New York University/Hospital for Joint Disease: Seminar in Advanced Rheumatology

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Researchers will likely have to wait for months before they find out if they can continue studies on the use of nerve growth factor inhibitors in treating osteoarthritis pain, according to Dr. Nancy E. Lane, Endowed Professor of Medicine and Rheumatology at the University of California, Davis, in Sacramento.

Over the past year, the Food and Drug Administration has put on clinical hold nearly all programs for nerve growth factor inhibitor (anti-NGF) development, particularly those related to treating knee pain in osteoarthritis. The agency requested that pharmaceutical manufacturers halt their trials because of reports that study subjects taking the drugs had developed rapidly progressive hip and knee osteoarthritis requiring total joint replacement. A few of those patients also were reported to have had osteonecrosis. The fate of those studies could be determined later this year, when the FDA meets with the pharmaceutical companies involved in developing NGF inhibitors to discuss the issue, Dr. Lane said at a rheumatology meeting sponsored by New York University.

Dr. Lane, who was an investigator for Pfizer’s anti-NGF drug tanezumab, said the drug makers developing these compounds have been studying the possible causes of the adverse effects. The question remains whether the disease progression was due to reduced pain and increased activity, or if the inhibition of NGF compromised blood flow to the bone, resulting in osteonecrosis, she said. Regardless of whether the anti-NGF trials continue, Dr. Lane said understanding the NGF receptor TrkA and how to inhibit it may "bear fruit in the long term."

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.