Table 2

Value of ultrasonography in remission of rheumatoid arthritis

Author (year)[ref] Phase*

Study population, duration of remission or LDA (definition)

Number; type of joints

US modality, definition of synovitis (A-F)

OutcomeRisk estimates (95% CI)

Authors' conclusions

Limitations#


Balsa (2010) [20]

2

97 RA in remission >2 months (physician's judgment); 88 controls

42; PIP, MCP, wrists, elbows, shoulders, knees, ankles, MT, MTP

GSUS & PDUS

A

Of RA in remission, 92% GSUS-positive and 42% PDUS-positive;

88% of non-arthritic controls GSUS-positive

Of sets ARA 1981, DAS28 and SDAI, the SDAI is closest to the absence of inflammation on US

j,o


Brown (2006) [11]

2

107 RA in remission > 6 months (physician's judgment)

8; MCP2-5, wrist (RC, IC, DRU, UC) of dominant hand

GSUS & PDUS

B

73% GSUS-positive

43% PDUS-positive

In many patients in remission, inflammation is found on US

o,x


Brown (2008) [21]

2

102 RA in remission > 6 months (physician's judgment)

8; MCP2-5, wrist (RC, IC, DRU, UC) of dominant hand

GSUS & PDUS

B

PDUS predicts radiographic progression at one year: OR = 12 (3.3, 44)

Presence of PDUS predicts radiographic progression in joints of patients in remission

o,v,x


Foltz (2011) [22]

2

85 RA in remission or with LDA > 2 months (DAS < 2.4)

14; wrists, MCP2,3,5, MTP2,3,5

GSUS & PDUS

A

PDUS predicts flare: OR = 6.3 (2.0, 20); PDUS predicts radiographic progression: OR = 1.4 (1.1, 1.9)

Inflammation on PDUS predicts radiographic progression and flare of patients in remission or with LDA

o,q,v


Ozgocmen (2008) [9]

1

52 RA of whom a subgroup in remission > 2 months (Preliminary ARA 1981 + DAS < 3.2)

14; MCP1-5, wrists (USTL, RSTL)

GSUS & PDUS

C

62% of 32 patients (in ARA 1981 remission) PDUS-positive

58% of 31 patients (in DAS28 remission) PDUS-positive

PDUS inflammation is found for 2 different remission criteria sets, in a similar number of patients

i,j,k,l,o,r,t,


Peluso (2011) [23]

2

48 early (7 months) RA in remission > 6 months (DAS < 1.6)

46 LSRA (118 mo.) in remission > 6 months (DAS < 1.6)

12; MCP2-3, PIP2-3, wrists (RC, UC)

GSUS & PDUS

Not given

56% early RA

GSUS-positive;

83% LSRA GSUS-positive;

PDUS predicts flare:

OR = 3.6 (1.4, 9.0)

PDUS shows predictive value for flare

In many patients in remission, inflammation is found on US

g,i,l,n,o,p,r,t,u,v


Saleem (2009) [24]

2

100 RA in remission > 6 months (DAS < 2.6)

16; wrists (RC, UC,IC), MCP1-5

GSUS & PDUS

D

88% GSUS-positive

PDUS-positive 58%

In > 55% of patients in remission inflammation is found on PDUS

i,o,r,x


Saleem (2010) [25]

2

47 RA in remission > 6 months (DAS28 < 2.6) of whom a subgroup of 20 patients is assessed also by US

18; wrists, PIP, MCP

GSUS & PDUS

F

In group that flared after 2 years, at baseline 88% GSUS-positive and 44% PDUS-positive. In group that did not flare after 2 years, at baseline 82% GSUS-positive and 45% PDUS- positive

In many patients in remission inflammation is found on PDUS, but does not predict flare

o,r,u,v,w,x


Saleem (2011) [10]

2

128 RA in remission > 6 months (ACR 2011)

6; wrist, MCP2-5 of the dominant hand

GSUS & PDUS

D

Around 50% PDUS-positive when using ACR2011, DAS28, SDAI remission sets

For 3 different remission criteria sets a similar number of patients is PDUS-positive

c,h,i,j,k,l,o,p,r,t,u,v,x


Scire (2009) [26]

2

106 early RA (<12 months), of whom

43 in remission > 3 months (DAS < 1.6)

44; shoulders, elbows, wrists, MCP, PIP, knees, ankles, MTP

GSUS & PDUS

E

95% GSUS-positive, 41% PDUS-positive

PDUS positivity predicts flare: OR = 13 (1.6, 104)

In many patients in remission, inflammation found on PDUS, predictive of flare

g,i,j,k,l,m,p,r,t,u,v


Wakefield (2007) [27]

3

10 early (<12 months) RA in remission (DAS28 < 2.6)

42; shoulders, elbows, wrists, MCP, PIP, knees,tibiotalar, MT, MTP

GSUS & PDUS

Not given

50% GSUS-positive and 15% PDUS-positive in clinically normal joints

In many RA-patients in remission, PDUS inflammation is found

i,n,t,x


A, according to Wakefield 2005 [32]. B, semi quantitative definitions based on binary definitions by Brown 2006 [11], Wakefield 2004 [19], Karim 2004 [33] and Newman1996 [34]. C, GSUS: Hypoechogeneity; PDUS: grade 0, no flow signal in the synovium; grade 1, separate dot signals or short linear signals; grade 2, clearly discernible vascularity with either many small vessels or several long vessels with or without visible branching, though involving less than half the area of the synovium; grade 3, vessels involving more than half the area of the synovium. D, semiquantitative definitions based on binary definitions by Brown 2006 [11], Wakefield 2004 [19], Karim 2004 [33]. No PDUS definitions. E, Wakefield 2005 [32] and Newman 1996 [34]. F, according to Outcome Measures in Rheumatology (OMERACT) definitions, but not clear from footnotes which definitions have been used. US, ultrasonography, GSUS, greyscale ultrasonography; PDUS, power Doppler ultrasonography; aCCP, anti-cyclic citrullinated peptide; JE, joint effusion; SH, synovial hypertrophy; IA, inflammatory arthritis; LDA, Low disease activity; LSRA, long standing RA; RA, rheumatoid arthritis; UA, undifferentiated arthritis; RF, rheumatoid factor; OR, odds ratio; DRU, distal radio-ulnar; IC, intercarpal; MT, midtarsal; RC, radiocarpal; RSTL, radial styloid; USTL, ulnar styloid; UC, ulnocarpal; SDAI, simplified disease activity index. *Adaptation of phases according to Sackett & Haynes (Additional file 2, box 1): Phase 1. Do US results in patients with the condition differ from those without the condition? Phase 2. Are patients with certain US results more likely to have the condition? Phase 3. Do US results distinguish patients with and without the condition among those in whom it is clinically sensible to suspect the condition? Phase 4. Do patients undergoing the US fare better in their ultimate health outcome than similar untested patients? # See Additional file 3. ¶GSUS pos. (%) and PDUS pos. (%) signify the percentages of individuals with at least one inflamed joint applying the respective US modality.

Ten Cate et al. Arthritis Research & Therapy 2013 15:R4   doi:10.1186/ar4132

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