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Imaging

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.


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Clinical Rheumatology

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