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Timo A Auer,1,2 Keitaro Sofue,3 Eisuke Ueshima,3 Nina Rauer,1 Takeru Yamaguchi,3 Bernhard Gebauer,1 Bernd Hamm,1 Takamichi Murakami,3 Christian E Althoff1 1Department of Radiology, Charité - University Medicine Berlin, Berlin, Germany; 2Berlin Institute of Health (BIH), Berlin, Germany; 3Department of Radiology, Kobe University Graduate School of Medicine, Kobe, JapanCorrespondence: Timo A Auer, Department of Radiology, Campus Virchow-Klinikum, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, Berlin, 13353, Germany, Tel +49-30-450-557001, Fax +49-30-450-557901, Email timo-alexander.auer@charite.deObjective: The purpose of this study was to investigate outcomes of transarterial chemoembolization (TACE) in treating hepatocellular carcinoma (HCC) comparing the different approaches used in Germany and Japan.Methods: This binational IRB-approved retrospective dual-center study included a total of 94 HCC patients subdivided in a German and a Japanese cohort. For each patient, liver and tumor volumetry was performed using computed tomography (CT) and magnetic resonance imaging (MRI). Furthermore, a comprehensive risk profile, including body constitution and liver and kidney function was established. Primary endpoints were progression-free and overall survival (PFS/OS).Results: PFS in the German cohort was 168 vs 224d in the Japanese cohort (p=0.640). When subdivided by BCLC stage, no significant differences were reported (p=0.160– 0.429). OS was significantly longer in the Japanese cohort with 856 vs. 303d (p< 0.001). OS for BCLC A was significantly longer in the Japanese cohort (1960 vs. 428d; p< 0.001), while survival rates did not differ significantly in BCLC B (785 vs 330d; p=0.067) and C-stages (208 vs 302d; p=0.186). Older age (p=0.034), poorer liver/kidney function (p=0.025-0-035), and a higher liver/tumor ratio (p< 0.001) were found to correlate with shorter survival. ECOG scores were significantly higher in the German cohort (p=0.002).Conclusion: While OS is longer in TACE-treated patients in the Japanese cohort compared to the German cohort, the two approaches seem to be equally effective as PFS does not differ significantly. The different survival rates may be caused by the different clinical performance status of the selected collectives. In very early and early stage HCC, TACE in Japan seems to be an effective treatment option while in Germany for patients in those stages TACE remains a second-line option for patients not available for surgery or ablation.Keywords: HCC, TACE, liver, hepatocellular carcinoma, interventional oncology

Objectives: To evaluate contrast-enhanced ultrasound (CE-US) as a monitoring tool to assess hypervascularisation of synovial processes in knee osteoarthritis (OA) treated with intra-articular injections of the bradykinin-receptor 2 antagonist icatibant compared to contrast-enhanced magnetic resonance imaging (CE-MRI). Patients and Methods: In a randomised, double-blind, placebo-controlled trial, 41 patients with painful knee OA underwent US (12.5 MHz for B-mode and 3-8 MHz for CE-US), and 36 of the patients underwent additional MRI (0.2T) at baseline and after 3 injections of the study drug (after a mean of 22.2 days). A total of 15 patients received placebo (group A), 12 patients 500 microg icatibant (group B) and 14 patients 2000 microg icatibant (group C). Pain and the synovial process (B-mode, power Doppler US (PD-US), CE-US, CE-MRI) were assessed at both time points. Results: At baseline, the placebo group showed more activity in terms of effusion in the superior and lateral recess in ultrasound as well as in PD-US in the lateral recess. Pain improved significantly in all subgroups. Effect sizes were 0.43 (pain at rest) and 0.52 (pain during activity) in group B vs 0.48 and 1.11 in group C. There was no change of US and MRI parameters. We found moderate to good correlation (r) and kappa values (kappa) for effusion in the superior recess (r = 0.591, k = 0.453), effusion in the lateral recess (r = 0.304, k = 0.440) and contrast enhancement (r = 0.601, k = 0.242) between US and MRI. Conclusions: Our results show that CE-US and CE-MRI have good agreement in assessing inflammatory changes in knee OA. For the 41 patients with OA, an analgesic effect of icatibant could clearly be shown, especially for pain during activity in the high dose icatibant group. However, we could not find an anti-inflammatory effect of icatibant by CE-US compared to CE-MRI. [ABSTRACT FROM AUTHOR]

Hepatitis C virus (HCV) infection can lead to hepatic fibrosis. The advent of direct-acting antivirals (DAAs) has substantially improved sustained virological response (SVR) rates. In this context, kidney transplant recipients (KTRs) are of particular interest due to their higher HCV infection rates and uncertain renal excretion and bioavailability of DAAs. We investigated liver stiffness after DAA treatment in 15 HCV-infected KTRs using ultrasound shear wave elastography (SWE) in comparison with magnetic resonance elastography (MRE). KTRs were treated with DAAs (daclatasvir and sofosbuvir) for three months and underwent SWE at baseline, end of therapy (EOT), and 3 (EOT+3) and 12 months (EOT+12) after EOT. Fourteen patients achieved SVR12. Shear wave speed (SWS)-as a surrogate parameter for tissue stiffness-was substantially lower at all three post-therapeutic timepoints compared with baseline (EOT: -0.42 m/s, p < 0.01; CI = -0.75--0.09, EOT+3: -0.43 m/s, p < 0.01; CI = -0.75--0.11, and EOT+12: -0.52 m/s, p < 0.001; CI = -0.84--0.19), suggesting liver regeneration after viral eradication and end of inflammation. Baseline SWS correlated positively with histopathological fibrosis scores (r = 0.48; CI = -0.11-0.85). Longitudinal results correlated moderately with APRI (r = 0.41; CI = 0.12-0.64) but not with FIB-4 scores (r = 0.12; CI = -0.19-0.41). Although higher on average, SWE-derived measurements correlated strongly with MRE (r = 0.64). In conclusion, SWE is suitable for non-invasive therapy monitoring in KTRs with HCV infection.

The aim of this case report is to present real-time CEUS-guided biopsy for diagnosing rare benign splenic pathologies after inconclusive findings on cross-sectional imaging. We present the case of a 50-year-old male patient who received a contrast-enhanced computed tomography scan of the thorax during the evaluation for lung transplant due to lung fibrosis, with incidental finding of disseminated hypodense splenic lesions. During follow-up imaging, the patient did not tolerate a complete MRI examination, and two acquired pulse sequences did not confirm the final diagnosis. While CT-guided biopsy revealed no results, CEUS-guided target biopsy with repeated contrast injections showed a benign littoral cell angioma of the spleen. The use of real-time CEUS-guided target biopsy during lesion washout may be a useful tool to improve the accuracy of biopsy and accelerate the diagnosis in patients with parenchymal lesions after inconclusive cross-sectional imaging findings which may pose a challenge for CT-guided biopsy., Competing Interests: Conflict of interest Authors do not report any financial or personal connections with other persons or organizations which might negatively affect the contents of this publication and/or claim authorship rights to this publication., (© Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.)

Besides the liver, hepatitis C virus (HCV) infection also affects kidney allografts. The aim of this study was to longitudinally evaluate viscoelasticity changes in the liver and in kidney allografts in kidney transplant recipients (KTRs) with HCV infection after treatment with direct-acting antiviral agents (DAAs). Fifteen KTRs with HCV infection were treated with DAAs (daclatasvir and sofosbuvir) for 3 months and monitored at baseline, end of treatment (EOT), and 3 (FU1) and 12 (FU2) months after EOT. Shear-wave speed (SWS) and loss angle of the complex shear modulus (φ), reflecting stiffness and fluidity, respectively, were reconstructed from multifrequency magnetic resonance elastography data with tomoelastography post-processing. After virus elimination by DAAs, hepatic stiffness and fluidity decreased, while kidney allograft stiffness and fluidity increased compared with baseline (hepatic stiffness change at FU1: -0.14 m/s, p < 0.01, and at FU2: -0.11 m/s, p < 0.05; fluidity at FU1: -0.05 rad, p = 0.04 and unchanged at FU2: p = 0.20; kidney allograft stiffness change at FU1: +0.27 m/s, p = 0.01, and at FU2: +0.30 m/s, p < 0.01; fluidity at FU1 and FU2: +0.06 rad, p = 0.02). These results suggest the restoration of mechanically sensitive structures and functions in both organs. Tomoelastography can be used to monitor the therapeutic results of HCV treatment non-invasively on the basis of hepatic and renal viscoelastic parameters.

Background: Abdominal aortic aneurysms (AAA) primarily affect men over 65 years old who often have many other diseases, with similar risk factors and pathobiological mechanisms to AAA. The aim of this study was to assess the prevalence of simple renal cysts (SRC), chronic kidney disease (CKD), and other kidney diseases (e.g. nephrolithiasis) among patients presenting with AAA., Methods: Two groups of patients (97 AAA and 100 controls), with and without AAA, from the Surgical Clinic Charité, Berlin, Germany, were selected for the study. The control group consisted of patients who were evaluated for a kidney donation (n = 14) and patients who were evaluated for an early detection of a melanoma recurrence (n = 86). The AAA and control groups were matched for age and sex. Medical records were analyzed and computed tomography scans were reviewed for the presence of SRC and nephrolithiasis., Results: SRC (74% vs. 57%; p<0.016) and CKD (30% vs. 8%; p<0.001) were both more common among AAA than control group patients. On multivariate analysis, CKD, but not SRC, showed a strong association with AAA., Conclusions: Knowledge about pathobiological mechanisms and association between CKD and AAA could provide better diagnostic and therapeutic approaches for these patients.

Objective: To develop a whole-body magnetic resonance imaging (MRI) scoring system for peripheral arthritis and enthesitis., Methods: After consensus on definitions/locations of MRI pathologies, 4 multireader exercises were performed. Eighty-three joints were scored 0-3 separately for synovitis and osteitis, and 33 entheses 0-3 separately for soft tissue inflammation and osteitis., Results: In the last exercise, reliability was moderate-good for musculoskeletal radiologists and rheumatologists with previously demonstrated good scoring proficiency. Median pairwise single-measure/average-measure ICC were 0.67/0.80 for status scores and 0.69/0.82 for change scores; κ ranged 0.35-0.77., Conclusion: Whole-body MRI scoring of peripheral arthritis and enthesitis is reliable, which encourages further testing and refinement in clinical trials.

Background:  Abdominal aortic aneurysm has become increasingly important owing to demographic changes. Some other diseases, for example, cholecystolithiasis, chronic obstructive pulmonary disease, and hernias, seem to co-occur with abdominal aortic aneurysm. The aim of this retrospective analysis was to identify new comorbidities associated with abdominal aortic aneurysm., Methods:  We compared 100 patients with abdominal aortic aneurysms and 100 control patients. Their preoperative computed tomographic scans were examined by two investigators independently, for the presence of hernias, diverticulosis, and cholecystolithiasis. Medical records were also reviewed. Statistical analysis was performed using univariate analysis and multiple logistic regression analysis., Results:  The aneurysm group had a higher frequency of diverticulosis ( p  = 0.008). There was no significant difference in the occurrence of hernia ( p  = 0.073) or cholecystolithiasis ( p  = 1.00). Aneurysm patients had a significantly higher American Society of Anesthesiology score (2.84 vs. 2.63; p  = 0.015) and were more likely to have coronary artery disease ( p  < 0.001), congestive heart failure ( p  < 0.001), or chronic obstructive pulmonary disease ( p  < 0.001). Aneurysm patients were more likely to be former ( p  = 0.034) or current ( p  = 0.006) smokers and had a significantly higher number of pack years ( p  < 0.001). Aneurysm patients also had a significantly poorer lung function. In multivariate analysis, the following factors were associated with aneurysms: chronic obstructive pulmonary disease (odds ratio, OR = 12.24; p  = 0.002), current smoking (OR = 4.14; p  = 0.002), and coronary artery disease (OR = 2.60; p  = 0.020)., Conclusions:  Our comprehensive analysis identified several comorbidities associated with abdominal aortic aneurysms. These results could help to recognize aneurysms earlier by targeting individuals with these comorbidities for screening., Competing Interests: The authors declare no conflict of interest related to this article., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: The purpose of this systematic review was to evaluate the evidence for the effectiveness of parent-mediated interventions on occupational performance of children with autism spectrum disorder (ASD)., Method: We conducted a search of academic databases using terms such as autism spectrum disorder, parent, caregiver, and intervention. Five hundred eighty-two articles were reviewed, and 109 were selected for full-text review. The final analysis included 13 articles., Results: Strong evidence was found for the efficacy of parent-mediated intervention for increasing child joint attention. Moderate evidence was found for the improvement of language scores, expressive language, nonverbal communication, initiation and response to interaction, behavior, play, adaptive functioning, ASD symptoms, and social communication., Conclusion: This systematic review suggests that parent-mediated interventions for children with ASD can improve various aspects of communication and ASD symptoms, with emerging support for occupational performance. Occupational therapy practitioners are well suited to facilitate these interventions to support families with children with autism., (Copyright © 2019 by the American Occupational Therapy Association, Inc.)

Background: Only a few prospective trials exist regarding the use of novel direct-acting antiviral agents (DAAs) in kidney transplant recipients (KTR) with chronic hepatitis C virus (HCV) infection., Methods: This prospective single-center trial evaluated treatment with daclatasvir (DCV) and sofosbuvir (SOF) over 12 weeks in 16 adult chronic HCV infected KTR and eGFR > 30 ml/min/1.73m 2 . Primary endpoint was sustained virological response 12 weeks after end of therapy (SVR12). Beside baseline liver biopsy, hepatic function and glucose metabolism were regularly assessed., Results: Four of 16 study patients had previously failed interferon-based HCV treatment. Liver biopsy showed mostly moderate fibrosis score before therapy with DCV/SOF was initiated at a median of 10.3 years after transplantation. In total, 15 of 16 KTR achieved SVR12. One patient showed early viral relapse because of resistance-associated variants (RAVs) in the HCV NS5A region. Rescue treatment with SOF/velpatasvir/voxilaprevir resulted in SVR12. DAAs treatment led to significant improvement of liver metabolism and glucose tolerance accompanied with no therapy-associated major adverse events and excellent tolerability., Conclusions: Our study demonstrates safety, efficacy and functional benefit of DCV/SOF treatment in KTR with chronic HCV infection. We provide data on rescue strategies for treatment failures due to present RAVs and amelioration of hepatic function and glucose tolerance., Trial Registration: Registry name: European Clinical Trials Register; Trial registry number (Eudra-CT): 2014-004551-32 , Registration date: Aug 28th 2015.

Objective: Whole-body magnetic resonance imaging (WB-MRI) is a relatively new technique that can enable assessment of the overall inflammatory status of people with arthritis, but standards for image acquisition, definitions of key pathologies, and a quantification system are required. Our aim was to perform a systematic literature review (SLR) and to develop consensus definitions of key pathologies, anatomical locations for assessment, a set of MRI sequences and imaging planes for the different body regions, and a preliminary scoring system for WB-MRI in inflammatory arthritis., Methods: An SLR was initially performed, searching for WB-MRI studies in arthritis, osteoarthritis, spondyloarthritis, or enthesitis. These results were presented to a meeting of the MRI in Arthritis Working Group together with an MR image review. Following this, preliminary standards for WB-MRI in inflammatory arthritides were developed with further iteration at the Working Group meetings at the Outcome Measures in Rheumatology (OMERACT) 2016., Results: The SLR identified 10 relevant original articles (7 cross-sectional and 3 longitudinal, mostly focusing on synovitis and/or enthesitis in spondyloarthritis, 4 with reproducibility data). The Working Group decided on inflammation in peripheral joints and entheses as primary focus areas, and then developed consensus MRI definitions for these pathologies, selected anatomical locations for assessment, agreed on a core set of MRI sequences and imaging planes for the different regions, and proposed a preliminary scoring system. It was decided to test and further develop the system by iterative multireader exercises., Conclusion: These first steps in developing an OMERACT WB-MRI scoring system for use in inflammatory arthritides offer a framework for further testing and refinement.

We investigated the correlation between hepatic venous pressure gradient (HVPG) and liver shear wave speed (SWS) measured by multi-frequency time-harmonic ultrasound elastography (THE) before and after transjugular intrahepatic portosystemic shunt (TIPS) implantation. Ten patients with ascites, cirrhotic liver disease and portal hypertension were prospectively examined with invasive HVPG measurement and THE before and after TIPS implantation. HVPG and SWS decreased after TIPS placement from 20.4 ± 2.2 mmHg to 9.8 ± 4.1 mmHg (mean ± standard deviation) and from 3.87 ± 0.54 m/s to 3.27 ± 0.44 m/s. Mean reduction HVPG was -10.6 ± 3.7 mmHg, p < 0.001; mean reduction SWS was -0.60 ± 0.29 m/s, p < 0.001. A linear correlation was observed between HVPG and SWS (R = 0.59, p = 0.0061). THE-measured SWS is a first potential direct ultrasound marker for liver decompression following TIPS in ascites-associated cirrhotic liver disease and therefore might be suitable to non-invasively detect portal hypertension., (Copyright © 2016 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.)

Purpose: Paclitaxel-coated balloons (PCB) inhibit neointimal proliferation in arteries. The purpose of this retrospective analysis was to investigate the effect of PCB in in-stent restenosis after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhotic liver disease., Materials and Methods: Six patients (mean age: 65 ± 10 years) with recurrent in-stent restenoses in TIPS (5 bare stents, 1 covered stent) underwent a single percutaneous transluminal angioplasty (PTA) with PCB (3 µg paclitaxel/mm(2)). Post-interventional outcome and patency were compared with those of prior plain optimal balloon angioplasty (POBA) in the same patients. During a two-year follow-up period, all patients underwent angiographic examinations at 6-month intervals. In-stent minimal lumen diameter (MLD) and late lumen loss (LLL) were assessed. Paclitaxel residues on balloon and sheath surfaces as well as venous plasma concentrations (0 - 24 hours) were analyzed., Results: PCB decreased the need for clinically driven repeat PTA (POBA: 53 % of angiographic examinations; paclitaxel PTA: 19 %; P = 0.014). LLL/diameter stenosis was higher after POBA (2.4 ± 1.5 mm/28 ± 18 %) than after PCB (0.5 ± 0.8 mm/7 ± 11 %, P = 0.029). Residual paclitaxel on balloons was 28 ± 9 % of dose and 0.2 ± 0.1 % on sheath surfaces. Paclitaxel plasma concentrations were below detectable levels throughout the first 24 hours after the interventions in all patients. The procedure was well tolerated and no clinical side effects attributable to paclitaxel were observed., Conclusion: In patients with recurrent in-stent stenoses, a single PTA with PCB resulted in a prolonged secondary patency due to pseudointimahyperplasia without a systemic effect of paclitaxel., Key Points: •Intimahyperplasia is a common reason for long-time TIPS dysfunction. •First-in-man local paclitaxel application in TIPS patients with recurrent in-stent stenoses. •PTA with PCB resulted in a prolonged secondary patency compared to POBA. •No systemic effects of Paclitaxel were detected., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: To compare clinical examination versus whole-body magnetic resonance imaging (WB-MRI) of enthesitis in patients with early axial spondyloarthritis during 3 years of continuous etanercept (ETN) treatment., Methods: Forty-one patients underwent clinical and WB-MRI examinations for enthesitis at baseline and after 2 and 3 years of treatment. Twenty-one sites were assessed in 4 anatomic regions - anterior chest wall, pelvis, knee, and foot., Results: Clinical examination at baseline detected enthesitis in 57% of the patients (85 lesions, mean 2.1 lesions, SD 2.9), most of them in the pelvis (42 lesions in 17 patients) and anterior chest wall (19 lesions in 10 patients). The proportion of patients with clinically detected enthesitis decreased to 19% at Year 2 (mean 0.5, SD 1.5) and 14% at Year 3 (mean 0.7, SD 1.8). WB-MRI detected enthesitis at baseline in 21% of patients (22 lesions, mean 0.5 lesions, SD 1.1), also most frequently in the pelvis (12 lesions) and anterior chest wall (7 lesions). MRI-positive enthesitis decreased to 13% at Year 2 (mean 0.2 lesions, SD 0.5) and 14% at Year 3 (mean 0.2 lesions, SD 0.5). There was positive correlation of clinical and MRI findings at baseline at the anterior chest wall (p = 0.001) and the pelvis (p = 0.0001). No correlation was found at the knee and foot at baseline and for all regions at followup., Conclusion: Both clinical examination and WB-MRI show a decrease in enthesitis after 2 and 3 years of ETN treatment, but correlation was limited to the pelvis and anterior chest wall at baseline.

Objective: To assess the relationship between active inflammation and development of chronic lesions in the spine and sacroiliac (SI)-joints on MRI in early axial spondyloarthritis (SpA) during treatment with etanercept., Methods: Here, we analyzed the 41 patients of the ESTHER trial, who were treated with etanercept over 3 continuous years and of whom MRIs were available for baseline, year 2, and year 3. MRIs were scored for active inflammation (STIR sequences) and chronic changes (T1 sequence) such as fatty lesions, erosions, and ankylosis in the SI joints and spinal vertebral units (VUs)., Results: The mean fatty lesion scores increased between baseline and year 2 both in the spine (1.13 at baseline vs. 1.40 at year 2, p = 0.0254) and in the SI joints (4.76 at baseline vs. 5.46 at year 2, p = 0.27), but we found no further increase of the fatty lesion score between years 2 and 3. New fatty lesions at years 2 and 3 developed nearly exclusively in SI joint quadrants and VUs in which active MRI inflammation was present at baseline. Fatty lesions disappeared only in 3 SI joint quadrants and in none of VUs at years 2 and 3. Erosion and ankylosis scores remained unchanged., Conclusion: Our data indicate a relationship between the presence of active MRI inflammation and the new development of fatty lesions. Furthermore, there was no increase of fatty lesions during continuous treatment of axial SpA patients with etanercept after successful suppression of active inflammation. Whether this is predictive of stopping radiographic progression needs to be further investigated., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Steroid injection of the sacroiliac joints is widely used for the management of active sacroiliitis in patients with spondyloarthritis (SpA). The aims of this study were to prospectively investigate the effectiveness of corticosteroid injection of the sacroiliac joints and to identify factors determining positive and negative outcome. Twenty-nine patients (18 female, 11 male) suffering from sacroiliitis were treated by computed tomography (CT)-guided administration of 40 or 60 mg triamcinolone acetonide per joint. Clinical outcome of the intervention was determined using a visual analog scale from days 1 to 7 as well as after 1, 3, and 6 months. Patients were grouped according to intra-articular (n = 22) and peri-articular positions (n = 7) of the tip of the puncture needle. In patients with intra-articular needle position (76 %), the mean pain score decreased significantly from 7.3 (±1.9) to 3.9 (±3.4) at day 7 and to 3.9 (±3.4) after 1 month, 4.2 (±3.3) after 3 months, and 5.2 (±2.9) after 6 months. The group with peri-articular needle position (24 %) did not show a statistically significant pain reduction throughout the entire 6-month follow-up period. A substantial reduction of inflammatory back pain (reduction of at least 4 visual analog scale (VAS) points) was reported by 55 % of patients after 3 months and 45 % of patients after 6 months. Our results demonstrate that intra-articular CT-guided steroid instillation can achieve sufficient pain and symptom control for 6 months in patients suffering from active sacroiliitis. It is therefore recommended to perform this intervention under appropriate image guidance to ensure proper positioning of the needle tip.

Objective: The objective of this study was to investigate the correlation between hepatic venous pressure gradient (HVPG) and in vivo viscoelasticity of the liver and spleen before and after transjugular intrahepatic portosystemic shunt (TIPS) implantation., Materials and Methods: Ten patients with portal hypertension were examined twice by 3-dimensional multifrequency magnetic resonance elastography as well as prior and subsequent TIPS intervention; HVPG was also measured during TIPS placement. Five harmonic vibrations (25-60 Hz) were transferred to the abdominal region and recorded for the reconstruction of 2 viscoelastic constants, |G*| and φ, corresponding to the magnitude and the phase angle of the complex shear modulus G* of the liver and spleen., Results: All patients had cirrhosis, yielding high |G*| values in the liver (8.34 ± 2.18 kPa) and spleen (8.44 ± 1.36 kPa). In both organs, a decrease of |G*| after TIPS placement was observed (liver: 8.34 ± 2.18 kPa vs 7.02 ± 1.46 kPa, P = 0.01; spleen: 8.44 ± 1.36 kPa vs 7.06 ± 1.32 kPa, P = 0.01), whereas φ was insensitive to TIPS. Relative changes in |G*| of the spleen were correlated with the relative change of HVPG (R² = 0.659, P = 0.013)., Conclusions: The observed linear correlation between spleen viscoelasticity HVPG raises the prospect of an image-based noninvasive assessment of portal pressure by magnetic resonance elastography in the follow-up of TIPS placements.

Objective: The aim of this study was to assess the degree of fluctuation of osteitis on MRI during long-term treatment with etanercept (ETN) in patients with early axial SpA (axSpA) with active inflammation (osteitis) on whole-body MRI in the spine and/or the SI joints at baseline., Methods: We analysed MRI data from 328 SI joint quadrants and 943 spine vertebral units (VUs) in terms of osteitis in the pooled data set of 41 patients who were treated with ETN for 3 consecutive years. Scoring was performed by two blinded radiologists at baseline, year 2 and year 3., Results: Through years 2 and 3, osteitis on MRI resolved completely in 56 of 144 (38.9%) SI joint quadrants and in 20 of 40 (50%) VUs affected at baseline, while persistent osteitis was found in 24 of 144 (16.7%) SI joint quadrants and in 8 of 40 (20.0%) spine VUs. The development of new osteitis in sites that were free of osteitis at baseline only occurred in 2 of 131 (1.5%) SI joint quadrants and in 3 of 862 (0.4%) spine VUs in both year 2 and year 3., Conclusion: There was a consistently small amount of osteitis on MRI in patients with early axSpA compared with baseline values, and only a very low rate of new-onset osteitis was found during 3 years of continuous treatment with ETN., Trial Registration: www.clinicaltrials.gov, NCT00844142., (© The Author 2014. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Objective: In patients with early active axial spondyloarthritis (axSpA) with a disease duration of < 5 years, the longterm efficacy of 3 years of continuous etanercept (ETN) treatment was assessed., Methods: In a previously reported ESTHER trial, patients with axSpA were randomized to treatment with ETN (n = 40) versus sulfasalazine (SSZ; n = 36) in the first year. We analyzed the clinical, laboratory, and magnetic resonance imaging (MRI) response in the pooled dataset of patients (study population; n = 61), including patients with ankylosing spondylitis (AS, n = 31) and nonradiographic axSpA (nr-axSpA, n = 30) who were continuously treated with ETN for 3 consecutive years. Data were analyzed using the last observation carried forward and completer analysis., Results: In the entire group of patients in the study population (n = 61), the mean Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) decreased from 5.7 (± 1.3) at baseline to 2.6 (± 2.4) at Year 3. The Ankylosing Spondylitis Disease Activity Score (ASDAS) decreased from 3.4 (± 0.8) to 1.5 (± 1.0). Also, mean values for MRI spine and sacroiliac joint scores showed a significant decrease. Response rates in the nr-axSpA group were similar and at least as good compared to the AS group for all outcome measures. When comparing remission stages, we found that ASDAS inactive disease correlated better with C-reactive protein and MRI remission than with Assessment of SpondyloArthritis international Society partial remission., Conclusion: There was a consistent and sustained clinical response in patients with early axSpA treated with ETN over 3 years. ClinicalTrials.gov registration number NCT00844142.

Purpose: This study was designed to evaluate the technical feasibility and the image quality of intra-arterial 320-row CT angiography (ia-CTA) in the detection of transplant renal artery stenosis (TRAS) using a very low dose of contrast agent., Methods: Evaluation of ia-CTA using a 4F catheter in ten patients with impaired renal transplant function and suspected TRAS. Average amount of contrast agent applied was 10 ± 3.7 ml standard deviation (SD). Patient serum creatinine levels had been monitored for 72 h. TRAS was detected and graded (1: less than 20 %; 2: 20-49 %; 3: 50-74 %; 4: 75-99 %; 5: total occlusion) and presence of kinking was recorded. Attenuation and vessel delineation were parameters for image quality analysis of the renal arterial supply, divided into four segments. Subjective image quality., Results: Ia-CTA of the renal transplant was technically successful in all patients, revealing relevant stenoses in 7 of 10 patients. Serum creatinine levels before and after ia-CTA were 2.71 ± 1.46 and 2.56 ± 1.39 mg/dl, respectively. None of the patients developed signs of contrast-induced nephropathy within 72 h. Subjective image quality was excellent in all four segments, rated by two separate readers. No segment was found to be nondiagnostic. Mean attenuation values in the arterial segments ranged between 754 and 987 Hounsfield units., Conclusions: Wide detector ia-CTA for the diagnosis of TRAS is feasible using very low doses of contrast agent and results in high image quality.

Objective: Assessment of structural damage of sacroiliac joints (SIJ) in patients with axial spondyloarthritides (axSpA) has been discussed as a useful outcome measure in clinical trials. The aim of our study was to evaluate different magnetic resonance imaging (MRI) scoring methods and pulse sequences with a focus on fatty lesions and bony erosions., Methods: Seventy-five patients with the diagnosis of axSpA underwent MRI at 3 timepoints as part of the ESTHER trial, which compared 2 groups of patients treated with etanercept or sulfasalazine. Two MRI sequences [unenhanced T1-weighted (T1w) turbo spin-echo (TSE) and unenhanced T1w opposed-phase gradient-echo sequences (opGRE)] and 2 different scoring systems (simple and comprehensive Berlin method) were used for the evaluation of fatty lesions and erosions of the SIJ. Differences between techniques and methods were evaluated by intraclass correlation coefficients (ICC) and standardized response means (SRM)., Results: Applying the simple Berlin method, mean fatty lesion scores for etanercept-treated patients were 4.59 and 5.19 at baseline and Week 48, respectively, while the comprehensive Berlin method revealed mean fatty lesion scores of 6.59 and 7.64, respectively. Corresponding SRM were 0.59 and 0.86 for simple and comprehensive methods, respectively, while ICC dropped from 0.76-0.77 to 0.59-0.62. Scoring of erosions on T1w opGRE images resulted in a higher interreader agreement (ICC of 0.65) compared to T1w TSE sequences (ICC of 0.18)., Conclusion: Better characterization of fatty lesion changes within 1 year was achieved by the comprehensive Berlin scoring method; however, more reader variation has to be taken into account. The delineation of erosions is markedly improved when using T1w opGRE pulse sequences.

Objective: To evaluate active inflammatory lesions (AIL) and structural changes (SC) in patients with active non-radiographic axial spondyloarthritis (nr-axSpA) compared with patients with ankylosing spondylitis (AS) on whole-body MRI (wb-MRI)., Method: 75 patients with active disease and a symptom duration of <5 years (39 with AS and 36 with nr-axSpA) were investigated with a comprehensive wb-MRI protocol and scored for AIL and SC in the spine, sacroiliac joints (SIJs) and non-axial manifestations., Results: 92% of patients with AS showed active inflammation in the SIJ, 53% in the spine and 94% and 39%, respectively, in the nr-axSpA group. There was a non-significant trend towards more inflammation in patients with AS compared with patients with nr-axSpA in SIJs and spine. Peripheral enthesitis/osteitis was more common in patients with AS (n=22) than in those with nr-axSpA (n=12) (p=0.05). SC were more common in patients with AS than in those with nr-axSpA, with significantly higher scores for SIJ fatty bone marrow deposition (FMD) in patients with AS (4.8±3.2) compared with those with nr-axSpA (2.4±2.7; p=0.001) and more frequent bone proliferation in the spine and the SIJ (p=0.02 and p=0.005, respectively). SIJ erosions were more common in AS (score 4.2±2.3) than in nr-axSpA (score 3.8±1.8) patients (not significant)., Conclusions: Wb-MRI detects active inflammation and SC more frequently in the SIJs than in the spine. Half of the patients showed inflammation in non-axial sites. Active inflammatory and structural lesions were present both in patients with AS and those with nr-axSpA, being only slightly more common in patients with AS.

Objective: We assessed whether there is a difference to etanercept (ETA) treatment in patients with ankylosing spondylitis (AS) compared with non-radiographic axial SpA (nr-axSpA) patients with a disease duration <5 years., Method: AS (n=20) and nr-axSpA (n=20) patients who were treated with ETA for 1 year were compared for differences in baseline data and treatment effect. Clinical, laboratory and MRI of sacroiliac joints (SI-joints) and spine were analysed., Results: At baseline, there were no significant differences between the 20 AS and the 20 nr-axSpA patients regarding age, disease duration, gender, HLA-B27 and clinical disease activity in terms of Bath AS Disease Activity Index (BASDAI), C-reactive protein and MRI SI-joint and spine scores in the AS compared with the nr-axSpA group. After 1 year of treatment with ETA the treatment effect was similarly good in AS and nr-axSpA (reduction of BASDAI by 3.3 (95% CI 2.2 to 3.8) vs 3.6 (95% CI 2.8 to 4.4) and reduction of AS Disease Activity Score by 1.8 (95% CI 1.5 to 2.2) vs 1.8 (95% CI 1.5 to 2.1), respectively., Conclusions: The response rate to TNF-blockers does not differ between AS and nr-axSpA if the baseline data regarding symptom duration and disease activity are similar for the two groups.

Purpose: The aims of this study were (1) to assess the frequency and duration of drug-free remission and efficacy of etanercept (ETA) treatment after flare in patients with early active axial spondyloarthritis who were treated with ETA (n=40) versus sulfasalazine (SSZ, n=36) for 48 weeks and (2) to analyse the efficacy of ETA treatment in patients in year 2 who did not reach remission at week 48., Method: At week 48, patients who reached study remission (Assessment of Spondyloarthritis international Society (ASAS) plus MRI remission) were followed up without active treatment up to 1 year. In case of a flare, patients were treated with ETA for another year. All patients who were not in ASAS plus MRI remission at week 48 were treated with ETA in year 2., Results: ASAS plus MRI remission at week 48 was reached significantly more often in ETA-treated compared to SSZ-treated patients (33% vs 11%, p=0.03). However, the flare rate was not different between these two groups: 69% in the ETA group versus 75% in the SSZ group. Only 8% of patients initially treated with ETA versus 3% of those initially treated with SSZ reached permanent drug-free remission (not significant). After treatment with ETA over 1 year, patients with flare showed an improvement in all clinical and imaging variables., Conclusion: Patients with axial spondyloarthritis treated with ETA over 1 year did not reach drug-free remission in a higher percentage compared to patients from a control group treated with SSZ.

Modern diagnostic possibilities pose a number of challenges. When is a precise genetic diagnosis justifiable in today's climate of cost-cutting? We would like to pose that question to Sir William Osler. Sir William was a keen observer, a master 'translator' of science into clinical medicine. Would he have required or supported genetic testing? We treated a patient whose case reminded us of Sir William's belief that clinical exactness was the ultimate aim, regardless of cost.

Aim: To investigate the relationship between active inflammatory lesions on whole-body MRI (wb-MRI) and new development of chronic lesions on T1 MRI in patients with early axial spondyloarthritis (SpA) treated either with etanercept (ETA) or sulfasalazine (SSZ)., Methods: Wb-MRIs of 65 patients treated either with ETA (n=35) or SSZ (n=30) over 1 year were scored for active inflammation, fatty lesions, erosions and ankylosis in the 23 vertebral units (VUs) of the spine and in the sacroiliac joints (SI joints). Scoring was performed by two blinded radiologists., Results: If there was no previous inflammation in the bone no new fatty lesions occurred in SI joint quadrants and only a few (0.6%) in spine VUs. There was a significant relationship between disappearance of inflammation and the appearance of fatty lesions: if baseline inflammation resolved fatty lesions occurred in 10.5% of SI joint quadrants and 17.9% of VUs. If inflammation did not resolve over 1 year, fatty lesions occurred less frequently: 2.4% (SI joint quadrants) and 7.2% (VUs). There was a significantly higher increase of the mean fatty lesion score between baseline and week 48 in the ETA (4.0 vs 4.8 for the SI joints and 1.9 vs 2.7 for the spine) compared to the SSZ (3.0 vs 3.2 for the SI joints and 1.1 vs 1.2 for the spine, respectively) group (p=0.001 and p=0.020 for the differences). No significant changes in the erosion or ankylosis score were observed in any of the two groups during this time., Conclusions: These data indicate that there is a close interaction between inflammation, tumour necrosis factor blockade and the development of fatty lesions in subchondral bone marrow of patients with axial SpA.

This study aims to characterize patients with early rheumatoid arthritis (RA) based on different definitions of early RA (disease duration, fulfillment of the American College of Rheumatology (ACR) criteria), and to determine whether these different definitions affect magnetic resonance imaging (MRI) findings of the hand. A cohort of 58 patients with early RA previously described was re-evaluated. There were 43 women and 15 men with a median age of 49 years, a disease duration of less than 2 years, and negative radiographs who were followed up for 6-41 months. MR images of the hand and wrist of these patients were retrospectively evaluated for the presence of synovitis, erosions, and tenosynovitis. The presence and distribution of these MRI findings were analyzed in three groups: fulfillment of 1987-ACR criteria, 6-month disease duration, and 12-month disease duration. Median disease duration was 11 months (range 1-24 months). Thirty patients (52%) fulfilled the ACR criteria. More patients fulfilling ACR criteria had MCP erosions and carpal synovitis compared with those not fulfilling the criteria; however, the difference was not significant. No significant difference was seen in the prevalence of synovitis, tenosynovitis, or erosions between the three groups. Patients with early RA of 2-years duration and negative hand X-ray findings are a homogenous group, regarding their MRI findings.

Objective: To evaluate the potential of MRI of finger and wrist joints for diagnosing early RA. MRI was evaluated as a stand-alone tool and in combination with ACR criteria and serum markers such as RF., Methods: Ninety-nine patients (31 men, 68 women; median age 46 years) with unspecified arthritis or suspected RA and negative X-ray findings were included. MR images of the hand and wrist of these patients were retrospectively evaluated for the presence of synovitis, erosions and tenosynovitis. The clinical diagnosis (early RA or non-RA) was made by a rheumatologist after clinical follow-up for 6-41 months. Clinical and laboratory data were collected from all patients., Results: Fifty-eight patients had a clinical diagnosis of RA and 41 were diagnosed as non-RA. Step-wise logistic regression of all MR parameters evaluated identified tenosynovitis of the flexor tendons to be the most powerful predictor of early RA (sensitivity = 60%, specificity = 73%). Including ACR criteria in the analysis, positive serum RF and tenosynovitis were the strongest predictors of early RA (sensitivity = 83%, specificity = 63%). When serum anti-cyclic citrullinated peptides (CCP), ANA and CRP were included as additional parameters, anti-CCP and flexor tenosynovitis were the strongest predictors of early RA (sensitivity = 79%, specificity = 73%)., Conclusions: Flexor tenosynovitis diagnosed by MRI of the hand is a strong predictor of early RA. Combining flexor tenosynovitis on MRI with positive serum anti-CCP or positive RF is an even stronger predictor of early RA.

Ankylosing spondylitis is the prototypical spondyloarthritis. Early diagnosis has gained clinical importance with the advent of new therapeutic options such as TNF-alpha inhibitors, which can dramatically improve clinical outcome when initiated early. Whole-body MRI can contribute important diagnostic information for detecting early forms of spondyloarthritis because it enables evaluation of all important joints that may be involved in the disease process as a one-stop shop modality. MRI allows much more accurate diagnostic evaluation of the thoracic spine, which is affected in the majority of patients. This article provides an overview of the use of whole-body magnetic resonance imaging (MRI) in the spondyloarthritides. The recommendations given reflect the most recent scientific data and expert opinions. The focus of this review is on MRI findings at both the axial and the appendicular skeleton and the technical feasibility of whole-body MRI in the clinical setting.

Introduction: Magnetic resonance imaging (MRI) of active inflammatory changes of the sacroiliac joint (SIJ) in spondyloarthritis (SpA) is performed with short tau inversion recovery (STIR) sequences and fat-saturated T1-weighted fast spin-echo (FSE) sequences after administration of gadolinium-based contrast medium (T1/Gd). The aim of the present study was to compare these two pulse sequences in terms of diagnosis, diagnostic confidence, and quantification of inflammatory changes., Materials and Methods: The study included 105 patients with suspected SpA; 72 patients developed clinical SpA over time. All patients were examined with STIR and T1/Gd and each of the two sequences was analyzed separately in conjunction with unenhanced T1 FSE images. For quantitative estimation of inflammatory changes, each sacroiliac joint (SIJ) was divided into 4 quadrants (and severity per quadrant was assigned a score of 0-4, resulting in a maximum sum score of 16 per SIJ). Diagnostic confidence was assessed on a visual analogue scale ranging from 0 to 10., Results: Active sacroiliitis was diagnosed in 46 patients and ruled out in 34 using STIR, whereas findings were inconclusive in 25 patients. The corresponding numbers for T1/Gd were 47, 44, and 14. Diagnostic confidence was significantly lower for STIR (7.3+/-2.6) compared with T1/Gd (8.7+/-1.9) (p<0.001). The sum scores were 2.5 (+/-3.3) for STIR and 2.2 (+/-3.2) for T1/Gd for the right SIJ and 2.2 (+/-2.9) (STIR) and 1.9 (+/-3.1) (T1/Gd) for the left SIJ. Agreement was high with intraclass correlation coefficient (ICC) values of 0.86 for the right SIJ and 0.90 for the left SIJ and positive correlation (r=0.62 right, 0.60 left)., Summary: STIR sequences alone are sufficient for establishing a reliable diagnosis and quantify the amount of inflammation in active sacroiliitis. A contrast-enhanced study is dispensable in patients with established disease or in the setting of clinical follow-up studies. However, a contrast-enhanced MR sequence is beneficial to ensure maximum diagnostic confidence when patients with early sacroiliitis are examined.

Objective: To develop a new method of digital synovial vascularisation quantification by using contrast-enhanced musculoskeletal ultrasonography (MUS) in detecting synovitis in patients with knee osteoarthritis (OA) compared with healthy subjects and MRI., Methods: Evaluation of 41 patients with painful knee OA and 6 healthy subjects. The severity of knee pain was evaluated. All patients and all 6 healthy subjects underwent contrast medium-enhanced (CE)-MUS with SonoVue, and 36 patients additionally underwent CEMRI with Magnevist. Joint effusion, synovial thickening and pain were assessed and compared with B-mode and Power Doppler sonography (PDS) as well as contrast medium enhancement., Results: Pain evaluated by the visual analogue scale(VAS) hardly correlated with other markers of disease activity measured by ultrasound (US) in B-mode or MRI. US of the superior recess revealed an effusion or synovial thickening in 58%. PDS findings were positive in 63%, and CE-MUS in the superior knee recess was positive in 95%. MRI showed effusion in the superior recess in 61% and showed positive findings in 82% when using contrast medium. The kappa value was 0.48 between US and MRI with regard to the effusion in the superior recess, and 0.53 between PD signal in the superior recess and effusion in the superior recess by US. Using MRI as the reference standard, there was a sensitivity of 72% for assessing effusion in the superior recess and 81% for assessing effusion in the lateral recess., Conclusion: Assessment of disease activity (synovitis) in knee OA by VAS is not sufficient. US PDS was more sensitive than B-mode, and CE-MUS was more sensitive than PDS and CE-MRI in detecting synovitis in patients with painful knee OA. Also, CE-MRI was more sensitive in detecting inflammatory changes in the superior recess than without contrast medium. Using CE-MUS and performing time/intensity analysis has shown to be a good model for evaluation of an inflammatory process in the setting of knee OA in the superior recess.

Objective: To compare MRI evaluation of a painful hindfoot of patients with spondyloarthritides (SpA) on low-field (0.2 T) versus high-field (1.5 T) MRI., Materials and Methods: Patients with SpA and hindfoot pain were randomly referred to either high-field or low-field MRI. Twenty-seven patients were evaluated (male/female: 17:10; mean age: 39+/-1.4 years). Fifteen patients were examined by low-field and 12 by high-field MRI. Two patients (evaluated by high-field MRI) were excluded. Images were separately read by two radiologists who later reached a consensus. In each patient the prevalence of erosions, fluid, synovitis or bone marrow edema of the hindfoot joints, tendinosis or tenosynovitis of tendons, enthesitis of the plantar fascia and Achilles tendon and retrocalcaneal bursitis were recorded. Clinical and demographic parameters were comparable between both groups., Results: MRI evaluation of joints and tendons of the hindfoot revealed no significant differences in patients with SpA groups for all parameters. Analyzing all joints or tendons together, there was no statistically significant difference between the two groups., Conclusion: Low-field and high-field MRI provide comparable information for evaluation of inflammatory hindfoot involvement. Thus, low-field MRI can be considered as a reliable diagnostic tool for the detection of hindfoot abnormalities in SpA patients.

Entheses are sites where tendons, ligaments, joint capsules or fascia attach to bone. Inflammation of the entheses (enthesitis) is a well-known hallmark of spondyloarthritis (SpA). As entheses are associated with adjacent, functionally related structures, the concepts of an enthesis organ and functional entheses have been proposed. This is important in interpreting imaging findings in entheseal-related diseases. Conventional radiographs and CT are able to depict the chronic changes associated with enthesitis but are of very limited use in early disease. In contrast, MRI is sensitive for detecting early signs of enthesitis and can evaluate both soft-tissue changes and intraosseous abnormalities of active enthesitis. It is therefore useful for the early diagnosis of enthesitis-related arthropathies and monitoring therapy. Current knowledge and typical MRI features of the most commonly involved entheses of the appendicular skeleton in patients with SpA are reviewed. The MRI appearances of inflammatory and degenerative enthesopathy are described. New options for imaging enthesitis, including whole-body MRI and high-resolution microscopy MRI, are briefly discussed.

Objective: The objective of this study was to validate the accuracy of 64-MDCT densitometry of soft and intermediate plaques., Materials and Methods: Acrylonitrile-butadiene-styrene resin (47 H) and acrylic (110 H) were used to simulate soft and intermediate plaques, respectively, in coronary artery models (diameters of 3 and 4 mm). The variable parameters were heart rate (50, 65, 80, and 95 beats per minute), reconstruction algorithm (half and segmentation), coronary artery enhancement (150, 250, 350, and 450 H), CT densitometry site (arterial lumen or center), shape of plaque (D-shaped, centric, and eccentric), and level of stenosis due to plaque (25%, 50%, and 75% of arterial diameter). Measured CT attenuation values of soft and intermediate plaques were compared for different combinations of parameters. Repeated measures analysis of variance, Wilcoxon's signed rank, Mann-Whitney U, and Kruskal-Wallis tests were used for statistical analyses., Results: For measuring soft plaque, CT densitometry was accurate at low heart rates with the use of a half reconstruction algorithm (p < 0.01) on intracoronary artery enhancement of 250 H (p < 0.01). For both soft and intermediate plaques, the densitometry measurements near the arterial lumen were overestimated and higher than those at the center (p < 0.01). For plaques that were 50% or more of the arterial diameter, accurate CT densitometry was possible., Conclusion: Coronary artery enhancement has a significant impact on 64-MDCT densitometry measurements of coronary artery plaques, especially of soft plaques. A large plaque size, densitometry performed not near the arterial lumen but at the center of the plaque, intracoronary enhancement of 250 H, and a low heart rate increase the accuracy of plaque densitometry.

Purpose: To evaluate the incidence of MRI-related claustrophobia and prematurely terminated MRI (ptMRI) examinations due to claustrophobia in a large-scale cohort study., Materials and Methods: The hospital's computerized radiology information system (RIS) was retrospectively analyzed for all 1.5-Tesla MRI examinations and reports during the year 2004. Data collected included demographic information, body part examined, known claustrophobia, and whether the examination was prematurely terminated. All information available on the MRI examinations and the patient-based data (i.e., excluding any additional examinations per patient) were analyzed., Results: A total of 5798 MRI reports of 4821 patients were evaluated. A total of 95 patients (1.97%) suffered from claustrophobia and 59 (1.22%) prematurely terminated the examination due to claustrophobia. The incidence of ptMRI was higher in women than men (no statistical significance). The majority of patients with ptMRI were between 20 and 80 years old. Patients undergoing head MRI showed the highest incidence of ptMRI and those undergoing extremity, breast, or pelvic MRI had the lowest. Prone compared to supine positioning results in the lowest ptMRI incidence (P < 0.05)., Conclusion: Claustrophobic reactions cause a relatively low incidence of ptMRI and are influenced by sex, body part examined, and positioning within the MR scanner. Sedation and prone positioning might help overcome these reactions., ((c) 2007 Wiley-Liss, Inc.)

Objective: To compare dedicated low-field MRI (lfMRI) with conventional MRI (cMRI) in the detection and scoring of synovitis, tenosynovitis and erosions in patients with rheumatoid arthritis., Patients and Methods: The wrist and finger joints of 17 patients with rheumatoid arthritis (median (range) disease duration 8 years (7-12); Disease Activity Score 3.3 (2.6-4.5)) were examined by 0.2 T lfMRI and 1.5 TcMRI. The protocols comprised coronal spin-echo and three-dimensional gradient-echo sequences before and after contrast medium administration. Synovitis of the metacarpophalangeal and proximal interphalangeal joints 2-5 and the wrist joints was scored according to Outcome Measures in Rheumatology recommendations. Tenosynovitis and erosions were scored using 4-point and 6-point scales, respectively. The results were analysed by calculating kappa values and performing McNemar's test intra-individually on a joint-by-joint basis., Results: Agreement between the two MRI techniques was good to excellent for synovitis and erosions, and moderate for tenosynovitis. Of the 306 joints evaluated, 245 and 200 joints showed synovitis in lfMRI and cMRI, respectively. Scoring of synovitis of the finger joints yielded kappa values from 0.69 to 0.94. Of the 68 flexor tendons evaluated, tenosynovitis was diagnosed by lfMRI in 24 and by cMRI in 33 instances. Of the 391 bones evaluated, 154 and 139 showed erosions in lfMRI and cMRI, respectively. kappa values for erosion scores were between 0.65 and 1., Conclusion: Dedicated, lfMRI shows high agreement with cMRI in diagnosing and scoring synovitis, tenosynovitis and erosions in rheumatoid arthritis when using standardised scoring systems.

Objective: To investigate the impact of a double dose compared to a single dose of contrast material in low-field magnetic resonance imaging (MRI) on semi-quantitative scoring of synovitis in patients with rheumatoid arthritis (RA)., Methods: This prospective study included 38 RA patients (23 women and 15 men, mean age 51 years). All patients underwent low-field MRI of the hand before administration of contrast medium, after intravenous injection of 0.1 mmol/kg gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA), and after another dose of 0.1 mmol/kg Gd-DTPA. Two readers (A and B) blinded to dosage independently scored the single dose and double dose image sets for synovitis according to outcome measures in rheumatology (OMERACT) recommendations. Contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) were also calculated for each set., Results: 149 metacarpophalangeal (MCP) joints were evaluated. There was good inter-reader agreement for each of the two sets (intra-class correlation coefficient of 0.75 for the single dose set and 0.83 for the double dose). Median CNR and SNR values were 5.4 and 15.9, respectively, for the single dose set and 8.5 and 16.6, respectively, for the double dose set (p<0.0001). Single dose set mean synovitis scores were 1.7 and 1.6 for readers A and B, respectively. Double dose set scores were 1.9 and 2.0, respectively. Thus, higher synovitis scores were recorded for the double dose sets than the single dose sets (p<0.005)., Conclusion: In low-field MRI, when evaluating RA, the dose of the contrast material influences synovitis scoring. Therefore, dosage of contrast material should be taken into consideration when using extremity dedicated low-field MRI.

Objective: We investigated the diagnostic yield of histological examined formalin-fixed blood clots (FFBCs) in comparison with the established procedures of fine-needle aspiration biopsy (FNAB) and core biopsy (CB) obtained by percutaneous puncture under computed tomography (CT) guidance., Methods: A total of 76 CT-guided punctures with removal of tissue by means of all 3 different techniques (FFBC, FNAB, and CB) were performed. Specimens were obtained from the lung (n=18), mediastinum (n=10), upper abdominal organs (n=32), pelvis (n=4), retroperitoneum (n=4), bones (n=7), and neck (n=1). All results were correlated with the clinical course of the patients (minimum, 6 months; mean period, 10 months). The results of each technique were compared. Results of a combined use of FFBC and FNAB were analyzed., Results: The overall sensitivity (regardless of biopsy site) was 79% for FFBC, 83% for FNAB, and 95% for CB. In chest biopsies, FFBC reached a sensitivity of 92%, FNAB of 86%, and CB of 96%. In liver biopsies, the sensitivities were 47%, 70%, and 88% for FFBC, FNAB, and CB and, for the remaining biopsy sites, 90%, 90%, and 100%, respectively. The combination of FFBC and FNAB showed higher sensitivities than FFBC and FNAB alone. Overall sensitivity for the combination was 88%, with 92%, 72%, and 100% for thorax, liver, and other locations. A definitive diagnosis was made by FFBC in 87% of cases, by FNAB in 74%, and by CB in 88%. The combination of FFBC and FNAB showed a definite diagnosis in 90% of the cases. A tentative diagnosis has been established in 12%, 7%, 5%, and 4%, respectively. In 4 cases (5%), all 3 techniques failed to yield reliable diagnoses., Conclusions: The examination of FFBCs is a useful supplement to the established technique of CT biopsy. In combination with FNAB, FFBC has a comparable sensitivity as CB in chest punctures and other extrahepatic lesions.

Since the advent of highly effective TNF-alpha inhibitors for treating spondyloarthritides, referring rheumatologists have been requesting the sensitive visualization of inflammatory changes not only of the sacroiliac joints but of the entire spine. Given that changes in spondyloarthritis may be very subtle, their visualization by means of magnetic resonance (MR) imaging relies critically on selecting the proper imaging protocol. Spinal changes associated with spondyloarthritis are florid anterior spondylitis (or Romanus lesion), florid diskitis (or Andersson lesion), ankylosis, insufficiency fractures of the ankylosed spine, syndesmophytes, arthritis of the apophyseal and costovertebral joints, and enthesitis of the interspinal ligaments. A comparison of MR imaging findings with those of conventional radiography in individual patients reveals strengths and weaknesses of both modalities. Results of this comparison suggest that syndesmophytes are depicted better with radiography; ankylosis, equally well with both imaging techniques; and all other lesions, better with MR imaging. Classification of the different findings based on the typical signal-intensity changes seen on MR images enables standardized reporting, and scoring the lesions may be helpful in clinical trials.