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Here we focus on the use of imaging modalities such as ultrasound and magnetic resonance imaging (MRI) for the diagnosis and management of rheumatoid arthritis (RA). Video interviews with Professor Philip Conaghan of Leeds, UK and Veena Ranganath, Associate Clinical Professor, University of California Los Angeles, Division of Rheumatology, provide useful insights to apply these modalities in clinical practice. Each has advantages and disadvantages for the visualization of inflammation as well as structural damage, acknowledging that feasibility is influenced by availability, cost and patient burden. Both visualize synovitis and are more sensitive for detection of erosions. Osteitis, or bone marrow edema, which has been shown to predict joint damage is only visualized by MRI.
Ultrasound can be our “stethoscope” in managing RA patients; thus, learning to use this technique is an important opportunity for rheumatologists. Dr. Ingrid Moller of Instituto Poal de Reumatologia, Barcelona, Spain describes the EULAR Points to Consider for health professionals undertaking musculoskeletal ultrasound for rheumatic and musculoskeletal diseases.[Ann Rheum Dis. 2016 Dec 9. pii: annrheumdis-2016-210741. doi: 10.1136/annrheumdis-2016-210741] Ultrasound is a “hands on” technique to enable visualization of synovitis that may not be clinically apparent in a patient in clinical remission. This can influence decision-making, whether treatment should be maintained or tapered.
In contrast, MRI, although more costly with higher patient burden, is a valuable tool to identify both synovitis and osteitis, as well as erosions. Sensitively visualizing these features of joint inflammation and damage, Short Tau Inversion Recovery (STIR) images readily detect changes in inflammation and thus response to treatment. Using contrast, synovitis can be differentiated from joint effusion where synovitis enhances while joint effusion doesn’t. Contrast-enhanced studies are more sensitive and therefore the option to detect minimal synovitis to also influence treatment decisions.
Ultrasound and MRI are well- established tools in clinical practice and effectively complement clinical examination and conventional radiography. We hope that these videos provide you with helpful information to assist in your use of these modalities.
Back to the future: forget ultrasound and focus on clinical assessment in rheumatoid arthritis management
Roberto Caporali, Josef S SmolenAnn Rheum Dis. 2017 Aug 2. doi: 10.1136/annrheumdis-2017-211458. [Epub ahead of print]
Extended report: The first double-blind, randomised, parallel-group certolizumab pegol study in methotrexate-naive early rheumatoid arthritis patients with poor prognostic factors, C-OPERA, shows inhibition of radiographic progression
Tatsuya Atsumi, Kazuhiko Yamamoto, Tsutomu Takeuchi, Hisashi Yamanaka, Naoki Ishiguro, Yoshiya Tanaka, Katsumi Eguchi, Akira Watanabe, Hideki Origasa, Shinsuke Yasuda, Yuji Yamanishi, Yasuhiko Kita, Tsukasa Matsubara, Masahiro Iwamoto, Toshiharu ShojiAnn Rheum Dis 2016;75:75-83
The EULAR points to consider for health professionals undertaking musculoskeletal ultrasound for rheumatic and musculoskeletal diseases.
Siddle HJ, Mandl P, Aletaha D, et al.Annals of the Rheumatic Diseases, December 2016.
Tightening up? Impact of musculoskeletal ultrasound disease activity assessment on early rheumatoid arthritis patients treated using a treat to target strategy
Dale J, Purves D, McConnachie A, McInnes I, Porter D.Arthritis Care & Research, 66: 19–26
Haavardsholm EA, Aga AB, Olsen IC, Lillegraven S, Hammer HB, Uhlig T et al.Arthritis Care Res (Hoboken). 2014 Jan;66(1):19-26..
Targeting ultrasound remission in early rheumatoid arthritis: the results of the TaSER study, a randomised clinical trial
Dale J, Stirling A, Zhang R, Purves D, Foley J, Sambrook M, Conaghan PG, van der Heijde D, McConnachie A, McInnes IB, Porter D.Annals of the Rheumatic Diseases 2016;75:1043-1050.
Short-term changes on MRI predict long-term changes on radiography in rheumatoid arthritis: an analysis by an OMERACT Task Force of pooled data from four randomised controlled trials
Peterfy C, Strand V, Tian L, Østergaard M, Lu Y, DiCarlo J, Countryman P, Deodhar A, Landewé R, Ranganath VK, Troum O, Conaghan PG.Annals of the Rheumatic Diseases Published Online First: 14 December 2016