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of joint inflammation 2.3 Assessment



  • of joint inflammation 2.3 Assessment
  • Arthritis and Pain Management: Assessment and Measurement of Pain
  • Introduction
  • The purpose of the SAJI website is to enhance the ability of users to identify joint inflammation using standardized joint assessment technique. Visit the SAJI. GlycA is a novel inflammatory biomarker measured using nuclear a novel inflammatory marker, GlycA, for assessment of rheumatoid arthritis. MRI can detect early joint inflammation with high sensitivity and without the use for the assessment of synovitis, bone oedema and bone erosion,10 that is, joint . at week 4, − ()/+ () at week 8 and − ()/− () at week

    of joint inflammation 2.3 Assessment

    This was a cross-sectional study and thus we are unable to examine the differential effect, if any, on treatment response in patients who are overweight or obese. Other patient co-morbidities such as osteoarthritis and fibromyalgia were not obtained. Aside from ESR and CRP we did not measure markers that others have correlated with obese patients such as adiponectin and leptin.

    Lastly, we noted there was a trivial difference in the depth from skin to joint in the obese patients, but only at the wrist 0. This difference was not significant enough to explain lower scores by way of beam penetration in the obese patients.

    This study suggests that in a cohort of RA patients whose rheumatologist was considering switching therapy, obese RA subjects had lower PDUS scores than non-obese patients while having similar clinical disease activity scores. This implies that clinically assessed swollen joints are less likely to represent true synovitis in obese RA patients, suggesting that RA disease activity can be overestimated by CDAI and DAS28 calculations.

    EMB drafted and revised the manuscript, analyzed and interpreted the data. VKR revised the manuscript, made substantial contributions to conception and design of the study, acquisition of data and interpretation of data. ABA made substantial contributions to acquisition of data and design of the study.

    JDF made substantial contributions to analysis and interpretation of data as well as critically revising the manuscript for important intellectual content.

    All authors have approved the manuscript for submission, and have given necessary attention to ensure the integrity of the work. We confirm that each individual named as an author meets the Uniform Requirements for Manuscripts Submitted to Biomedical Journals criteria for authorship.

    Multivariate Logistic model for GSUS accounts for correlation among different joints in the same patient. National Center for Biotechnology Information , U. Published online Mar 4. Duffy , 1 David A. Elashoff , 1 Sitaram S. Vangala , 1 John Fitzgerald , 1 and Veena K. Author information Article notes Copyright and License information Disclaimer.

    Received Sep 21; Accepted Jan This article has been cited by other articles in PMC. Associated Data Data Availability Statement We will share data with any investigator interested in replicating these findings or interested in future collaborations, pursuant to institutional and IRB regulations, in accordance with patient privacy, confidentiality. Abstract Background Clinical swollen joint examination of the obese rheumatoid arthritis RA patient can be difficult.

    Methods Cross-sectional clinical and laboratory data were collected on 43 RA patients. Electronic supplementary material The online version of this article doi: Ultrasound, Obesity, Outcome measures, Rheumatoid arthritis. Results Demographic characteristics were similar among BMI groups. Open in a separate window. Conclusion This study suggests that in a cohort of RA patients whose rheumatologist was considering switching therapy, obese RA subjects had lower PDUS scores than non-obese patients while having similar clinical disease activity scores.

    Acknowledgments Cesar Olmos provided significant assistance in the collection of data. Availability of data and materials We will share data with any investigator interested in replicating these findings or interested in future collaborations, pursuant to institutional and IRB regulations, in accordance with patient privacy, confidentiality.

    Competing interests The authors declare that they have no competing interests. Consent for publications Not applicable. Additional file Additional file 1: Contributor Information Erin M.

    American College of Rheumatology report on reasonable use of musculoskeletal ultrasonography in rheumatology clinical practice. EULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis. Rowbotham E, Grainger A. Musculoskeletal ultrasound including definitions for ultrasonographic pathology.

    Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: Power Doppler ultrasonography is useful for assessing disease activity and predicting joint destruction in rheumatoid arthritis patients receiving tocilizumab—preliminary data.

    Ultrasonographic and radiographic results from a two-year controlled trial of immediate or one year delayed addition of infliximab to ongoing methotrexate therapy in patients with erosive early rheumatoid arthritis. Assessment of inflammatory activity in rheumatoid arthritis: Power Doppler ultrasound, but not low-field magnetic resonance imaging, predicts relapse and radiographic disease progression in rheumatoid arthritis patients with low levels of disease activity.

    Abnormal body composition phenotypes in older rheumatoid arthritis patients: Higher rates and clustering of abnormal lipids, obesity, and diabetes in psoriatic arthritis compared with rheumatoid arthritis. Obesity is independently associated with impaired quality of life in patients with rheumatoid arthritis. Body mass index and clinical response to infliximab in rheumatoid arthritis.

    The American Rheumatism Association Revised criteria for the classification of rheumatoid arthritis. Examination of intra and interrater reliability with a new ultrasonographic reference atlas for scoring of synovitis in patients with rheumatoid arthritis. Overweight decreases the chance of achieving good response and low disease activity in early rheumatoid arthritis. Treating rheumatoid arthritis to target: Triple Therapy in early active rheumatoid arthritis: Fibromyalgic rheumatoid arthritis and disease assessment.

    Association of concomitant fibromyalgia with worse Disease Activity Score n 28 joints, Health Assessment Questionnaire and Short Form 36 scores in patients with rheumatoid arthritis. Association of high body mass index with decreased treatment response to combination therapy in recent-onset rheumatoid arthritis patients. Obesity and reduction of the response rate to anti-tumor necrosis factor alpha in rheumatoid arthritis: Association of obesity with worse disease severity in rheumatoid arthritis as well as with comorbidities: Underweight and obese states both associate with worse disease activity and physical function in patients with established rheumatoid arthritis.

    Waist circumference based abdominal obesity may be helpful as a marker for unmet needs in patients with RA. Associations between body mass, radiographic joint damage, adipokines and risk factors for bone loss in rheumatoid arthritis. A high body mass index has a protective effect on the amount of joint destruction in small joints in early rheumatoid arthritis. Adiponectin is a mediator of the inverse association of adiposity with radiographic damage in rheumatoid arthritis.

    There are no guidelines to help us decide which RA patients should have an US scan of their joints or how often, despite the constant effort to generate recommendations regarding the use of imaging techniques in the management of patients with RA [ 5 ]. There is no straightforward indicator of the risk of continuing with active joint inflammation, despite the use of several US prediction factors for disease progression and damage [ 6 — 8 ].

    As several outcome measures are required to establish if patients with RA have active disease or not, we identified the need to integrate clinical and laboratory parameters in a prediction model that could improve the quality of care we provide to our patients, by enabling the identification of those at risk of having positive PD signal in their joints.

    In an ideal situation, patients with a previous diagnosis of RA or with the suspicion of having developed IA are offered an US examination of their joints to increase the chance of correct diagnosis and optimise disease control. In reality, because of limited resources, patients are referred to US clinics in a selective manner, based on their clinician expertise and need, and availability of US resources.

    However, it is widely recognised that subtle joint inflammation is often missed by the clinical examination [ 11 ]. It was proposed that RA treatment should target the control of sub-clinical inflammation as assessed by US or MRI , instead of being exclusively guided by clinical examination and laboratory measures [ 12 ], and that remission criteria for patients with RA should also include joint US examination [ 13 , 14 ].

    The rationale of our research project was to generate useful information for clinicians that can be easily applied in real life and can help identify patients at risk of having active inflammation in their joints. Our statistical modelling framework is based on data routinely collected from a heterogeneous RA population.

    The aim of our study was to build a statistical model to assess the influence of several outcome measures on the presence of PD signal.

    The selected outcomes were as follows: We conducted a real-life, retrospective cohort study of patients seen to our US outpatient clinics in the order of their referral, between May and September We used an established protocol of US examination of hands comprising flexor tendons and 22 joint assessments dorsal longitudinal and transverse views , which is the standard of practice for our US clinics.

    All the patients were referred to this clinic for inflammatory symptoms in their hands, and their clinical examination was equivocal. No inclusion or exclusion criteria were applied for the selection of patients, to ensure the general applicability of the prediction model we propose. We also stratified patients based on their disease activity assessed using the disease activity score assessing 28 joints DAS We also performed a cluster analysis of patients with similar DAS scores using the aforementioned outcome measures.

    The settings used were as follows: Because of the small number of joints with PD signal only patients with equivocal clinical examination were referred for an US examination of their hands , we did not report separately the grades of PD signal. We proposed a regression model to assess the contribution of every outcome measure to the risk of having active joint inflammation as well as predict PD signal.

    We conducted a real-life study including patients referred for the suspicion of active joint inflammation new referrals for S-IA, RA patients and patients with other inflammatory rheumatic conditions.

    The proposed regression model was based on a beta-binomial distribution with the response ranging from 0 to 10 for the PD score variable and a mix of main interaction effects for the outcome measures stated earlier. Negative interaction effects show that the respective outcome is associated with a lower number of joints with PD signal. We collected data from consecutive patients referred to our rheumatologist-led US clinic to have a scan of their hand joints aiming to answer the clinician question about the presence of active inflammation in their joints.

    There were patients with established RA, 93 were referred for the clinical suspicion of IA, 29 were previously diagnosed with psoriatic arthritis PsA and 46 patients had other diagnoses, including crystal arthropathies, sarcoidosis, osteoarthritis and chronic pain.

    We analysed in parallel the characteristics of the two main groups of patients: The assessment of the follow-up clinical letters of S-IA patients revealed that The rest of the patients initially referred with the suspicion of IA In terms of biologic treatments, Out of patients with established RA, 89 patients These patients were excluded from the further analysis that stratified them based on their disease activity.

    Tendon abnormalities such as effusion and tendon sheet thickening were more frequently observed in patients with RA vs. In five cases, the presence of PD was associated with osteophytes and they have been diagnosed with inflammatory OA. The binominal model analysis evaluated the impact of several variables on the risk of having active joint inflammation assessed by the presence of PD. The most negative values suggested a lower risk for positive PD signal in correlation with a certain parameter.

    Similarly, the average PD score of a patient diagnosed with RA and treated with tocilizumab decreased by 1. The effect of different variables on the risk for a higher PD score was close to a zero value in the case of treatment with MTX and etanercept. For example, our prediction model suggested that in this group, the RA patients treated with MTX or etanercept monotherapy had a similar risk of having active joint inflammation on US. In this particular case, all the outcome measures taken into consideration in the prediction model are more relevant than being treated with MTX rather than etanercept.

    Marginal effects of different variables on the number of joints with PD signal in patients with other arthropathies vs.

    We also attempted a cluster analysis of patients with similar DAS scores using the following variables: Although there was no obvious clustering of patients based on their diagnosis, the analysis revealed five big clusters with a large jump in the levels of two consecutive nodes Fig. The results of our comparative analysis between the two groups of patients reflected their selection: As expected, the number of joints with active inflammation and clinical swelling was low.

    Patients with established RA had longer disease duration and more obvious chronic inflammatory changes defined as SH and tendon inflammatory changes. Chronic joint changes characteristic for RA are known to pose clinical difficulty in assessing for the presence of active inflammation.

    As frequently encountered in clinical practice, patients with chronic conditions probably have better coping strategies, and this can account for the reported difference in the GVAS assessment between the two groups, despite similar pain scores. A large proportion of our study patients with positive PD signal in at least one of their hand joints was diagnosed with a form of IA following the US scan Also, our study showed that about one in two patients with inflammatory joint pains has active arthritis based on US examination, even if they have not been previously diagnosed with any joint disease.

    The binominal regression analysis model found that certain parameters can have different impacts on the PD signal risk prediction. It is difficult to appreciate the magnitude of the effect of different parameters taken into consideration in this prediction model because of the limited number of patients included in our study.

    Tocilizumab is considered one of the most potent inhibitors of synovial inflammation and was expected to be associated with the lower risk for PD signal, even in the context of joint pains.

    This is the first study to propose a statistical prediction model integrating clinical, laboratory and US parameters aiming to predict which characteristics are associated with an increased risk of having active joint inflammation at the US examination in two different groups of patients.

    The main diagnosis difficulties arise when a patient does not fulfil criteria for a diagnosis of IA, and the availability of US scans is limited.

    Despite the effort to establish guidelines for early diagnosis of RA integrating US data [ 16 ], there are no algorithms to help with the exclusion of IA in the context of inflammatory hand pains. Ideally, all patients with inflammatory hand pain should have an US examination to exclude joint inflammation.

    The US examination was proven effective in altering treatment decision and had increased sensitivity compared to clinical examination [ 17 ]. As the patients were referred to have a scan because of the difficulty to appreciate if their joints had active inflammation or not, rather than being screened for US abnormalities in the context of arthritis, the two groups of patients are not representative for the general group of patients with IA and established RA.

    It is recognised that patients with established RA have chronic inflammatory changes, and the presence of swelling is not always indicative of presence of active inflammation, whereas patients with no previous diagnosis of arthritis might get swellings if their joints become inflamed. However, previous studies found a disparity between the clinical assessment of joint swelling and tenderness and the presence of PD signal in patients with established RA [ 18 ].

    In our study, the presence of PD did not correlate with the erosion scores in RA patients, probably because the two phenomena are temporarily distinct. Previous studies have been focused on patients with early RA, establishing the importance of US for early diagnosis [ 15 ], disease progression assessment [ 19 ] and prediction of risk to develop arthritis [ 3 , 20 ].

    Our study has some important limitations: This prediction risk model, if validated, will ensure patient access to US scans based on the stratification of their risk of having sub-clinical joint inflammation to minimise the risk of under-diagnosing active RA in the context of limited NHS clinical resources. The US score used included only hand joints as the patients referred to our US clinics had hand joint inflammatory pains.

    We do not suggest the extrapolation of our study findings for other joint areas or for other inflammatory arthropathies.

    Arthritis and Pain Management: Assessment and Measurement of Pain

    erosions, hand osteoarthritis, inflammatory arthritis, pain, function a clinical assessment in the CAS-K study if they reported knee pain (rather than hand pain or hand .. AIMS-2 pain subscale, (), (), (, ). RA is a chronic inflammatory disease predominantly affecting joints, with clinical synovitis, through the presence of joint swelling as part of a joint count assessment. .. Physician TJC, mean (s.d.), (), (), (). Musculoskeletal ultrasound (MSUS) with power Doppler (PDUS) has become an accepted modality to identify features of inflammatory arthritis.




    erosions, hand osteoarthritis, inflammatory arthritis, pain, function a clinical assessment in the CAS-K study if they reported knee pain (rather than hand pain or hand .. AIMS-2 pain subscale, (), (), (, ).


    RA is a chronic inflammatory disease predominantly affecting joints, with clinical synovitis, through the presence of joint swelling as part of a joint count assessment. .. Physician TJC, mean (s.d.), (), (), ().


    Musculoskeletal ultrasound (MSUS) with power Doppler (PDUS) has become an accepted modality to identify features of inflammatory arthritis.


    Subclinical inflammation is more common in patients with RA in clinical remission Ultrasound (US) assessment of small joints is routinely used for the .. Median and IQR, (, ), 0 (0, 5), (, ), (, ).


    Ultrasound and magnetic resonance imaging assessment of joint disease in Cystic fibrosis arthropathy (CFA) is a term commonly used for joint pain with and . Serology. Routine bloods were taken for full blood count, biochemistry.

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