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Extended report
Utility of ultrasound joint counts in the prediction of rheumatoid arthritis in patients with very early synovitis
  1. Andrew Filer1,2,
  2. Paola de Pablo1,2,
  3. Gina Allen3,
  4. Peter Nightingale4,
  5. Alison Jordan5,
  6. Paresh Jobanputra5,
  7. Simon Bowman5,
  8. Christopher D Buckley1,2,
  9. Karim Raza1,2
  1. 1MRC Centre for Immune Regulation, School of Immunity and Infection, The University of Birmingham, Birmingham, UK
  2. 2Department of Rheumatology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  3. 3Green Templeton College, University of Oxford, Oxford, UK
  4. 4Wolfson Computer Laboratory, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
  5. 5Department of Rheumatology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  1. Correspondence to Dr A Filer, Rheumatology Research Group, School of Immunity and Infection, College of Medical and Dental Sciences, Institute for Biomedical Research, The University of Birmingham, Birmingham B15 2TT, UK; a.filer{at}


Objectives Early therapy improves outcomes in rheumatoid arthritis (RA). It is therefore important to improve predictive algorithms for RA in early disease. This study evaluated musculoskeletal ultrasound, a sensitive tool for the detection of synovitis and erosions, as a predictor of outcome in very early synovitis.

Methods 58 patients with clinically apparent synovitis of at least one joint and symptom duration of ≤3 months underwent clinical, laboratory, radiographic and 38 joint ultrasound assessments and were followed prospectively for 18 months, determining outcome by 1987 American College of Rheumatology (ACR) and 2010 ACR/European League Against Rheumatism criteria. Sensitivity and specificity for 1987 RA criteria were determined for ultrasound variables and logistic regression models were then fitted to evaluate predictive ability over and above the Leiden rule.

Results 16 patients resolved, 13 developed non-RA persistent disease and 29 developed RA by 1987 criteria. Ultrasound demonstrated subclinical wrist, elbow, knee, ankle and metatarsophalangeal joint involvement in patients developing RA. Large joint and proximal interphalangeal joint ultrasound variables had poor predictive ability, whereas ultrasound erosions lacked specificity. Regression analysis demonstrated that greyscale wrist and metacarpophalangeal joint involvement, and power Doppler involvement of metatarsophalangeal joints provided independently predictive data. Global ultrasound counts were inferior to minimal power Doppler counts, which significantly improved area under the curve values from 0.905 to 0.962 combined with the Leiden rule.

Conclusion In a longitudinal study, extended ultrasound joint evaluation significantly increased detection of joint involvement in all regions and outcome groups. Greyscale and power Doppler scanning of metacarpophalangeal joints, wrists and metatarsophalangeal joints provides the optimum minimal ultrasound data to improve on clinical predictive models for RA.

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  • Funding The ultrasound equipment used in this study was funded by Arthritis Research UK, and the Rheumatology Research Group is a member of the EU AutoCure Consortium.

  • Competing interests CDB and KR have received grants and honoraria from Wyeth, Cellzome, UCB and Pfizer. AF has received grant support from Cellzome and Pfizer. SB has received honoraria or grant support from Roche, Genentech, UCB, GlaxoSmithKline and Astra-Zeneca. PdP, GA, PN, AJ and PJ declare no conflicts of interest.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the Solihull Local Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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