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Sodium magnetic resonance imaging (MRI) can be used to evaluate the change in the proteoglycan content in Achilles tendons (ATs) of patients with different AT pathologies by measuring the 23Na signal-to-noise ratio (SNR). As 23Na SNR alone is difficult to compare between different studies, because of the high influence of hardware configurations and sequence settings on the SNR, we further set out to measure the apparent tissue sodium content (aTSC) in the AT as a better comparable parameter. Ten healthy controls and one patient with tendinopathy in the AT were examined using a clinical 3 Tesla (T) MRI scanner in conjunction with a dual tuned 1H/23Na surface coil to measure 23Na SNR and aTSC in their ATs. 23Na T1 and T2* of the AT were also measured for three controls to correct for different relaxation behavior. The results were as follows: 23Na SNR = 11.7 ± 2.2, aTSC = 82.2 ± 13.9 mM, 23Na T1 = 20.4 ± 2.4 ms, 23Na T2s* = 1.4 ± 0.4 ms, and 23Na T2l* = 13.9 ± 0.8 ms for the whole AT of healthy controls with significant regional differences. These are the first reported aTSCs and 23Na relaxation times for the AT using sodium MRI and may serve for future comparability in different studies regarding examinations of diseased ATs with sodium MRI.

Scientific reports 10, 15106 (2020). doi:10.1038/s41598-020-72208-y, Published by Macmillan Publishers Limited, part of Springer Nature, [London]

Background Because of overlapping phenotypical presentations, the diagnostic differentiation of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) remains challenging. Thus, this study aimed to examine the diagnostic value of distinct imaging features obtained by high-resolution 3-T MRI for the diagnostic differentiation. Materials and methods Seventeen patients with PsA and 28 patients with RA were imaged at high resolution using 3-T MRI scanners and a dedicated 16-channel hand coil. All images were analyzed according to the outcome measures in rheumatology clinical trials’ (OMERACT) RAMRIS (Rheumatoid Arthritis Magnetic Resonance Imaging Score) and PsAMRIS (Psoriatic Arthritis Magnetic Resonance Imaging Score) for the presence and intensity of synovitis, flexor tenosynovitis, bone edema, bone erosion, periarticular inflammation, bone proliferation, and joint space narrowing. Next, odds ratios (OR) were calculated to determine the strength of the associations between these imaging features, demographic characteristics, and the outcome RA vs. PsA. Results PsA could be differentiated from RA by extracapsular inflammatory changes (PsAMRIS sub-score “periarticular inflammation”), with low odds for the presence of RA (OR of 0.06, p Conclusion High-resolution imaging is beneficial for the identification of relevant imaging features that may assist the clinical differentiation of inflammatory conditions of the hand. At the MCP level, extracapsular inflammatory changes were strongly associated with PsA and may consequently allow the imaging differentiation of PsA and RA.

Objective To evaluate musculoskeletal ultrasound (MSUS) as a screening tool for rheumatoid arthritis (RA) and osteoarthritis (OA) patients in a rheumatology-screening program. Patients and methods To raise awareness for rheumatic diseases, a mobile rheumatology office was deployed in different cities of Germany (“Rheuma-Truck”). Standardized questionnaire assessment, testing for rheumatoid factor and citrullinated peptide antibodies and medical student driven MSUS of the clinically dominant hand/foot including wrist, MCP-II, -III, -V, PIP-II, -III, MTP-II and -V were offered free of charge to the population. In case of suspicious results, a rheumatologist was consulted. Results In MSUS, 192 of 560 selected volunteers (aged 18–89, mean 52.7 years; 72.9% female) had suspicious findings including synovitis or erosions primarily affecting the MTP-II (11.8%), dorsal wrist (8.9%), and MCP-II (7%). 354 of the 560 volunteers further visited a rheumatologist of whom 76 were diagnosed with RA. According to the ‘US7 Score’, a sum scores ≥ 5 was significantly predictive for RA (odds ratio (OR) 5.06; confidence interval (CI) 0.83–35.32). 313 volunteers displayed signs of OA including osteophytes, while MCP-II (36.2%), MCP-III (14.8%), and the wrist (10.5%) were mostly affected. Diagnosis of RA was favoured over OA if the wrist (OR 4.2; CI 1.28–13.95), MTP-II (OR 1.62; CI 1.0–2.6), and MCP-V (OR 2.0; CI 1.0–3.8) were involved. Conclusion Medical student driven MSUS by the ‘US7 Score’ can facilitate diagnosis of RA in rheumatology-screening programs due to the level of the score and the affected joints. A high rate of unknown OA signs was detected by MSUS. A mobile rheumatology office displays an opportunity to screen patients for RA and OA.

Objective ACHILLES aimed to demonstrate efficacy of secukinumab on Achilles’ tendon enthesitis in spondyloarthritis (SpA) patients. Methods Patients ≥18 years (n = 204) with active PsA or axial SpA and heel enthesitis were randomized 1:1 to secukinumab 150/300 mg or placebo up to week 24, and thereafter placebo patients were switched to secukinumab. Results At week 24, a higher, yet statistically non-significant (P = 0.136), proportion of patients in secukinumab vs placebo reported resolution of Achilles tendon enthesitis in affected foot (42.2% vs 31.4%; odds ratio [OR] = 1.63; 95% CI: 0.87, 3.08). Proportion of patients reporting resolution of enthesitis based on Leeds Enthesitis Index was higher with secukinumab vs placebo (33.3% vs 23.5%; OR = 1.65; 95% CI: 0.85, 3.25) at week 24. Mean change from baseline in heel pain at week 24 was higher in secukinumab patients vs placebo (−2.8 [3.0] vs −1.9 [2.7]). Greater improvements with secukinumab were observed in heel enthesopathy activity and global assessment of disease activity. Imaging evaluation by local reading confirmed heel enthesitis on MRI at screening for all patients. Based on central reading, 56% presented with bone marrow oedema and/or tendinitis; according to Heel Enthesitis MRI Scoring System (HEMRIS) post hoc analysis, 76% had signs of entheseal inflammation while 86% had entheseal inflammation and/or structural changes. Conclusion A substantial proportion of patients showed no signs of inflammation on the centrally read MRIs despite a clinical diagnosis of heel enthesitis, thus highlighting that the discrepancy between the clinical and imaging assessments of enthesitis requires further investigation. Although ACHILLES did not meet the primary end point, the study reported clinically meaningful improvements in patient-related outcomes. Trial registration clinicaltrials.gov, NCT02771210

Prior to surgical interventions physicians and patients with inflammatory rheumatic diseases remain concerned about interrupting or continuing anti-inflammatory medication. For this reason, the German Society for Rheumatology has updated its recommendations from 2014.After a systematic literature search including publications up to 31 August 2021, the recommendations on the use of of glucocorticoids, conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biologics (bDMARDs) were revised and recommendations on newer drugs and targeted synthetic (ts)DMARDs were added.The glucocorticoid dose should be reduced to as low as possible 2-3 months before elective surgery (in any case10 mg/day) but should be kept stable 1-2 weeks before and on the day of surgery. In many cases csDMARDs can be continued, exceptions being a reduction of high methotrexate doses to ≤15 mg/week and wash-out of leflunomide if there is a high risk of infection. Azathioprine, mycophenolate and ciclosporin should be paused 1-2 days prior to surgery. Under bDMARDs surgery can be scheduled for the end of each treatment interval. For major interventions Janus kinase (JAK) inhibitors should be paused for 3-4 days. Apremilast can be continued. If interruption is necessary, treatment should be restarted as soon as possible for all substances, depending on wound healing.Whether bDMARDs increase the perioperative risk of infection and the benefits and risks of discontinuation remain unclear based on the currently available evidence. To minimize the risk of a disease relapse under longer treatment pauses, in the updated recommendations the perioperative interruption of bDMARDs was reduced from at least two half-lives to one treatment interval.HINTERGRUND: Vor operativen Eingriffen stellt sich Ärzten und Patienten mit entzündlich rheumatischen Erkrankungen weiterhin die Frage nach einer Unterbrechung oder Fortsetzung der entzündungshemmenden Medikation. Die Deutsche Gesellschaft für Rheumatologie hat hierfür ihre Empfehlungen von 2014 aktualisiert.Nach einer systematischen Literaturrecherche mit Einschluss von Publikationen bis zum 31.08.2021 wurden die Empfehlungen zum Umgang mit Glukokortikoiden, konventionell synthetischen „disease-modifying antirheumatic drugs“ (csDMARDs) und Biologika (bDMARDs) überarbeitet und Empfehlungen zu neueren Substanzen und „targeted synthetic (ts) DMARDs“ ergänzt.Die Glukokortikoiddosis sollte 2 bis 3 Monate vor elektiven Eingriffen so niedrig wie möglich reduziert (in jedem Fall10 mg/Tag), 1 bis 2 Wochen vor und am Operationstag jedoch stabil gehalten werden. csDMARDs können in vielen Fällen fortgeführt werden, Ausnahmen sind eine Reduktion hoher Methotrexat-Dosierungen auf ≤15 mg/Woche und Auswaschen des Leflunomid bei hohem Infektionsrisiko. Azathioprin, Mycophenolat und Ciclosporin sollten 1 bis 2 Tage vor der Operation pausiert werden. Unter bDMARDs können Operationen zum Ende des jeweiligen Therapieintervalls geplant werden. Januskinase(JAK)-Inhibitoren sollten bei größeren Eingriffen für 3 bis 4 Tage pausiert werden. Apremilast kann fortgeführt werden. Bei notwendiger Unterbrechung gilt für alle Substanzen, die Therapie in Abhängigkeit der Wundheilung baldmöglichst wieder zu beginnen.Ob bDMARDs das Infektionsrisiko perioperativ erhöhen und welche Rolle die Absetzzeit dabei spielt, bleibt bei gegenwärtiger Evidenz noch unklar. Um das Risiko eines Krankheitsschubs unter längerer Therapiepause zu minimieren, wurde in den aktualisierten Empfehlungen die perioperative Pausierung von bDMARDs von mindestens 2 Halbwertszeiten auf ein Therapieintervall reduziert.

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.Bei einer systemischen Erkrankung ist systemisches Denken erforderlich. In diesem Leitbild definieren wir Rheumatologie, beschreiben die Rolle der Deutschen Gesellschaft für Rheumatologie und umschreiben den rheumatologischen „Geist“, der uns für und in unserem Fach antreibt. Rheumatologen widmen sich der Verbesserung der Lebensqualität ihrer Patienten im akuten, chronischen und Rehabilitationsstadium auf Basis der aktuellen Datenlage und einer tragfähigen Arzt-Patienten-Beziehung. Wir denken, handeln und interagieren systemisch, wissenschaftlich, konsequent, transparent, verlässlich, integrativ, innovativ und begeistert.

Background Tofacitinib is a novel Janus kinase (JAK) inhibitor approved for the treatment of rheumatoid arthritis, psoriatic arthritis, and ulcerative colitis. In clinical trials, the most common adverse events observed were nasopharyngitis, upper respiratory tract infections, and zoster. JAKs are found downstream of the type II cytokine receptor family used by a number of TH17 cell-associated cytokines for signal transduction. These cytokines lead to the secretion of antiviral and antimicrobial peptides (AMPs) by keratinocytes or synoviocytes. Blocking the JAK pathway might result in a diminished secretion of antimicrobial and antiviral peptides causing higher susceptibility to infections in patients treated with JAK inhibitors. Methods We treated primary human keratinocytes and synoviocytes with tofacitinib and subsequently added various cytokines and bacterial surface proteins before evaluation of the response via RT-qPCR. CD69 expression on tofacitinib-treated PBMCs was investigated via flow cytometry. Results We found a markedly reduced gene expression of all tested antiviral peptides such as MX1 or ISG15 in keratinocytes and synoviocytes in the presence of tofacitinib in vitro. Additionally, we found that JAK inhibition reduced activation of T cells after stimulation with bacterial LPS or viral VZV gE. Conclusions The antiviral immunity is strongly inhibited in the presence of tofacitinib in vitro, while the antimicrobial immunity does not seem to be affected. In T cells, the overall activation process seems to be influenced by tofacitinib. These findings suggest that tofacitinib has an impact on antiviral immunity such as patients treated with tofacitinib often show adverse events like herpes zoster. Graphical abstract

Reasons of mon- and oligoarthritis are heterogeneous. The diagnostic approach includes a detailed medical anamnesis, physical examination and imaging (conventional X-ray, sonography, MRI and, CT). Analysis of the synovial fluid is required in suspected septic arthritis and frequently helps in diagnosis and differential diagnosis of crystal arthropathies. Dual-energy-CT (DECT) detects sodium urate crystals and can replace joint puncture in some cases. In addition to crystal arthropathies and septic arthritis, differential diagnosis of mon-/oligoarthritis includes reactive arthritis, arthrosis and monarthritic courses of SpA/PsA. A rheumatologist should be consulted particularly in the case of persistent monarthritides, in order to initiate a specific therapy to prevent secondary damage.

Objective.To assess associations of synovial perfusion, cartilage quality, and outcome in rheumatoid arthritis (RA).Methods.Synovial perfusion and cartilage quality were assessed by dynamic contrast-enhanced magnetic resonance imaging in metacarpophalangeal joints of 28 treatment-naive patients with RA at baseline and at 3 and 6 months after methotrexate. Analysis was by linear mixed modeling.Results.Synovial perfusion variables were associated with remission (p < 0.05) and cartilage quality (p < 0.004). Maximum synovial enhancement was associated to European League Against Rheumatism response (p < 0.05). Synovial perfusion improved in nonresponders over time (p < 0.05).Conclusion.Synovial perfusion relates to remission, response, and cartilage quality in a cohort of therapy-naive patients with early RA.

ObjectiveTo analyse the impact of the COVID-19 pandemic on rheumatic patients’ and rheumatologists’ usage, preferences and perception of digital health applications (DHAs).MethodsA web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media (Twitter, Instagram and Facebook), QR code and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.ResultsWe analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of rheumatic and musculoskeletal diseases (RMDs) and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%). The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists). Only a minority (ConclusionThe COVID-19 pandemic instigated an increase in patients’ and rheumatologists’ acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.

To investigate health care costs associated with biologic disease-modifying antirheumatic drugs (bDMARDs) in a German real-world cohort of adult biologics-naive patients with psoriatic arthritis (PsA).Claims data from the Institute for Applied Health Research Berlin (InGef) research database for patients with a PsA diagnosis and bDMARD claims record (index date) between January 1, 2014, and December 31, 2017, and no bDMARD prescriptions for 365 days before the index date were retrospectively analyzed. Primary outcomes were determination of health care resource utilization and associated annual health care costs for overall and individual bDMARDs in the 12-month pre-index and post-index periods. These outcomes were compared between persistent and nonpersistent groups. Nonpersistence was defined as treatment gap or switch to a bDMARD other than the index therapy.Among 10,954 patients with a PsA diagnosis, 348 were eligible. Although mean ± SD post-index costs were significantly higher in the persistent group than the nonpersistent group (€27,869 ± 8,001 versus €21,897 ± 10,600, P 0 .001) due to higher bDMARD acquisition costs (€23,996 ± 4,818 versus €16,427 ± 9,033, P 0.001), persistence reduced inpatient treatment costs (-€760), outpatient treatment costs (-€192), other drug costs (-€724), and sick leave costs (-€601).Although initiation of bDMARDs increased the total health care costs irrespective of persistence status, partial cost offsets were observed in the persistent patient population.

Physical therapy has always been a pillar of the treatment of inflammatory rheumatic diseases in addition to targeted drug treatment; nevertheless, it is only established in the treatment guidelines for a few diseases. Within the last two decades the discovery of myokines has uncovered the physiological correlations of the anti-inflammatory effect of physical activity. For rheumatoid arthritis and spondylarthritis, several randomized controlled trials provide sufficient evidence to make well-founded recommendations. For connective tissue diseases (CTD) the data situation is clearly sparser but nevertheless shows that the positive effects of physical activity prevail. In the following article the authors present the most important clinical studies on sport and inflammatory rheumatic diseases and from these derive possible therapeutic recommendations.Die physikalische Therapie stellt neben einer gezielten medikamentösen Therapie seit jeher eine Säule der Behandlung entzündlich rheumatischer Erkrankungen dar, ist aber bisher nur bei wenigen Erkrankungen in den Behandlungsleitlinien etabliert. Innerhalb der letzten 2 Jahrzehnte konnten durch die Entdeckung der Myokine die physiologischen Zusammenhänge von antiinflammatorischer Wirkung und sportlicher Betätigung aufgedeckt werden. Für die rheumatoide Arthritis und die Spondyloarthritiden liefern mehrere randomisiert kontrollierte Studien eine ausreichende Evidenz, um fundierte Empfehlungen geben zu können. Für die Kollagenosen ist die Datenlage deutlich spärlicher, zeigt aber dennoch, dass die positiven Effekte durch Bewegungstherapie überwiegen. In dem folgenden Beitrag stellen die Autoren die wichtigsten Studien zum Thema Sport bei entzündlich rheumatischen Erkrankungen vor und leiten daraus mögliche therapeutische Empfehlungen ab.

Background The currently available scoring methods for enthesitis are often measures of pain but not of inflammation at entheseal sites. The Outcome Measures in Rheumatology Clinical Trials (OMERACT) psoriatic arthritis (PsA) magnetic resonance imaging (MRI) scoring system (PsAMRIS) assesses inflammation and damage in PsA and was particularly developed for the hands. The ACHILLES trial used clinical measures for heel enthesitis in combination with MRI scoring based on PsAMRIS. Methods Patients (age ≥ 18 years) with spondyloarthritis (SpA) and PsA were included in the trial if they presented with clinical and MRI-positive heel enthesitis. MRI of the affected heel was performed at three time points: screening, Week 24 and Week 52. Inflammatory MRI findings (tendinitis, bursitis and bone marrow oedema [BME]) in the area of the Achilles tendon and/or plantar aponeurosis, periarticular inflammation of the ankle joint and heel erosion were assessed qualitatively (absent/present). In addition, BME and bone erosion were quantitatively assessed based on PsAMRIS, where their proportion was compared to the volume of the affected bone. Mean scores of BME and bone erosion quantification were calculated, and the mean composite score (based on PsAMRIS) was calculated based on the individual score of each subject for periarticular inflammation, BME and bone erosion and further extended for bursitis and tendinitis. Modifications to PsAMRIS were introduced by categorising oedema length as ≤/> 0.5 cm and locating bone erosion. Conclusions In ACHILLES, MRI was used to assess and evaluate heel enthesitis. Due to the lack of a validated scoring system for heel enthesitis at the time of ACHILLES initiation, this trial applied quantitative scoring based on PsAMRIS, with specific adaptations for the heel. Trial registration National Clinical Trial Registry, NCT02771210. Registered 13 May 2016.

A few days after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was declared a pandemic, the German Society for Rheumatology (DGRh) compiled the first group of recommendations for the care of patients with inflammatory rheumatic diseases in light of SARS-CoV-2/coronavirus disease 2019 (COVID-19). These first recommendations were based on an expert consensus and were largely non-evidence-based. Now that the first scientific data from registries, cross-sectional studies, case reports and case series are available, the DGRh has developed a timely update. This update is based on a literature search of publications available through 15 June 2020 and addresses preventive measures (such as hygiene measures or vaccinations) and the use of immunomodulatory/immunosuppressive drugs. Driven by the commitment to let patients benefit from these new evidence-based recommendations as quickly as possible, the DGRh published the update in German on its homepage and in the Zeitschrift für Rheumatologie immediately after completion. Here we report the key recommendations to make them available to the international community, provide the scientific methodology used to develop the recommendations, give additional thoughts and advice for the management of patients with rheumatic diseases during the COVID-19 pandemic and discuss our recommendations in the context of other international recommendations.

Background To compare the glycosaminoglycan (GAG) content of lumbar intervertebral disks (IVDs) of patients with ankylosing spondylitis (AS) and healthy volunteers and to investigate the association of GAG depletion and disease-related clinical and imaging features. Methods Lumbar spines of 50 AS patients (mean age 50 ± 10.5 years) and 30 age-matched volunteers were studied with 3-T magnetic resonance imaging (MRI) and conventional radiographs (CR). The MRI protocol included high-resolution morphological sequences and the compositional GAG chemical exchange saturation transfer imaging technique (gagCEST). Morphological images were analyzed by three raters for inflammatory activity, fat deposition, disk degeneration, and structural changes on CR. Clinical and serological measures included the Bath AS Disease Activity (BASDAI) and Bath AS Function (BASFI) Indices and C-reactive protein (CRP) levels. GagCEST values of both groups were compared using a linear mixed model. Kendall-Tau correlation analyses were performed. Results GagCEST values were significantly lower in AS patients (2.0 ± 1.7%) vs. healthy volunteers (2.4 ± 1.8%), p = 0.001. Small, yet significant correlations were found between gagCEST values and CRP levels (τ = − 0.14, p = 0.007), BASFI (τ = − 0.18, p

Background Even though cartilage loss is a known feature of psoriatic arthritis (PsA), little is known about its role in the pathogenesis of PsA. Using delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) as a non-invasive marker of the tissue’s proteoglycan content, such early (i.e., pre-morphological) changes have been associated with inflammation in rheumatoid arthritis (RA). Yet, this association has not been studied before in PsA. Methods The metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints of 17 patients with active PsA were evaluated by high-resolution clinical standard morphological and dGEMRIC sequences using a 3T MRI scanner (Magnetom Skyra, Siemens) and a dedicated 16-channel hand coil. Images were analyzed by two independent raters for dGEMRIC indices, PsA MRI scores (PsAMRIS), and total cartilage thickness (TCT). Kendall tau correlation coefficients (τ) were calculated. Results We found significant negative correlations between dGEMRIC indices and total PsAMRIS (τ = − 0.5, p = 0.012), synovitis (τ = − 0.56, p = 0.006), flexor tenosynovitis (τ = − 0.4, p = 0.049), and periarticular inflammation (τ = − 0.72, p

Background The use of patient-reported outcomes (PROs) allows for patient-centered, measurable, and transparent care. Electronic PROs (ePROs) have many benefits and hold great potential to improve current usage of PROs, yet limited evidence exists regarding their acceptance, usage, and barriers among rheumatologists. Objective This study aims to evaluate the current level of acceptance, usage, and barriers among German rheumatologists regarding the use of ePROs. The importance of different ePRO features for rheumatologists was investigated. Additionally, the most frequently used PROs for patients with rheumatoid arthritis (RA) were identified. Methods Data were collected via an online survey consisting of 18 questions. The survey was completed by members of the Working Group Young Rheumatology of the German Society for Rheumatology (Arbeitsgemeinschaft Junge Rheumatologie der Deutschen Gesellschaft für Rheumatologie [DGRh]) at the 2019 annual DGRh conference. Only members currently working in clinical adult rheumatology were eligible to complete the survey. Results A total of 119 rheumatologists completed the survey, of which 107 (89.9%) reported collecting PROs in routine practice and 28 (25.5%) already used ePROs. Additionally, 44% (43/97) were planning to switch to ePROs in the near future. The most commonly cited reason for not switching was the unawareness of suitable software solutions. Respondents were asked to rate the features of ePROs on a scale of 0 to 100 (0=unimportant, 100=important). The most important features were automatic score calculation and display (mean 77.50) and simple data transfer to medical reports (mean 76.90). When asked about PROs in RA, the respondents listed pain, morning stiffness, and patient global assessment as the most frequently used PROs. Conclusions The potential of ePROs is widely seen and there is great interest in them. Despite this, only a minority of physicians use ePROs, and the main reason for not implementing them was cited as the unawareness of suitable software solutions. Developers, patients, and rheumatologists should work closely together to help realize the full potential of ePROs and ensure a seamless integration into clinical practice.

Background: To evaluate the value of 3 Tesla (T) magnetic resonance imaging (MRI) changes of flexor tendon pulleys for the differentiation of psoriatic (PsA) and rheumatoid arthritis (RA), using a novel 16-channel high resolution hand coil. Methods: Seventeen patients with active PsA, 20 patients with active RA and 16 healthy controls (HC) underwent high-resolution 3T MRI using the dedicated 16-channel hand coil. Images were analyzed by three independent readers for the degree of inflammatory changes, thickness of flexor tendon pulleys and comparison to the outcome measures for RA clinical trials (OMERACT) PsA MRI score (PsAMRIS) and to its sub-scores. For correlation analyses Spearman rho correlation was calculated. Results: Flexor tendon pulleys were thicker in PsA than in RA patients (mean difference 0.16 mm, p

Objective.Markers for treatment response in rheumatoid arthritis (RA) are lacking. The aim of the study was to assess the performance of the RA magnetic resonance imaging (MRI) scoring system (RAMRIS) in combination with serum biomarkers to predict response to methotrexate (MTX) treatment in therapy-naive patients with early RA by using high-field MRI.Methods.Twenty-eight patients with RA were prospectively assessed with baseline 3-T MRI of the clinical dominant hand, 3 and 6 months after MTX. The patients met the 2010 American College of Rheumatology/European League Against Rheumatism (EULAR) criteria [average age 56.8 yrs (range 39–74); positive for rheumatoid factor and/or anticyclic citrullinated peptide antibodies; disease duration < 6 mos (range 2–23 weeks)]. RAMRIS and serum biomarkers consisting of various experimental proteins including receptor activator of nuclear factor-κB ligand (RANKL) were obtained. Remission or treatment response was defined according to EULAR. To adjust for intrapersonal correlation, generalized linear mixed models were used.Results.Treatment response at 3 months was associated to low RAMRIS erosion subscores and low total RAMRIS scores (p = 0.019 and 0.03, respectively). Remission at 6 months was associated to low RANKL levels (p = 0.033). In multivariate analyses, response at 3 and 6 months was predicted more accurately with the inclusion of total RAMRIS score, RAMRIS synovitis subscore at the second metacarpophalangeal (MCP) joint, or a combination of the two (p value likelihood ratio test = 0.035, 0.035, and 0.041, respectively). Remission was more accurately predicted with inclusion of RANKL, with no significant predictive effect of MRI.Conclusion.Baseline total RAMRIS can predict EULAR response. RAMRIS synovitis subscore at the second MCP joint and RANKL are associated with response and remission, respectively.

ObjectivesThis study aims to provide a comprehensive analysis of the age-dependent risk of psoriatic arthritis (PsA). For this purpose, it focuses on the varying incidences within the different age groups.MethodsThe data were collected as part of the morbidity-based risk adjustment of the statutory health insurance companies in Germany. This survey recorded the International Statistical Classification of Diseases and Related Health Problems (ICD)-coded diagnoses of 65 million German citizens. Our population-based study used these raw data to calculate the prevalence of PsA in the first step. Subsequently, we employed a new approach for the estimation of the age-specific and sex-specific incidence of PsA.ResultsThe age-specific and sex-specific incidence of PsA showed a continuous increase with rising age until it peaked slightly before the age of 60 and declined thereafter. The maximum value was higher in women (40 per 100 000 py) than in men (30 per 100 000 py). Furthermore, the incidence rate tends to climb over the survey period.ConclusionsThe data sets identified an unexpected high incidence. A meta-analysis by Scotti et al and other recent population-based studies served as a reference for the comparison. The pattern of the age-specific incidence illustrated that the risk for PsA disease shows considerable variations depending on age.

Background Remission is arguably the ultimate therapeutic goal in rheumatoid arthritis (RA). Applying modern strategies, clinical remission can be achieved in a substantial number of patients with early RA (ERA). Even in those patients, the number and scope of erosions can increase. We, therefore, investigated the value of MRI for the detection of radiological progression in patients with DAS28 improvement and/or clinical remission of the German Remission-plus cohort. Methods Data-sets of 80 RA patients (according to 2010 ACR/EULAR criteria) from the Remission-plus study cohort, who fulfilled the following criteria, were retrospectively analysed: availability of two consecutive MRI scans (low-field MRI, follow-up interval 1 year) of the clinically dominant hand and wrist, and the presence of DAS28 (CRP) scores at both time points, which was used to assess disease activity. Results Seventy-one of the 80 investigated patients presented a numerical improvement of the DAS28 (CRP) after 12 months (DAS28(CRP) T0 average (Ø) 4.96, SD 1.2; DAS28 T4 (12 month) Ø 2.6, SD 1.0), 73% of them also improved in the RAMRIS-Score, while 24% demonstrated an increase despite DAS28 improvement and 3% showed equal values. 48% of patients who improved in the DAS28 reached EULAR remission. 41% of these patients had an increase in the RAMRIS Erosion-subscore after 12 months. When considering EULAR response criteria (non-response (n = 7), moderate response (n = 19), good response (n = 45)), an increase of erosions was found in 71.4% of non-responders, 52.6% of moderate responders, and 31.1% of good responders after 12 months, all compared to baseline. Conclusion Up to 40% of patients in this study demonstrated a progressive erosive disease detected by MRI despite DAS28 improvement or EULAR remission. Future studies are needed to determine the prognostic clinical impact of disease progression in MRI despite clinical remission, and to investigate if DAS28 remission may be an insufficient therapeutic goal and should be accompanied by MRI remission criteria.

Background The aim of the study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) for five joints of the hand (RAMRIS-5) in patients with early rheumatoid arthritis (RA) before and after the initiation of methotrexate (MTX) therapy using high-resolution, 3-T magnetic resonance imaging (MRI). Methods Twenty-eight patients with a seropositive, early RA (disease duration of less than 6 months (range 2–23 weeks)) according to 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) criteria (mean age 56.8 years, range 39–74) were prospectively assessed with a baseline investigation including clinical assessment (disease activity score of 28 joints (DAS-28) and C-reactive protein (CRP)) and 3-T MRI of the clinically dominant hand. Follow-up visits were performed 3 and 6 months after initiation of a MTX therapy at baseline. MRI scans were analyzed in accordance with RAMRIS and the simplified RAMRIS-5. Results DAS-28 and CRP decreased significantly after initiation of MTX therapy. Even though erosion scores increased over time, RAMRIS and RAMRIS-5 also decreased significantly after the start of therapy. There was a strong correlation between the total RAMRIS-5 and RAMRIS at baseline (r = 0.838; P

In recent years, the role of articular cartilage for understanding pathogenesis as well as for clinical research has become increasingly important. Whereas previously cartilage could only be assessed invasively, various imaging procedures are available for its evaluation now. Although still widely used, conventional radiography bears significant limitations since it assesses cartilage indirectly by joint space width. Today, the cartilage thickness and structure can be reliably evaluated using ultrasound, although the molecular structure cannot be determined, yet. Besides ultrasound, MRI offers the possibility to image morphological changes with a very high resolution. In addition, the quality and composition of joint cartilage can already be measured due to a constant technical improvement and new MRI sequences such as dGEMRIC even in small joints (e.g. MCP or MTP joints). Despite the advantages of contrast agents for the detection of inflammation, its use is reevaluated today. Regarding that contrast agent-free imaging techniques for the assessment of joint cartilage are developed with great effort to depict its quality and changes over time. These novel MRI methods such as T2/T2*- and T1ρ-mapping, gagCEST, and sodium imaging provide promising quantitative imaging biomarkers that can detect early cartilage changes before morphological alterations occur. Hence, US and MRI will likely be of paramount importance in future clinical trials and clinical assessment of inflammatory and degenerative joint diseases not only for understanding pathogenesis but also for using its possible value in daily practice.

To identify differences of radiocarpal cartilage alterations in osteoarthritis and arthritis using multiparametrical magnetic resonance imaging (MRI) comprising morphological and biochemical sequences without gadolinium-based contrast agent administration. In this prospective study, multiparametrical MRI of the radiocarpal cartilage was performed in 47 participants (mean age, 46.6 ± 17.6 years; min., 20 years; max., 79 years) on a 3 Tesla MRI. The cohort consisted of 11 patients suffering from arthritis, 10 patients with osteoarthritis, 14 patients after distal radius fracture, and 12 healthy volunteers. The radiocarpal cartilage was assessed using morphological (DESS, TrueFISP) and biochemical (T2*) MRI sequences without the application of intravenous contrast agent. The modified Outerbridge classification system for morphological and region-of-interest analyses for biochemical analysis was applied to assess the degree of cartilage damage in each patient before data were statistically tested for significant difference between the groups using a post hoc Tukey test. In morphological imaging, cartilage damage was significantly more frequent in arthritis and osteoarthritis than in healthy volunteers (DESS: p = 0.01, p = 0.0004; TrueFISP: p = 0.02, p = 0.0001). In T2* imaging, patients with osteoarthritis showed higher cartilage damage compared to patients with arthritis (p = 0.01). With multiparametrical MRI, it is possible to identify differences of radiocarpal cartilage alterations of patients with arthritis and osteoarthritis using the combination of morphological and biochemical MR imaging of the radiocarpal cartilage without the application of contrast agent. Multiparametrical MRI without the usage of contrast agent may be a potential tool helping to distinguish both entities. • Multiparametrical MRI with morphological and biochemical sequences allows the differentiation of patients with arthritis and osteoarthritis. • High-resolution MRI of radiocarpal cartilage is possible without administration of contrast agent.

Tryptophan and its metabolites have been suggested to play a role in inflammatory processes. However, studies in rheumatoid arthritis (RA) are scarce, which prompted us to investigate two cohorts of RA patients to better understand the importance of tryptophan metabolism in this disease.Tryptophan and its metabolites were characterised by ELISA in a cross-sectional cohort 1 (81 RA, 55 OA) and a longitudinal cohort 2 (25 RA, 3 visits over 6 months) to investigate discriminatory power between diseases and predicitive value for radiologic outcome, respectively. Radiologic outcome was monitored by RA MRI Score (RAMRIS), including grading of synovitis, bone oedema and erosion, as well as delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) index assessing cartilage quality of the MCP II joint.RA patients showed higher levels of serum serotonin (RA: 206.8 ng/ml ± 156.7; OA: 81.2 ng/ml ± 63.6) and estimated indoleamine (2,3)-dioxygenase (IDO) activity (kynurenine / tryptophan ratio; RA: 0.065±0.067; OA: 0.021±0.010). IDO activity showed similar, or better discriminatory power between RA and OA (AUC 0.914) than anti-CCP antibody level (AUC 0.922) and rheumatoid factor (RF, AUC 0.783), respectively. In cohort 2, regression analysis revealed a predictive value of baseline serotonin levels and IDO activity for changes in RAMRIS score and erosions at month six, respectively.This study supports the hypothesis that tryptophan and its metabolites can be used as biomarkers predicting radiologic outcome and discriminate between RA and OA patients. Overall, our results strengthen the notion that tryptophan metabolism is closely linked to RA disease mechanisms.

Until now, most major medical advancements have been achieved through hypothesis-driven research within the scope of clinical trials. However, due to a multitude of variables, only a certain number of research questions could be addressed during a single study, thus rendering these studies expensive and time consuming. Big data acquisition enables a new data-based approach in which large volumes of data can be used to investigate all variables, thus opening new horizons. Due to universal digitalization of the data as well as ever-improving hard- and software solutions, imaging would appear to be predestined for such analyses. Several small studies have already demonstrated that automated analysis algorithms and artificial intelligence can identify pathologies with high precision. Such automated systems would also seem well suited for rheumatology imaging, since a method for individualized risk stratification has long been sought for these patients. However, despite all the promising options, the heterogeneity of the data and highly complex regulations covering data protection in Germany would still render a big data solution for imaging difficult today. Overcoming these boundaries is challenging, but the enormous potential advances in clinical management and science render pursuit of this goal worthwhile.

The aim of the study was to investigate biochemical cartilage composition under methotrexate (MTX) therapy and to intra-individually assess the impact of inflammation severity on cartilage composition by using dGEMRIC MRI in patients with early rheumatoid arthritis (eRA).dGEMRIC of MCP joints of the index and middle finger of 28 patients from the AthroMark cohort were examined prior to MTX-therapy as well as after 3 and 6 month. OMERACT RA MRI score and clinical parameters (CRP and DAS28) were registered at any time point. Each patient's second and third MCP joints were dichotomised into the joint with more severe synovitis versus the joint with less severe synovitis according to the RAMRIS synovitis subscore.MCP joints with more severe synovitis ('bad joints') demonstrated significantly lower dGEMRIC values compared to MCP joints with less severe synovitis ('good joints') at time-points 0 and 3 months (p=0.002; p=0.019, respectively). After 6 months of MTX therapy no significant difference of dGEMRIC index was found between good and bad joint (p=0.086).Under MTX therapy, biochemical cartilage integrity remains stable; no further cartilage destruction occurred if patients were treated early in the course of the disease. In addition, six months of MTX therapy triggered an alignment of dGEMRIC index of MCP joints with initially severe synovitis and less severe synovitis in an intra-individual assessment. This underlines the importance of an early treatment in eRA to reduce further cartilage damage of the inflamed joints.

OBJECTIVE The objective of this study was to investigate the correlation between semiquantitative and quantitative dynamic contrast-enhanced (DCE) parameters with delayed gadolinium-enhanced magnetic resonance imaging (MRI) of the cartilage (dGEMRIC). METHODS Fifteen patients with early rheumatoid arthritis (RA) from the ArthroMark cohort were investigated at a 3-T MRI scanner. The metacarpophalangeal (MCP) joint of the index finger was examined with DCE-MRI and dGEMRIC. Semiquantitative and quantitative DCE perfusion parameters were calculated. The RA MRI score of the second MCP joint and the joint space width were measured. RESULTS Significant correlations were noted between both semiquantitative and quantitative DCE parameters and the RA MRI score of the second MCP joint. There was a significant negative correlation between DCE parameters and dGEMRIC. No association between joint space width and DCE parameters was observed. CONCLUSIONS Semiquantitative and quantitative analyses of perfusion are applicable to show that cartilage damage correlates with the inflammation activity despite the absence of joint space narrowing.

To intra-individually assess the association of inflammation severity and cartilage composition measured by RAMRIS synovitis sub-score and delayed gadolinium-enhanced magnetic resonance imaging of the cartilage (dGEMRIC) of metacarpophalangeal (MCP) joints in patients with rheumatoid arthritis (RA). Forty-three patients with RA according to ACR/EULAR classification criteria (age 52.9 ± 14.5 years, range, 18–77 years) were included in this study. All study participants received 3-T MRI scans of the metacarpophalangeal joints of the second and third finger (MCP 2 and 3). The severity of synovitis was scored according to the RAMRIS synovitis sub-score by two readers in consensus. In the cases with identical synovitis sub-scores, two radiologists decided in consensus on the joint with more severe synovitis. Cartilage composition was assessed with dGEMRIC. To test the association of inflammation severity and cartilage damage and in order to eliminate inter-patient confounders, each patient’s MCP 2 and 3 were dichotomized into the joint with more severe synovitis versus the joint with less severe synovitis for a paired Wilcoxon test of dGEMRIC value. There was a significant difference of dGEMRIC value (median of difference: 47.12, CI [16.6; 62.76]) between the dichotomized MCPs (p = 0.0001). There was a significant correlation between dGEMRIC value and RAMRIS synovitis grading of the joint with more severe synovitis (r = 0.5; p

Psoriasis (Pso) and psoriatic arthritis (PsA) are inflammatory disorders which can severely impair health and quality of life. For both Pso and PsA, an increasing prevalence has been reported.1 2 Comprehensive data on the prevalence and incidence of Pso and PsA are important in order to adequately allocate specialist care and financial resources. These data are incomplete for Pso and especially PsA. In particular, no population-based study has estimated their prevalence or incidence in Germany. We obtained the statutory health insurance data of approximately 65 million people from 2009 to 2012, covering 80% of the German population. Pso and PsA age-standardised prevalence based on the International Classification of Diseases (ICD) codes was obtained and age-standardised incidence rates calculated as described previously.3 Briefly, cross-sectional prevalence data of consecutive years were used in conjunction with different assumed mortality rates of 1.1–1.5, with assumed …

Background Chronic rheumatic diseases need long-term treatment and professional supervision. Mobile apps promise to improve the lives of patients and physicians. In routine practice, however, rheumatology apps are largely unknown and little is known about their quality and safety. Objective The aim of this study was to provide an overview of mobile rheumatology apps currently available in German app stores, evaluate app quality using the Mobile Application Rating Scale (MARS), and compile brief, ready-to-use descriptions for patients and rheumatologists. Methods The German App Store and Google Play store were systematically searched to identify German rheumatology mobile apps for patient and physician use. MARS was used to independently assess app quality by 8 physicians, 4 using Android and 4 using iOS smartphones. Apps were randomly assigned so that 4 apps were rated by all raters and the remaining apps were rated by two Android and two iOS users. Furthermore, brief app descriptions including app developers, app categories, and features were compiled to inform potential users and developers. Results In total, 128 and 63 apps were identified in the German Google Play and App Store, respectively. After removing duplicates and only including apps that were available in both stores, 28 apps remained. Sixteen apps met the inclusion criteria, which were (1) German language, (2) availability in both app stores, (3) targeting patients or physicians as users, and (4) clearly including rheumatology or rheumatic diseases as subject matter. Exclusion criteria were (1) congress apps and (2) company apps with advertisements. Nine apps addressed patients and 7 apps addressed physicians. No clinical studies to support the effectiveness and safety of apps could be found. Pharmaceutical companies were the main developers of two apps. Rheuma Auszeit was the only app mainly developed by a patient organization. This app had the highest overall MARS score (4.19/5). Three out of 9 patient apps featured validated questionnaires. The median overall MARS score was 3.85/5, ranging from 2.81/5 to 4.19/5. One patient-targeted and one physician-targeted app had MARS scores >4/5. No significant rater gender or platform (iOS/Android) differences could be observed. The overall correlation between app store ratings and MARS scores was low and inconsistent between platforms. Conclusions To our knowledge, this is the first study that systematically identified and evaluated mobile apps in rheumatology for patients and physicians available in German app stores. We found a lack of supporting clinical studies, use of validated questionnaires, and involvement of academic developers. Overall app quality was heterogeneous. To create high-quality apps, closer cooperation led by patients and physicians is vital.

To assess glycosaminoglycan (GAG) content of lumbar intervertebral discs (IVD) in patients with spondyloarthritis (SpA) using glycosaminoglycan chemical exchange saturation transfer (gagCEST).Ninety lumbar intervertebral discs of nine patients with SpA and nine age-matched healthy controls (eight patients with ankylosing spondylitis; one patient with spondylitis related to inflammatory bowel disease; mean age: 44.1 ± 14.0 years; range: 27-72 years) were examined with a 3T magnetic resonance imaging (MRI) scanner in this prospective study. The MRI protocol included standard morphological, sagittal T2 -weighted (T2 w) images to assess Pfirrmann score of the five lumbar IVDs (L1 to S1) and biochemical imaging with gagCEST to calculate a region of interest analysis of nucleus pulposus (NP) and annulus fibrosus (AF). Prior to statistical testing of gagCEST effects (MTRasym values in percent) in patients and controls, IVDs were classified according to the Pfirrmann score.Significantly lower gagCEST values of NP and AF were found in SpA patients compared with healthy volunteers (NP: 1.41% ± 0.41%, P = 0.001; 95% confidence interval, CI [0.600%-2.226%]; AF: 1.19% ± 0.32%, P 0.001; CI [0.560%-1.822%]) by comparing the differences of the means. Pooled nondegenerative IVDs (Pfirrmann 1 and 2) had significantly lower gagCEST effects in patients suffering from SpA compared with healthy controls in NP (P 0.001; CI [1.176%-2.337%]) and AF (P 0.001; CI [0.858%-1.779%]). No significant difference of MTRasym values was found in degenerative IVDs between patients and controls in NP (P = 0.204; CI [-0.504%-2.170%]).GagCEST analysis of morphologically nondegenerative IVDs (Pfirrmann score 1 and 2) in T2 w images demonstrated significantly lower GAG values in patients with spondyloarthritis in NP and AF, possibly representing a depletion of GAG in spondyloarthritis in the absence of morphologic degeneration.

Dear Editor We read with great interest the article by Baker et al 1 who showed that early MRI measures independently predict erosive progression on X-ray and MRI after 1 and 2 years in therapy-naive patients with rheumatoid arthritis (RA) from the randomised-controlled GO-BEFORE trial. Due to these findings, we re-evaluated MRI data from the German REMISSION-PLUS Cohort2 ,3 at our centre to verify if a MRI score may predict negative response in patients with RA before therapy-escalation …

The objective of this study was to evaluate a simplified version of the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) reduced to five joints of the hand (RAMRIS5).94 patients with rheumatoid arthritis (62 female; age 59±12 years, range 25-83 years; disease duration 60±90 months (median: 22 months, first quartile: 7 months, third quartile: 66 months) from the REMISSION PLUS study cohort who had complete files on C-reactive protein (CRP) levels and Disease Activity Score of 28 joints (DAS28) and complete MRI of the clinical dominant hand at baseline and after one year under anti-rheumatic therapy (follow-up time 12.5±1.1 months) in a dedicated extremity MRI scanner at 0.2T were included in this retrospective study.There was a strong correlation between RAMRIS5 and the RAMRIS sum-score for all patients (r=0.87, p0.001) at baseline and follow-up (r=0.87, p0.001). Among the subscores there was a significant correlation between RAMRIS5 and RAMRIS-MCP (baseline: r=0.66, p0.001; follow-up: r=0.74, p0.001) as well as between RAMRIS5 and RAMRIS-wrist (baseline: r=0.72, p0.001, follow-up: r=0.69, p0.001) at baseline and follow-up.RAMRIS5, a modified shorter RAMRIS score based on five joints of the hand is a viable tool for semi-quantitative assessment of joint damage in RA. This abbreviated score might reduce the time needed for image analysis in MRI-controlled studies in RA and might facilitate the use of MRI in studies on therapy response assessment in RA.

Background To evaluate a combined rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for hand and foot (HaF-score) in rheumatoid arthritis (RA). Methods Magnetic resonance imaging (MRI, 0.2 Tesla) of the dominant hand and foot of 26 ACPA positive RA patients before and 6 months after initiation of methotrexate was obtained. RAMRIS of the hand was complemented by corresponding scoring of the foot (MTP I-V; HaF-score). Disease Activity Score 28 (DAS28) and a tender and swollen joint count (JC) of the joints scored in MRI were recorded. Changes in these scores (Δ) were assessed. Results ΔHaF-score correlated significantly with ΔDAS28 (r = 0.820, 95%-CI 0.633-0.916). Correlations to ΔDAS28 were best for changes in the synovitis subscore (0.648) and bone marrow edema (0.703). Correlations to ΔDAS28 were significantly better for of the ΔHaF-score than ΔRAMRIS (0.499, 0.139-0.743, p = 0.0368). All patients with at least moderate response (EULAR criteria, n = 11) had continuing disease activity on MRI, including five cases with new erosions, three of them at the feet. Improvements of the hand JC or foot JC were seen in 16 and 15 cases, respectively. However, MRI of the hand or feet improved in only 10 and 9 cases, respectively. No patient fulfilled SDAI remission criteria. Conclusions The HaF-score identifies patients with continuing disease activity despite clinical response that would have been missed by consideration of the traditional RAMRIS or the DAS28 alone. Response as opposed to remission may be an insufficient goal in RA as all patients showed continuing disease activity, especially at the feet.

To analyse whether synovial markers of the clinically dominant metacarpophalangeal (MCP) joint reflect global disease activity measures in rheumatoid arthritis (RA).Arthroscopically-guided synovial biopsies from the dominant metacarpophalangeal (MCP) joint of 10 patients with RA (DAS283.2) were stained for determination of the synovitis score, CD68, vascular endothelial growth factor (VEGF), hypoxia-inducible factor 1α (HIF-1α). MRI and ultrasound were used to calculate the RAMRIS and US7 score respectively. Arthroscopy of the same joint was repeated in 6 patients after 6 months.The synovitis score significantly correlated to DAS28 (Spearman r=0.74), CRP (r=0.69), and US7 (r=0.66); sublining CD68 macrophages to CRP (r=0.6); HIF-1α to DAS28 (r=0.77), CRP (r=0.73); and VEGF to DAS28 (r=0.753) and RAMRIS (r=0.663). All patients showed a reduction of the DAS28 after 6 months (mean±SD: 5.2±1.5 vs. 2.75±1.1; p0.05). There were three patients with a good EULAR response, and only these showed declining sublining CD68 macrophages in the control biopsy (χ2 test: LR 8.3, p=0.05). Two of the remaining patients with increasing CD68 sublining macrophages showed a deterioration of the RAMRIS.Some histological findings in arthroscopically-guided biopsies of the dominantly affected MCP joint reflect global disease activity measures and their changes in RA patients. Moreover, repeated MCP synovial biopsy may distinguish true responders from individuals with residual disease activity, who are not readily recognized by clinical means.

Objectives To evaluate the utility of sequentially acquired, post hoc fused, magnetic resonance imaging (MRI) and multi-pinhole single photon emission computed tomography (MPH-SPECT) with technetium-99m-labeled disphosphonates (Tc99m-DPD) for the identification of finger joints with later erosive progression in early rheumatoid arthritis (ERA) patients. Methods Ten consecutive ERA patients prospectively underwent MPH-SPECT and MRI of metacarpophalangeal (MCP) joints prior to and after 6 months methotrexate therapy. Tc99m-DPD uptake was measured at proximal and distal MCP sites using regional analysis. The course of joint pathologies was scored according to the Rheumatoid Arthritis MRI Score (RAMRIS) criteria. Results The frequency of increased Tc99m-DPD uptake, synovitis and bone marrow edemadecreased under MTX therapy; but the number of bone erosions increased. Joints with progressive and new erosions on follow-up had a higher baseline Tc99m-DPD uptake (2.64 ± 1.23 vs. 1.43 ± 0.91) ( p = 0.02). Conclusions Joints with erosive progression are characterized by an early increased Tc99m-DPD uptake, even in absence of MRI bone pathologies. Tc99m-DPD MPH-SPECT might thus be of additional value to morphological MRI for the identification of RA patients with a high risk for erosive progression.

To investigate patterns of inflammatory MRI pathologies of the fore- and midfoot in rheumatoid arthritis (RA) and early RA (ERA) and their changes under therapy. In this prospective study, MRI data of the foot of 39 RA patients (29 female, 10 male; age: 54 ± 13 years; disease duration: 35 ± 37 months; baseline DAS28: 3.0 ± 2.0; medication: 29 DMARD, 1 biological, 9 symptomatic or non-specific treatment) were evaluated for synovitis in 314 joints, bone marrow edema and erosions according to RAMRIS criteria in a total of 585 joints. The change in joint pathology intensity was evaluated on follow-up MRI (time of follow-up: 8 ± 4 months) in 25 patients. Inflammation was generally more frequent in the metatarsophalangeal (MTP) joints (221/292; 76 %) than in the proximal metatarsal (47/292; 16 %) and tarsal bones (24/292; 8 %). The overall most frequently involved joints of the foot were MTP 5 (51/292; 18 %) and 1 (49/292; 17 %). Change under therapy was most frequently seen in the MTP 1 joint. Progress of inflammation in the MTP 1 was more frequently found in ERA patients than in patients with established RA (disease duration >12 months) (p = 0.002). In RA, the MTP joints, primarily MTP 5 and 1, are the predominant sites of inflammatory MRI pathologies of the foot. A change of inflammatory activity under therapy can be most frequently noted in the MTP 1 joint. This information might be helpful to improve effectiveness of MRI-controlled therapy approaches and clinical trials.

Medical curricula are currently being reformed in order to establish interactive and case-based teaching concepts. Here we present a novel radiological course combining several innovative training components and report our initial experience with its practical implementation and the students' evaluation of it.A novel longitudinal radiological teaching course was established, integrated with the medical curriculum and evaluated systematically. Radiology case vignettes were created for three clinical teaching modules. Using a PC with PACS access, web-based databases and CASUS cases, a problem-oriented, case-based, and independent way of learning was implemented, which served as a complementary form of teaching to established radiology courses and lectures.In student evaluations the novel CLICR course fared significantly better than the conventional radiology block course. More than 50% of the participating students gave the highest rating for 'overall satisfaction' with the novel CLICR course compared to only 3% for 'overall satisfaction' with the conventional block course. A similar trend was observed for the other endpoints. Both the innovative interactive concept of the course and the opportunity to use a web-based database has been favourably accepted by students.An interactive, case-based teaching concept like the presented CLICR course, and web-based databases appear to be useful extensions to the radiology course programme.

The dental X-ray set should not be used in a stereotyped way, but should be regarded as an instrument with a wealth of potential. For its optimal utilization the operator should be familiar with the principles of projection geometry and of image formation. The diagnostic problem should be analysed so that the determination of projections and angulations of the X-ray beam will result in the maximum information. To ascertain true morphology and interpret the radiographic images three-dimensionally multiple views are required. Distortion is a disturbing factor in radiographic image formation and methods minimizing distortion are to be preferred. The benefits of occlusal radiography are emphasized. In order to limit the detrimental effects of ionizing radiation X-ray examinations should not be used unless the outcome represents a net benefit to the patient. However, it is wrong policy to restrict the number of radiographs in dental practice if substantial indications for radiography exist.

Introduction Synovial inflammation and joint destruction in rheumatoid arthritis (RA) may progress despite clinical remission. Dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) is increasingly used to detect synovial inflammation in RA. Although small joints such as metacarpophalangeal (MCP) joints are mainly affected by RA, MRI findings have never been directly compared to histological synovitis in MCP synovial tissue. The objective of the current study was therefore to analyse if DCE-MRI relates to histological signs of synovitis small RA joints. Methods In 9 RA patients, DCE-MRI (3 Tesla, dynamic 2D T1 weighted turbo-flash sequence) of the hand was performed prior to arthroscopically-guided synovial biopsies from the second MCP of the imaged hand. Maximum enhancement (ME), rate of early enhancement, and maximum rate of enhancement were assessed in the MCP. Synovial biopsies were stained for determination of sublining CD68 and the Synovitis Score. Correlations between MRI and histological data were calculated according to Spearman. Results ME of the MCP significantly correlated to sublining CD68 staining (r = 0.750, P = 0.02), the Synovitis Score (r = 0.743, P = 0.02), and the subscores for lining layer hypertrophy (r = 0.789, P = 0.01) and cellular density (r = 0.842; P = 0.004). Conclusions Perfusion imaging of synovial tissue in RA finger joints employing DCE-MRI reflects histological synovial inflammation. According to our study, ME is the most closely associated parameter amongst the measures considered.