intraobserver and interobserver reliability for both the MSUS evaluation of MT and CSA (ICC & GE;0.93). The MSUS scoring system showed excellent intraobserver reliability (& kappa;=1.0) and very good interobserver reliability (& kappa;=0.85). There was also a high intra- and inter-observer reliability for the histological scorings (& kappa; & GE;0.85 and mean & kappa;=0.70, respectively), as well as high reliability between the histology and MSUS scoring systems (ICC=0.92). All results were statistically significant (p & LE;0.001).ConclusionMSUS measures of MT and CSA and the novel MSUS scoring system for degenerative muscle changes in sarcopenia was found to be reliable and strongly associated with histological findings

Do patient-reported measures of disease activity in rheumatoid arthritis vary between countries? Results from a Nordic collaboration

Objectives To investigate whether patient-reported outcomes vary across countries and are influenced by cultural/contextual factors. Specifically, we aimed to assess inter-country differences in tender joint count (TJC), pain and patient's global health assessment (PGA), and their impact on disease activity (DAS28-CRP) in RA patients from five Nordic countries. Methods We collected data (baseline, 3- and 12-months) from rheumatology registers in the five countries comprising RA patients starting a first ever MTX or a first ever TNF inhibitor (TNFi). In order to assess the role of context (=country), we separately modelled TJC, pain and PGA as functions of objective variables (CRP, swollen joint count, age, sex, calendar period and disease duration) with linear models. Analyses were performed at each time point and for both treatments. We further assessed the impact of inter-country differences on DAS28-CRP. Results A total of 27 645 RA patients started MTX and 19 733 started a TNFi. Crude inter-country differences at MTX start amounted to up to 4 points (28 points scale) for TJC, 10 and 27 points (0-100 scale) for pain and PGA, respectively. Corresponding numbers at TNFi start were 3 (TJC), 27 (pain) and 24 (PGA) points. All differences were reduced at 3- and 12-months, and attenuated when adjusting for the objective variables. The variation in predicted DAS28-CRP across countries amounted to Conclusions Inter-country differences in TJC, pain and PGA are greater than expected based on differences in objective measures, but have a small clinical impact on DAS28-CRP across countries.Peer reviewe

How does a cadaver model work for testing ultrasound diagnostic capability for rheumatic-like tendon damage?

To establish whether a cadaver model can serve as an effective surrogate for the detection of tendon damage characteristic of rheumatoid arthritis (RA). In addition, we evaluated intraobserver and interobserver agreement in the grading of RA-like tendon tears shown by US, as well as the concordance between the US findings and the surgically induced lesions in the cadaver model. RA-like tendon damage was surgically induced in the tibialis anterior tendon (TAT) and tibialis posterior tendon (TPT) of ten ankle/foot fresh-frozen cadaveric specimens. Of the 20 tendons examined, six were randomly assigned a surgically induced partial tear; six a complete tear; and eight left undamaged. Three rheumatologists, experts in musculoskeletal US, assessed from 1 to 5 the quality of US imaging of the cadaveric models on a Likert scale. Tendons were then categorized as having either no damage, (0); partial tear, (1); or complete tear (2). All 20 tendons were blindly and independently evaluated twice, over two rounds, by each of the three observers. Overall, technical performance was satisfactory for all items in the two rounds (all values over 2.9 in a Likert scale 1-5). Intraobserver and interobserver agreement for US grading of tendon damage was good (mean κ values 0.62 and 0.71, respectively), with greater reliability found in the TAT than the TPT. Concordance between US findings and experimental tendon lesions was acceptable (70-100 %), again greater for the TAT than for the TPT. A cadaver model with surgically created tendon damage can be useful in evaluating US metric properties of RA tendon lesions