Power Doppler Ultrasound Score Research Articles

Combination of ultrasound power Doppler-verified synovitis and seropositivity accurately identifies patients with early-stage rheumatoid arthritis.

We conducted this retrospective study to identify objective and comprehensive diagnostic criteria for early-stage rheumatoid arthritis (RA) that are based on ultrasound (US) and serologic findings. From August 2014 to May 2016, we recruited 216 consecutive patients at Hospital 1 and 223 consecutive patients at Hospital 2 who were suspected to have RA and underwent US of bilateral hands. In the US of bilateral hands from 22 sites, the findings obtained by grayscale and power Doppler (PD) assessments were each graded on a semi-quantitative scale from 0 to 3. We also examined the assessment of the novel outcome measures in rheumatology (OMERACT)-European League Against Rheumatism (EULAR) combined power Doppler ultrasound score (ie the cPD score) and the Global OMERACT-EULAR Synovitis Score. We used the US findings and the combination of US and serologic findings to evaluate the diagnostic performance of these modalities. Seventy patients (32.4%) at Hospital 1 and 59 patients (26.5%) at Hospital 2 were diagnosed as having RA. The best-balanced diagnostic performance at each hospital was achieved using a combination, such as (1) the presence of PD grade ≥2 articular synovitis or (2) the presence of PD grade ≥1 articular synovitis and serologic positivity, as well as by using (1) the presence of cPD grade=3 or (2) a cPD grade ≥2 and serologic positivity. The combination of a PD assessment or the cPD score with the measurement of autoantibodies of rheumatoid factor and/or anti-cyclic citrullinated peptide antibodies can accurately identify patients with early-stage RA.

Role of Interleukin 37 as a Novel Proangiogenic Factor in Juvenile Idiopathic Arthritis.

The aim of this study was to investigate interleukin 37 (IL-37) levels in the serum and synovial fluid of patients with juvenile idiopathic arthritis (JIA), its expression in peripheral blood mononuclear cells, and correlation with disease activity and angiogenesis. Seventy JIA patients and 50 control subjects were examined. The Juvenile Arthritis Disease Activity Score in 27 joints (JADAS-27) was calculated. Immunoassays were used to measure the serum and synovial fluid levels of IL-37, vascular endothelial growth factor (VEGF), soluble VEGF receptor 1 (sVEGF-R1), and sVEGF-R2. Relative expression of IL-37 mRNA in peripheral blood mononuclear cells and the power Doppler ultrasound score of the affected joint were measured. Patients with JIA were subdivided as 20 systemic-onset, 20 polyarticular, and 30 oligoarticular (10 persistent, 20 extended) cases. Serum levels of IL-37, VEGF, VEGF-R1, and VEGF-R2 and relative IL-37 mRNA expression were significantly higher in JIA patients when compared with the control subjects (p < 0.001). These concentrations were significantly higher in systemic-onset JIA compared with those in polyarticular and oligoarticular JIA, and in polyarticular JIA when compared with oligoarticular JIA (p < 0.001). Serum, synovial, and mRNA expression levels of IL-37 were positively correlated with C-reactive protein, erythrocyte sedimentation rate, Juvenile Arthritis Disease Activity Score in 27 joints, power Doppler ultrasound score (p < 0.001), and the serum and synovial VEGF and VEGF-RI and -R2 levels (p < 0.05). Our results demonstrate that IL-37 levels and mRNA expression were significantly increased in JIA patients, and their levels were positively correlated with disease activity and markers of angiogenesis (VEGF and VEGF receptors), suggesting that IL-37 may be correlated with angiogenesis.

Subclinical synovitis and enthesitis in psoriasis patients and controls by ultrasonography in Saudi Arabia; incidence of psoriatic arthritis during two\xa0years

ObjectiveTo evaluate ultrasonographic subclinical inflammatory synovitis and enthesitis in psoriasis patients, without clinical arthritis or enthesitis compared with healthy controls, with a 2-year follow-up to study the associated incidence of psoriatic arthritis (PsA).MethodsA total of 109 consecutive psoriasis vulgaris patients without clinical signs of PsA and 90 healthy controls were included from two tertiary medical centers. Subjects underwent dermatological examination, PASI score evaluation for severity of psoriasis, musculoskeletal examination using 68/66 joints count for tenderness and swollen joints. Patients were assessed for CRP, musculoskeletal ultrasound (MSUS) in the form of grayscale ultrasound (GSUS), and power Doppler ultrasound (PDUS) for eight entheses and 34 joints to detect MSUS subclinical enthesitis and synovitis. All patients were followed-up for 2 years to detect evolving PsA.ResultsSubclinical enthesitis and synovitis were detected in 39.5% of psoriasis patients and 10% of controls (P < 0.001). CRP was significantly higher in psoriasis patients with MSUS manifestations (P < 0.01). PDUS and GSUS subclinical synovitis and/or enthesitis were detected at least in one site in psoriatic patients more than in controls (P < 0.05). During a 2-year follow-up of patients, the annual PsA incidence was 4.3%. Psoriasis patients who developed PsA showed a higher prevalence of baseline enthesitis, higher PDUS and GSUS synovitis scores, and higher baseline CRP level than those who did not develop PsA.ConclusionsMSUS subclinical synovitis and enthesitis are quite common in psoriasis patients. The incidence of PsA in Saudi’s psoriasis patients was slightly higher than worldwide reports. Subclinical enthesitis, PDUS, and GSUS synovitis could predict PsA development.

Predicting disease progression and poor outcomes in patients with moderately active rheumatoid arthritis: a systematic review.

ObjectivesAccess to biologic DMARDs for RA is often restricted to those with severe disease. This systematic review aimed to identify prognostic factors in patients with moderate disease activity who may be at risk of disease progression and poor clinical outcomes.MethodsMEDLINE, Embase and Cochrane databases were searched (final search 22 September 2017), and data from patients with moderate disease [28-joint DAS (DAS28) >3.2–≤5.1] were included. Studies were evaluated according to the measure(s) of progression/poor outcome used: radiographic, disease activity or other indicators.ResultsThe searches identified 274 publications, of which 30 were selected for data extraction. Fourteen studies were prioritized, because they specifically analysed patients with moderate RA. Nine studies reported radiographic progression outcomes for 3241 patients, three studies reported disease activity progression for 1516 patients, and two studies reported other relevant outcomes for 2094 patients. Prognostic factors with consistent evidence for progression/poor outcome prediction were as follows: DAS28 ≥ 4.2, the presence of anti-CCP antibodies, and power Doppler ultrasound score ≥1. Some predictors were specific to either disease activity or radiographic progression.ConclusionSeveral criteria used in standard clinical practice were identified that have the potential to inform the selection of patients with moderate RA who are at greater risk of a poor outcome. A combination of two or more of these factors might enhance their predictive potential. Further work is required to derive clinical decision rules incorporating these factors.

Musculoskeletal ultrasound as a biomarker of remission - results from a one-year prospective study in patients with rheumatoid arthritis.

To assess the role of musculoskeletal ultrasound (MSUS) as a biomarker of remission and to compare the rates of clinical and imaging remission in patients with rheumatoid arthritis (RA) on different types of treatment. One hundred and forty-one patients underwent physical and ultrasound examination at 5 visits (at baseline and after 1, 3, 6 and 12 months). Patients were divided into two groups according to the type of treatment, which involved synthetic (sDMARDs) and biologic (bDMARDs) disease-modifying antirheumatic drugs. Ultrasound assessment of the wrist, second and third metacarpophalangeal, second and third proximal interphalangeal joints, and the second and fifth metatarsophalangeal joints was performed on gray scale ultrasound (GSUS) and on power Doppler ultrasound (PDUS) (German US7-score). The rate of imaging and clinical remission (DAS28, SDAI, CDAI, and Boolean) was established. The percentage of patients in clinical remission with persistent PD signal was assessed. In the sDMARDs group at month twelve, 43.6% of the patients achieved DAS28 remission, 5.1% - SDAI, 3.8% - CDAI, and 3.8% - Boolean remission. In the bDMARDs group 49.2% achieved DAS28 remission, 6.3% - SDAI, 4.8% - CDAI, and 4.8% - Boolean remission. Irrespective of which clinical index was applied, all patients in clinical remission had persistent synovial hypertrophy on GSUS. Synovial PD signal (PDUS score≥1) was detected in 77% and 71% of patients in DAS28 remission in the sDMARDs and bDMARDs group, respectively. Patients in SDAI, CDAI and Boolean remission in both treatment groups did not have а positive PD signal. There is persistence of synovitis both in patients on sDMARDs and bDMARDs in DAS28 clinical remission. This fact points to a discordance between DAS28 clinical remission and the imaging remission assessed by MSUS irrespective of the type of treatment. MSUS may be a feasible imaging method for the assessment of residual inflammation in daily rheumatology practice.

Musculoskeletal ultrasound for predicting remission in patients with rheumatoid arthritis: results from a 1-year prospective study.

To assess the role of musculoskeletal ultrasound as a predictor for the achievement of DAS28 remission in patients with rheumatoid arthritis (RA). One hundred and forty-one patients underwent physical and ultrasound examination at five visits (at baseline and after 1, 3, 6 and 12months). Patients were divided into two groups according to the type of treatment, which involved synthetic (sDMARDs) and biologic (bDMARDs) disease-modifying antirheumatic drugs. Ultrasound assessment of the wrist, second and third metacarpophalangeal, second and third proximal interphalangeal joint, second and fifth metatarsophalangeal joint (the German US7 score) was performed on gray scale (GS) and on power Doppler ultrasound (PDUS). The rate of clinical remission and clinical and sonographic predictors for the achievement of DAS28 remission at month 12 were assessed. In the sDMARDs group at month 12, 43.6% of the patients achieved DAS28 remission, 5.1%-SDAI, 3.8%-CDAI, and 3.8%-Boolean remission. In the bDMARDs group, 49.2% achieved DAS28 remission, 6.3%-SDAI, 4.8%-CDAI, and 4.8%-Boolean remission. Predictors for DAS28 clinical remission in the sDMARDs group were low baseline DAS28 (p = 0.002), short disease duration (p = 0.007) and lower baseline PDUS score (p = 0.038). In the bDMARDs group low baseline DAS28 (p < 0.001) and PDUS score (p = 0.035) predicted DAS28 remission. Shorter disease duration, lower baseline DAS28 and PDUS scores are associated with a higher probability of achieving DAS28 remission at month 12 in patients with RA. Musculoskeletal ultrasound and in particular the German US7-scoring system may be used as a predictor for the achievement of clinical remission in RA patients.

The role of Doppler Ultrasonography in evaluating disease activity in a group of juvenile idiopathic arthritis patients

The goal of the study is the evaluation of Power Doppler ultrasound (PDUS) ability to detect the disease activity in juvenile idiopathic artheritis (JIA) patients compared to clinical and biological markers. In forty JIA patients, 1120 joints were assessed clinically and with Doppler ultrasonography. The semi quantitative four grade scale (0–3) was used for grading the PDUS. The disease activity was assessed using the 28-joint Disease Activity Score (DAS28-CRP). Synovitis was detected clinically in 17.5% of examined joints, while ultrasound detected synovitis was found in 18.8%; including 3.5% of clinically normal joints. DAS28-CRP was significantly associated with US findings. Ultrasound evidence of synovial hyperplasia significantly correlated with joint swelling r = 0.87, while PDUS was significantly correlated with joints tenderness, r = 0.92. PDUS assessment of synovial vascularization could detect mild disease activity with 100% sensitivity and 75% specificity. Kappa statistics revealed marked agreement (0.83) between tenderness and power Doppler US. Patients showing higher PDUS score (>/=2) are mostly having active disease. ConclusionUltrasound and PDUS are reliable methods for detection of synovitis and disease activity in JIA, early in the disease and during clinical remission.

Superb Microvascular Imaging of the Median Nerve in Carpal Tunnel Syndrome: An Electrodiagnostic and Ultrasonographic Study.

To evaluate intraneural blood flow of the median nerve using superb microvascular imaging (SMI) and power Doppler ultrasonography (PDUS), and to examine their correlation with electroneuromyography in patients with carpal tunnel syndrome (CTS). A cross-sectional survey was used, and the study was conducted in the research unit of a training and research hospital. Patients diagnosed with CTS according to electroneuromyography studies were included in the study. Ultrasound measurements were taken using an Aplio-500 (Toshiba Medical System Corporation, Tokyo, Japan) device and a linear multifrequency 14-MHz probe. The cross-sectional area of the median nerve at the carpal tunnel level was measured by the direct tracing method using electronic calipers. The power Doppler ultrasonography and superb microvascular imaging scores were recorded by grading the vascularity between 0 and 3. Evaluation was made of a total of 113 hands of 80 patients (18 men, 62 women) with a mean age of 34.67 ± 12.82 years. The mean duration of symptoms was 12.34 ± 6.66 months. When the patients were grouped as mild, moderate, and severe CTS, there was a statistically significant difference between the SMI and PDUS grades (P < .05). As the severity of CTS increased, an increase in SMI and PDUS scores was observed. There was a strong correlation between SMI scores and motor distal latency (r = .71/P = .026), amplitude of sensory action potential (r = -.77/P = .029), and sensory neurotransmission rate (r = .77/P = .029). SMI seems to be more sensitive than PDUS for evaluating the vascularity of the median nerve in patients with CTS, and SMI grading is correlated with the ENMG results.

Ultrasound verified inflammation and structural damage in patients with hereditary haemochromatosis-related arthropathy

BackgroundChronic arthropathy occurs in approximately two thirds of patients with hereditary haemochromatosis (HH). The aim was to study inflammatory and structural lesions in patients with HH with (HH-A) and without arthropathy (HH-WA) using ultrasonography.MethodsThis was a cross-sectional study of 26 patients with HH-A, 24 with HH-WA and 37 with hand osteoarthritis (HOA). Clinical examination was performed in 68 joints, and we retrieved data on hand function, pain and global disease activity (all using a visual analogue scale (VAS)), morning stiffness and ferritin levels. Standard x-ray and ultrasound were conducted in 36 joints (hands, hips, knees and ankles), and we graded grey scale synovitis (GSS), power Doppler ultrasound (PD), osteophytes, erosions, tenosynovitis and cartilage damage semi-quantitatively in accordance with prior publications.ResultsUltrasound revealed a high proportion of inflammatory changes in HH-A; GSS was found in 96.2% and PD signals in 80.8% of patients (median GSS score 9, PD score 2.5). The frequency of these findings was similar in HOA. Inflammation was also common in HH-WA, yielding GSS in 83.3% and PD signals in 50.0% of patients. Cartilage damage was most prominent in HH-A as compared to HH-WA and HOA (median scores 11.0, 2.5 and 2.0, respectively). The prevalence and extent of erosions and osteophytes were similar in all groups. None of the ultrasound scores was associated with pain or function; GSS, PD, osteophyte and cartilage scores correlated with x-ray-verified structural damage.ConclusionA high prevalence of ultrasound-verified inflammation and cartilage damage was found in HH-A, and to a lesser extent in HH-WA. These findings were associated with x-ray-verified damage but not with clinical scores of pain and function.

Association of neutrophil to lymphocyte ratio with disease activity indices and musculoskeletal ultrasound findings in recent onset rheumatoid arthritis patients

Aim of the workTo study the relation between neutrophil-lymphocyte ratio (NLR) with disease activity indices and with musculoskeletal ultrasonographic findings in recent onset rheumatoid arthritis (RA) patients. Patients and methodsThe study consisted of 40 recently diagnosed RA patients and 40 matched control. Patients’ disease activity was assessed clinically by the disease activity score (DAS-28). Musculoskeletal ultrasound was performed to detect synovitis by Power-Doppler ultrasound (PDUS). The association of NLR with the disease activity indices and the PDUS score were analyzed. ResultsThe mean age of the patients was 44.5±2.7years, disease duration 9.4±4.5months and the female:male ratio was 2.3:1. Their disease activity was 4.7±1.33 and the PDUS score was 10.24±4.56. The NLR was significantly increased in the RA patients (3.28±0.59) compared to the control (1.7±0.23) (p<0.0002). There was a significant correlation between NLR with the disease duration (p<0.015), tender joint count (p<0.022), swollen joint count (p<0.018), morning stiffness (p<0.045), visual analogue scale (p<0.026), DAS-28 (p<0.049), erythrocyte sedimentation rate (p<0.032), C-reactive protein (p<0.017) and PDUS score (p<0.037). NLR was significantly elevated in highly active RA patients compared to patients with moderate and low disease activity (p<0.014). ConclusionNLR significantly correlated with disease activity indices in recent onset RA patients thus reflecting systemic inflammation with its advantages of being available, easy and cost accessible being as reliable as the DAS-28 hence it could be used as a marker of disease activity.

Ultrasonographic evaluation of enthesitis in patients with ankylosing spondylitis.

The aim of this study was to assess sensitivity and responsiveness of power Doppler ultrasound (PDUS) in detecting enthesitis for ankylosing spondylitis (AS) patients compared to clinical examinations. Twenty AS patients initiating etanerceptunderwent clinical and PDUS examinations of six bilateral entheseal sites at baseline and after 1, 2 and 3 months of treatment. Clinical and PDUS examinations identified at least one entheseal lesion in nine (45%) and 19 (95%) patients, respectively. Furthermore, of 240 entheseal sites examined in these 20 patients, PDUS detected 123 entheseal lesions (51.3% of sites), compared with only 47 entheseal lesions (19.6%) detected by clinical examination (P<0.05). The entheseal lesions found on PDUS were most commonly identified by calcification (33.3%), tendon edema (29.2%), abnormal blood flow (25.8%), a thickened tendon (22.1%), cortical irregularity (12.9%), bony erosions (9.6%) and bursitis at the tendon insertion to the bone cortex (7.1%). Improvements in clinical symptoms and laboratory parameters, and significant decreases in PDUS scores were observed following treatment with etanercept. Improvements in PDUS scores continued during follow-up in patients who entered remission following treatment. In conclusion, PDUS improves detection of structural and inflammatory abnormalities of the enthesis in AS compared to physical examination. In addition, PDUS may be useful inascertaining medications.

SAT0215 Ultrasound Disease Activity at 3 Months Predicts the Clinical Response at 6 Months of Patients with Rheumatoid Arthritis Treated by Biologic Disease Modifying Anti-Rheumatic Drugs

BackgroundEULAR recommendations for the use of imaging of the joints in the clinical management of rheumatoid arthritis (RA) states that inflammation seen on ultrasound (US) is considered to be useful...

AB1018 Articular Synovitis or Tenosynovitis - Which is More Involved toward Functional Disabilities in Patients with Rheumatoid Arthritis? Investigation of Wrist and Finger Joints by Ultrasound in Early-Stage Rheumatoid Arthritis

BackgroundBoth articular synovitis and tenosynovitis found by ultrasound (US) are representative findings in patients with rheumatoid arthritis (RA). These inflammatory changes appear to involve in functional disabilities of patients with...

AB0948 Power Doppler Ultrasound Monitoring of Response to Anti-TNFα Treatment in Patients with Rheumatoid Arthritis

BackgroundJoint synovial inflammation is the primary abnormality in rheumatoid arthritis (RA) and monitoring of the response of synovitis to treatments has a fundamental importance in the management of RA patients....

SAT0208 Seven-Joint Power Doppler Ultrasound Score is Discordant to DAS28, SDAI and CDAI in Treatment Target Identification in Rheumatoid Arthritis Patients with Fibromyalgia

BackgroundFM increases DAS28, SDAI and CDAI, misleading DMARD use and increasing costs and adverse events. (1,2) Seven-joint PDUS score is an objective measure of RA activity and, therefore, should not...

Interleukin‐17+CD8+ T Cells Are Enriched in the Joints of Patients With Psoriatic Arthritis and Correlate With Disease Activity and Joint Damage Progression

ObjectivePsoriatic arthritis (PsA) is associated with HLA class I genes, in contrast to the association with HLA class II in rheumatoid arthritis (RA). Since IL-17+ cells are considered important mediators of synovial inflammation, we sought to determine whether IL-17–producing CD8+ T cells may be found in the joints of patients with PsA and whether these cells might contribute to the disease process.MethodsMononuclear cells from paired samples of synovial fluid (SF) and peripheral blood (PB) from patients with PsA or patients with RA were stimulated ex vivo, and CD4− T cells were examined by flow cytometry for cytokine expression, cytotoxic markers, and frequencies of γ/δ or mucosal-associated invariant T cells. Clinical measures of arthritis activity (C-reactive protein [CRP] level, erythrocyte sedimentation rate [ESR], Disease Activity Score in 28 joints [DAS28]) and power Doppler ultrasound (PDUS) scores for the presence of active synovitis in the aspirated knee were recorded and assessed for correlations with immunologic markers.ResultsWithin the CD3+ T cell compartment, both IL-17+CD4− (predominantly CD8+) and IL-17+CD4+ T cells were significantly enhanced in the SF compared to the PB of patients with PsA (P = 0.0003 and P = 0.002, respectively; n = 21), whereas in patients with RA, only IL-17+CD4+ T cells were increased in the SF compared to the PB (P = 0.008; n = 14). The frequency of IL-17+CD4− T cells in PsA SF was positively correlated with the CRP level (r = 0.52, P = 0.01), ESR (r = 0.59, P = 0.004), and DAS28 (r = 0.52, P = 0.01), and was increased in patients with erosive disease (P < 0.05). In addition, the frequency of IL-17+CD4− T cells positively correlated with the PDUS score, a marker for active synovitis (r = 0.49, P = 0.04).ConclusionThese results show, for the first time, that the PsA joint, but not the RA joint, is enriched for IL-17+CD8+ T cells. Moreover, the findings reveal that the levels of this T cell subset are correlated with disease activity measures and the radiographic erosion status after 2 years, suggesting a previously unrecognized contribution of these cells to the pathogenesis of PsA.

Evaluation of the novel ultrasound score for large joints in psoriatic arthritis and ankylosing spondylitis: six month experience in daily clinical practice

BackgroundTo evaluate the utility of the recently introduced SOLAR score (sonography of large joints in Rheumatology), which has been validated in RA patients, in a cohort of patients with Psoriatic Arthritis (PsA) and Ankylosing Spondylitis (AS) presenting with involvement of large peripheral joints.MethodsThe recently established SOLAR score has been designed to determine the degree of inflammation in the shoulder, the elbow, the hip and the knee joint in patients suffering from RA. Since large joints are frequently involved in PsA and AS, synovitis and synovial vascularity were scored semiquantitatively (grade 0–3) by grey scale (GSUS) and power Doppler ultrasound (PDUS) utilizing the validated scoring system. Each joint was scanned from different angles, the knee joint for example was divided into four areas to score for synovitis: the suprapatellar longitudinal, the medial longitudinal, the lateral longitudinal, and the posterior region. Each area was scored from 0–3, so a maximum score of 12 could be achieved. PsA and AS patients presenting with peripheral joint disease involving large joints were examined at baseline, 3 and 6 months after initiation of local or systemic therapy (DMARDs/Biologics). For evaluation of the inflammatory status, the erythrocyte sedimentation rate (ESR) was determined.ResultsA cohort of 126 patients were enclosed, and 83 of these were followed for 6 months. At baseline before modification of the therapy, patients received DMARDs (n = 83), DMARDs plus biologics (n = 30), or biologic monotherapy (n = 29). Following intervention, all US scores demonstrated a marked improvement. The GSUS and the PDUS scores for all joint areas, except the PDUS score of the hip, exhibited a significant improvement (p < 0.05), while the GSUS of the knee showed even a highly significant (p < 0.001) change. The ESR displayed a significant decrease from 27 to 19 mm (p < 0.002) representing good treatment response.ConclusionThe SOLAR score, which has been recently introduced for RA patients, is a very suitable instrument for the qualitative and quantitative evaluation of large joint involvement in PsA and AS patients and allows for treatment monitoring.

THU0445 High ultrasonographic scores persist among patients with rheumatoid arthritis in clinical remission with normal serum MMP-3 values

BackgroundSerum matrix metalloproteinase-3 (MMP-3) levels are useful conventional markers of synovitis associated with rheumatoid arthritis (RA). Ultrasonography (US) has recently become more popular as a method of evaluating joint synovitis.ObjectivesTo...

AB0044 Correlation of peripheral il17 cytokine with activity parameters and ultrasound scores in rheumatoid arthritis

BackgroundIt is now recognized that some pro-inflammatory cytokines, such as IL-17, contribute to synovial neoangiogenesis and osteocartilaginous destruction in rheumatoid arthritis (RA). The serum concentration of this cytokine has also...

SAT0089 Non-Steroidal Anti-Inflammatory Drugs Have an Independent Effect on Synovial Vascularity Assessed by Musculoskeletal Ultrasound in Rheumatoid Arthritis

BackgroundMusculoskeletal ultrasound (MSUS) is useful in monitoring rheumatoid arthritis (RA) and is emphasized its high sensitivity for detecting synovitis and good correlation with clinical disease activity indices, such as Disease...