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SMJ // Article

Original Article

Clinical Evaluation and Power Doppler Sonography in Rheumatoid Arthritis: Evidence for Ongoing Synovial Inflammation in Clinical Remission

Authors: Salih Ozgocmen, MD, Huseyin Ozdemir, MD, Adem Kiris, MD, Zulkif Bozgeyik, MD, Ozge Ardicoglu, MD

Abstract

Objective: This study proposed to assess the relationship between power Doppler ultrasound examination and spectral Doppler analysis of hand joints with clinical and laboratory parameters in rheumatoid arthritis.


Methods: Patients receiving disease-modifying antirheumatic drugs or biologics (infliximab) underwent joint examination and were assessed by a Health Assessment Questionnaire, Duruoz's Hand Index, and Hand Function Test. All were categorized for disease activity using the American College of Rheumatology and disease activity score 28-joint (DAS28) criteria. Ten metacarpophalangeal joints and 4 wrist joints (ulnar-carpal and radiocarpal joints) in each patient were examined by power Doppler and spectral Doppler. Flow signal in the synovium was semiquantitatively graded. A cumulative flow signal score (CFS) and mean resistive index (RI) was calculated in each patient.


Results: Patients with active disease had significantly higher CFS compared with patients with inactive disease, but the mean RI was similar. Health Assessment Questionnaire, Duruoz's Hand Index, Larsen, and DAS28 scores correlated significantly with CFS, but the erythrocyte sedimentation rate and C-reactive protein scores did not. Mean RI did not correlate with clinical or laboratory parameters. A majority of patients who were in clinical remission according to American College of Rheumatology or DAS28 criteria had ongoing synovial inflammation on power Doppler ultrasound (58% and 62%, respectively).


Conclusion: Power Doppler examination of rheumatoid hand joints is a practical method to estimate synovial inflammation. A modification of current remission criteria by combining imaging techniques with clinical and laboratory examination may be conceivable. These results underscore the necessity of more sophisticated research, assessing the agreement between long-term Doppler changes and clinical parameters.


Key Points


* Power Doppler examination of rheumatoid hand joints is sensitive and complimentary to the clinical assessment.


* A considerable amount of patients in clinical remission continue to have ongoing synovial inflammation, which can be assessed using a sensitive method power Doppler ultrasound.


* Current remission criteria may be modified by combining clinical evaluation with sensitive and practical imaging methods.

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References

1. Firestein G. Etiology and Pathogenesis of Rheumatoid Arthritis. Philadelphia, WB Sounders Co, 2001.
 
2. Pinals RS, Masi AT, Larsen RA. Preliminary criteria for clinical remission in rheumatoid arthritis. Arthritis Rheum 1981;24:1308–1315.
 
3. Felson DT, Anderson JJ, Boers M, et al. The American College of Rheumatology preliminary core set of disease activity measures for rheumatoid arthritis clinical trials. The Committee on Outcome Measures in Rheumatoid Arthritis Clinical Trials. Arthritis Rheum 1993;36:729–740.
 
4. OMERACT, Conference on Outcome Measures in Rheumatoid Arthritis Clinical Trials. Proceedings. Maastricht, The Netherlands, April 29-May 3, 1992. J Rheumatol 1993;20:527–591.
 
5. Young A, van der Heijde DM. Can we predict aggressive disease? Baillieres Clin Rheumatol 1997;11:27–48.
 
6. Backhaus M, Kamradt T, Sandrock D, et al. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound, and contrast-enhanced magnetic resonance imaging. Arthritis Rheum 1999;42:1232–1245.
 
7. Fornage BD. Soft-tissue changes in the hand in rheumatoid arthritis: evaluation with US. Radiology 1989;173:735–737.
 
8. Wakefield RJ, Gibbon WW, Conaghan PG, et al. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: a comparison with conventional radiography. Arthritis Rheum 2000;43:2762–2770.
 
9. Kane D, Balint PV, Sturrock R, et al. Musculoskeletal ultrasound—a state of the art review in rheumatology. Part 1: Current controversies and issues in the development of musculoskeletal ultrasound in rheumatology. Rheumatology (Oxford) 2004;43:823–828.
 
10. Newman JS, Adler RS, Bude RO, et al. Detection of soft-tissue hyperemia: value of power Doppler sonography. AJR Am J Roentgenol 1994;163:385–389.
 
11. Qvistgaard E, Rogind H, Torp-Pedersen S, et al. Quantitative ultrasonography in rheumatoid arthritis: evaluation of inflammation by Doppler technique. Ann Rheum Dis 2001;60:690–693.
 
12. Walther M, Harms H, Krenn V, et al. Synovial tissue of the hip at power Doppler US: correlation between vascularity and power Doppler US signal. Radiology 2002;225:225–231.
 
13. Szkudlarek M, Court-Payen M, Strandberg C, et al. Power Doppler ultrasonography for assessment of synovitis in the metacarpophalangeal joints of patients with rheumatoid arthritis: a comparison with dynamic magnetic resonance imaging. Arthritis Rheum 2001;44:2018–2023.
 
14. Walther M, Harms H, Krenn V, et al. Correlation of power Doppler sonography with vascularity of the synovial tissue of the knee joint in patients with osteoarthritis and rheumatoid arthritis. Arthritis Rheum 2001;44:331–338.
 
15. Carotti M, Salaffi F, Manganelli P, et al. Power Doppler sonography in the assessment of synovial tissue of the knee joint in rheumatoid arthritis: a preliminary experience. Ann Rheum Dis 2002;61:877–882.
 
16. Naredo E, Bonilla G, Gamero F, et al. Assessment of inflammatory activity in rheumatoid arthritis: a comparative study of clinical evaluation with grey scale and power Doppler ultrasonography. Ann Rheum Dis 2005;64:375–381.
 
17. Arnett FC, Edworthy SM, Bloch DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum 1988;31:315–324.
 
18. Ramey DR, Raynauld JP, Fries JF. The health assessment questionnaire 1992: status and review. Arthritis Care Res 1992;5:119–129.
 
19. Ritchie DM, Boyle JA, McInnes JM, et al. Clinical studies with an articular index for the assessment of joint tenderness in patients with rheumatoid arthritis. Q J Med 1968;37:393–406.
 
20. Prevoo ML, van't Hof MA, Kuper HH, et al. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38:44–48.
 
21. Duruoz MT, Poiraudeau S, Fermanian J, et al. Development and validation of a rheumatoid hand functional disability scale that assesses functional handicap. J Rheumatol 1996;23:1167–1172.
 
22. Pinals RS, Baum J, Bland J, et al. Preliminary criteria for clinical remission in rheumatoid arthritis. Bull Rheum Dis 1982;32:7–10.
 
23. Mulherin D, Fitzgerald O, Bresnihan B. Clinical improvement and radiological deterioration in rheumatoid arthritis: evidence that the pathogenesis of synovial inflammation and articular erosion may differ. Br J Rheumatol 1996;35:1263–1268.
 
24. Molenaar ET, Voskuyl AE, Dinant HJ, et al. Progression of radiologic damage in patients with rheumatoid arthritis in clinical remission. Arthritis Rheum 2004;50:36–42.
 
25. Szkudlarek M, Court-Payen M, Jacobsen S, et al. Interobserver agreement in ultrasonography of the finger and toe joints in rheumatoid arthritis. Arthritis Rheum 2003;48:955–962.
 
26. Ozgocmen S, Kiris A, Kocakoc E, et al. Evaluation of metacarpophalangeal joint synovitis in rheumatoid arthritis by power Doppler technique: relationship between synovial vascularization and periarticular bone mineral density. Joint Bone Spine 2004;71:384–3888.
 
27. Hau M, Kneitz C, Tony HP, et al. High resolution ultrasound detects a decrease in pannus vascularisation of small finger joints in patients with rheumatoid arthritis receiving treatment with soluble tumour necrosis factor alpha receptor (etanercept). Ann Rheum Dis 2002;61:55–58.
 
28. Stone M, Bergin D, Whelan B, et al. Power Doppler ultrasound assessment of rheumatoid hand synovitis. J Rheumatol 2001;28:1979–1982.
 
29. Ribbens C, Andre B, Marcelis S, et al. Rheumatoid hand joint synovitis: gray-scale and power Doppler US quantifications following anti-tumor necrosis factor-alpha treatment: pilot study. Radiology 2003;229:562–569.
 
30. Teh J, Stevens K, Williamson L, et al. Power Doppler ultrasound of rheumatoid synovitis: quantification of therapeutic response. Br J Radiol 2003;76:875–879.
 
31. Ozgocmen S, Kiris A, Ardicoglu O, et al. Glucocorticoid iontophoresis for Achilles tendon enthesitis in ankylosing spondylitis: significant response documented by power Doppler ultrasound. Rheumatol Int 2005;25:158–160.
 
32. Salaffi F, Carotti M, Manganelli P, et al. Contrast-enhanced power Doppler sonography of knee synovitis in rheumatoid arthritis: assessment of therapeutic response. Clin Rheumatol 2004;23:285–290.
 
33. Terslev L, Torp-Pedersen S, Qvistgaard E, et al. Spectral Doppler and resistive index. A promising tool in ultrasonographic evaluation of inflammation in rheumatoid arthritis. Acta Radiol 2003;44:645–652.
 
34. Brown AK, Quinn MA, Karim Z, et al. Presence of significant synovitis in rheumatoid arthritis patients with disease-modifying antirheumatic drug-induced clinical remission. Evidence from an imaging study may explain structural progression. Arthritis Rheum 2006;54:3761–3773.