Wouter Stomp

MRI of hand and foot joints of patients with anticitrullinated peptide antibody positive arthralgia without clinical arthritis

Background Anticitrullinated peptide antibodies (ACPA) and acute phase reactants may be increased before arthritis becomes clinically detectable, suggesting that the processes underlying rheumatoid arthritis (RA) start preclinically. Whether local inflammation occurs in the preclinical phase is unknown. Therefore, we studied the small joints of ACPA positive arthralgia patients for local subclinical inflammation. Methods Imaging was performed using 1.5 T extremity MRI. Painful hand or foot joints of 21 ACPA positive arthralgia patients without clinical arthritis were imaged. For comparison, hand and foot joints of 22 ACPA positive RA patients and 19 symptom free controls were studied. Within ACPA positive arthralgia patients, painful and symptom free joint regions were imaged. Scoring was performed according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) method. Analyses were performed on joint region level and focused on inflammation (synovitis plus bone marrow oedema). Results The mean combined inflammation scores of the metacarpophalangeal/proximal interphalangeal joints of controls, painful joints of ACPA positive arthralgia patients and ACPA positive RA patients were 0.1, 0.7 and 3.7, respectively (p<0.001). Likewise, the mean combined inflammation scores of the wrist were 0.9, 2.3 and 10.3, respectively (p<0.001) and that of the metatarsophalangeal joints 0.5, 0.9 and 3.8, respectively (p=0.10). At the MCP joints, the combined inflammation score was significantly correlated with C reactive protein and erythrocyte sedimentation rate levels (rs=0.83 and rs=0.78, respectively) Conclusions The present data suggest that local subclinical inflammation occurs in ACPA positive arthralgia patients.

Concordance between inflammation at physical examination and on MRI in patients with early arthritis

BACKGROUND MRI is increasingly used to measure inflammation in rheumatoid arthritis (RA) research, but the correlation to clinical assessment is unexplored. This study determined the association and concordance between inflammation of small joints measured with MRI and physical examination. METHODS 179 patients with early arthritis underwent a 68 tender joint count and 66 swollen joint count and 1.5T MRI of MCP (2-5), wrist and MTP (1-5) joints at the most painful side. Two readers scored synovitis and bone marrow oedema (BME) according to the OMERACT RA MRI scoring method and assessed tenosynovitis. The MRI data were first analysed continuously and then dichotomised to analyse the concordance with inflammation at joint examination. RESULTS 1790 joints of 179 patients were studied. Synovitis and tenosynovitis on MRI were independently associated with clinical swelling, in contrast to BME. In 86% of the swollen MCP joints and in 92% of the swollen wrist joints any inflammation on MRI was present. In 27% of the non-swollen MCP joints and in 66% of the non-swollen wrist joints any MRI inflammation was present. Vice versa, of all MCP, wrist and MTP joints with inflammation on MRI 64%, 61% and 77%, respectively, were not swollen. BME, also in case of severe lesions, occurred frequently in clinically non-swollen joints. Similar results were observed for joint tenderness. CONCLUSIONS Inflammation on MRI is not only present in clinically swollen but also in non-swollen joints. In particular BME occurred in clinically non-inflamed joints. The relevance of subclinical inflammation for the disease course is a subject for further studies.

Evaluation of Magnetic Resonance Imaging–Detected Tenosynovitis in the Hand and Wrist in Early Arthritis

Magnetic resonance imaging (MRI) is a sensitive method to detect inflammation in rheumatoid arthritis (RA), visualizing synovitis, bone marrow edema, and tenosynovitis. The prevalence of MRI‐detected tenosynovitis and its diagnostic value in early arthritis are unclear. This study was undertaken to identify the frequency of MRI‐detectable tenosynovitis at the metacarpophalangeal (MCP) and wrist joints in early arthritis and the association of these with RA and the severity of RA.

MRI-detected subclinical joint inflammation is associated with radiographic progression

Background We recently demonstrated that MRI inflammation is prevalent in clinically non-swollen joints of early arthritis patients. In this study, we assessed the relevance of this subclinical inflammation with regard to radiographic progression. Methods 1130 joints (unilateral metacarpophalangeal 2–5, wrist and metatarsophalangeal 1–5) of 113 early arthritis patients underwent clinical examination and 1.5 T MRI at baseline, and radiographs at baseline and 1 year. Two readers scored the MRIs for synovitis, bone marrow oedema (BME) and tenosynovitis according to Rheumatoid Arthritis (RA) Magnetic Resonance Imaging (MRI) Scoring System (RAMRIS). Radiographic progression over 1 year was determined using the Sharp–van der Heijde scoring method. Results On patient level, BME, synovitis and tenosynovitis were associated with radiographic progression, independent of known risk factors (p=0.003, 0.001 and 0.011, respectively). Of all non-swollen joints (n=932), 232 joints (26%) had subclinical inflammation (≥1 MRI-inflammation feature present). These joints were distributed among 91% of patients. Radiographic progression was present in 4% of non-swollen joints with subclinical inflammation compared to 1% of non-swollen joints without subclinical inflammation (relative risks (RR) 3.5, 95% CI 1.3 to 9.6). Similar observations were done for BME (RR5.3, 95% CI 2.0 to 14.0), synovitis (RR3.4, 95% CI 1.2 to 9.3) and tenosynovitis (RR3.0, 95% CI 0.7 to 12.7) separately. Conclusions Radiographic progression was infrequent, but joints with subclinical inflammation had an increased risk of radiographic progression within year 1. This demonstrates the relevance of MRI-detected subclinical inflammation.

Relation of the weather and the lunar cycle with the incidence of trauma in the Groningen region over a 36-year period.

BACKGROUND The time distribution of injuries is not random. To assess the potential impact of weather and the phase of the moon on accidents, adjustment for known periodic and nonperiodic factors may be important. We compared the incidence of injuries with quantitative and qualitative weather variables as well as the lunar cycle, after correction for calendar and holiday-related factors. METHODS We extracted the daily number of trauma patients treated at the emergency department over 36 years (1970-2005) from the trauma database of our regional hospital. For each patient, age, sex, cause of injury, and severity of injury were recorded. This was combined with daily meteorological data including temperature, precipitation, sunshine, humidity, air pressure, and wind as well as the lunar phase. We also related the rate of change of these parameters with the incidence of injuries. A qualitative weather variable derived from temperature, sunshine duration, and precipitation was defined as bad, normal, or good. Periodicities were adjusted for with Poisson regression spline fitting analysis. RESULTS Several weather variables were related with the number of injuries. For most of these, better weather conditions were associated with an increase in trauma incidence. Good weather, which was present on 16.5% of the days, resulted in 10.1% (9.3-11.4 95% CI) more traumas compared with normal weather. Full moon was associated with a 2.1% (1.1-3.0 95% CI) lower trauma incidence than new moon. CONCLUSIONS Better weather conditions contribute to an increased incidence of trauma. Full moon is associated with a slightly lower trauma incidence.

The Course of Bone Marrow Edema in Early Undifferentiated Arthritis and Rheumatoid Arthritis: A Longitudinal Magnetic Resonance Imaging Study at Bone Level.

In patients with rheumatoid arthritis (RA), bone marrow edema (BME) scores are associated with development of erosions. However, little is known about the course and outcome of BME at bone level. We undertook this study to determine the association of BME and synovitis with the development of erosions in the same bone longitudinally.

Are rheumatoid arthritis patients discernible from other early arthritis patients using 1.5T extremity magnetic resonance imaging? a large cross-sectional study.

Objective. Magnetic resonance imaging (MRI) is increasingly used in rheumatoid arthritis (RA) research. A European League Against Rheumatism (EULAR) task force recently suggested that MRI can improve the certainty of RA diagnosis. Because this recommendation may reflect a tendency to use MRI in daily practice, thorough studies on the value of MRI are required. Thus far no large studies have evaluated the accuracy of MRI to differentiate early RA from other patients with early arthritis. We performed a large cross-sectional study to determine whether patients who are clinically classified with RA differ in MRI features compared to patients with other diagnoses. Methods. In our study, 179 patients presenting with early arthritis (median symptom duration 15.4 weeks) underwent 1.5T extremity MRI of unilateral wrist, metacarpophalangeal, and metatarsophalangeal joints according to our arthritis protocol, the foot without contrast. Images were scored according to OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) by 2 independent readers. Tenosynovitis was also assessed. The main outcome was fulfilling the 1987 American College of Rheumatology (ACR) criteria for RA. Test characteristics and areas under the receiver-operator-characteristic curves (AUC) were evaluated. In subanalyses, the 2010 ACR/EULAR criteria were used as outcome, and analyses were stratified for anticitrullinated protein antibodies (ACPA). Results. The ACR 1987 criteria were fulfilled in 43 patients (24.0%). Patients with RA had higher scores for synovitis, tenosynovitis, and bone marrow edema (BME) than patients without RA (p < 0.05). ACPA-positive patients had more BME (median scores 6.5 vs. 4.25, p = 0.016) than ACPA-negative patients. For all MRI features, the predictive value for the presence of RA was low (< 50%). For all MRI features the AUC were < 0.70. Patients who fulfilled ACR/EULAR 2010 criteria but not ACR87 criteria for RA had less synovitis than patients who were positive for RA according to both sets of criteria (p = 0.029). Conclusion. Although patients with RA had higher scores of MRI inflammation and ACPA-positive patients had more BME, the severity of MRI inflammation assessed according to RAMRIS does not accurately differentiate patients with RA from other early arthritis patients.

Evaluating processes underlying the predictive value of baseline erosions for future radiological damage in early rheumatoid arthritis

Objectives Baseline erosions are characteristic for rheumatoid arthritis (RA) and predictive for a severe disease course. The mechanisms leading to baseline erosions being a strong predictor for radiological progression are unknown. We aimed to increase this understanding by mediation analyses in an observational cohort and a cross-sectional MRI study. Methods 3256 hands and feet radiographs of 653 early RA patients assessed during 7 years of disease were scored using the Sharp–van der Heijde method. Mediation models and multivariate regression analyses were used to explore the association between baseline erosions, other predictors and radiological damage over time. 603 joints (MCP2-5 and MTP1-5) of 67 RA patients underwent 1.5 T MRI at baseline. Data on MRI inflammation were compared with clinical inflammation and baseline radiological erosions. Results Patients with baseline erosions had, at any point in time during 7 years, 3.45 times more joint damage than patients without erosions (p<0.001, 95% CI 3.00 to 3.98). Baseline erosions were an independent predictor and not a mediator between symptom duration, systemic or local clinical inflammation (erythrocyte sedimentation rate (ESR), swollen joint count (SJC)) or autoantibodies (anti-citrullinated-peptide antibodies, rheumatoid factor) and radiological damage. Subclinical MRI inflammation was studied in relation to erosions, revealing that 83% of the non-swollen joints with baseline erosions had subclinical MRI inflammation compared with 25% of the non-swollen joints without baseline erosions (OR 15.2 95% CI 3.1 to 102.1). The association between MRI inflammation and baseline erosions was independent of symptom duration, ESR, SJC and autoantibodies. Conclusions Baseline erosions are a predictor for future joint damage, independent of known predictors as time, autoantibodies or clinical measurable inflammation. Subclinical inflammation is suggested as an underlying mechanism.

SAT0041 The Course of Bone Marrow Edema in Early Undifferentiated and Rheumatoid Arthritis; A Longitudinal MRI Study on Bone Level

Background In rheumatoid arthritis (RA) patients, bone marrow edema (BME)-scores are associated with development of erosions. However, little is known on the course and outcome of BME at bone level. Therefore this study determined the association of BME and MRI-synovitis in the same bone longitudinally. Objectives This study was aimed to determine the course of BME and MRI-synovitis at bone level. Furthermore the association between the course of BME and local synovitis and the development of erosions in the same bone was studied. Methods 1,947 bones of MCP, wrist and MTP-joints of 59 patients presenting with rheumatoid or undifferentiated arthritis were studied using 1.5T MRI at baseline, after four and twelve months. Scanning and scoring of BME, synovitis and erosions were performed according to RAMRIS. The relation of the course of BME and synovitis to erosive progression at bone level during 1-year was evaluated. Results Of the bones showing BME at baseline (n=203), BME persisted in 56%, disappeared in 39%, and disappeared-reappeared seldom (5%). Stratified analyses at baseline revealed that BME was associated with erosive progression, in presence and in absence of local synovitis (ORs 7.5 95%CI 3.8-14.9 and 6.9 95%CI 1.9-25.6). Local synovitis, however, was not associated with erosive progression (OR 2.0 95%CI 0.6-7.0 in presence of BME and 1.9 95%CI 0.8-4.1 in the absence of BME). In multivariable GEE-analyses, persistent BME was strongly associated with erosive progression (OR 60 95%CI 17-318), in contrast to persistent synovitis (OR 1.4 95%CI 0.4-5.3). Conclusions BME frequently persists during the first year. Persistent BME was strongly associated with erosive progression in the same bone, independent of local synovitis. No independent association was observed for persistent synovitis. These findings are relevant for the comprehension on the development of erosions in RA. Disclosure of Interest None declared

OP0173 Concordance Between Joint Swelling or Tenderness at Physical Examination and Inflammation on MRI in Early Arthritis Patients

Background Magnetic Resonance Imaging (MRI) is increasingly used to measure disease activity in Rheumatoid Arthritis (RA) patients for research purposes. A main advantage of MRI is that it measures inflammation of the synovium of the joint, synovium of the tendons (tenosynovitis) and of the bone (bone marrow edema). The exact role of MRI in research as well as in daily practice in this patient group is not clear yet. Objectives An important issue, not yet addressed, is to understand to what extend inflammatory abnormalities on MRI are in concordance to abnormalities at physical examination of joints. We performed the present study to determine this. Methods 179 early arthritis patients included in the Leiden Early Arthritis Clinic underwent at the first visit a 68-tender and 66-swollen joint count (including MCP, wrist and MTP joints) and a 1.5T MRI of the MCP (2-4), wrist and MTP (1-5) joints at the most painful or dominant side. Synovitis and bone marrow edema were scored according to the RAMRIS method and in addition the presence of tenosynovitis at the wrists and MCP joints was determined. The MR images were scored by two readers and the average scores studied. The MRI data were dichotomized (cut-off ≥1) to compare concordance of the assessment of inflammation using MRI and physical examination. Results 1,790 small joints of 179 patients were studied. Of these joints; 15% of the MCP joints, 30% of the wrists and 11% of the MTP joints were swollen at physical examination. The prevalence of a score ≥1 synovitis, bone marrow edema and tenosynovitis on MRI in MCP joints was; 26%, 17% and 21%; in wrists 60%, 58% and 52% and in MTP joints 7% and 12%, respectively. In swollen MCP joints any inflammation was present in 86% (synovitis was present in 73%, bone marrow edema in 50% and tenosynovitis in 65%). Similarly, in swollen wrists any inflammation was present in 92% (83%, 75%, 78%, for the individual features respectively). In clinically not swollen MCP joints any inflammation was present in 27% (synovitis was present in 18%, bone marrow edema in 10% and tenosynovitis in 13%). In not swollen wrists, any inflammation was present in 66% (50%, 51%, 41%, for the individual features respectively). In not swollen MTP joints any sign of inflammation was observed in 13% (5% for synovitis and 11% for bone marrow edema). When evaluating all joints with any bone marrow edema, clinical joint swelling was absent in 53% of the MCP joints, 60% of the wrists and 78% of the MTP joints. When evaluating the joints with severe bone marrow edema (score ≥3), joint swelling was absent in 39% of the MCP joints, 35% of the wrists and 58% of the MTP joints. Similar analyses were done for joint tenderness and in the subgroup of early arthritis patients fulfilling the 2010-criteria for RA (n= 65); these analyses yielded comparable results. Conclusions This study shows that inflammation on MRI is present in a high percentage of the clinically swollen joints, but also in part of the non swollen joints. Moreover, a great majority of bone marrow edema lesions occur in clinically non swollen joints. The relevance of this subclinical inflammation with regards to the course of the disease is subject for further studies. Disclosure of Interest None Declared