[Magnetic resonance imaging of the hand as an early diagnostic method for rheumatoid arthritis].

AIM: To provide the qualitative and quantitative characteristics of changes revealed by the data of magnetic resonance imaging (MRI) of the hand and by those of X-ray study of the hand and foot in patients with early rheumatoid arthritis (ERA). SUBJECTS AND METHODS: The study enrolled 110 patients (90 females, 20 males; age 49.6 +/- 12.2 years) examined in the framework of the RADICAL program at the Research Institute of Rheumatology, Russian Academy of Medical Sciences. The mean duration of the disease was 5.61 +/- 3.17 months. The diagnosis of rheumatoid arthritis was established by the 1987 ARA criteria in all the patients on primary standard examination comprising X-ray study of the hand and feet and evaluation by the modified Sharp method. MRI of the hand was performed in all the patients, by assessing the result by the OMERACT-RAMRIS procedure. RESULTS: Destructive changes (cysts and erosions) evidenced by X-ray study were found in the wrists, metacarpophalangeal articulations (MPA), and foot in 7.27, 8.2, and 13.64%, respectively. MRI revealed destructions in the wrist, MPA, and metacarpal bone base in 50, 60, and 16.36%, respectively. Overall, erosions could be seen on X-ray films and MRI scans in 20.91 and 67.27%, respectively (p < 0.0001). MRI revealed bone edema (osteitis) in 46.4% of the patients; there was no difference in the detection rate between the extremities. MRI synovitis was found in 99% of the patients, the right hand being significantly more commonly affected. Detailed characterization of the changes revealed by MRI and Xray was obtained in patients with ERA. CONCLUSION: MRI detected erosions significantly more frequently than did X-ray (p < 0.001), which confirms the high value of low-field MRI diagnosis on primary examination of patients with ERA and supports the opinion that the results of this study should be included into the diagnostic criteria of ERA.

[Anticitrulline antibodies and wrist joint MRI parameters in patients with early arthritis].

AIM: To examine correlations between immunological markers, clinical parameters and MRI data in patients with early rheumatoid arthritis (RA) and undifferentiated arthritis (UDA). MATERIAL AND METHODS: The study was made of 211 patients with early RA (43 males, 168 females) and 47 patients with early UDA (mean age 48.6 +/- 13.4 years), duration of the symptoms 5.5 +/- 4.5 months). RF-positive were 136 (64.5%) patients. X-ray erosions were detected in 45 (21.3%) patients. RA activity was estimated by the integral DAS28 index (by 3 parameters), function--by HAO questionnaire (Russian version). The immunonephelometric analyzer (BN-100, Dade Behring, Germany) determined concentration of C-reactive protein (CRP), IgM. Anticitrulline antibodies (ACAB) were estimated by enzyme immunoassay, the upper limit of the norm was 5.0 U/ml. MR imaging (MRI) of both the wrists in RA patients was made on the 0.2 T Artoscan unit, the assessment was made with the reference atlas OMERACT-RAMRIS. RESULTS: IgM and ACAB levels were much higher in RA than in UDA. Among the patients positive by both tests (RF+ACAB) 95.2% had a typical clinical picture and RA diagnosis while 60% patients negative by RF and ACAB had UDA (p < 0.001); among patients positive by one of the tests the ratio UDA to RA was 1:2 (32.6 and 67.4%). In RA patients with very high ACAB (> 100 U/ml) CRP reached 38.10 +/- 48.29 mg/l while in negative ACAB--17.07 +/- 19.34 mg/l (p = 0.016). Wrist MRI detected synovitis and bone erosions in 93 and 66% cases, respectively. High ACAB level (> 100 U/ml) and CRP levels were associated with high DAS28, RF IgM and MRI erosions number. CONCLUSION: RF and ACAB patients are characterized by a typical RA picture in the disease onset (specificity 93.6%). MRI detects synovitis in the wrist joints in 93 and erosions in 66% early RA patients. Combination of high ACAB and CRP levels is associated with high RA activity, RF IgM and great number of erosions according to MRI and may serve a marker of a severe disease course.

[Early diagnosis of rheumatoid arthritis in modern clinical practice (results of a follow-up of a Moscow cohort of early arthritis patients participating in the program RADICAL)].

AIM: To estimate potentialities of early diagnosis of rheumatoid arthritis (RA) diagnosis in clinical practice in the course of the RADICAL program. MATERIAL AND METHODS: Of 366 patients participating in the trial 61 (16.7%) were males and 305 (83.3%) were females at the age of 47.76 +/- 14.1 years. The longest duration of the symptoms before consulting a doctor was 51 weeks, mean duration--5.7 weeks, 55% patients had the symptoms for 3 weeks. All the patients have undergone laboratory examination including leukocyte count, platelet count, estimation of ESR, concentration of C-reactive protein (CRP), rheumatoid factor (RF) and antibodies to a cyclic citrullated peptide (ACCP); roentgenography of the wrists and feet. On demand, antinuclear factor (ANF) and HLA-B27 were investigated. RA was diagnosed on the basis of ACR classification criteria. If the criteria were not complete at the moment of the study, the patient was referred to the group of "undifferentiated arthritis" (UA). The patients were examined before the treatment, 6 and 12 months later. The treatment was made according to Russian clinical recommendations. RESULTS: Prior to admission to hospital, 58% patients were suspected for RA, 18.3%--osteoarthrosis (OA), 14%--reactive arthritis. 18.9% were not diagnosed, other diagnoses were considered in 12.6% patients. At primary examination RA was diagnosed in 212 (57.9%) patients, UA was in 133 (36.3%) patients, 21 (5.7%) patients had other diagnoses. Twelve months later RA, UA and other diseases were diagnosed in 256 (69.9%), 70 (19.1%) and 40 (10.9%) patients, respectively. CONCLUSION: A 3-stage algorithm of early RA diagnosis is proposed. At the stage of the first contact with the patient in an outpatient clinic a valid RA suspition with consideration of modified EULAR criteria must be formulated. At the second stage a district rheumatologist must examine the patient outpatiently with determination of ACR classification criteria. In diagnosis verification the treatment must be started according to APP and EULAR clinical recommendations. If RA diagnosis can not be verified or rejected, the patient must be refered to hospital (stage 3). If verification of RA diagnosis is impossible, the diagnosis should be formulated as UA.