de Amorim JC, Torricelli AK, Frittoli RB
… +6 more, Lapa AT, Dertkigil SSJ, Reis F, Costallat LT, França Junior MC, Appenzeller S
Best Pract Res Clin Rheumatol
· 2018 Oct · PMID 31203921
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Systemic lupus erythematosus (SLE), presenting with new onset or worsening neuropsychiatric (NP) symptoms, is a challenge in clinical practice. Mimickers such as infections, drug-induced side effects, metabolic abnormali...Systemic lupus erythematosus (SLE), presenting with new onset or worsening neuropsychiatric (NP) symptoms, is a challenge in clinical practice. Mimickers such as infections, drug-induced side effects, metabolic abnormalities, malignancies, and alcohol-related disorders have to be excluded, before attributing the manifestations to disease activity. Proper diagnosis is essential to guide adequate management and reduce morbidity and mortality. In this review article, we will highlight clinical, laboratorial, and neuroradiological features that are helpful to assist in the differential diagnosis.
Best Pract Res Clin Rheumatol
· 2018 Jun · PMID 31171307
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Imaging is key to recognition of axial spondyloarthritis (SpA) because clinical and laboratory examinations have limited diagnostic utility. Only MRI can capture both inflammation and bone remodeling by simultaneous depi...Imaging is key to recognition of axial spondyloarthritis (SpA) because clinical and laboratory examinations have limited diagnostic utility. Only MRI can capture both inflammation and bone remodeling by simultaneous depiction of active and structural lesions and their anatomic location. Bone marrow edema of limited extent on the sacroiliac joint (SIJ) MRI is often nonspecific and should be interpreted along with the clinical context. Contextual interpretation of the SIJ lesion signature viewed simultaneously on fluid- and fat-sensitive MRI sequences enhances confidence in the recognition of disease. A critical re-appraisal of using pelvic radiographs in clinically suspected early spondyloarthritis is warranted because of substantial limitations. In health care settings with low threshold access to advanced imaging, MRI is the preferred modality in early SpA. CT has recently advanced spinal outcome research, but substantial radiation exposure in young patients with spondyloarthritis and limited evidence on its relevance in practice do not advocate its use in daily routine.
Intra-articular injection of hyaluronic acid (HA) is a controversial treatment for knee osteoarthritis (OA). While clinical efficacy of HA relative to saline injections has been demonstrated in many studies, these result...Intra-articular injection of hyaluronic acid (HA) is a controversial treatment for knee osteoarthritis (OA). While clinical efficacy of HA relative to saline injections has been demonstrated in many studies, these results are of limited value in real-world clinical practice since saline injection is not a knee OA treatment. Instead, rigorous postmarket comparative studies of HA versus approved knee OA treatments are encouraged. The conduct of such studies is particularly important given the paucity and heterogeneous nature of current evidence regarding nonsurgical knee OA treatment. KEY POINTS: • Societal guidelines recommend nonsteroidal anti-inflammatory drugs and corticosteroid injections, but not hyaluronic acid injections, for knee osteoarthritis (OA) despite inconsistent supportive data. • This article encourages rigorous comparative post-approval studies to clarify the role of nonsurgical treatments used in clinical practice for knee OA.
Palman J, Shoop-Worrall S, Hyrich K
… +1 more, McDonagh JE
Best Pract Res Clin Rheumatol
· 2018 Apr · PMID 30527427
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Juvenile idiopathic arthritis (JIA) is the most common inflammatory joint condition of childhood and represents seven JIA subtypes characterised by distinct clinical and laboratory variables. Genetic and environmental fa...Juvenile idiopathic arthritis (JIA) is the most common inflammatory joint condition of childhood and represents seven JIA subtypes characterised by distinct clinical and laboratory variables. Genetic and environmental factors are known to influence JIA, although many unanswered questions remain. Measurement of health outcomes in JIA is imperative for both clinical practice and research. Patient-reported outcomes present particular challenges in paediatric rheumatology in view of the importance of collecting reports from both the child/young person and the parent. Another challenge is the need for continuity of outcome measurement across the paediatric-adult interface during the process of transition in terms of both measurement tools and the mechanisms in the system to facilitate tracking of the young person into adult care. Finally, the need for adults with JIA to be seen as a distinct group in adult rheumatology practice is important for both service provision and outcome research.
Best Pract Res Clin Rheumatol
· 2017 Dec · PMID 30509448
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Animal models of human diseases are used to study a broad array of autoimmune disorders including spondyloarthritis (SpA). Various animal models, either genetically engineered, spontaneous or induced, have been described...Animal models of human diseases are used to study a broad array of autoimmune disorders including spondyloarthritis (SpA). Various animal models, either genetically engineered, spontaneous or induced, have been described to address the fundamental pathological features of human SpA. With the advent of novel techniques for manipulations in animal models, it has become possible to delineate critical pathways involved in SpA disease mechanisms and to develop novel therapeutics. In this chapter, we discuss animal models to study the fundamental characteristics of human SpA. None of the animal models developed exactly mimics human diseases, but some of the models closely resemble the group of human SpA diseases. The SKG mouse, in particular, harbours a point mutation in the ZAP-70 gene yielding reduced T-cell receptor (TCR) signalling, develops multi-organ inflammation under microbial influence, mimics human SpA disease pathogenesis and is a promising tool for designing new therapeutics against SpA. We describe the contribution of animal models to the earliest known disease mechanisms, including how attenuated T cell signalling contributes to disease pathogenesis as a result of genetic or environmental predisposition. We also discuss recent advances in the understanding of key cytokines that drive SpA pathophysiology and the crosstalk of gut microbiota with host genetic determinants of immune function and finally the potential future prospects to study these animal models to translate our knowledge of pathogenesis into clinical practice.
Arayssi T, Harfouche M, Darzi A
… +24 more, Al Emadi S, A Alnaqbi K, Badsha H, Al Balushi F, Dib C, Elzorkany B, Halabi H, Hammoudeh M, Hazer W, Masri B, Merashli M, Omair M, Salloum N, Uthman I, Zahirovic S, Ziade N, Bannuru RR, McAlindon T, Nomier MA, Singh JA, Christensen R, Tugwell P, Schünemann H, Akl EA
Clinical practice guidelines can assist rheumatologists in the proper prescription of newer treatment for rheumatoid arthritis (RA). The objective of this paper is to report on the recommendations for the management of p...Clinical practice guidelines can assist rheumatologists in the proper prescription of newer treatment for rheumatoid arthritis (RA). The objective of this paper is to report on the recommendations for the management of patients with RA in the Eastern Mediterranean region. We adapted the 2015 American College of Rheumatology guidelines in two separate waves. We used the adolopment methodology, and followed the 18 steps of the "Guidelines 2.0" comprehensive checklist for guideline development. For each question, we updated the original guidelines' evidence synthesis, and we developed an Evidence Profile (EP) and an Evidence to Decision (EtD) table. In the first wave, we adoloped eight out of the 15 original questions on early RA. The strength changed for five of these recommendations from strong to conditional, due to one or more of the following factors: cost, impact on health equities, the balance of benefits, and harms and acceptability. In the second wave, we adoloped eight out of the original 44 questions on established RA. The strength changed for two of these recommendations from strong to conditional, in both cases due to cost, impact on health equities, balance of benefits and harms, and acceptability. The panel also developed a good practice recommendation. We successfully adoloped 16 recommendations for the management of early and established RA in the Eastern Mediterranean region. The process proved feasible and sensitive to contextual factors.
Best Pract Res Clin Rheumatol
· 2017 Aug · PMID 29773272
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Registries and biobanks for juvenile dermatomyositis (JDM) have generated statistical power to help understand pathogenesis and determine treatment and long-term outcomes in this rare and heterogeneous disease. Genotype,...Registries and biobanks for juvenile dermatomyositis (JDM) have generated statistical power to help understand pathogenesis and determine treatment and long-term outcomes in this rare and heterogeneous disease. Genotype, autoantibodies, muscle histology and early clinical features may predict prognosis and guide personalised treatment. While corticosteroids and disease-modifying anti-rheumatic drugs improve outcomes, there remain children who experience refractory disease. Ongoing research into the aberrant immune response and novel biological targets is necessary. Best practice guidelines promote prompt stepwise treatment, and there is growing appreciation of the role of exercise in improving prognosis. Validated tools standardise assessment of disease activity and damage in musculoskeletal, mucocutaneous, pulmonary, cardiac, gastrointestinal and endocrine systems. Recently, an internationally agreed dataset for JDM has been defined for clinical practice and incorporation into registries. In the future, with bigger datasets, statistical models may guide stratification for personalised medicine and discern the most relevant outcome markers for research.
van Loosdregt J, van Wijk F, Prakken B
… +1 more, Vastert B
Best Pract Res Clin Rheumatol
· 2017 Aug · PMID 29773267
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In the past decades, we have gained important insights into the mechanisms of disease and therapy underlying chronic inflammation in juvenile idiopathic arthritis (JIA). These insights have resulted in several game-chang...In the past decades, we have gained important insights into the mechanisms of disease and therapy underlying chronic inflammation in juvenile idiopathic arthritis (JIA). These insights have resulted in several game-changing therapeutic modalities for many patients. However, additional progress still has to be made with regard to efficacy, cost reduction, minimization of side effects, and dose-tapering and stop strategies of maintenance drugs. Moreover, to really transform the current therapeutic strategies into personalized medicine, we need validated biomarkers to translate increased insights into clinical practice. In this article, we describe recent developments in JIA research and outline how clinical innovations need to go hand in hand with basic discoveries to really effect care for patients. Facilitating the transition from bench to bedside is crucial for addressing the major current challenges in JIA management. When successful, it will set new standards for a safe, targeted, and personalized medicine in JIA.
BACKGROUND: Canadian rheumatologists' attitudes toward and management of fibromyalgia remain uncertain. OBJECTIVE: The aim of this study was to explore management strategies and attitudes of Canadian rheumatologists towa...BACKGROUND: Canadian rheumatologists' attitudes toward and management of fibromyalgia remain uncertain. OBJECTIVE: The aim of this study was to explore management strategies and attitudes of Canadian rheumatologists toward fibromyalgia and concordance with guideline recommendations. METHODS: We administered a 17-item cross-sectional survey to Canadian rheumatologists and explored the concordance between respondents' management practices with the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia. RESULTS: Among 331 Canadian rheumatologists who were approached, 140 returned the survey for a 42% response rate. The majority felt that fibromyalgia was a useful clinical diagnosis (110/138 [80%]) but was divided as to whether fibromyalgia was objectively defined (75/138 [54%]) or a psychosocial condition (42/138 [30%]) or could result in an inability to work (37/138 [27%]). Contrary to guideline recommendations, most (82/134 [61%]) endorsed that tender points were useful for diagnosis. Half endorsed potentially refusing consultations with fibromyalgia patients, and only 42% (59/139) agreed that there were effective therapies for this syndrome. Consistent with the guideline, most respondents managed fibromyalgia with education, exercise therapy, antidepressants, and nonnarcotic analgesics (≥89% for all); however, fewer than half agreed that any of these modalities were effective (endorsement ranged from 9% to 47%). Assessment of the 2012 guideline revealed a number of important limitations. CONCLUSIONS: Canadian rheumatologists largely do not provide primary care for fibromyalgia. Most adhere to guideline recommendations for management of fibromyalgia, but few endorse these interventions as effective. Further research, including updating of the 2012 Canadian Guidelines for the diagnosis and management of fibromyalgia, is required to inform this disconnect.
Best Pract Res Clin Rheumatol
· 2017 Apr · PMID 29224699
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We highlight the important differences between the concepts of capacity and performance and highlight the development of measures and their application in common conditions encountered in health care practice with older...We highlight the important differences between the concepts of capacity and performance and highlight the development of measures and their application in common conditions encountered in health care practice with older people. A number of expert consensus projects have concluded that mobility, balance, muscle strength and dexterity are core domains for capacity measurement in older people. Instruments with evidence of adequate psychometric properties for the evaluation of capacity in response to intervention programmes include the Short Physical Performance Battery, hand grip strength, mini-BEST and 9-hole pegboard test. Measures that can track individual change and convey information that can be used to inform clinical decision-making, individual prognosis or prediction of events require greater precision. However, few such measures are available. Performance measurement usually focuses on basic or instrumental (advanced) Activities of Daily Living performed by people in their usual environments. Finally, we discuss the limitations of physical performance and capacity measures and future developments that may enhance the use of these measures in health and clinical care.
Best Pract Res Clin Rheumatol
· 2017 Apr · PMID 29224696
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The term 'spinal pain' collectively includes the cervical, thoracic and lumbosacral regions of the spine. The majority of older people experience spinal pain, and with an increasing proportion of older people, the preval...The term 'spinal pain' collectively includes the cervical, thoracic and lumbosacral regions of the spine. The majority of older people experience spinal pain, and with an increasing proportion of older people, the prevalence of spinal conditions are expected to increase in the coming decades. Musculoskeletal conditions of the spine in the older patient commonly include osteoarthritis and spinal stenosis, and the result of these degenerative diseases includes pain, stiffness and a decreased ability to engage in everyday activities. More than just the burden of pain, spinal pain has a significant considerable impact on the wellbeing and independence of older people within the community. Spinal pain is poorly managed, and knowledge of safe and effective treatment strategies are lacking because of the exclusion of older people in clinical research. Spinal pain in older people is a global health problem; the physical and personal impact of spinal directly threatens efforts to support healthy ageing.
Duffield SJ, Ellis BM, Goodson N
… +4 more, Walker-Bone K, Conaghan PG, Margham T, Loftis T
Best Pract Res Clin Rheumatol
· 2017 Apr · PMID 29224692
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People frequently live for many years with multiple chronic conditions (multimorbidity) that impair health outcomes and are expensive to manage. Multimorbidity has been shown to reduce quality of life and increase mortal...People frequently live for many years with multiple chronic conditions (multimorbidity) that impair health outcomes and are expensive to manage. Multimorbidity has been shown to reduce quality of life and increase mortality. People with multimorbidity also rely more heavily on health and care services and have poorer work outcomes. Musculoskeletal disorders (MSDs) are ubiquitous in multimorbidity because of their high prevalence, shared risk factors, and shared pathogenic processes amongst other long-term conditions. Additionally, these conditions significantly contribute to the total impact of multimorbidity, having been shown to reduce quality of life, increase work disability, and increase treatment burden and healthcare costs. For people living with multimorbidity, MSDs could impair the ability to cope and maintain health and independence, leading to precipitous physical and social decline. Recognition, by health professionals, policymakers, non-profit organisations, and research funders, of the impact of musculoskeletal health in multimorbidity is essential when planning support for people living with multimorbidity.
Best Pract Res Clin Rheumatol
· 2017 Jun · PMID 29224672
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The implementation of precision medicine requires the recruiting of patients in statistically enough numbers, the possibility of obtaining enough materials, and the integration of data from various platforms, which are a...The implementation of precision medicine requires the recruiting of patients in statistically enough numbers, the possibility of obtaining enough materials, and the integration of data from various platforms, which are all real limitations. These types of studies have been performed extensively in cancer but barely on systemic lupus erythematosus (SLE) or other rheumatic diseases. To consider the practical use of the information obtained from such studies, we have to take into account the best biological fluid to use, the ease to perform the analysis in clinical practice, and its relevance to clinical practice. Here we review the most relevant studies that have performed analyses that attempt to classify or stratify SLE. We focus on two types of studies: those that stratify individuals diagnosed with SLE and those that compare SLE with other autoimmune diseases, defining differences and similarities that may be clinically relevant in the future.
van Dongen JM, Ketheswaran J, Tordrup D
… +3 more, Ostelo RWJG, Bertollini R, van Tulder MW
Best Pract Res Clin Rheumatol
· 2016 Dec · PMID 29103555
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Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was init...Despite the increased interest in economic evaluations, there are difficulties in applying the results of such studies in practice. Therefore, the "Research Agenda for Health Economic Evaluation" (RAHEE) project was initiated, which aimed to improve the use of health economic evidence in practice for the 10 highest burden conditions in the European Union (including low back pain [LBP] and neck pain [NP]). This was done by undertaking literature mapping and convening an Expert Panel meeting, during which the literature mapping results were discussed and evidence gaps and methodological constraints were identified. The current paper is a part of the RAHEE project and aimed to identify economic evidence gaps and methodological constraints in the LBP and NP literature, in particular. The literature mapping revealed that economic evidence was unavailable for various commonly used LBP and NP treatments (e.g., injections, traction, and discography). Even if economic evidence was available, many treatments were only evaluated in a single study or studies for the same intervention were highly heterogeneous in terms of their patient population, control condition, follow-up duration, setting, and/or economic perspective. Up until now, this has prevented economic evaluation results from being statistically pooled in the LBP and NP literature, and strong conclusions about the cost-effectiveness of LBP and NP treatments can therefore not be made. The Expert Panel identified the need for further high-quality economic evaluations, especially on surgery versus conservative care and competing treatment options for chronic LBP. Handling of uncertainty and reporting quality were considered the most important methodological challenges.
Best Pract Res Clin Rheumatol
· 2016 Dec · PMID 29103554
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Given the scale and cost of the low back pain problem, it is imperative that healthcare professionals involved in the care of people with low back pain have access to up-to-date, evidence-based information to assist them...Given the scale and cost of the low back pain problem, it is imperative that healthcare professionals involved in the care of people with low back pain have access to up-to-date, evidence-based information to assist them in treatment decision-making. Clinical guidelines exist to promote the consistent best practice, to reduce unwarranted variation and to reduce the use of low-value interventions in patient care. Recent decades have witnessed the publication of a number of such guidelines. In this narrative review, we consider three selected international interdisciplinary guidelines for the management of low back pain. Guideline development methods, consistent recommendations and inconsistencies between these guidelines are critically discussed.
Lee H, Mansell G, McAuley JH
… +6 more, Kamper SJ, Hübscher M, Moseley GL, Wolfenden L, Hodder RK, Williams CM
Best Pract Res Clin Rheumatol
· 2016 Dec · PMID 29103550
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In recent years, there has been increasing interest in studying causal mechanisms in the development and treatment of back pain. The aim of this article is to provide an overview of our current understanding of causal me...In recent years, there has been increasing interest in studying causal mechanisms in the development and treatment of back pain. The aim of this article is to provide an overview of our current understanding of causal mechanisms in the field. In the first section, we introduce key concepts and terminology. In the second section, we provide a brief synopsis of systematic reviews of mechanism studies relevant to the clinical course and treatment of back pain. In the third section, we reflect on the findings of our review to explain how understanding causal mechanisms can inform clinical practice and the implementation of best practice. In the final sections, we introduce contemporary methodological advances, highlight the key assumptions of these methods, and discuss future directions to advance the quality of mechanism-related studies in the back pain field.
Hodder RK, Wolfenden L, Kamper SJ
… +4 more, Lee H, Williams A, O'Brien KM, Williams CM
Best Pract Res Clin Rheumatol
· 2016 Dec · PMID 29103549
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The evidence base regarding treatment for back pain does not align with clinical practice. Currently there is relatively little evidence to guide health decision-makers on how to improve the use, uptake or adoption of ev...The evidence base regarding treatment for back pain does not align with clinical practice. Currently there is relatively little evidence to guide health decision-makers on how to improve the use, uptake or adoption of evidence-based recommended practice for low back pain. Improving the design, conduct and reporting of strategies to improve the implementation of back pain care will help address this important evidence-practice gap. In this paper, we.
Best Pract Res Clin Rheumatol
· 2016 Dec · PMID 29103546
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Choosing the most fit-for-purpose outcome measurement instruments is fundamental because using inappropriate instruments can lead to detection bias and measurement inconsistency. Recent recommendations, consensus procedu...Choosing the most fit-for-purpose outcome measurement instruments is fundamental because using inappropriate instruments can lead to detection bias and measurement inconsistency. Recent recommendations, consensus procedures and systematic reviews on existing patient-reported outcome measures (PROMs) informed this manuscript, which provides suggestions on which outcome domains and measurement instruments to use in patients with low back pain (LBP). Six domains are identified as highly relevant: (1) physical functioning, (2) pain intensity, (3) health-related quality of life, (4) work, (5) psychological functioning and (6) pain interference. For each domain, one or more PROMs are suggested for clinical research and practice, selecting among those that are most frequently used and recommended, and that have satisfactory measurement properties in patients with LBP. Further research on the measurement properties of these suggested PROMs is needed while also considering other emerging instruments, such as the PROMIS computerised adaptive testing and short forms.
Mobasheri A, Bay-Jensen AC, Gualillo O
… +3 more, Larkin J, Levesque MC, Henrotin Y
Best Pract Res Clin Rheumatol
· 2017 Oct · PMID 30509415
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Osteoarthritis (OA) is the most common form of arthritis and a major cause of pain and disability. Recent work suggests that the global burden of OA is increasing, and costs associated with treatment are expected to incr...Osteoarthritis (OA) is the most common form of arthritis and a major cause of pain and disability. Recent work suggests that the global burden of OA is increasing, and costs associated with treatment are expected to increase dramatically as the aging human population expands. OA is currently diagnosed using radiography, but this technique is an indirect and insensitive measure of alterations in articular cartilage and fails to measure dynamic inflammatory processes in the joint. Radiographic changes detected overtime are small and occur in only a subset (progressors) of patients with OA. Therefore, we diagnose patients with OA on the basis of a diagnostic classification that is outdated. We also use the same tools and approaches for assessing the efficacy of new pharmacological and nonpharmacological interventions. In this review, we discuss the utility of soluble biochemical markers as biomarkers of OA and discuss whether we are close to using them in clinical practice. Combining patient information, functional imaging and carefully selected panels of biomarkers can help in achieving enhanced patient stratification and lead to better designed clinical trials. Biomarkers can be used for molecular endotyping and for developing more effective and more personalized treatments that will enhance clinical care for patients with OA.
The objective of this study was to develop and validate an optimal simplified combination of joints for ultrasonographic assessment of synovitis in wrists and hands in patients with rheumatoid arthritis (RA). Twenty-two...The objective of this study was to develop and validate an optimal simplified combination of joints for ultrasonographic assessment of synovitis in wrists and hands in patients with rheumatoid arthritis (RA). Twenty-two joints, including bilateral wrists, all proximal interphalangeal (PIP), and metacarpophalangeal (MCP) joints, were evaluated by grey-scale (GS) and power Doppler (PD) ultrasound using semi-quantitative scoring systems in 705 RA patients. Candidate joint sets were then selected by multiple linear regression analysis and the optimal candidate set was eventually validated in 235 RA patients. Through multiple linear regression analysis, the standard coefficient (β) of MCP2, MCP3, and MCP5 joints in terms of GS was higher than other joints. The adjusted R of the model composed of wrist, MCP2, MCP3, and MCP5 joints was greater than 0.9. Among the sum GS and PD scores of various selected joint combinations, total score-8, including bilateral wrist, MCP2, MCP3, and MCP5 joints, not only showed highest sensitivity and negative predictive value (93.86 and 92.90% for GS; 97.20 and 97.21% for PD, respectively) but also the best correlation with the total score-22 (r = 0.955 and 0.972 for GS and PD). The score-8 was further validated in 235 RA patients. The sensitivity for detecting synovitis by GS and PD was 94.35 and 94.12%, and the negative predictive values were 94.07 and 95.68%, respectively. Total score-8 system, including bilateral wrist, MCP2, MCP3, and MCP5 joints, is simple and efficient to pick up active synovitis of wrists and hands in patients with RA in daily practice.