Eiko Seki

Inhibitory effect of tacrolimus on progression of joint damage in patients with rheumatoid arthritis

To examine the inhibitory effect of tacrolimus on radiographic joint damage in patients with rheumatoid arthritis (RA).

Radiographic changes and factors associated with subsequent progression of damage in weight-bearing joints of patients with rheumatoid arthritis under TNF-blocking therapies—three-year observational study

Abstract Objectives: The long-term effects of tumor necrosis factor (TNF)-blocking therapies on weight-bearing joints in patients with rheumatoid arthritis (RA) have not been fully characterized. The purpose of this study was to assess the radiographic changes of weight-bearing joints in patients with RA during 3-year of TNF-blocking therapies and to identify factors related to the progression of joint damage. Methods: Changes in clinical variables and radiological findings in 243 weight-bearing joints (63 hips, 54 knees, 71 ankles, and 55 subtalar joints) in 38 consecutive patients were investigated during three years of treatment with TNF-blocking agents. Multivariate logistic regression analysis was used to identify risk factors for the progression of weight-bearing joint damage. Results: Seventeen (14.5%) of proximal weight-bearing joints (hips and knees) showed apparent radiographic progression during three years of treatment, whereas none of the proximal weight-bearing joints showed radiographic evidence of improvement or repair. In contrast, distal weight-bearing joints (ankle and subtalar joints) displayed radiographic progression and improvement in 20 (15.9%) and 8 (6.3%) joints, respectively. Multivariate logistic analysis for proximal weight-bearing joints identified the baseline Larsen grade (p < 0.001, OR:24.85, 95%CI: 5.07–121.79) and disease activity at one year after treatment (p = 0.003, OR:3.34, 95%CI:1.50–7.46) as independent factors associated with the progression of joint damage. On the other hand, multivariate analysis for distal weight-bearing joints identified disease activity at one year after treatment (p < 0.001, OR:2.13, 95%CI:1.43–3.18) as an independent factor related to the progression of damage. Conclusions: Baseline Larsen grade was strongly associated with the progression of damage in the proximal weight-bearing joints. Disease activity after treatment was an independent factor for progression of damage in proximal and distal weight-bearing joints. Early treatment with TNF-blocking agents and tight control of disease activity are necessary to prevent the progression of damage of the weight-bearing joints.

Continuous peripheral nerve block in forearm for severe hand trauma.

We studied the use of a continuous peripheral nerve block (CPNB) in the distal forearm and wrist immediately after emergent surgery for severe hand trauma in 22 hands. After emergent surgery, a 2-3 cm longitudinal incision was made at the distal forearm and an 18-gauge catheter was inserted along the peripheral nerves. All patients received postoperative analgesia by continuous infusion of 0.2% ropivacaine at 2 ml/h for seven to 21 days. Pain score remained low during postoperative period and only a small number of analgesic rescues were needed. There were no major complications related to the CPNB and one patient showed mild superficial infection at the insertion site that immediately recovered after catheter removal. This method provides good postoperative analgesia without loss of motor function in extrinsic hand muscles and should be considered as a postoperative pain management for severe hand trauma.

FRI0508 Correlation of power doppler ultrasonographic findings with site-matched histopathology of the synovial tissue

Background Ultrasonography (US) has been recently established as an imaging modality to evaluate inflamed joints of patients with rheumatoid arthritis (RA). It is reported that power doppler ultrasonography (PDUS) is capable of directly visualizing and quantifying synovial inflammation [1]. However, detailed correlation between the PDUS findings and histopathological findings of RA synovial tissues, such as accumulation of various inflammatory cells, neovasculogenesis, and synovial hyperplasia, still remains unclear. Objectives To assess the significance of PDUS in the evaluation of synovial lesion of the knee joint by comparing the PDUS findings with site-matched histopathological findings. Methods We studied 23 patients who were undergoing arthroplasty of the knee joint because of RA or osteoarthritis (OA). Predetermined sites of the knee joint were examined with US before arthroplasty. Synovitis was classified semiquantitatively with grey scale (GS) and PDUS findings. PD signal was graded as 0 (normal), 1 (minor), 2 (moderate), and 3 (major) [2]. Synovial tissues were obtained during arthroplasty from the corresponding sites evaluated by the US. Histopathology of the synovial tissue was evaluated by haematoxylin and eosin staining and immunohistochemical staining with factor VIII. The degree of inflammatory cell infiltrates, synovial lining layer thickness and vascularity was graded as 0 (normal), 1 (mild change), 2 (moderate change), and 3 (severe change) [3]. Results Positive PDUS (grade 2 or 3) was found in 11 of 19 knee joints in patients with RA, but was not observed in all patients with OA. We compared imaging findings of preoperative PDUS with histopathological findings of the synovial specimens. We found that the PDUS findings were mostly correlated with each histopathological grade of synovitis and the vascularity showed the highest correlation with the PDUS findings (r=0.541, P<0.01) as expected. However, the site-matched comparison indicated that the blood vessels, possibly low-velocity blood flow, were not apparently detected by the PDUS. Thus, the sensitivity and specificity of PDUS findings for histopathological vascularity were 91% and 58%, respectively. Conclusions We showed that positive findings of PDUS were closely associated with histopathological findings of active synovitis. However, our results suggest that PDUS is not sufficiently powerful in evaluating blood vessels with low-velocity blood flow in the synovial tissue. References Naredo E, et al. Ann Rheum Dis. 2008; 67:1017-22. Hammer HB, et al. Ann Rheum Dis. 2011; 70:1995-8. Takase K, Clin Exp Rheumatol. 2012; 30: 85-92. Disclosure of Interest None Declared

SAT0402 Evaluation of weight-bearing joint damage in patients with rheumatoid arthritis using a new radiographic scoring method (ARASHI)

Background The radiographic joint damage in rheumatoid arthritis (RA) is commonly evaluated by van der Heijde total Sharp score, however only small joints of hands and feet are assessed in this method. We developed and demonstrated a new radiographic scoring method for Large joint of rheumatoid arthritis (Assessment of Rheumatoid Arthritis by Scoring of Large Joint Destruction and Healing in Radiographic Imaging: ARASHI) in EULAR 20111). Objectives The purpose of this study is to evaluate the radiographic damage of hip and knee joints in rheumatoid arthritis (RA) during TNF-blocking therapies by this new radiographic scoring method, and to clarify the pattern of the progression of hip and knee joints during 2 years of TNF-blocking therapies. Methods “ARASHI status score” consists of 4 categories; joint space narrowing (0∼3 points), erosion (0∼3 points), joint surface (0∼6 points), and stability (0∼4 points), (total 0-16 points). “ARASHI change score” consists of 5 categories; porosis (-1∼1 point), joint space narrowing (-1∼2 points), erosion (-2∼2 points), joint surface (-6∼6 points), and stability (-1∼1 point), (total -11∼12 points). Increase in more than 1 point of change score was considered as progression of joint damage. hirty seven consecutive patients (4 male, 33 women, mean age of 58.7 years old) were enrolled in this study. All patients fulfilled the ACR 1987 revised criteria. The joints with history of surgical intervention were excluded from this analysis, and the radiographic findings of 65 hip joints and 53 knee joints were evaluated at baseline using the ARASHI status score, and at 1 and 2 years after TNF-blocking therapies (infliximab or etanercept) using the ARASHI change score. Results There were 2 hip and 8 knee joints with 3 and more points of the status score at baseline. All of these joints showed significant increase in the change score at 1 or 2 years after TNF-blocking therapies. On the other hand, in hip and knee joints with pre-existing status score of 0-2 points, only 5.6% of the joints showed progression of joint damage during follow-up. Conclusions ARASHI scoring method was useful for radiographic assessment of the status and progression of the large weight-bearing joints. In this study, we demonstrated that hip and knee joints with pre-existing damage greater than 2 points of status score were highly predisposed to progressive destruction even under TNF-blocking therapies. Therefore, it is essential that there is less status score in hip and knee joints at the start of TNF-blocking therapies. References Nasu Y, Nishida K, Hashizume K et al. The verification of a new radiographic scoring method for large joint damage of rheumatoid arthritis (ARASHI status score) relevant to clinical and radiographic parameters. Ann Rheum Dis 2011;70(Suppl3):727 Disclosure of Interest None Declared

OP0015 Evaluation of Hip and Knee Joint Damage in Patients with Rheumatoid Arthritis Using a Newly Developed Radiographic Scoring Method (ARASHI)

Background The radiographic joint damage in patients with rheumatoid arthritis (RA) is commonly evaluated by van der Heijde total Sharp score, intended only for the assessment of small joints. For the evaluation of large joints, Larsen grade is usually used. However, this grading system, composed of only 6 grades (0-5), has several limitations such as ceiling effect within the grade. Therefore, we developed a new radiographic scoring method for large joints in RA (Assessment of Rheumatoid Arthritis by Scoring of Large Joint Destruction and Healing in Radiographic Imaging: ARASHI) 1). Objectives The purpose of this study is to evaluate the radiographic damage of hip and knee joints in RA during TNF-blocking therapies by this new radiographic scoring method, and to clarify the pattern of the progression of damage during 2 year therapies. Methods ‘ARASHI status score’ consists of 4 categories; joint space narrowing (0∼3 points), erosion (0∼3 points), joint surface (0∼6 points), and stability (0∼4 points), (total score range 0-16 points)1). ‘ARASHI change score’ consists of 5 categories; porosis (-1∼1 point), joint space narrowing (-1∼2 points), erosion (-2∼2 points), joint surface (-6∼6 points), and stability (-1∼1 point), (total score range -11∼12 points) 1). Increase in more than 1 point of change score was considered as progression of joint damage. Fifty one consecutive patients (6 males, 45 women, mean age of 59.9 years old) were enrolled in this study. All patients fulfilled the ACR 1987 revised criteria. The joints with history of surgical intervention were excluded from this analysis. The radiographic findings of96 hip joints and 86 kneejoints were evaluated at baseline using the ARASHI status score, and at 1 and 2 years after TNF-blocking therapies (infliximab, etanercept or adalimumab) using the ARASHI change score. Results There were 4 hip joints and 8 knee joints with 3 and more points of the status score at baseline. All of these joints resulted in significant increase in the change score during 2-year TNF-blocking therapies. On the other hand, joints with pre-existing status score of 0-2 points showed progression of joint damage only in 4.3% of the hip joints and in 9.0% of the knee joints during the follow-up period. Conclusions ARASHI scoring method was useful for radiographic assessment of the status and the progression of damage in large weight-bearing joints. In this study, we demonstrated that hip and knee joints with pre-existing damage greater than 2 points of the status score were highly predisposed to progressive destruction even under TNF-blocking therapies. Therefore, it is prerequisite for the hip and knee joints to be radiologically evaluated not to exceed status score 2 before the start of TNF-blocking therapies. References A. Kaneko, I. Matsushita, K. Kanbe, K. Arai, Y. Kuga, A. Abe, T. Matsumoto, N. Nakagawa, K. Nishida. Development and validation of a new radiographic scoring system to evaluate bone and cartilage destruction and healing of large joints with rheumatoid arthritis: ARASHI (Assessment of rheumatoid arthritis by scoring of large joint destruction and healing in radiographic imaging) study. Mod Rheum 2013, in-press. Disclosure of Interest None Declared