Using Mri To Diagnose Early Ra
One of the possible practical applications of MRI in early RA is to help differentiate this condition from other inflammatory arthropathies. McGonagle et al. reported a study of 20 patients with recentonset knee effusion and found that prominent perientheseal bone marrow oedema was a feature in six of ten spondyloarthropathy patients but was not found in the RA patients studied. In another study by the same group , MRI scans of the MCP joints of the dominant hand were used to try to distinguish between acuteonset RA, which carries a good prognosis and insidiousonset disease, which does not. Bone marrow oedema at the articular margin was found to be a useful differentiating feature, being present in 13 of 22 patients with a poor prognosis and in none of a group of patients with a good prognosis. However, capsular enhancement was more common in the group with a good prognosis. The authors hypothesize that these early MRI changes may define two distinct locations for pathology in patients satisfying criteria for early RA. Intrasynovial inflammation may characterize those with a poor prognosis , and extrasynovial, capsular inflammation may be a marker of good prognosis, associated with remission or possibly evolution into one of the spondyloarthropathies.
Pathogenesis Of Ra And Ra
The pathogenesis of RA has been understood to some extent only. However, there is evidence that the process of joint destruction is initiated in the joint cavity and bone marrow. In addition, adipose tissue may also play a pro-inflammatory and pro-destructive role. So far, it has not been determined what triggers the formation of inflammatory infiltrates in the synovial membrane. Environmental factors, such as cigarette smoking and porphyromonas gingivalis, are thought to play a role. In certain predisposed individuals, the synovium may thicken rapidly within a few months due to hyperplasia, which is an increase in the number of fibroblast-like synoviocytes from 13 layers to up to 12 layers. The subintima layer, which in healthy individuals is composed of loose connective tissue with blood and lymphatic vessels, nerve fibers and several cell types, may thicken as a result of edema caused by migration and retention of infiltrating cells. This thickened synovium is well-visible on US and MRI scans.
The thickened synovium is also characterized by increased vascularity, which is a result of angiogenesis. This aspect of the disease is also well-visible on both Doppler ultrasonography and MRI on contrast-enhanced T1-weighted images. DCE-MRI shows increased permeability of neovessels.
Cost Of Diagnosis And Treatment
Table 1 presents the direct medical cost related to the diagnosis of RA. The conventional total diagnostic cost was estimated at $59.20 USD . The cost of the alternative diagnosis process was $269.57 USD. The largest share of this cost was related to the use of imaging techniques, including x-rays, US, and MRI .
Table 1 Direct Costs Related to Diagnosis of Presumptive Seronegative RA
Table 2 shows that the estimated mean cost per seronegative RA patient for 1 year of follow-up was $5,419.3 USD , while Table 3 presents the mean cost for OA as $526.3 USD . The highest cost in seronegative RA was related to the pharmacological treatment, accounting for $5,332.6 USD . For OA, the proportion of pharmacological treatment in the total cost of the treatment per year was 92.2%.
Table 2 Estimation of Direct Cost of RA Treatment* in the First Year After Diagnosis per Patient
Table 3 Estimation of Direct Cost of OA Treatment in the First Year After Diagnosis per Patient*
We calculated the cost of biologic therapy assuming that these biodrugs were included in month 6 of treatment -after conventional DMARD therapy failure- representing the highest cost of pharmaceutical therapy.
Assuming patients with seronegative RA without biologic therapy, the cost of treatment continued to be higher than that of OA. According to Table 2, we estimated the cost per year with DMARD therapy as $1,123.6 USD compared with that of OA, with a cost of $526.3 USD
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Mri In Rheumatoid Arthritis: Assessing Disease Activity Remission Prognosis
Magnetic resonance imaging shows changes in bone and cartilage and can discriminate these from fluid and soft tissue around the joints, making it a good technique to measure synovial volume and inflammation characteristic of rheumatoid arthritis .1 The use of T2-weighted images identifies structures with high water content clearly, and regions of high vascularity are further delineated by injection of gadolinium contrast. The combined evidence from studies over the past decade has suggested an extensive role for MRI in the management of RA.
Evidence From MRI Studies
Relationships between bone marrow edema and synovitis in RA have been well established.2 Divergent findings have emerged from more recent MRI studies that questioned earlier beliefs that the relationship between synovitis and BME was the primary cause of bone erosion and that synovial pathways were fundamental to the initiation of BME, erosions, or thinning of cartilage. More recent MRI studies suggest multiple separate etiologies that are more likely to be independent risk factors for RA degeneration:
Using MRI to Measure Disease Activity
- MRI stands out from other modalities for its ability to characterize BME clearly. BME has been equated with histologic osteitis and signals the presence of synovitis.
- Combining MRI data with knowledge of synovial pathobiology may be used to identify signatures of bone erosion in RA.
- MRI can be used as an alternative to standard radiographs to detect bone cartilage loss.
How Is An Mri Used To Diagnose Osteoarthritis
A radiologist may perform an MRI of a joint with possible osteoarthritis if X-rays are inconclusive. The doctor may also want to look for possible tears and strains in other tissues surrounding the joint.
During the visit, the MRI technician will ask you to lie on a table. He or she will then move the table into the MRI machine, so that the injured area is in the machine. This means that if your shoulder is being looked at, only the top half of your body will need to be in the machine. Your MRI results will then be sent to your doctor, who youll see at a follow-up appointment.
When examining an MRI, an orthopedist will typically look for the following structures, which may indicate osteoarthritis:
- damage to the cartilage
- osteophytes, also called bone spurs
- subchondral sclerosis, which is increased bone density or thickening in the subchondral layer of the joint
- joint effusion, or excess swelling of fluid around the joint
- synovitis, which refers to inflammation of the synovial membrane in joints
- tears in ligaments, which may increase your risk for early osteoarthritis, or cause pain or impaired function
Before scheduling an MRI, your doctor will first review your symptoms and ask:
- your degree of pain
- how long youve had pain
- activities that are difficult because of your pain or decreased mobility
Your doctor will also perform a physical examination and look for the following:
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What Does Rheumatoid Arthritis Look Like On An Mri
MRI provides very detailed pictures of your organs, tissues, and bones by using a strong magnet, radio waves, and a computer. With these clear images, bone erosions in your joints can be more easily identified on MRI than on x-ray.
MRI can also reveal issues within the joints that are unable to be seen on . Two features of rheumatoid arthritis that your doctor may look for include:
Inflammation: MRI can show inflammation of the lining of your joints, known as synovitis. This is an early sign of .
Bone marrow edema: This occurs when excess fluid builds up in your bone marrow. If bone marrow edema is present, its often an indicator of eventual bone erosions.
Bone erosions, inflammation, and bone marrow edema on MRI can help diagnose rheumatoid arthritis in its early stages.
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Comparison Of Us And Mri In The Evaluation Of The Different Knee Pathologies In Patients With Ra
The reliability of US compared with MRI findings was measured using kappa agreement, and the results are shown in Table 3. US revealed at least moderate agreement with MRI in diagnosing different lesions of the knee joints in the patients with RA. The agreement in the diagnosis of synovitis , ligament injury , joint effusion , tenosynovitis , joint space narrowing , bone erosion , and soft tissue swelling is listed in Table 3.
Rheumatoid Arthritis Classification Criteria
To help doctors make diagnoses, the American College of Rheumatology and the European League Against Rheumatism collaborated to create the 2010 Rheumatoid Arthritis Classification Criteria.
These criteria set a minimum standard for what signs and symptoms must be noted before RA can be diagnosed.2 A total point score of 6 or more indicates rheumatoid arthritis.
|Normal C-reactive protein and normal erythrocyte sedimentation rate|
|1 point||Abnormal CRP or abnormal ESR|
Points may be added over time or retrospectively, meaning the signs and symptoms do not necessarily have to be recorded at the same doctors appointment.
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Inclusion And Exclusion Criteria
We analyzed electronic health records between July 2016 and June 2017, for all patients referred to the Center by their insurance companies or payers with a presumptive diagnosis of seronegative RA. Patients were included if they tested negative for both RF and ACPA biomarkers, but fulfilled the classification criteria of RA according to ACR/EULAR 2010 classification criteria.1
We excluded patients without typical clinical symptoms of RA, with a sole serological negative test, patients younger than 18 years of age, those with juvenile-onset idiopathic arthritis, patients with spondyloarthritis,9 those with other autoimmune disorders like systemic lupus erythematosus,10 Sjogren syndrome,11 or those not fulfilling the clinical domains of ACR/EULAR 2010 classification criteria.1
Pathological Changes Within The Rheumatoid Joint
Conahan et al. reported an apparent progression of pathology within the rheumatoid joint during the first 612 months, and our own observations have confirmed this . Synovitis develops initially, and is often followed by bone marrow oedema and finally by bony erosion, as seen on MRI scans. Radiographic erosions are recognized a further 6 months later, about 1218 months after symptom onset . The finding of bone marrow oedema was not recognized in the rheumatoid joint before the advent of MRI and has no radiological correlate. Specifically, it is not associated with periarticular osteopenia . It appears as increased signal intensity of bone on T2weighted images after fat suppression, resulting from an increased amount of water in the marrow, and may represent the internal bony response to external attack by the inflamed synovium. Bone marrow oedema in early RA has been found to be strongly associated with subsequent erosion at the same site , and appears to be an important early pathological feature. It often accompanies the development of erosion and may subside once erosions become inactive, but proof of this awaits further longitudinal studies. Unfortunately, histological verification of the bone oedema seen in MR images is unlikely to be possible in early disease because of difficulties in obtaining appropriate biopsy tissue.
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How Can You Tell The Difference Between Rheumatoid Arthritis And Osteoarthritis
The main difference between osteoarthritis and rheumatoid arthritis is the cause behind the joint symptoms. Osteoarthritis is caused by mechanical wear and tear on joints. Rheumatoid arthritis is an autoimmune disease in which the bodys own immune system attacks the bodys joints. It may begin any time in life.
Benefits Of Mri In Diagnosing Ra
Radiographs are the current gold standard for evaluating joint damage in RA, and it is likely that radiography will continue to be used in daily clinical practice for monitoring arthritis disease progression. However, conventional radiography is not sensitive enough for depicting bone damage in early disease and is also insufficient for assessing synovial inflammation. These limitations have led to emerging interest in the multiplanar imaging abilities of MRI in RA and to wider use of MRI for assessing synovitis and bone damage .
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What Happens During The Mri Exam
You may be asked to wear a hospital gown during the MRI scan.
As the MRI scan begins, you will hear the equipment making a muffled thumping sound that will last for several minutes. Other than that sound, you should experience no unusual sensations during the scanning. Certain MRI exams require an injection of a contrast material. This helps identify certain anatomic structures on the scan images.
Feel free to ask questions and tell the technologist or doctor if you have any concerns.
What Else Could It Be
When a doctor thinks about how likely you are to have one disease over another, or over several others, this is called a differential diagnosis. There are many conditions your doctor may consider besides RA, and besides other forms of autoimmune arthritis:
Polymyalgia rheumatica: This is more common over age 50, generally less painful than RA, and associated more with shoulders and hips.
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Rheumatoid Factor And Anti
One blood test measures levels of rheumatoid factors in the blood. Rheumatoid factors are proteins that the immune system produces when it attacks health tissue.
About half of all people with rheumatoid arthritis have high levels of rheumatoid factors in their blood when the disease starts, but about 1 in 20 people without rheumatoid arthritis also test positive.
A related blood test known as anti-cyclic citrullinated peptide test is also available. Anti-CCPs are antibodies also produced by the immune system.
People who test positive for anti-CCP are very likely to develop rheumatoid arthritis, but not everybody with rheumatoid arthritis has this antibody.
Those who test positive for both rheumatoid factor and anti-CCP may be more likely to have severe rheumatoid arthritis requiring higher levels of treatment.
Access To Modern Imaging
The use of ultrasound in rheumatology practice was first widely adopted in Europe but is now gaining ground in the United States. In November 2012, the American College of Rheumatology published a report on reasonable uses of ultrasound in clinical practice. By reasonable, they mean that the health benefits exceed possible negative consequences by a wide margin .
Among multiple uses, the ACR panel endorsed applying ultrasound to the diagnosis and monitoring of RA in many joints, but they were clear that the technology is not a mandatory component of rheumatology practice. Recommendations on the use of MRI in RA are anticipated in 2013.
Both MRI and ultrasound are more expensive than X-rays. Medicare and several private insurers allow MRI or ultrasound to be used in the evaluation of extremity pain, not specifically to diagnose RA.
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Lowcost Officebased Mri Systems
A major impediment to the use of MRI in the investigation of common rheumatic disorders is cost. At more than US$300 per scan of the wrist , MRI is expensive, but this cost would be more than recovered if it allowed identification of the patient with a good prognosis and prevented the unnecessary use of biological agents. New lowcost, lowfield, dedicatedextremity MRI systems which are officebased are being developed . Peterfy et al. investigated the application of such a system to imaging of the wrist in RA and devised a method for scoring erosions and jointspace narrowing based on a radiographic scoring system. Whether these lowfield, dedicatedextremity MRI units can provide the same quality of information as the larger machines has yet to be demonstrated, but they have the potential to improve access to this imaging modality for the clinician. MRI will be competing with other imaging techniques such as highquality ultrasound, which has been shown to have promise in assessing synovitis at the finger joints in inflammatory arthritis , and must be priced competitively if it is to become widely used.
Comparison With Other Imaging Modalities
Many of the important new developments in MRI scanning have been paralleled by similar findings using ultrasound. Several ultrasound studies have confirmed the importance of subclinical disease activity with increased synovial thickness on grey-scale ultrasound and positive scores for synovial vascularity on PDUS in RA patients who are in apparent clinical remission., Naredo et al showed that a fall in PDUS signal in clinically active joints predicted a lack of damage progression in those joints over time. Although bone oedema cannot be detected by ultrasound, there is an intriguing association between PDUS signal in the synovium above the joint and bone oedema in the bone below, which were highly correlated in a Danish study. There are strengths and weaknesses of both forms of imaging. MRI has the benefits of offering high image resolution and is capable of detecting all the important aspects. of joint inflammation and damage, including bone oedema and cartilage thinning, at all joint sites, especially the highly informative region of the wrist. Downsides of MRI include prolonged scanning time , potential in some patients for claustrophobia and high cost. Ultrasound is user-friendly and low cost but not all joints are accessible , reproducibility is variable and bone oedema cannot be detected. Other imaging modalities such as XR and CT have important roles in monitoring damage progression in RA but are not capable of depicting inflammation.
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