Characterization of bone marrow lesions in axial spondyloarthritis using quantitative T1 mapping MRI.

OBJECTIVE: Conventional magnetic resonance imaging (MRI) uses T1-weighted and short-tau inversion recovery (STIR) sequences to characterize bone marrow in axial spondyloarthritis. However, quantification is restricted to estimating the extent of lesions because signal intensities are highly variable both within individuals and across patients and MRI scanners. This study evaluates the performance of quantitative T1 mapping for distinguishing different types of bone marrow lesions of the sacroiliac joints. MATERIALS AND METHODS: In this prospective study, 62 patients underwent computed tomography (CT) and MRI of the sacroiliac joints including T1, STIR, and T1 mapping. Bone marrow lesions were characterized by three readers and assigned to one of four groups: sclerosis, osteitis, fat lesions, and mixed marrow lesions. Relaxation times on T1 maps were compared using generalized estimating equations and receiver operating characteristics (ROC) analysis. RESULTS: A total of 119 lesions were selected (sclerosis: 38, osteitis: 27, fat lesions: 40; mixed lesions: 14). T1 maps showed highly significant differences between the lesions with the lowest values for sclerosis (1516±220 ms), followed by osteitis (1909±75 ms), and fat lesions (2391±200 ms); p<0.001. T1 mapping differentiated lesions with areas under the ROC curve of 99% (sclerosis vs. osteitis) and 100% (other comparisons). CONCLUSION: T1 mapping allows accurate characterization of sclerosis, osteitis, and fat lesions at the sacroiliac joint but only for homogeneous, non-mixed lesions. Thus, further sequence development is needed before implementation in clinical routine.

Osteitis pubis following holmium laser enucleation of the prostate.

Osteitis pubis is a rare, inflammatory condition involving the pubic symphysis. While osteitis pubis has been reported following many urological procedures, including those addressing bladder outlet obstruction such as transurethral resection of the prostate, it has never been reported after holmium laser enucleation of the prostate (HoLEP). Here, we detail the clinical course of a patient found to have osteitis pubis following HoLEP. This patient presented several weeks after surgery with non-specific, persistent symptoms of groin pain and difficulty ambulating, alerting our clinicians to consider osteitis pubis which was confirmed on MRI of the pelvis. While the majority of osteitis pubis cases are managed with locally invasive techniques, our patient's symptoms were successfully managed conservatively with Foley catheter placement, oral antibiotics and close follow-up. At 9 months postoperative, the patient has reported complete resolution of symptoms and continues to be followed closely.

Osteomielitis crònica no bacteriana / Osteomielitis crónica no bacteriana / Chronic non-bacterial osteomyelitis

Introducció. L’osteomielitis crònica no bacteriana (OCNB)és una entitat poc freqüent en pediatria. Es tracta d’unamalaltia inflamatòria no infecciosa de l’os que sol cursaramb remissions i exacerbacions espontànies. Té una etiologia desconeguda. Sol presentar-se com un dolor ossisubagut, acompanyat o no de clínica sistèmica, i és necessari descartar altres causes, com la neoplàstica o la infecciosa. Les proves d’imatge donen suport al diagnòstic.Observació clínica. Es presenten dos casos de pacients ambdolor ossi insidiós a les extremitats inferiors de diversessetmanes d’evolució, amb alteració de la força i la mobilitat. Ambdós casos s’associen a anorèxia. L’analítica presenta elevació dels paràmetres inflamatoris, VSG (velocitatde sedimentació globular) i PCR (proteïna C reactiva). Lagammagrafia òssia i la ressonància magnètica nuclear permeten fer el diagnòstic d’OCNB. En ambdós casos es fatractament amb antiinflamatoris no esteroidals durant quatre setmanes, i es requereix l’addició de bifosfonats a causad’una resposta parcial.Comentaris. L’OCNB és una causa d’inflamació òssia en elsinfants en què un diagnòstic precoç i la instauració d’untractament efectiu permet evitar complicacions. És important tenir-la en compte en fer el diagnòstic diferencial deldolor ossi insidiós. Un coneixement millor en pot disminuirl’infradiagnòstic. (AU)

Introducción. La osteomielitis crónica no bacteriana (OCNB) esuna entidad poco frecuente en pediatría. Se trata de una enfermedad inflamatoria no infecciosa del hueso que suele cursar conremisiones y exacerbaciones espontáneas. Su etiología es desconocida. Suele presentarse como un dolor óseo subagudo, acompañado o no de clínica sistémica, y es necesario descartar otrascausas como la neoplásica o la infecciosa. Las pruebas de imagenapoyan el diagnóstico.Observación clínica. Se presentan dos casos de pacientes con doloróseo insidioso en extremidades inferiores de varias semanas de evolución con alteración de la fuerza y la movilidad. Ambos casosse asocian a anorexia. A nivel analítico presentan elevación de losparámetros inflamatorios, VSG (velocidad de sedimentación globular) y PCR (proteína C reactiva). La gammagrafía ósea y la resonancia magnética nuclear permiten realizar el diagnóstico de OCNB.En ambos casos se realiza tratamiento con antiinflamatorios noesteroideos durante cuatro semanas, requiriendo la adición de bifosfonatos debido a respuesta parcial.Comentarios. La OCNB es una causa de inflamación ósea en losniños en la que un diagnóstico precoz y la instauración de untratamiento efectivo permite evitar complicaciones. Es importantetenerla en cuenta al realizar el diagnóstico diferencial del doloróseo insidioso. Un mayor conocimiento puede disminuir su infradiagnóstico. (AU)

Introduction. Chronic non-bacterial osteomyelitis (CNBO) is a rarecondition in pediatrics. It is a non-infectious inflammatory diseaseof the bone that usually results in spontaneous remissions andexacerbations. Its etiology is unknown. It usually presents as subacute bone pain, with or without systemic signs and symptoms. Itis often necessary to rule out other causes such as neoplastic orinfectious. Imaging tests support the diagnosis.Clinical observation. We present two cases of patients with insidious bone pain in the lower extremities of several weeks of evolution with impaired strength and mobility. Both cases were associated with anorexia nervosa. Laboratory evaluation showed elevatedinflammatory parameters, erythrocyte sedimentation rate andC-reactive protein. Bone scintigraphy and nuclear magnetic resonance imaging allowed the diagnosis of CNBO. In both cases,treatment with nonsteroidal anti-inflammatory drugs was performed for 4 weeks, requiring the addition of bisphosphonates due topartial response.Comments. CNBO is a cause of bone inflammation in children inwhich early diagnosis and effective treatment can prevent complications. It is important to keep this entity in mind when makingthe differential diagnosis of insidious bone pain. Greater knowledgemay decrease its underdiagnosis. (AU)

Prospective Comparison of the Imaging Value of 99m Tc-MDP Bone Scan and 68 Ga-FAPI-04 PET/CT in Synovitis, Acne, Pustulosis, Hyperostosis, and Osteitis Syndrome.

PURPOSE: This study aimed to explore the imaging value of 68 Ga-FAPI-04 PET/CT in synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome and compare it with that of 99m Tc-MDP bone scan. METHODS: Nineteen participants with SAPHO syndrome underwent 68 Ga-FAPI-04 PET/CT and 99m Tc-MDP bone scan. Demographic data and clinical features were recorded, SAPHO imaging features were analyzed, and the osteoarticular lesion detection rate in both methods was calculated. RESULTS: This prospective study recruited 4 men and 15 women aged 52.4 ± 8.6 years. The anterior chest wall was involved in all participants (100%). Palmoplantar pustulosis was the most common (36.8%) skin symptom. 99m Tc-MDP bone scan and 68 Ga-FAPI-04 PET/CT together detected 84 osteoarticular lesions, of which 91.7% (77/84) were detected by the former and 96.4% (81/84) by the latter. Furthermore, 68 Ga-FAPI-04 PET/CT detected 5 cases of knee and hip joint synovitis. CONCLUSIONS: 68 Ga-FAPI-04 PET/CT was more sensitive than 99m Tc-MDP bone scan when evaluating osteoarticular lesions in SAPHO syndrome and could also evaluate synovial lesions. 68 Ga-FAPI-04 PET/CT could be a good imaging method for SAPHO syndrome but requires further verification in a more extensive research cohort.

Synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome with cranial bone involvement: Case report and literature review.

Synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome is a rare autoimmune inflammatory disease characterized by osteoarticular and dermatological manifestations. The most common osteoarticular manifestations involve the anterior chest wall, axial skeleton, and long bones. Cranial bone involvement is less reported in SAPHO syndrome. We herein present three cases of SAPHO syndrome with cranial bone involvement, and review the previous literature on similar manifestations. It was revealed that SAPHO syndrome could lead to cranial bone involvement, which could involve the dura mater, leading to hypertrophic pachymeningitis, but the outcome is usually good. Janus kinase inhibitors may be a potential treatment option.

Radiation osteitis: incidence and clinical impact in the setting of radiation treatment for soft tissue sarcoma.

OBJECTIVE: Radiotherapy is an important component of soft tissue sarcoma management. Radiation osteitis is a common radiographic finding identified in the setting of radiotherapy on magnetic resonance imaging (MRI). This study aims to identify the incidence of radiation osteitis in patients who received radiotherapy for soft tissue sarcoma and if a further workup, including a biopsy, was performed for concerning MRI findings. MATERIALS AND METHODS: Medical records of patients with soft tissue sarcoma who received radiotherapy from 2008 to 2020 were retrospectively reviewed. Patients with at least one MRI of the sarcoma site following radiotherapy and information regarding radiotherapy treatments were included. MRIs of these patients were reviewed for the presence of radiation osteitis by two musculoskeletal radiologists. The clinical course of these patients including biopsy for concerning MRI findings, local recurrence, and metastasis was recorded. RESULTS: Thirty soft tissue sarcoma patients who received radiation for soft tissue sarcoma were included. Radiation osteitis was present in 18 patients. The time to osteitis present on MRI following radiotherapy completion was a median of 4.5 months. Biopsy for concerning MRI findings was performed in eight patients, five for local recurrence, and three for regional osseous metastasis. Three patients had confirmed osseous metastases. CONCLUSION: Although radiation osteitis is often a benign imaging finding, it can be difficult to discern these lesions from potentially malignant sites of disease. We recommend multidisciplinary management of soft tissue sarcoma at sarcoma centers to appropriately identify benign from malignant lesions and decide the necessity of a biopsy.

The Natural Sequence in Which Subclinical Inflamed Joint Tissues Subside or Progress to Rheumatoid Arthritis: A Study of Serial MRIs in the TREAT EARLIER Trial.

OBJECTIVE: The natural trajectory of clinical arthritis progression at the tissue level remains elusive. We hypothesized that subclinical inflammation in different joint tissues (synovitis, tenosynovitis, osteitis) increases in a distinct temporal order in patients with clinically suspect arthralgia (CSA) who develop rheumatoid arthritis (RA) and subsides in a different sequence when CSA spontaneously resolves. METHODS: We studied 185 serial magnetic resonance images (MRIs) from CSA patients with subclinical joint inflammation from the placebo arm of the TREAT EARLIER trial: 52 MRIs from 21 RA progressors (MRIs conducted at 1 year before, at 4 months before, and upon RA development), and 133 MRIs from 35 patients with spontaneous resolution of pain (MRIs conducted at baseline and at 4, 12, and 24 months). MRIs were scored for osteitis, synovitis, and tenosynovitis. We used cross-lagged models to evaluate 2 types of time patterns between pairs of inflamed tissues: a simultaneous pattern (coinciding changes) and a subsequent pattern (inflammatory changes in 1 tissue preceding changes in another tissue). RESULTS: In patients who developed RA, synovitis, tenosynovitis, and osteitis increased simultaneously. Increasing osteitis occurred in the final 4 months before RA diagnosis, following incremental tenosynovitis and synovitis changes during the 1 year to 4 months before diagnosis (P < 0.01). In anti-citrullinated protein antibody (ACPA)-positive and ACPA-negative patients who progressed to RA, osteitis increased just before RA development. In patients with pain resolution, simultaneous decreases in synovitis, tenosynovitis, and osteitis occurred, with tenosynovitis decreasing in the first 4 months after CSA onset preceding decreasing synovitis and osteitis during 4-12 months (P = 0.02 and P < 0.01). CONCLUSION: We identified natural sequences of subclinical inflammation in different joint tissues, which deepens our understanding of clinical arthritis and RA development. During RA progression, increasing osteitis followed previous increases in tenosynovitis and synovitis. During pain resolution, tenosynovitis decreased first, followed by decreasing synovitis and osteitis.

The promising role of DECT in the diagnosis of Osteitis Condensans Ilii: a case report.

Osteitis condensans ilii (OCI) is a noninflammatory condition of no clear etiology, cause of axial low back pain. It is characterized by sclerotic bone lesions at the iliac region of the sacroiliac joints. The diagnosis is based on radiological findings and the exclusion of other conditions associated with back pain. We present a case of bilateral OCI in a young woman with bone sclerosis at sacroiliac joints diagnosed with the use of Dual Energy CT.

[Groin pain in athletes-sportsmen's groin]. / Sportlerleiste ­ "Sportsmen's groin".

CLINICAL/METHODICAL ISSUE: Groin pain in athletes can have various causes. Radiologically, osteitis pubis and clefts with affection of the interpubic disc as well as muscle and tendon tears near the pubic bone can be clearly identified. STANDARD RADIOLOGICAL METHODS: Magnetic resonance imaging (MRI) is the imaging modality of choice, as well as single-leg stand imaging (flamingo view radiographs), and where appropriate symphysography. METHODICAL INNOVATIONS: Optimized MRI sequence protocol with oblique (axial oblique) slices parallel to the linea arcuata of the iliac bone is recommended. High-resolution MRI sequences and symphysography can detect superior and secondary cleft formation. Instabilities of the pubic symphysis can be diagnosed using flamingo view radiographs. PERFORMANCE: The MRI findings of osteitis pubis and clinical symptoms correlate. The presence of parasymphyseal bone marrow edema is the earliest morphological sign of acute osteitis pubis on MR imaging. Edema in the periosteal tissue and isolated muscle lesions next to the symphysis are generally associated with more severe clinical symptoms. ACHIEVEMENTS AND PRACTICAL RECOMMENDATIONS: Close communication between radiologists and the referring physicians is indispensable when planning an adequate imaging protocol, and precise knowledge of the clinical symptoms in the case of clinical suspicion of osteitis pubis allows for a reliable diagnosis and provides important prognostic information.

Performance of an MRI scoring system for inflammation of joints and entheses in peripheral SpA: post-hoc analysis of the CRESPA trial.

OBJECTIVES: The aim of this study was to investigate the reliability, validity, and sensitivity to change of a novel MRI scoring system in early peripheral SpA (pSpA). METHODS: MRI of the pelvis and lower extremities was performed before initiation of the TNF inhibitor golimumab in 56 patients and repeated in 46 patients who achieved sustained clinical remission after 24, 36 or 48 weeks. Three readers applied a semi-quantitative MRI scoring system for lower-extremity joint and entheseal inflammation. Four lesion types were assessed: entheseal osteitis, entheseal soft-tissue inflammation, joint osteitis, and joint synovitis/effusion. MRI response was defined as a decrease in MRI lower-extremity inflammation index (sum of scores from 75 sites, each scored 0-3) above the smallest detectable change (SDC). RESULTS: At follow-up, the MRI index decreased in 34 of 46 patients (74%), and 15 (33%) patients achieved MRI response, i.e. a decrease above SDC of 2.8. When restricting the analysis to patients with clinical involvement of lower-extremity sites that were assessed by MRI, 13 of 28 (46%) achieved MRI response. Interreader reliability was very good, with an average-measure intraclass correlation coefficient of 0.92 (95% CI: 0.85-0.95) for status scores and 0.89 (0.80-0.94) for change in scores. The MRI index correlated with other measures of disease activity, including CRP [Spearman's rho 0.41 (0.23-0.56)], swollen joint count of 6 joints [0.47 (0.27-0.63)], tender enthesis count of 14 entheses [0.32 (0.12-0.50)] and pain score [0.28 (0.08-0.46)], all P < 0.05. CONCLUSION: The proposed MRI lower-extremity inflammation index demonstrated reliability, validity, and sensitivity to change in patients with early pSpA. TRIAL REGISTRATION: Clinicaltrials.gov, http://clinicaltrials.gov, NCT01426815.

Idiopathic Osteosclerosis and Condensing Osteitis in a Sample of the Lebanese Population: A Digital Panoramic Based Study.

Background: Idiopathic osteosclerosis (IO) is an area of enlarged bone production in the jaw that usually appears radiopaque and round, elliptical, or irregular in shape. Condensing osteitis (CO) is a focalized osseous reaction leading to periapical sclerotic bone growth. Objective: The aim of this study was to investigate the prevalence, localization, shape, and dental relationship of IO and CO in a group of Lebanese patients and to correlate these findings to age and gender. Methods: 520 digital panoramic radiographs of patients (215 men and 305 women) ranging in age from 18 to 77 (mean age 40.89 years) who visited the Faculty of Dental Medicine, Lebanese University, for dental treatment were included in this study and assessed for IO and CO. The prevalence of the two lesions according to gender and age, as well as their localization, and dental relationship, were recorded and saved in an Excel sheet. Results: Among the 520 radiographs, 47 (9%) showed IO, and 30 (5.8%) showed CO. Both lesions are more frequent among females in their third decade and are essentially found in the mandible, mainly in relation to the root apices. Conclusion: Within the limits of this study, we concluded that in our sample of the Lebanese population, the prevalence of IO and CO is low and supports the theory that IO can be defined as developmental variations of normal bony architecture unrelated to a local stimulant, and CO could be considered reactive bone formations related to pulpitis, deep restoration, or caries.

Presence of axial spondyloarthritis associated sacroiliitis and structural changes on MR enterography: A direct comparison with sacroiliac joint MRI.

INTRODUCTION: To investigate the acute inflammatory and structural changes of sacroiliitis as auxiliary findings on magnetic resonance enterography (MRE) and their presence on closely timed conventional magnetic resonance imaging of the sacroiliac joint (SI joint MRI). MATERIALS AND METHODS: We screened axial spondyloarthritis patients for the simultaneous presence of MREs and SI joint MRIs. Two blinded radiologists evaluated SI joint MRIs and MREs on two separate occasions. We used the Assessment of SpondyloArthritis International Society (ASAS)/Outcome Measures in Rheumatology Network (OMERACT) definitions for SI joint MRI. We implemented previously published standard definitions for osteitis, erosion, sclerosis, and fatty infiltration of SI joint in MREs that contain T1w and T1w post-gadolinium sequences. RESULTS: SI joint MRI and MRE images were present in 43 patients. The median time between the two modalities was 14 (0-89) days. Twelve patients had ASAS-defined positive SI joint MRI. Radiologist-1 and radiologist-2 detected osteitis on MRE in nine and eight out of these 12 patients, respectively. The two radiologists detected ankylosis and fatty metaplasia with a complete agreement and sclerosis with an almost perfect agreement. Both radiologists agreed on erosions on SI joint MRI in the same 10 cases. Radiologists did not identify acute inflammatory or structural changes on MRE in patients with a negative SI joint MRI for these lesions. CONCLUSION: Along with intestinal findings, additional reporting of acute inflammatory and structural changes of the SI joint on a MRE is valuable and may alert physicians to the presence of previously not diagnosed axial spondyloarthritis.

Subchondral bone attenuation coefficient utility of the sacroiliac margins to differentiate spondyloarthritis and osteitis condensans ilii.

INTRODUCTION: Differentiating ankylosing spondylitis (AS) from osteitis condensans ilii (OCI) remains challenging for clinicians. The aim of this study was to determine whether Subchondral Bone Attenuation Coefficient of the SacroIliac margins (SBAC-SI) is different in AS, OCI and diffuse idiopathic skeletal hyperostosis (DISH). METHODS: A monocentric retrospective observational study was performed at the University Hospital of Besançon. Patients included were followed for AS, DISH or OCI and underwent CT scan including sacroiliac joint. Patients with tumour lesion of bone or a history of pelvic radiotherapy were excluded. AS and OCI patients were matched with a control of the same age and sex. SBAC-SI was evaluated by the sum of 24 identical circular regions of interest, 8 per slice (anterior, middle and posterior). RESULTS: Thirty AS and AS controls, 31 DISH, 29 OCI and OCI controls were included. SBAC-SI score was 9727 (±2430) in the OCI group (p<0.001), 3563 (±1860) in the AS group, 3899 (±1937) in the DISH group, 4224 (±1693) in the AS control group and 5445 (±1205) in the OCI control group. A threshold of 7500 HU had the best discriminative value between OCI and AS (youden index: 0.89). In AS, disease duration is negatively associated with SBAC-SI (r: -0.623; p<0.01) and HLA B27 is associated with lower SBAC-SI (6523 (5198; 7137) vs 2809 (1568; 3371); p<0.001). CONCLUSION: SBAC-SI is significatively different between AS and OCI and could help to distinguish these two diseases.

Athletic Osteitis Pubis Detected on 18 F-FDG PET/CT.

ABSTRACT: A 37-year-old male personal trainer presented with debilitating groin pains, fever, and night sweats. Enlarged inguinal lymph nodes were noticed during physical examination, and blood tests showed elevated erythrocyte sedimentation rate and C-reactive protein. 18 F-FDG PET/CT excluded lymphoma and other malignancy but showed intense FDG uptake at the pubic symphysis and cortical erosions of the pubic bones on CT. The patient was diagnosed with osteitis pubis, an inflammatory condition of the pubic symphysis commonly seen in athletes. Treatment with anti-inflammatory drugs was initiated. Within several weeks, pain decreased, and inflammatory markers normalized.

Walking Disabilities in Association With Tenosynovitis at the Metatarsophalangeal Joints: A Longitudinal Magnetic Resonance Imaging Study in Early Arthritis.

OBJECTIVE: The relationship between functional disability and magnetic resonance imaging (MRI) inflammation has been studied for the hands, but has not been well established for the feet, even though walking difficulties are common. Therefore, our objective was to study whether walking difficulties were associated with MRI inflammation at metatarsophalangeal (MTP) joints in early arthritis patients, at diagnosis and during 24 months of follow-up. METHODS: A total of 532 consecutive patients presenting with early arthritis reported on the presence and severity of walking difficulties (Health Assessment Questionnaire question 4a, scale 0-3), and underwent unilateral contrast-enhanced MRI of MTP joints 1-5 at baseline. In total, 107 patients had clinical and MRI data at follow-up (4, 12, and 24 months). MRI inflammation (synovitis, tenosynovitis, and osteitis) was scored in line with the Rheumatoid Arthritis Magnetic Resonance Imaging Scoring system. At baseline, the association of walking disability with MRI inflammation was assessed using regression. Longitudinally, the association between a change in walking disability with a change in MRI inflammation was studied with linear mixed models. RESULTS: At baseline, 81% of patients with walking disabilities had MRI inflammation at MTP joints, versus 68% without walking disabilities (P < 0.001). Total MRI inflammation (i.e., the sum of tenosynovitis, synovitis, and osteitis) was associated with severity of walking disability (ß = 0.023, P < 0.001). Studying the MRI features separately, tenosynovitis, synovitis, and osteitis were all univariably associated with severity of walking disability (P < 0.001, P < 0.001, and P = 0.014, respectively). In multivariable analysis, the association was strongest for tenosynovitis. During follow-up, a decrease in MTP inflammation was associated with a decrease in walking disability (ß = 0.029, P = 0.001); in multivariable analyses only, tenosynovitis was independently associated (ß = 0.073, P = 0.049). CONCLUSION: Of the different inflamed tissues in MTP joints, predominantly MRI-detected tenosynovitis was associated with walking disabilities. Likewise a reduction in tenosynovitis related to a decrease in walking disabilities. These results increase our understanding of the involvement of tenosynovitis in walking disabilities in early arthritis.

Osteitis Pubis Treated With Platelet-Rich Plasma: A Case Report.

ABSTRACT: Osteitis pubis is a common source of groin pain in athletes participating in sports requiring kicking, twisting, and pivoting movements. Athletes will present with progressive pain or discomfort in the pubic area or groin. There is usually point tenderness over the pubic symphysis and pain localizing to the adductor or rectus abdominis tendons. Conservative management often includes activity modification, oral medications, progressive rehabilitation, therapeutic ultrasound, steroid injections, and prolotherapy. Osteitis pubis can be refractory to conservative management and can keep an athlete sidelined for as long as 2 years. Platelet-rich plasma (PRP) injections have been used for pubic symphysis pain, but reports have focused on pathology affecting the rectus abdominis or hip adductor muscle tendons. In this article, we present a case of isolated osteitis pubis, without overlapping rectus abdominis or adductor tendon involvement, successfully treated with an ultrasound-guided PRP injection of the fibrocartilage.

Effect of initiating biologics compared to intensifying conventional DMARDs on clinical and MRI outcomes in established rheumatoid arthritis patients in clinical remission: Secondary analyses of the IMAGINE-RA trial.

OBJECTIVES: To compare the effect of treat-to-target-based escalations in conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics on clinical disease activity and magnetic resonance imaging (MRI) inflammation in a rheumatoid arthritis (RA) cohort in clinical remission. METHOD: One-hundred patients with established RA, Disease Activity Score based on 28-joint count-C-reactive protein (DAS28-CRP) < 3.2, and no swollen joints (hereafter referred to as 'in clinical remission') who received csDMARDs underwent clinical evaluation and MRI of the wrist and second to fifth metacarpophalangeal joints every 4 months. They followed a 2 year MRI treatment strategy targeting DAS28-CRP ≤ 3.2, no swollen joints, and absence of MRI osteitis, with predefined algorithmic treatment escalation: first: increase in csDMARDs; second: adding a biologic; third: switch biologic. MRI osteitis and Health Assessment Questionnaire (HAQ) (co-primary outcomes) and MRI combined inflammation and Simplified Disease Activity Index (SDAI) (key secondary outcomes) were assessed 4 months after treatment change and expressed as estimates of group differences. Statistical analyses were based on the intention-to-treat population analysed using repeated-measures mixed models. RESULTS: Escalation to first biologic compared to csDMARD escalation more effectively reduced MRI osteitis (difference between least squares means 1.8, 95% confidence interval 1.0-2.6), HAQ score (0.08, 0.03-0.1), MRI combined inflammation (2.5, 0.9-4.1), and SDAI scores (2.7, 1.9-3.5). CONCLUSIONS: Treat-to-target-based treatment escalations to biologics compared to escalation in csDMARDs more effectively improved MRI inflammation, physical function, and clinical disease activity in patients with established RA in clinical remission. Treatment escalation in RA patients in clinical remission reduces clinical and MRI-assessed disease activity. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT01656278.