• Users Online: 122
  • Print this page
  • Email this page

 
Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 27  |  Issue : 1  |  Page : 33-39

A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients


Department of Rheumatology and Rehabilitation, Sohag Faculty of Medicine, Sohag University, Sohag, Egypt

Date of Submission23-Jul-2018
Date of Acceptance31-Jul-2018
Date of Web Publication08-Jan-2019

Correspondence Address:
Dr. Hanan Sayed M. Abozaid
Department of Rheumatology and Rehabilitation, Sohag Faculty of Medicine, Sohag University, Postal Code: 82524 Sohag
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JMU.JMU_74_18

Get Permissions

  Abstract 

Background: The damaging effect of rheumatoid arthritis (RA) on cartilage, bone, ligaments, and tendons has raised the importance of the disease activity and severity assessment to enable therapeutic decisions and to evaluate disease outcome. Aim: The aim is to compare the clinical examination of the Disease Activity Score (DAS)-28 with the musculoskeletal ultrasonography (US) examination in RA patients. Moreover, finding if we can use ultrasonographical results as a tool for predicting subsequent radiological damage. Patients and Methods: It is a longitudinal study included 60 adult RA patients. Patients were under assessment at baseline, 6 months, and 12 months from the recruitment time. Twenty-eight joints of DAS were assessed for tenderness and swelling. US gray scale (GS) and US power Doppler (PD) score also was done at each visit. Results: DAS-28, with its parameters, is positively and highly significantly correlated to synovitis severity both by US GS and US-PD score along the study follow-up visits. There was highly significant difference between the number of 28 swollen and tender joints by clinical examination with both US GS and US-PD. Linear regression analysis to predict the number of swollen and tender joints after 12 months showed significance between US PD with swollen and tender joints' numbers. The correlation was positive and significant between Larsen score at 12 months with GS US and PD US assessment, but linear regression analysis was only significant for Larsen score with only GS US. Conclusion: GS US and PD is a sensitive and reliable noninvasive method complementary to standard clinical assessment and could be a tool for predicting subsequent joints' damage.

Keywords: Disease activity score 28, musculoskeletal ultrasonography, rheumatoid arthritis


How to cite this article:
Ali RH, Daifallah OS, Abozaid HS, Abu Alfadl EM, Elsayed SA. A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients. J Med Ultrasound 2019;27:33-9

How to cite this URL:
Ali RH, Daifallah OS, Abozaid HS, Abu Alfadl EM, Elsayed SA. A longitudinal study of the 28 joints of disease activity score by ultrasonographical examination in rheumatoid arthritis patients. J Med Ultrasound [serial online] 2019 [cited 2021 Apr 11];27:33-9. Available from: http://www.jmuonline.org/text.asp?2019/27/1/33/249634


  Introduction Top


Rheumatoid arthritis (RA), with its characteristic synovitis which damages cartilage, bone, ligaments, and tendons, has raised the importance for the assessment of the disease activity and severity to enable therapeutic decisions and to evaluate disease outcome and response to treatment. In RA, structural damage is associated with pain and functional impairments.[1] Tender and swollen joint counts (SJCs) are essential features that should be examined during the routine clinical examination. The combination of joint counts and patients' acute phase response, fatigue and pain scales, and stiffness are the measures to estimate disease activity.[2]

The measures were based on their sensitivity to change, their lack of redundancy, their content validity, whether they sampled multiple domains of RA activity, or whether they predicted important outcomes including disability, radiographic damage, and death. The American College of Rheumatology (ACR) criteria for remission,[3] the ACR improvement criteria,[4] and different continuous disease activity indices include these measures in various combinations.

The disease activity driven, or treat-to-target, treatment strategies need ideal measurement of disease activity. The most favorable measure for monitoring disease control is the DAS for 28 joints (DAS-28). The DAS-28 is a simplified form of its predecessor, the DAS.[5]

Early diagnosis of an aggressive course of synovitis or pannus is crucial for the basis of a decision for aggressive treatment. In the early phases of joint destruction, only a hypervascularized pannus can be detected.[6]

Clinical evaluation of joint pain and swelling has not been enough, and conventional plain radiography depicts indirect signs of cartilage loss and bony erosions.[7] Rheumatologists found that these DAS-28 scores had their limitations. Apart from disease activity, all individual component scores might be influenced by comorbidities,[8] joint counts can also be affected by a physician- and patient-related factors, and a patient's general health rating can be elevated because of noninflammatory or personal factors.[9]

Musculoskeletal ultrasonography (US) is a noninvasive and relatively inexpensive bedside imaging method with high patient acceptability.[10] Several studies have demonstrated that high-frequency US is accurate for detecting joint effusion.[11],[12],[13] and synovitis.[14] Compared with magnetic resonance imaging[6] and direct arthroscopic visualization,[15] it has the advantage of the ability to examine all peripheral joints as many times as required at the time of consultation, which improves the accuracy of the clinical evaluation.

The US is a focus of attention since it has been proved to be more sensitive than clinical examination for synovitis detection. Moreover, in a study of patients with oligoarthritis, almost two-thirds of the patients had evidence of subclinical disease, and one-third could be reclassified as having polyarticular disease using US.[16] US can evaluate synovitis at the anatomic and vascular level. The B-mode gray scale (GS) setting enables the visualization of synovial hypertrophy and effusion, while the power Doppler (PD) setting allows the visualization of the movement of blood vessels, therefore detecting increased microvascular blood flow in synovitis.[10]

Aim of the work

We have two aims at this work; the first aim is comparing the number of inflamed joints detected by US with the number of tender and swollen joints detected by clinical examination, we used the 28 joints of DAS as the reference. The The second aim is testing if we can use ultrasonographical results as tools for predicting subsequent radiological damage.


  Patients and Methods Top


This study was carried out at the Department of Rheumatology and Rehabilitation, Sohag University hospital, during the period 2014–2016. The goals, steps, and methodology of the study were explained to the patients, and the consent forms were obtained. The study protocol was approved by the Ethics Committee of Sohag Faculty of Medicine, Egypt. The study is a longitudinal observational study included sixty adult RA patients, diagnosed according to the 2010 ACR/European League Against Rheumatism (EULAR) classification criteria; patients were under assessment at baseline, 6 months, and 12 months from the recruitment time. The included patient age at disease onset was after 16 years old. We have excluded from the study patients with other forms of connective tissue disease, osteoarthritis, trauma, and previous joint surgery.

The patients were under clinical, laboratory, and US evaluation at baseline, 6 months, and 12 months. The following data were recorded for each patient at study entry: age, sex, symptoms duration, morning stiffness, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroids received for RA before study entry, disease-modifying antirheumatic drugs (DMARDs) prescribed, extra-articular involvement of RA, drugs received for RA. At each visit, 28 joints including bilateral glenohumeral, elbow, wrist, metacarpophalangeal (MCP), proximal interphalangeal (PIP) of the hands, and knee joints were assessed for tenderness and swelling. Tender joint count and SJC were recorded for each patient. A global pain intensity visual analog scale score (VAS pain; range 0–100 mm) and a VAS score for the patient's overall assessment of disease activity (range 0–100 mm) were recorded too.

Laboratory assessment

During each visit for the patients, they were under blood tests for C reactive protein (CRP) level, Erythrocyte Sedimentation Rate (ESR), Rheumatoid factor (measured by nephelometry), anti-Cyclic Citrullinated Peptide (anti CCP test), and complete blood count (CBC).

US assessment

Systematic GS and PD examination of the 28 joints was performed at each visit by a single rheumatologist experienced in US who was unaware of the clinical findings and he used; Ultrasonographic device model LOGIQ E, General Electric Medical Systems (GE healthcare), 12 USA, includes Multifrequency linear array transducers with frequency from 15 to 18 MHz US device.

GS synovitis scoring has been evaluated using a 4-Grade scale from 0 to 3 with the following subjective definitions for each category: Grade 0 = the absence of synovial thickening, Grade 1 = mild synovial thickening, Grade 2 = moderate synovial thickening, and Grade 3 = marked synovial thickening.

PD synovitis scoring using a 4-Grade scale from 0 to 3 with the following definition for each category: Grade 0 = absence of signal, no intra-articular flow, Grade 1 = mild, one or two vessels signal (including one confluent vessel) for small joints and two to three signals for large joints (including two confluent vessels); Grade 2 = moderate confluent vessels (>Grade 1) and <50% of normal area; and Grade 3 = marked vessels' signals in more than half the synovial area.

Joint synovitis was defined as the presence of intra-articular effusion and/or synovial hypertrophy.

Synovial blood flow was evaluated by PD in the hand joints. PD imaging was performed by selecting a region of interest that included the bony margins, articular space, and a variable view of surrounding tissues.

The conventional radiographic assessment used Larsen's scoring system[17] at the 12-month visit: plain X-ray was done for each patient and Larsen's score was calculated for each patient.

Statistical analysis

Data were recorded in Excel data sheet and analyzed using (Statistical Package for the Social Sciences software program version 24, IBM, Chicago, USA). Qualitative variables were recorded as frequencies and percentages and were compared by Chi-square test. Quantitative variables were presented as the mean ± standard deviation (SD) for normally distributed data and median with interquartile range for nonnormally distributed data and were compared by independent t-test. P < 0.05 was considered statistically significant.


  Results Top


The study included 60 Rheumatoid Arthritis patients, 56 are females (93.3%), and 4 are males, mean ± SD of age is 43.57 ± 10.51, the mean duration of symptoms was 4 years, with SD 1.3, and ranged from 1 to 7 years. Nearly 80% of the patients were RF positive and 83.3% of patients were anti-CCP positive at the recruitment time. The sixty patients completed the assessment at 6 months, while at 12 months, 6 patients missed the assessment due to unwilling to complete or traveling. The results of the comparison of the clinical and laboratory assessments between the three visits were; There was a significant difference between different times of follow-up regarding the acute phase reactants as a mean of both ESR and CRP decreased significantly from 0 month to 12 months with P= (0.004 and 0.009), respectively.

Furthermore, there was a significant difference regarding RF as 80% of patients had positive RF at 0 month and this percentage increased significantly to 86.6% after 6 months and 96.7% after 12 months. On the other hand, there was nonsignificant difference in Anti-CCP and CBC parameters (white blood cells [WBCs], platelets [PLTs], and hemoglobin [HB]); the other main assessments are displayed in [Table 1] and [Table 2].
Table 1: Main assessment at follow-up periods

Click here to view
Table 2: Disease Activity Score 28 parameters and ultrasonography assessment at follow up periods

Click here to view


The Pearson correlation between the US GS score values and US PD score values with each of the ESR, CRP, and DAS28 at different follow-up periods was always positive with high significance (r > 0.56 and P < 0.001).

We did a comparison between the clinical examination and the US examination of the number of detected 28 swollen joints and tender joints and the results of comparison were highly significant with P < 0.001 at the three follow-up periods [Figure 1] and [Figure 2].
Figure 1: Comparison of swollen joints number with both US gray scale and US power Doppler at the three visits. At start of the study, mean and standard deviation of swollen joint count (7.17 ± 2.60), US-gray scale (16.43 ± 4.40) and of US-power Doppler (14.83 ± 4.59) with P = (0.001). At 6 months (mean and standard deviation of swollen joint count (5.57 ± 2.90), US-gray scale (11.50 ± 5.72) and of US-power Doppler (11.10 ± 6.15) with P = (0.001). At 12 months (mean and standard deviation of swollen joint count (5.23 ± 3.23), US-gray scale (12.53 ± 5.11) and of US-power Doppler (11.63 ± 5.21) with P = (0.001)

Click here to view
Figure 2: Comparison of tender joints' number with both US gray scale and US Power Doppler at the three visits. At the start of the study, mean and standard deviation of Temasek Junior College (9.73 ± 4.46), US-gray scale (14.83 ± 4.59) and of US-power Doppler (16.43 ± 4.40) with P = (0.001). At 6 months (mean and standard deviation of Temasek Junior College (7.80 ± 4.60), US-gray scale (11.10 ± 6.15) and of US-power Doppler (11.50 ± 5.72) with P = (0.001). At 12 months (mean and standard deviation of Temasek Junior College (7.53 ± 4.21), US-gray scale (11.63 ± 5.21) and of US-power Doppler (12.53 ± 5.11) with P = (0.001)

Click here to view


The correlation between the number of detected inflamed joints by US (PD and GS) at 0 month of the study with the tender joints count at 12 months was positive and significant (r = 0.7, P= 0.04), but the correlation with the SJC at 12 months was positive and significant with only the US PD (r = 0.8, P= 0.03).

Linear regression analysis to predict the number of swollen and tender joints (after 12 months) from US GS to PD joint number at start showed significance between US PD joints number and swollen joints and tender joints [Table 3] and [Table 4].
Table 3: Linear regression analysis between swollen joints at 12 months and ultrasonography assessment at start month

Click here to view
Table 4: Linear regression between tender joints at 12 months and ultrasonography assessment at the start time

Click here to view


X-ray radiological changes still as one of the important parameters in the measuring of RA severity; in this study, we read the Larsen score for hands and feet at the 12 month assessment, and we did correlation between it and US assessment at 0 month of the study, which showed positive and significant correlation r = 0.67 and P < 0.05 with both PD and GS number, but linear regression analysis was only significant with GS US < 0.005. Correlation of Larsen score with the other disease parameters showed positive significance with the following: ESR (r = 0.7, P = 0.04), DAS 28 (r = 0.76, P = 0.001), and SJC (r = 0.6, P = 0.03).


  Discussion Top


In the early phases of joint destruction, only a hypervascularized pannus can be detected, early diagnosis of synovitis or pannus is essential for taking a decision of aggressive treatment. Many studies suggested improved sensitivity in the detection of synovitis, effusions within the joint, and bone erosions in rheumatoid joints using ultrasound (US) in comparison with traditional clinical examination and conventional radiography.[18],[19],[20]

In this study, we worked for the 28 joints of DAS score as the most acceptable tool for measuring the diseases activity; we worked by two different ways for the assessment of these joints: the clinical examination of the tenderness and swelling of joints compared with the musculoskeletal US examination of the same joints, we wanted to find how sensitive is the US over the clinical in detecting the activity and severity of inflammation of these joints.

Our study included 60 adult patients fulfilling ACR/EULAR 2010 RA classification criteria, we followed them along 12 months: at baseline, 6 months, and 12 months. Follow-up was clinical (number of tender, swollen joints, and VAS), laboratory by CRP level, and ESR, CBC, DAS-28, and US examination by GS and PD the same hand joints.

Mean age of the patients was 43 years, with (SD 10.5), mean duration of symptoms was 4 years, with (SD 1.3), 87.6% of patients complained of morning stiffness at the first visit but the percent decreased to 43.3% after 6 months and became 30% after 12 months, and this difference was significant (P = 0.04) and may we can explain this change by the response to the treatment strategy of patients which adjusted at the follow up visits in order to decrease the disease activity. Only four patients in our study group had extra-articular manifestations at 0 month and still after 6 months. About treatment there was nonsignificant difference between the three visits in the steroids and disease-modifying antirheumatic drugs, but there was a significant difference in the NSAIDs, monotherapy, and combination therapy.

When we have done laboratory investigations to our patients, we found a significant difference along follow-up visits in the followings; acute phase reactants decreased significantly with the decrease in the disease activity, the percentage of RF-positive patients was significantly increasing. On the other hand, there was nonsignificant difference in CBC parameters (WBCs, PLTs, and HB).

Clinically, we found high significant difference through the three follow visits (0, 6, and 12 months) in the count of swollen joints, tender joints, VAS, and DAS-28 (P < 0.001) as a mean value of them decreased significantly from 0 to 12 months. This agreed with the results of Terslev et al.[21] as they showed good correlation between clinical improvement of the joint and decrease in DAS-28 in a longitudinal study.

By US examination, there was highly significant difference through the three follow-up visits (0, 6, and 12 months), US GS number, US PD score, and US PD joint number (P < 0.001) as a mean value of them decreased significantly. This was similar to the results of Elkhouly et al.[22]

The point, which we focused on in this study, is the differences between number of inflamed joints which were detected by clinical assessment and by US assessment and was significantly different, and this raises the value of US use in the assessment of disease activity, and directs our aim to be not satisfied with only clinical examination during monitoring of disease progression.

Consequently, these tools are of interest for monitoring RA patients in remission; we found that the baseline GS number and PD-US number can be used as predictive tool for number of swollen and tender joints after 12 months using linear regression analysis as follows:

  • Swollen joint = 0.722+ (US PD joint number at start × 0.304)


  • OR

    = 2.551 + (US GS number at start × 0.163)

  • Tender joint = 0.660 + (US PD joint number × 0.463)


OR

= 0.853 + (US GS number at start × 0.039)

Dougados et al.[23] reported that the RA patients who were in disease remission or with low-level activity, baseline GS number, and PD-US number predicted relapse. Furthermore, several studies reported that the presence of subclinical synovitis by Doppler US is considered a predictive for radiographic progression in the future,[24],[25] Peluso et al. studied 96 patients with early and long-standing RA in stable clinical remission for at least 6 months (DAS <0.6). US evaluation was on the second and third MCP, PIP joints, and the wrist of two hands. Of the negative PD (PD−) RA patients, 20% had a clinical flare during the 12-month follow-up period compared with 47% of positive PD (PD+) patients (P = 0.009), Scirè et al.[24] showed in 106 RA patients with clinical remission that a PD signal was a predictor for a future flare. In another one, the authors studied 93 patients with RA in clinical remission for 6 months and 26% of patients experienced a flare within the year; increased baseline PD activity was independently associated with the risk of flare.[26]

In our study, DAS was always positively and highly significantly correlated to disease severity both by US gray score and US PD score at any time during follow-up of our patients from start, after 6 months, and after 12 months. In a Swiss RA cohort, a significant but modest correlation between US (GS and PD score) and DAS-28 scoring was found.[27] Interestingly, when RA patients were prospectively evaluated, the same authors observed a positive association between GS (r = 0.41) and/or PD changes (r = 0.54) and change in DAS28.

We found also that ESR was always positively and highly significantly correlated to US GS and US PD score at any time during follow-up of our patients; CRP was also positively and highly significantly correlated to US GS and US PD score after 6 months and after 12 months, but it was nonsignificantly correlated to them at 0 month. Elkhouly et al.[22] found also a statistically significant correlation between ESR (P = 0.004) and GS US (P = 0.004). In a study of Ellegaard et al.,[28] PD was correlated with laboratory markers of inflammation, CRP, and ESR.

Garrigues et al.[29] concluded in their study that the concordance between clinical joint evaluation (CJE) and US was low at the MCP joints, wrists, and shoulders. Luukkainen et al.[30] also reported poor correlations between CJE and US at the MCP joints. Measurements in 37 patients with RA indicated a low correlation between the DAS-28 score and the 40-joint ultrasound score. This disparity calls into question use of the DAS-28 score as an assessment tool.[31]

In agreement, many studies have reported that subclinical synovitis can be detected by imaging of patients who have achieved clinical remission (DAS-28 <2.6) after treatment, and such patients have a greater chance of bone erosion in the long run,[32],[33],[34] we also found the significant correlation between the US joints examination at the baseline assessment with the radiological joint changes scored by Larsen at the 12-month visit.


  Conclusion Top


We propose in this study that the use of musculoskeletal ultrasonographical examination could be a reliable method for improving the outcome of the standard clinical assessment in Rheumatoid synovial inflammation. We recommend the need to have more work in this point to raise the role of involving US joints assessment in RA within the disease activity score.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Aletaha D, Smolen J, Ward MM. Measuring function in rheumatoid arthritis: Identifying reversible and irreversible components. Arthritis Rheum 2006;54:2784-92.  Back to cited text no. 1
    
2.
Felson DT, Anderson JJ, Boers M, Bombardier C, Chernoff M, Fried B, 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;36:729-40.  Back to cited text no. 2
    
3.
Pinals RS, Baum J, Bland J, Fosdick WM, Kaplan SB, Masi AT, et al. Preliminary criteria for clinical remission in rheumatoid arthritis. Bull Rheum Dis 1982;32:7-10.  Back to cited text no. 3
    
4.
Felson DT, Anderson JJ, Boers M, Bombardier C, Furst D, Goldsmith C, et al. American college of rheumatology. Preliminary definition of improvement in rheumatoid arthritis. Arthritis Rheum 1995;38:727-35.  Back to cited text no. 4
    
5.
Farheen K, Agarwal SK. Assessment of disease activity and treatment outcomes in rheumatoid arthritis. J Manag Care Pharm 2011;17:S09-13.  Back to cited text no. 5
    
6.
Backhaus M, Ohrndorf S, Kellner H, Strunk J, Backhaus TM, Hartung W, et al. Evaluation of a novel 7-joint ultrasound score in daily rheumatologic practice: A pilot project. Arthritis Rheum 2009;61:1194-201.  Back to cited text no. 6
    
7.
Hau M, Schultz H, Tony HP, Keberle M, Jahns R, Haerten R, et al. Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joints in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array). Arthritis Rheum 1999;42:2303-8.  Back to cited text no. 7
    
8.
van Tuyl LH, Boers M. Patient's global assessment of disease activity: What are we measuring? Arthritis Rheum 2012;64:2811-3.  Back to cited text no. 8
    
9.
Masri KR, Shaver TS, Shahouri SH, Wang S, Anderson JD, Busch RE, et al. Validity and reliability problems with patient global as a component of the ACR/EULAR remission criteria as used in clinical practice. J Rheumatol 2012;39:1139-45.  Back to cited text no. 9
    
10.
Wakefield RJ, Green MJ, Marzo-Ortega H, Conaghan PG, Gibbon WW, McGonagle D, et al. Should oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis 2004;63:382-5.  Back to cited text no. 10
    
11.
Ostergaard M, Court-Payen M, Gideon P, Wieslander S, Cortsen M, Lorenzen I, et al. Ultrasonography in arthritis of the knee. A comparison with MR imaging. Acta Radiol 1995;36:19-26.  Back to cited text no. 11
    
12.
Østergaard M. Can imaging be used for inflammatory arthritis screening? Semin Musculoskelet Radiol 2012;16:401-9.  Back to cited text no. 12
    
13.
Alasaarela E, Tervonen O, Takalo R, Lahde S, Suramo I. Ultrasound evaluation of the acromioclavicular joint. J Rheumatol 1997;24:1959-63.  Back to cited text no. 13
    
14.
Jacobson JA, Andresen R, Jaovisidha S, De Maeseneer M, Foldes K, Trudell DR, et al. Detection of ankle effusions: Comparison study in cadavers using radiography, sonography, and MR imaging. AJR Am J Roentgenol 1998;170:1231-8.  Back to cited text no. 14
    
15.
Karim Z, Wakefield RJ, Quinn M, Conaghan PG, Brown AK, Veale DJ, et al. Validation and reproducibility of ultrasonography in the detection of synovitis in the knee: A comparison with arthroscopy and clinical examination. Arthritis Rheum 2004;50:387-94.  Back to cited text no. 15
    
16.
Larché MJ, Seymour M, Lim A, Eckersley RJ, Pétavy F, Chiesa F, et al. Quantitative power Doppler ultrasonography is a sensitive measure of metacarpophalangeal joint synovial vascularity in rheumatoid arthritis and declines significantly following a 2-week course of oral low-dose corticosteroids. The Journal of rheumatology 2010. pp.jrheum-100322.  Back to cited text no. 16
    
17.
Larsen A. How to apply larsen score in evaluating radiographs of rheumatoid arthritis in long-term studies. J Rheumatol 1995;22:1974-5.  Back to cited text no. 17
    
18.
Zhang W, Doherty M, Pascual E, Barskova V, Guerne PA, Jansen TL, et al. EULAR recommendations for calcium pyrophosphate deposition. Part II: Management. Ann Rheum Dis 2011;70:571-5.  Back to cited text no. 18
    
19.
Mandl P, Naredo E, Wakefield RJ, Conaghan PG, D'Agostino MA; OMERACT Ultrasound Task Force. A systematic literature review analysis of ultrasound joint count and scoring systems to assess synovitis in rheumatoid arthritis according to the OMERACT filter. J Rheumatol 2011;38:2055-62.  Back to cited text no. 19
    
20.
Le Boedec M, Jousse-Joulin S, Ferlet JF, Marhadour T, Chales G, Grange L, et al. Factors influencing concordance between clinical and ultrasound findings in rheumatoid arthritis. J Rheumatol 2013;40:244-52.  Back to cited text no. 20
    
21.
Terslev L, Torp-Pedersen S, Qvistgaard E, Bliddal H. Spectral doppler and resistive index. A promising tool in ultrasonographic evaluation of inflammation in rheumatoid arthritis. Acta Radiol 2003;44:645-52.  Back to cited text no. 21
    
22.
Elkhouly T, Elnady BM, Rageh EM. Validity of Doppler subclinical synovitis as an activity marker associated with bone erosions in rheumatoid arthritis patients during clinical remission. Egypt J Radiol Nucl Med 2016;47:985-90.  Back to cited text no. 22
    
23.
Dougados M, Jousse-Joulin S, Mistretta F, d'Agostino MA, Backhaus M, Bentin J, et al. Evaluation of several ultrasonography scoring systems for synovitis and comparison to clinical examination: Results from a prospective multicentre study of rheumatoid arthritis. Ann Rheum Dis 2010;69:828-33.  Back to cited text no. 23
    
24.
Scirè CA, Montecucco C, Codullo V, Epis O, Todoerti M, Caporali R. Ultrasonographic evaluation of joint involvement in early rheumatoid arthritis in clinical remission: Power Doppler signal predicts short-term relapse. Rheumatology (Oxford) 2009;48:1092-7.  Back to cited text no. 24
    
25.
Peluso G, Michelutti A, Bosello S, Gremese E, Tolusso B, Ferraccioli G. Clinical and ultrasonographic remission determines different chances of relapse in early and long standing rheumatoid arthritis. Ann Rheum Dis 2011;70:172-5.  Back to cited text no. 25
    
26.
Saleem B, Brown AK, Quinn M, Karim Z, Hensor EM, Conaghan P, et al. Can flare be predicted in DMARD treated RA patients in remission, and is it important? A cohort study. Ann Rheum Dis 2012;71:1316-21.  Back to cited text no. 26
    
27.
Zufferey P, Möller B, Brulhart L, Tamborrini G, Scherer A, Finckh A, et al. Persistence of ultrasound synovitis in patients with rheumatoid arthritis fulfilling the DAS28 and/or the new ACR/EULAR RA remission definitions: Results of an observational cohort study. Joint Bone Spine 2014;81:426-32.  Back to cited text no. 27
    
28.
Ellegaard K, Torp-Pedersen S, Terslev L, Danneskiold-Samsøe B, Henriksen M, Bliddal H. Ultrasound colour Doppler measurements in a single joint as measure of disease activity in patients with rheumatoid arthritis – Assessment of concurrent validity. Rheumatology (Oxford) 2009;48:254-7.  Back to cited text no. 28
    
29.
Garrigues F, Jousse-Joulin S, Bouttier R, Nonent M, Bressollette L, Saraux A. Concordance between clinical and ultrasound findings in rheumatoid arthritis. Joint Bone Spine 2013;80:597-603.  Back to cited text no. 29
    
30.
Luukkainen RK, Saltyshev M, Koski JM, Huhtala HS. Relationship between clinically detected joint swelling and effusion diagnosed by ultrasonography in metatarsophalangeal and talocrural joints in patients with rheumatoid arthritis. Clin Exp Rheumatol 2003;21:632-4.  Back to cited text no. 30
    
31.
Hammer HB, Bolton-King P, Bakkeheim V, Berg TH, Sundt E, Kongtorp AK, et al. Examination of intra and interrater reliability with a new ultrasonographic reference atlas for scoring of synovitis in patients with rheumatoid arthritis. Ann Rheum Dis 2011;70:1995-8.  Back to cited text no. 31
    
32.
Ogishima H, Tsuboi H, Umeda N, Horikoshi M, Kondo Y, Sugihara M, et al. Analysis of subclinical synovitis detected by ultrasonography and low-field magnetic resonance imaging in patients with rheumatoid arthritis. Mod Rheumatol 2014;24:60-8.  Back to cited text no. 32
    
33.
Kawashiri SY, Suzuki T, Nakashima Y, Horai Y, Okada A, Iwamoto N, et al. Ultrasonographic examination of rheumatoid arthritis patients who are free of physical synovitis: Power Doppler subclinical synovitis is associated with bone erosion. Rheumatology (Oxford) 2014;53:562-9.  Back to cited text no. 33
    
34.
Szkudlarek M, Wakefield RJ, Backhaus M, Terslev L. The discriminatory capacity of ultrasound in rheumatoid arthritis: Active vs. inactive, early vs. advanced, and more. Rheumatology (Oxford) 2012;51 Suppl 7:vii6-9.  Back to cited text no. 34
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

Top
 
  Search
 
    Similar in PUBMED
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed1681    
    Printed96    
    Emailed0    
    PDF Downloaded168    
    Comments [Add]    

Recommend this journal