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The study investigates the performance of a dedicated whole-body magnetic resonance imaging (MRI) interpretation software with regard to diagnostic efficiency using quantitative and qualitative parameters. Forty-eight oncologic patients underwent whole-body computed tomography (WB-CT) and whole-body magnetic resonance imaging (WB-MRI). In a quantitative analysis, the times needed for interpretation of the CT and MRI datasets were measured. The MRI studies were read using a standard workstation and the whole-body MRI interpretation software, respectively. In the qualitative analysis, the numbers of metastases were separately recorded for 13 organ systems, again interpreting the MRI images on the standard workstation and with the dedicated software. Moreover, user friendliness and system usability were evaluated using a standardized questionnaire. Use of the whole-body MRI interpretation software significantly reduced the MRI interpretation time compared with the standard workstation. There was no significant difference between interpretation time of WB-CT and interpretation time of WB-MRI using the dedicated software. Comparison with WB-CT as the reference method demonstrated no significant difference between the whole-body MRI interpretation software prototype and the standard interpretation software in the number of metastases detected. In conclusion, the use of the dedicated whole-body reading software improves the interpretation process of WB-MRI studies with respect to time efficiency and system usability.

Erdheim–Chester disease is a rare form of non-Langerhans cell histiocytosis characterized by foamy histiocyte infiltration of the skeleton and viscera. A case of Erdheim–Chester disease that was initially mistaken for Ormond's disease is presented with a discussion of the tests required to differentiate between the two diagnoses. Background A 54-year-old man presented with fever, abdominal pain, anemia, elevated C-reactive protein level and decreased renal function. Idiopathic retroperitoneal fibrosis (Ormond's disease) had been diagnosed in the past, leading to surgical ureterolysis. Re-evaluation of the CT scans and histological biopsy samples revealed unusual sclerosis of the long bones and diffuse infiltrates of foamy histiocytes in the bone marrow and the retroperitoneum. Investigations Physical examination, laboratory tests including hemoglobin concentration, erythrocyte sedimentation rate, C-reactive protein level, β2-microglobulin level, creatinine level, CT of the chest and abdomen, bone scintigraphy, bone marrow and soft tissue biopsies and immunohistochemistry. Diagnosis Erdheim–Chester disease with retroperitoneal fibrosis and bone sclerosis. Management Treatment with glucocorticoids failed. The patient's symptoms improved significantly after initiation of interferon-α therapy.

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.

Purpose of review The role of imaging in the diagnosis, management, and follow-up of patients with spondyloarthritis (SpA) has become dramatically more important with the introduction of new therapies such as tumor necrosis factor-α inhibitors. In the current review, contemporary perspectives on developments and advancements in the field of SpA imaging along with several novel imaging techniques for the diagnosis and follow-up of SpA will be discussed. Recent findings No new imaging modalities have been introduced in the last decade. However, new advances and improvements within the known modalities are constantly being presented and tested. Such advances include the use of contrast material and sonoelastography in the ultrasound evaluation of enthesitis, hybridization of PET imaging with computed tomography and MRI for the evaluation of the axial and peripheral skeleton, as well as advances within MRI such as whole-body MRI and diffusion-weighted sequences. These techniques will be presented and their advantages and disadvantages will be critically discussed. Summary Promising new techniques in the field of SpA imaging are constantly emerging. The benefits and advantages of the presented techniques over the known ones need further validation.

Background To date, only a single controlled trial provided evidence that non-steroidal anti-inflammatory drugs (NSAIDs) given continuously reduce radiographic progression compared with an on-demand therapy over 2 years in patients with ankylosing spondylitis (AS). In the current study, we tested whether such an effect of NSAIDs could be confirmed in another randomised trial. Methods Patients with AS were randomised for treatment with either continuous (150 mg/day) or on-demand diclofenac for 2 years. Tumour necrosis factor-blocker treatment was not allowed during the entire study period. The primary outcome was the difference in radiographic progression in the spine as measured by the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS) scored by two readers blinded to treatment arm and time point. Results 62 of 85 patients enrolled in the continuous arm and 60 of 82 enrolled in the on-demand arm completed the study. The mSASSS progression was numerically higher in the continuous group (1.28 (0.7 to 1.9) vs 0.79 (0.2 to 1.4)) (p=0.39). If only patients were analysed who were either C reactive protein positive or had syndesmophytes at baseline, there was again a higher radiographic progression in the continuous versus the on-demand group: 1.68 (0.7 to 2.6) vs 0.96 (0.0 to 1.9) and 2.11 (1.1 to 3.1) vs 0.95 (0.0 to 1.9), respectively. There was no difference between the two treatment groups regarding adverse events. Conclusions In our study, continuous treatment with diclofenac over 2 years did not reduce radiographic progression compared with on-demand treatment in AS. Trial registration numbers EudraCt-no 2007-007637-39; ClinicalTrials.gov NCT00715091.

Objective.Near-infrared fluorescence optical imaging (FOI) is a novel imaging technology in the detection and evaluation of different arthritides. FOI was validated in comparison to magnetic resonance imaging (MRI), greyscale ultrasonography (GSUS), and power Doppler ultrasonography (PDUS) in patients with early rheumatoid arthritis (RA).Methods.Hands of 31 patients with early RA were examined by FOI, MRI, and US. In each modality, synovitis of the wrist, metacarpophalangeal joints (MCP) 2–5, and proximal interphalangeal joints (PIP) 2–5 were scored on a 4-point scale (0–3). Sensitivity and specificity of FOI were analyzed in comparison to MRI and US as reference methods, differentiating between 3 phases of FOI enhancement (P1–3). Intraclass correlation coefficients (ICC) were calculated to evaluate the agreement of FOI with MRI and US.Results.A total of 279 joints (31 wrists, 124 MCP and 124 PIP joints) were evaluated. With MRI as the reference method, overall sensitivity/specificity of FOI was 0.81/0.00, 0.49/0.84, and 0.86/0.38 for wrist, MCP, and PIP joints, respectively. Under application of PDUS as reference, sensitivity was even higher, while specificity turned out to be low, except for MCP joints (0.88/0.15, 0.81/0.76, and 1.00/0.27, respectively). P2 appears to be the most sensitive FOI phase, while P1 showed the highest specificity. The best agreement of FOI was shown for PDUS, especially with regard to MCP and PIP joints (ICC of 0.57 and 0.53, respectively), while correlation with MRI was slightly lower.Conclusion.FOI remains an interesting diagnostic tool for patients with early RA, although this study revealed limitations concerning the detection of synovitis. Further research is needed to evaluate its full diagnostic potential in rheumatic diseases.

Dual-energy computed tomography (DECT) is an emerging imaging technique for examining patients with suspected gout. Single-source dual-energy CT (S-DECT) is a new way of obtaining DECT information on conventional CT scanners rather than using special dual-source CT systems. We tested the feasibility of S-DECT (320-row CT; Aquilion ONE, Toshiba Medical Systems, Otawara, Japan) in 6 patients (5 men, 1 woman; mean age 61.3, range 48 to 69 years) with acute arthralgia and suspected gout, and compared the S-DECT findings with the results of joint aspiration. Three patients had a diagnosis of gouty arthritis with negatively birefringent crystals in synovial fluid, in addition to gouty tophi in S-DECT. Three patients had no detectable crystals by polarization microscopy and no tophi on DECT. Their final diagnoses were rheumatoid arthritis, activated osteoarthritis, and septic arthritis in one case each. This initial experience suggests that S-DECT might be a valuable alternative to dual-source CT. Hence, more patients may benefit from its additional diagnostic abilities in the future.

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.

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-tonoise 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 (pv0.0001). 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 (pv0.005). 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.

The aim of the study is to evaluate in vivo fluorescence imaging of experimental inflammatory joint disease by applying two different near-infrared (NIR) dyes in a model of Borrelia-induced Lyme arthritis.Forty mice, 20 with Lyme arthritis and 20 controls, were examined. Two nonspecific NIR carbocyanine dyes, indocyanine green (ICG) and a hydrophilic carbocyanine derivative (1,1'-bis-[4-sulfobutyl] indotricarbocyanine-5,5'-dicarboxylic acid diglucamide monosodium salt [SIDAG]), were administered intravenously at two doses. Fluorescence images were acquired before and during 120 seconds after injection of cyanine dyes. For both dyes, the area under the curve (AUC) was determined for the interval between 40 and 80 seconds after injection. In addition, the slope of the signal decrease was compared among animal groups. Results were compared with histological findings.The general temporal fluorescence intensity course for ICG was characterized by a rapid increase, with a peak at 40-50 seconds followed by a decrease; conversely for SIDAG, by a slow increase. AUC analysis for both dyes showed that the fluorescence signal differed significantly between controls and arthritic animals (P.05). Within these groups, there were significant differences between the two doses investigated. ICG differed significantly between control and arthritic animals in the slope of the signal decrease for both doses investigated (P.05). Histological examination showed early stages of inflammation in arthritic animals.NIR fluorescence imaging based on the pharmacokinetic behavior of ICG or SIDAG is a promising approach to detect inflammatory joint changes of experimental arthritis. Moreover, SIDAG is suited to differentiate inflammatory and noninflammatory joints 24 hours after dye application.

Objective To determine whether the effects of anti–tumor necrosis factor α (TNFα) in reducing the signs and symptoms of ankylosing spondylitis (AS) coincide with a reduction in spinal inflammation as detected by magnetic resonance imaging (MRI). Methods Pre- and postgadolinium T1 and STIR MR images of the spine were acquired at baseline and at week 24 in patients with AS who participated in a multicenter, randomized, double-blind, placebo-controlled study. Patients were randomly assigned at an 8:3 ratio to receive infusions of infliximab (5 mg/kg) or placebo at weeks 0, 2, and 6 and then every 6 weeks thereafter. MR images were obtained and evaluated independently by 2 readers who were blinded to the treatment allocation and time sequence of the images. Results A total of 194 patients in the infliximab group and 72 patients in the placebo group had evaluable images at baseline and week 24. About 80% of the patients had at least 1 active spinal lesion at baseline, as assessed by MRI. The improvement in the MRI Activity Score after 6 months was significantly greater in the patients who received infliximab (mean 5.02, median 2.72) than in those who received placebo (mean 0.60, median 0.0) (P < 0.001). Almost complete resolution of spinal inflammation was seen in most patients who received infliximab, irrespective of baseline activity. Conclusion Patients with AS who received infliximab therapy showed a decrease in spinal inflammation as detected by MRI, whereas those who received placebo showed persistent inflammatory spondylitis.

To prospectively compare mitral valve regurgitation fractions calculated at electron-beam computed tomography (CT) (Doppler echocardiography as reference standard) and to evaluate accuracy of electron-beam CT volume and flow measurements compared with magnetic resonance (MR) imaging results.Institutional review board approval and informed consent were obtained. Volume and flow measurements were performed at electron-beam CT in 219 patients (197 men, 22 women; mean age, 61.5 years +/- 10.4 [standard deviation]), of whom 157 had known isolated mitral valve regurgitation. Regurgitation volume was calculated as the difference between left ventricular total and forward stroke volumes. Regurgitation fractions were compared with corresponding echocardiographic grades (grades 0-IV) by using Spearman rank correlation and a weighted kappa test. In 22 patients, CT volume and flow measurements were compared with MR results by using intraclass correlation.Regurgitation fractions at CT correlated well with echocardiographic grading (rank correlation coefficient, r(S) = 0.82; P.05). Mean regurgitation fractions for echocardiographic grades 0, I, II, III, and IV were 3.1% +/- 6.2, 12.7% +/- 9.9, 25.3% +/- 12.3, 40.4% +/- 11.5, and 55.9% +/- 13.7, respectively. The most suitable thresholds for differentiating echocardiographic grades were calculated regurgitation fractions of 6%, 20%, 30%, and 44%; with these thresholds, individual echocardiographic grades were differentiated (grades 0 vs I-IV, 0-I vs II-IV, 0-II vs III-IV, and 0-III vs IV, respectively) with sensitivities of 89%, 87%, 86%, and 93% and specificities of 81%, 87%, 92%, and 91%, respectively. There was perfect agreement in classification of mitral valve insufficiency between electron-beam CT and echocardiography in 134 (61%) patients and a mismatch by one grade in 72 (33%) and by two grades in 13 (6%) (kappa = 0.84). Intraclass correlation coefficients between CT and MR imaging for total and forward stroke volumes and regurgitation volume and fraction were 0.88, 0.79, 0.93, and 0.89, respectively.Electron-beam CT provides quantitative information on severity of mitral valve regurgitation, but semiquantitative classification of regurgitation showed mismatch between electron-beam CT and Doppler echocardiography by at least one grade in more than one-third of all patients.

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.

Objective To develop an ultrasonographic (US) synovitis scoring system suitable for evaluation of finger joint inflammation in patients with active rheumatoid arthritis (RA) and to compare semiquantitative US scoring with quantitative US measurements. Methods US was performed at the palmar and dorsal sides of the second through fifth metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in 10 healthy subjects and in the clinically more affected hand in 46 RA patients. Ten patients additionally underwent magnetic resonance imaging (MRI). Synovitis was measured, standardized, and scored according to a semiquantitative method. The 2 methods (semiquantitative US scoring, quantitative US) were compared and statistical cutoffs were identified using receiver operating characteristic (ROC) curve analysis. MRI results were compared with semiquantitative US scoring and quantitative US results. The optimal US scoring method from 6 joint combinations was identified (ROC curve analysis). Results Synovitis was most frequently detected in the palmar proximal area (86% of affected joints). We found no significant differences between individual PIP joints or between individual MCP joints, indicating that all fingers within each of these joint groups should be treated equally for statistical calculations, although each joint group as a whole should be treated separately. The optimal cutoff point to distinguish between “health” and “pathology” was 0.6 mm both for MCP joints (sensitivity 94%, specificity 89%) and for PIP joints (sensitivity 90%, specificity 88%). There was no significant difference between semiquantitative US scores and quantitative US measurements. The best results for joint combinations were achieved using the “sum of 4 fingers” (second through fifth MCP and PIP joints) and “sum of 3 fingers” (second through fourth MCP and PIP joints) methods. Comparison of MRI results with semiquantitative US scores revealed high concordance. Conclusion US evaluation of finger joint synovitis can be considerably simplified by focusing on the palmar side and by applying semiquantitative grading instead of quantitative measurements. For evaluation of treatment efficacy based on synovitis in RA patients, we recommend using the “sum of 3 fingers” method in longitudinal trials.

Purpose: To evaluate multi-slice spiral computed tomography (MSCT) for measurements of left ventricular volumes, ejection fraction (EF), and myocardial mass in comparison with electron beam CT (EBCT) as a reference method. Material and Methods: Six minipigs underwent both standardized contrast-enhanced MSCT (effective acquisition time per cardiac cycle 125.7±30.1 ms, reconstructed slice thickness 8 mm) and EBCT (acquisition time 50 ms, collimated slice thickness 8 mm). The contrast-to-noise ratio of the left ventricle was measured in each animal, and the contour sharpness of the myocardium was analyzed. Volumes (EDV, ESV, SV) ejection fraction (EF), and muscle mass were calculated by MSCT and by EBCT using the slice summation method. Results: MSCT had a higher contrast-to-noise ratio and delineated the myocardial contours more sharply than EBCT. There was a close linear correlation between both modalities for all parameters (EDV: rP=0.88, ESV: rP=0.91, SV: rP=0.85, EF: rP=0.93; mass: rP=0.90; P Conclusions: Image quality in MSCT is superior to that of EBCT. Functional parameters correlate well between both modalities, but the accuracy of MSCT is limited by its lower temporal resolution.

Objectives: We sought to determine the agreement between electron-beam computed tomography (CT) and cardiac catheterization for the quantification of mitral regurgitation and to evaluate their association with echocardiographic assessment. Material and Methods: Fifty patients with congestive heart failure were examined both by electron-beam CT and catheterization to calculate mitral regurgitation volume and fraction based on the difference between the left ventricular stroke and aortic flow volume. The severity of regurgitation was also compared with visual assessment by echocardiography (grade, 0-4+). Results: The mean values for the mitral regurgitation volume and fraction did not differ significantly between electron-beam CT and catheterization (mean differences: 0.2 mL/m 2 and -0.9%, P > 0.05 each, limits of agreement: -14.0 to 14.4 mL/m 2 and -26.3 to 24.5%, respectively) and showed a good correlation (r = 0.79 and r = 0.76, respectively; P < 0.05 each). Good levels of correlation were observed between echocardiographic severity grading and quantitative measurements of regurgitation volume and fraction, which were somewhat better between echocardiography and electron-beam CT (r S = 0.78 and r S = 0.84, respectively; P < 0.05 each) than between echocardiography and catheterization (r S = 0.72 and r S = 0.81, respectively; P < 0.05 each). Conclusion: Our results suggest that electron-beam CT allows for quantification of mitral valve regurgitation with similar accuracy as cardiac catheterization. Measurements with both modalities correlated well with the results of echocardiographic assessment.

Objective: To verify changes in left ventricular (LV) volumes and regional myocardial wall motion after implantation of a textile cardiac support device (CSD) for passive external constraint in non-ischemic dilated cardiomyopathy. Methods: In nine male patients participating in a non-randomized clinical trial LV volumes were determined and the segmental LV wall motion was studied by contrast-enhanced electron-beam CT in a sectionwise manner at three ventricular levels (base, middle and apex of ventricle) before and 32 ^ 6 months after CSD implantation. In 16 myocardial segments ejection fraction and wall thickening were measured semiautomatically after drawing the myocardial contours. The wall motion score index was calculated based on semiquantitative visual grading in each segment. Results: The global LV volumes decreased significantly from 304.3 ^ 90.9 to 231.5 ^ 103.9 ml at end-diastole and from 239.7 ^ 83.7 to 164.0 ^ 97.7 at end-systole (P , 0:05). Overall ejection fraction increased from 14.8 ^ 8.2 to 25.7 ^ 17.1% (P , 0:05). A segment-by-segment analysis demonstrated a significant increase of regional ejection fraction in the basal myocardium as well as in the mid-inferior, mid-inferolateral, and mid-anterolateral myocardium. Overall wall thickening increased from 16.4 ^ 13.3 to 24.2 ^ 18.1% (P , 0:05), but without significant differences in a segment-by-segment comparison. The mean wall motion score index improved from 2.70 ^ 0.26 to 2.20 ^ 0.71 (P , 0:05), with an increased wall motion in eight (89%) patients. A section-by-section analysis demonstrated significantly improved wall motion in the inferior and lateral segments at each ventricular level. Postoperatively, the number of akinetic and markedly hypokinetic segments decreased significantly (P , 0:05) from 56 (39%) to 26 (18%) and from 76 (53%) to 56 (37%), respectively. Conclusion: CSD implantation improves segmental wall motion, predominantly in the inferior and lateral myocardium, and reduces the number of akinetic and hypokinetic segments. q 2003 Elsevier B.V. All rights reserved.

Objective To determine the role of ultrasound and magnetic resonance imaging (MRI) compared with conventional radiography in the detection of chronic and acute inflammatory manifestations of rheumatoid arthritis (RA) of the shoulder joint. Methods Forty-three consecutive patients with known RA prospectively underwent clinical examination, radiography, ultrasound, and MRI of the shoulder joints. Each patient was assigned a clinical/laboratory score consisting of 7 parameters, including measurements of shoulder mobility, the erythrocyte sedimentation rate, and C-reactive protein level. Conventional radiography was standardized and performed in 2 planes. Ultrasound was performed in 10 predefined planes using a 7.5-MHz linear transducer. MRI at 1.5T comprised transverse and oblique coronal T1- and T2*-weighted fast spin-echo, gradient-echo (GRE), and inversion-recovery sequences with a matrix size of up to 512 pixels. A dynamic T1-weighted GRE sequence was acquired with intravenous administration of contrast medium. Erosions were assessed using all 3 imaging techniques on a 4-point scale. Soft-tissue involvement was evaluated according to the presence of synovitis, tenosynovitis, and bursitis on ultrasound and MRI. The results in the study group were compared with those obtained in a control group of 10 patients with shoulder pain. Results In the study group, erosions of the humeroscapular joint were detected by conventional radiography in 26 patients, by ultrasound in 30 patients, and by MRI in 39 patients; the differences were statistically significant for the comparisons of conventional radiography with MRI and for ultrasound versus MRI (P < 0.0001). Conventional radiography detected 12 erosions of the scapula and MRI detected 15. Synovitis was demonstrated in 12 patients by ultrasound and in 27 patients by MRI (P = 0.0003). Tenosynovitis was observed in 15 patients by ultrasound and in 28 patients by MRI (P = 0.0064). Bursitis was detected in 13 patients by ultrasound and in 18 patients by MRI. The findings on dynamic contrast-enhanced MRI correlated significantly with the detection of synovitis by ultrasound and erosions by static MRI (P < 0.05). Conclusion Ultrasound and MRI supplement conventional radiography in assessing the shoulder joint. Although conventional radiography can be used as the sole method of following up known joint destruction in RA, ultrasound and, preferably, MRI are recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results.

PURPOSE The prospective investigation of the therapeutic effect of CT-guided intra-articular corticosteroid injection into inflammatory sacroiliac (SI) joints compared to conventional treatment with nonsteroidal anti-inflammatory drugs (NSAIDS) in children with juvenile spondyloarthropathy (jSpA) and the determination of the role of dynamic magnetic resonance imaging (MRI) in establishing the indication and monitoring the therapy. MATERIALS AND METHODS The study comprises 89 children with known jSpA who were diagnosed by MRI to have a unilateral or bilateral sacroiliitis. Therapy with NSAIDS was initiated or continued in all 89 patients. Four weeks after the diagnostic MRI, two groups were distinguished according to the clinical response to NSAIDS, with group 1 consisting of 33 responders and group 2 of 56 non-responders. The patients of group 2 were treated with CT-guided intra-articular corticosteroid injection (low-dose injection) while the therapy with NSAIDS was continued. A total of 83 SI joints were punctured without complications, 27 bilaterally and 29 unilaterally. The indication for the intervention was based on inflammatory activity as determined by MRI. The therapy was monitored by clinical follow-up every 8 to 12 weeks over a period of 20 months. Follow-up by dynamic MRI was performed in all 56 children of group 2 and in 15 of the 33 children of group 1 within 8 +/- 4 months of the initial examination. RESULTS A total of 87.5% of the children in group 2 showed a statistically significant decrease in their subjective complaints from 6.9 +/- 3.4 to 1.8 +/- 1.7 (p < 0.05) as measured on a visual analog scale (VAS from 0 to 10). Improvement was seen as early as 1.5 +/- 1.0 weeks after the intervention and lasted for a mean of 12 +/- 6 months. The children in group 1 already showed similar improvement of the VAS from 6.8 +/- 3.2 to 1.5 +/- 1.4 (p < 0.05) during the initial four weeks of NSAIDS therapy, with the improvement lasting for the 20-month observation period. The follow-up dynamic MRI (0.1 mmol/kg body weight) during therapy showed a statistically significant lower contrast-enhancement in both groups (group 1: 117 +/- 43 % versus 38 +/- 24 %, p < 0.05; group 2: 127 +/- 59 % versus 38 +/- 22 %, p < 0.05). One third of the patients of group 2 showed progression of joint destruction despite absence of subjective complaints. CONCLUSION CT-guided intra-articular corticosteroid injection has proven an effective, symptomatic, and uncomplicated therapy of acute sacroiliitis in patients with jSpA. Dynamic MRI has a role in establishing the indication for intervention but its role for any follow-up is restricted to cases with inconclusive clinical response.

Summary Rheumatoid arthritis (RA) is the most frequent chronic inflammatory arthropathy that often leads to joint destruction. Essential for the progress of the disease are both an early diagnosis and a sensitive follow-up of synovitis. In this paper, we present new laser based imaging techniques for the transillumination of small finger joints. The “Laserscan” technique allows the transillumination of small finger joints using red laser light with a wavelength of 675nm. The laser is positioned above the finger joint and a CCD camera detects the scattering distribution below the joint. After processing the data through a statistical machine learning method, we could show in a preliminary clinical study that it was possible to correctly classify the inflammatory status of 62 of 72 joints from 22 patients with RA compared to precise clinical examination. Sagittal optical tomography is a further development of “Laserscan”. In this technique, a red laser is moved in sagittal plane above the proximal interphalangeal finger joint while a detector underneath the joint measures the scattered light distribution in the same plane. Using model-based iterative image reconstruction algorithms, sagittal cross-sectional images are obtained based on the acquired data. These images reflect the distribution of scattering and absorption properties within and around the joint cavity of a first healthy volunteer.

ObjectiveWe 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 MethodAS (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.ResultsAt 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.ConclusionsThe 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.

The OMERACT Magnetic Resonance Imaging (MRI) Task Force has developed and evolved the psoriatic arthritis MRI score (PsAMRIS) over the last few years, and at OMERACT 10, presented longitudinal evaluation by multiple readers, using PsA datasets obtained from extremity MRI magnets. Further evaluation of this score will require more PsA imaging datasets. As well, due to improved image resolution since the development of the original rheumatoid arthritis MRI scoring system (RAMRIS), the Task Force has worked on semiquantitative assessment of joint space narrowing, and developed a reliable method as a potential RAMRIS addendum, although responsiveness will need to be evaluated. One of the strengths of MRI is the ability to detect subclinical synovitis, so the group worked on obtaining low disease activity/clinical remission datasets from a number of international centers and presented cross-sectional findings. Subsequent longitudinal evaluation of this unique resource will be a major continuing focus for the group.

The aim of this study was to perform phantom measurements to prove the feasibility of single-source dual-energy computed tomography (DECT) of the extremities using a volume scan mode. In addition, we, for the first time, wanted to determine which concentrations of monosodium urate (MSU) in gout and calcium pyrophosphate (CP) in pseudogout are needed to detect or distinguish these soft tissue depositions with DECT.We created a hand-shaped plastic phantom assembled with a descending order of concentrations of MSU (6.25%-50%) and CP (1.56%-50%) with similar attenuation in conventional computed tomographic (CT) images. Dual-energy imaging was done on a standard 320-row CT scanner with acquisition of 2 volumes: one at 80 and the other at 135 kV. Using linear regression analysis, dual-energy gradients were calculated for MSU and CP. Thereafter, we selected a specific region of interest on the dual-energy graph to color-code MSU and CP on the images. Three blinded readers scored 10 scans of the randomly equipped phantom, corresponding to 60 samples, to determine the sensitivity and specificity of this technique. Receiver operating characteristics analysis was done to determine the diagnostic power.We found a dual-energy gradient for MSU of 1.020 ± 0.006 and for CP of 0.673 ± 0.001. Assessment of the randomized phantom scans indicates reliable detection of MSU at concentrations of 12.5 % or higher and that of CP at 6.25 % or higher, corresponding to deposits with mean Hounsfield unit values of 59.8 for MSU and 101.1 for CP. The sensitivity for MSU ranged from 83.3% to 97.3% at 15/90 mA (135/80 kV) and from 86.7% to 97.3% at 100/570 mA. Specificity was 96.7% to 100% in 15/90 mA and 100% in 100/570 mA of scans. However, there was inferior sensitivity for CP owing to lower concentrations. In the receiver operating characteristics analysis, the area under the curve for MSU ranged from 0.867 to 0.947 at 15/90 mA and from 0.867 to 0.919 at 100/570 mA and that for CP from 0.659 to 0.745 and from 0.718 to 0.750, respectively.This phantom study shows that single-source DECT allows detection and characterization of crystal deposits when present in soft tissue at relatively low concentrations. Further studies in patients have to prove its benefits in diagnostic imaging and treatment monitoring as well as its significance compared with dual-source CT systems.

Rheumatologists have long considered OA and PsA as two completely distinct arthropathies. This review highlights how some forms of generalized OA and PsA may afflict the same entheseal-associated anatomical territories. While degeneration or inflammation may be clearly discernible at the two extremes, there may be a group of patients where differentiation is impossible. Misdiagnosis of a primary degeneration-related pathology as being part of the PsA spectrum could lead to apparent failure of disease-modifying agents, including apparent anti-TNF and apparent IL23/17 axis therapy failure. This is not a reflection of poor clinical acumen, but rather a failure to appreciate that the pathological process overlaps in the two diseases. Whether the category of OA–PsA overlap disease exists or whether it represents the co-occurrence of two common arthropathies that afflict the same anatomical territories has implications for the optimal diagnosis and management of both OA and PsA.

Objective. The aim of this study was to assess the degree of fluctuation of osteitis on MRI during longterm 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.

Objective To evaluate radiographic progression in patients with ankylosing spondylitis (AS) receiving two different doses of the tumour necrosis factor antagonist golimumab. Methods 356 patients with AS were randomly assigned to placebo, or golimumab 50 mg or 100 mg every 4 weeks (wks). At wk16, patients with inadequate response early escaped with blinded dose adjustments (placebo→golimumab 50 mg, 50 mg→100 mg). At wk24, patients still receiving placebo crossed over to golimumab 50 mg. Lateral view radiographs of the cervical/lumbar spine were obtained at wk0, wk104 and wk208, and scored (two blinded readers, modified Stoke AS Spine Score (mSASSS)). Observed data were used for wk104 analyses; missing wk208 scores were linearly extrapolated. Results Wk104 changes from baseline in mSASSS averaged 1.6±4.6 for placebo crossover, 0.9±2.7 for 50 mg and 0.9±3.9 for 100 mg. By wk208, following golimumab therapy for 3.5–4 years, mean changes in mSASSS were 2.1±5.2 for placebo crossover, 1.3±4.1 for 50 mg and 2.0±5.6 for 100 mg. Less than a third of patients (placebo crossover, 19/66 (28.8%); 50 mg, 29/111 (26.1%); 100 mg, 35/122 (28.7%)) had a definitive change from baseline mSASSS (>2). Less radiographic progression was observed through wk208 in patients without baseline syndesmophytes (0.2 vs 2.8 in patients with ≥1 syndesmophyte; p1.5 mg/dl; p=0.0004). Conclusions No difference in mSASSS change was observed between golimumab 50 mg and 100 mg. The radiographic progression rate remained stable at years 2 and 4, suggesting no acceleration of new bone formation over time. Golimumab-treated AS patients with no syndesmophytes and less systemic inflammation at baseline had considerably less radiographic progression.

To evaluate efficacy and safety of ustekinumab in patients with ankylosing spondylitis (AS).In this prospective, open-label, single-arm, proof-of-concept clinical trial (ClinicalTrials.gov identifier NCT01330901), ustekinumab in a dose of 90 mg was administered subcutaneously at baseline, week 4 and week 16 in 20 patients with active AS. Eligible patients were required to have a diagnosis of AS according to the modified New York criteria and an active disease defined as a Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) score of ≥4 despite previous non-steroidal anti-inflammatory drug (NSAID) treatment. The primary study endpoint was the proportion of patients reached the Assessment of SpondyloArthritis International Society 40 (ASAS40) response at week 24.At week 24, ASAS40 response was reached by 65% of the patients. ASAS20, ASAS5/6 and ASAS partial remission were observed in 75%, 50% and 30% of the patients, respectively. A ≥50% improvement of the BASDAI (BASDAI50) occurred in 55% of the patients. A total of 50% and 20% of the patients achieved the AS Disease Activity Score (ASDAS) clinically important improvement and major improvement, respectively. At week 24, 35% of the patients had an ASDAS inactive disease (ASDAS1.3). Significant improvement of other patient-reported outcome parameters and active inflammation as detected by MRI as well as significant reduction of NSAIDs intake occurred during the treatment. Clinical response correlated with reduction of active inflammation on MRI and of serum C reactive protein level. Overall, ustekinumab was well tolerated.In this prospective, open-label, proof-of-concept clinical trial, ustekinumab treatment was associated with a reduction of signs and symptoms in active AS and was well tolerated.

The OMERACT magnetic resonance imaging (MRI) in inflammatory arthritis group previously developed the rheumatoid arthritis MRI score (RAMRIS) for use in clinical studies, evaluated the use of extremity MRI, and initiated development of a psoriatic arthritis MRI score (PsAMRIS). At OMERACT 9 the group looked at clarifications of applying the RAMRIS, and presented data from a study examining how the contrast agent gadolinium affects RAMRIS outcomes. Much of the group’s effort has been aimed at the iterative development of its PsA score, and reported exercises examining this score demonstrated encouraging results, allowing subsequent presentation of a preliminary PsAMRIS. The large amount of data presented were followed by discussions with the wider audience highlighting constructive suggestions for future research priorities, including further feasibility studies, understanding imaging remission, and further improvements to PsAMRIS.

Involvement of the axial skeleton is a characteristic feature of spondyloarthritis (SpA). Asymmetrical arthritis and enthesitis of the peripheral joints are found in about 30–60% of patients.1–3 A 52-year-old patient with a history of psoriasis reported inflammatory back pain, painful ankles and knees and severe morning stiffness on admission. The physical examination revealed tender entheses at different locations: upper thoracic spine, lumbar spinous processes, both iliac crests and posterior superior iliac spines. Furthermore, there was tenderness of both sacroiliac joints, both knees and both ankles without joint swelling. HLA-B27 antigen was negative. The sedimentation rate (70/76) and levels of C reactive protein (1.48 mg/dl) were increased. The Bath Ankylosing Spondylitis Activity Index was 6.0, and the Bath Ankylosing Spondylitis Functional Index was 4.6. Radiographs of the pelvis showed bilateral grade 3 sacroiliitis. Thus, ankylosing spondylitis (AS) associated with psoriasis was diagnosed. Treatment on admission comprised methotrexate (15 mg/week) and prednisolone (5 mg/day). Whole-body MRI (WB-MRI) was performed on a special 1.5 T scanner (Avanto, Siemens, Germany) for evaluation of the extent of suspected widespread inflammatory lesions. Images of the entire body, excluding the hands, were acquired in a head-to-toe scan using parallel imaging and a whole-body surface coil …

Involvement of the sacroiliac joints (SIJ) is a major and characteristic feature of the spondyloarthritides (SpA). In early ankylosing spondylitis and undifferentiated SpA (uSpA) sacroiliitis is the most common early clinical finding and the presumed first manifestation of the disease. Magnetic resonance imaging has proved useful for visualising inflammation in the SIJ in adults and children. Recently, initial localisation of the inflammation in the SIJ has been described in some detail, but it has not been completely defined to date--either in imaging or in histopathological studies. This is mainly owing to the lack of data in very early disease and the lack of follow up studies. Here we present a patient with early disease, which may augment our understanding of this stage of SpA.

To assess the contribution of contrast material in detecting and evaluating enthesitis of pelvic entheses by MRI.Sixty-seven hip or pelvic 1.5-T MRIs (30:37 male:female, mean age: 53 years) were retrospectively evaluated for the presence of hamstring and gluteus medius (GM) enthesitis by two readers (a resident and an experienced radiologist). Short tau inversion recovery (STIR) and T1-weighted pre- and post-contrast (T1+Gd) images were evaluated by each reader at two sessions. A consensus reading of two senior radiologists was regarded as the gold standard. Clinical data was retrieved from patients' referral form and medical files. Cohen's kappa was used for intra- and inter-observer agreement calculation. Diagnostic properties were calculated against the gold standard reading.A total of 228 entheses were evaluated. Gold standard analysis diagnosed 83 (36%) enthesitis lesions. Intra-reader reliability for the experienced reader was significantly (p = 0.0001) higher in the T1+Gd images compared to the STIR images (hamstring: k = 0.84/0.45, GM: k = 0.84/0.47). Sensitivity and specificity increased from 0.74/0.8 to 0.87/0.9 in the STIR images and T1+Gd sequences. Intra-reader reliability for the inexperienced reader was lower (p 0.05).Evidence showing that contrast material improves the reliability, sensitivity, and specificity of detecting enthesitis supports its use in this setting.

Objective.We investigated the performance of magnetic resonance imaging (MRI) compared to conventional radiographs for detection of chronic structural changes in the sacroiliac joints (SIJ) in patients with axial spondyloarthritis (SpA).Methods.We included 112 patients with definite axial SpA (68 with ankylosing spondylitis and 44 with nonradiographic axial SpA), for whom radiographs and MRI scans of the SIJ performed at the same time were available. Radiographs and MRI of the SIJ were scored for subchondral sclerosis (score 0–2), erosions (score 0–3), and joint space changes (score 0–5) in each SIJ. Readers provided an overall impression of the extent of damage according to the scoring system of the modified New York criteria.Results.In total, 224 SIJ from 112 patients were available for analysis. There was rather low agreement between MRI and radiographs concerning definite erosions of SIJ (κ = 0.11), moderate agreement for definite subchondral sclerosis (κ = 0.46) and definite joint space abnormalities (κ = 0.41), and almost perfect agreement for joint ankylosis (κ = 0.85). MRI demonstrated a good overall performance in detection of definite “chronic” sacroiliitis, with a sensitivity of 84% and a specificity of 61%. For sacroiliitis fulfilling the modified New York criteria, MRI had a sensitivity of 81% and a specificity of 64% using radiographs as the reference method.Conclusion.MRI demonstrated good overall performance for detection of chronic structural changes in the SIJ as compared to radiographs.

Psoriasis is an important clinical feature in ankylosing spondylitis (AS) and spondyloarthritis (SpA) in general,1 with inflammatory spinal disease developing in 5%–25% of psoriasis cases.2 ,3 However, there have been few studies assessing the differences between AS patients with and without concomitant psoriasis.4–9 Our aim was to compare the demographic, clinical and imaging characteristics between AS patients with and without psoriasis. Baseline data from an 80% random sample of the AS Study for the Evaluation of Recombinant Infliximab Therapy (ASSERT) database were used for this analysis. Details of the ASSERT trial and study population have been previously published.10 Briefly, patients with active AS (fulfilling modified New York criteria) for at least 3 months, a Bath AS disease activity index score of at least 4 (range 0–10) and a spinal pain assessment score of at least 4 (range 0–10) were eligible for the study. AS patients with …

The skin, a large and complex organ, is exposed to more damaging agents than any other tissue. It therefore exhibits a very wide range of inflammatory disease patterns and reactions to infectious agents, as well as a large number of tumors. The breadth of dermatopathology is consequently immense, and a knowledge of dermatopathology in correlation to the clinical details of dermatology is a necessary prerequisite for definite diagnosis. This chapter provides a simple outline of the important patterns of inflammatory and infectious dermatoses and describes some important and common tumors that occur in the skin.

Magnetic Structural changes in axial Spondyloarthritis (axSpA) are best identified by conventional radiographs, while magnetic resonance imaging (MRI) is considered the gold standard for assessment of inflammatory changes. Imaging of the axial skeleton is crucial for the diagnosis but also for classification to non-radiographic axSpA according to the 2009 ASAS classification criteria. Despite the existing definitions for a positive MRI for the sacroiliac joints and the spine, these predefined lesions can also be seen in other conditions, representing pitfalls and false-positive conclusions in patients with similar clinical symptoms who do not have SpA. Diagnosis of SpA should result from the combination of clinical, laboratory and imaging findings.

To test the hypothesis that microanatomical differences in joint disease localisation could be exploited using high-resolution MRI to better differentiate among rheumatoid arthritis (RA), spondyloarthritis/psoriatic arthritis (SpA/PsA) and osteoarthritis (OA) in clinical practice. Sixty-nine patients with suspected inflammatory joint disease of the hand or feet underwent high-resolution MRI using a small loop coil. Images were scored blinded to the clinical status. Various joint changes like periostitis, osteitis, erosions, enthesitis and synovitis were recorded. The image-based diagnosis was compared with the clinical diagnosis. In 59.4 % of the patients the clinical diagnosis was confirmed on image analysis. This was high for OA (80 %), moderately good for RA (67 %) but only 50 % for SpA/PsA. The major difficulty was to distinguish OA from SpA/PsA where common imaging findings are evident including periostitis (SpA/PsA 45 %, OA 40 % compared with RA 0 %; P = 0.015). Likewise, osteitis was frequently detected in SpA/PsA (79 %) and OA (80 %) and less frequently in RA (42 %) (P = 0.014). Characterisation of inflammatory disorders of small joints merely using high-resolution MRI remains challenging especially in the differentiation between OA and PsA. These findings are likely explained by common microanatomical similarities in disease expression rather than limitations of imaging techniques. • High-resolution MRI is increasingly used to investigate joint disease. • Osteitis and periostitis occur in psoriatic and osteoarthritis (but not rheumatoid arthritis). • In severely affected patients the amount of synovitis and erosions is similar.

Objective To evaluate golimumab9s effect on MRI-detected spinal inflammation in ankylosing spondylitis (AS). Methods Patients were randomly assigned to subcutaneous injections of placebo (n=78), golimumab 50 mg (n=138), or golimumab 100 mg (n=140) every 4 weeks. An MRI substudy comprising 98 patients (placebo n=23, 50 mg n=37, 100 mg n=38) at eligible MRI substudy sites had serial spine MRI scans (sagittal plane, 1.5T scanners, T1 and short tau inversion recovery sequences) at baseline and weeks 14 and 104. Two blinded (treatment, image order) readers independently evaluated MRI spinal inflammation using AS spine MRI-activity (ASspiMRI-a) scores; reader scores were averaged. Changes from baseline to weeks 14 and 104 were compared among treatment groups using analysis of variance on van der Waerden normal scores both with (post-hoc) and without (prespecified) adjustment for baseline ASspiMRI-a scores. Results Median baseline ASspiMRI-a scores were lower in the 100 mg (3.5) than placebo (6.8) and 50 mg (7.8) groups. Median decreases in activity scores from baseline to week 14 were −0.5 for placebo, −3.5 for 50 mg (p=0.047 vs placebo), and −1.5 for 100 mg (p=0.14 vs placebo). After adjusting for baseline ASspiMRI-a score imbalance, significant improvements were observed with both 50 mg (p=0.011) and 100 mg (p=0.002) versus placebo. ASspiMRI-a scores improvement achieved with golimumab was maintained at week 104. Improvement in ASspiMRI-a scores correlated with improvement in the recently developed AS disease activity score (ASDAS) and C-reactive protein (CRP) levels but not with other key AS clinical outcomes. Conclusion Golimumab significantly reduced MRI-detected spinal inflammation of AS; improvements were sustained to week 104 and correlated with improvement in ASDAS and CRP.

ObjectiveTo 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).Method75 patients with active disease and a symptom duration of Results92% 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).ConclusionsWb-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.

ObjectiveTo investigate the relationships between several health outcomes in ankylosing spondylitis (AS).MethodsBaseline pretreatment data from 214 patients with AS participating in the AS Study for the Evaluation of Recombinant Infliximab Therapy were analysed. Measures of health-related quality of life (HRQoL) and physical function were used as dependent variables in linear regression analysis. Associations between HRQoL (36-Item Short Form (SF-36)), physical function, clinical disease activity, spinal mobility, structural damage, MRI inflammation, disease duration, age, gender, body mass index and HLA-B27 were explored. Univariate associations were retested in multivariate models. The robustness of the models was evaluated by sensitivity analyses.ResultsThe physical component of SF-36 was independently associated with measures of physical function and disease activity (adjusted R2 (adjR2)=0.39–0.40). The mental component of SF-36 was independently associated with physical function (adjR2=0.07). Physical function was independently associated with measures of spinal mobility and disease activity (adjR2=0.39–0.45). Spinal mobility was hierarchically shown to be an intermediate variable between structural damage and physical function, while physical function was shown to be intermediate between spinal mobility and the physical component of SF-36.ConclusionAccording to the proposed stratified model for health outcomes in AS, HRQoL is determined by physical function and disease activity, physical function is determined by spinal mobility and disease activity, and spinal mobility is determined by structural damage and inflammation of the spine. As more is learnt about how to measure AS, knowledge about the disease improves and better decisions can be made on the assessment and treatment of this disease.

Objective Many rheumatologists and radiologists routinely assess conventional radiographs of the hands, and it is often unclear how to proceed if radiography reveals only cyst-like lesions (CLLs), with otherwise normal findings. The present study was undertaken to evaluate the use of 320-row multidetector computed tomography (MDCT) of the hands in the further assessment of CLLs of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints identified on conventional radiography. Methods MCP and PIP joints (n = 1,120 joints) of 56 consecutive patients (44 women [mean age 55 years, range 31–72 years] and 12 men [mean age 57 years, range 37–77 years]) were prospectively scored for the presence of cysts, CLLs, and erosions of the PIP and MCP joints, first on conventional radiographs, then on MDCT. Scoring was performed by 2 independent readers under blinded conditions. Intraclass correlation coefficients were calculated. Results By conventional hand radiography, 13 patients (total of 260 joints assessed) were identified as having CLLs in 1 or more joints (total of 36 joints [11 PIP and 25 MCP]). By MDCT, the findings in 19 of 36 joints (53%) were diagnosed as erosions, while 7 of 36 (19%) were confirmed as true cysts, and 10 joints (28%) were normal (false positive). Among the patients with CLLs, 10 of 224 joints with no abnormality seen radiographically had erosions as seen on MDCT. Interreader agreement for erosions was 0.854 (95% confidence interval [95% CI] 0.831–0.874) by conventional hand radiography and 0.952 (95% CI 0.943–0.959) by MDCT. Conclusion Our results indicate that radiographic appearance of cyst-like lesions may actually represent erosions and should lead to initiation of further imaging tests.

ObjectiveTo investigate the relationship between MRI inflammation at the vertebral unit and the formation and growth of syndesmophytes at the same vertebral unit.MethodsAn 80% random sample of the ASSERT database was analysed. MRI were scored using the ankylosing spondylitis (AS) spinal MRI activity score (at baseline, 24 and 102 weeks) and spinal x-rays were scored using the modified Stoke AS spine score (at baseline and 102 weeks). Data were analysed at the patient level and the vertebral unit level using a multilevel approach to adjust for within-patient correlation.ResultsThere was a slightly increased probability of developing syndesmophytes in vertebral units with MRI activity, which was maintained after adjustment for within-patient correlation (per vertebral unit level) and treatment, and after further adjustment for potential confounders, resulting in significant OR ranging from 1.51 to 2.26. Growth of existing syndesmophytes at the vertebral unit level was not associated with MRI activity. At the patient level only a trend for an association was observed.ConclusionMRI inflammation in a vertebral unit slightly increases the propensity to form a new syndesmophyte in the same vertebral unit, but does not predict the growth of already existing syndesmophytes. Despite this association, the large majority of new syndesmophytes developed in vertebral units without inflammation. The subtle association at the vertebral unit level did not translate into an association at the patient level.

IntroductionTakayasu arteritis (TA) is a large vessel vasculitis involving the aorta and its major branches. T cell-mediated autoimmunity is thought to play a major role in its pathogenesis, while the role of B cells is still unclear.MethodsB cell subsets in the peripheral blood of 17 patients with TA were analysed and compared with nine patients with active systemic lupus erythematosus (SLE) and nine healthy controls by flow cytometry. Based on these findings, three patients with active refractory TA were treated with B cell depletion therapy (BCDT) using monoclonal anti-CD20 antibodies (rituximab).ResultsThe absolute number and frequency of peripheral blood CD19+/CD20−/CD27high antibody-secreting cells in patients with active TA was significantly higher than in healthy donors. As in active SLE, the majority of these cells are newly generated plasmablasts which significantly correlated with TA activity. Three patients with active refractory TA and expansion of plasmablasts were successfully treated with BCDT, which resulted in remission.ConclusionDisturbances of B cell homeostasis may be critical in TA. Circulating plasmablasts could be a useful biomarker of disease activity and a tool for selecting appropriate candidates for BCDT. B cells and plasmablasts/plasma cells may therefore represent novel targets for effective therapies for TA.

Objective.To develop and validate a magnetic resonance imaging (MRI) method of assessment of joint space narrowing (JSN) in rheumatoid arthritis (RA).Methods.Phase A: JSN was scored 0–4 on MR images of 5 RA patients and 3 controls at 15 wrist sites and 2nd–5th metacarpophalangeal (MCP) joints by 8 readers (7 once, one twice), using a preliminary scoring system. Phase B: Image review, discussion, and consensus on JSN definition, and revised scoring system. Phase C: MR images of 15 RA patients and 4 controls were scored using revised system by 5 readers (4 once, one twice), and results compared with radiographs [Sharp-van der Heijde (SvdH) method].Results.Phase A: Intraobserver agreement: intraclass correlation coefficient (ICC) = 0.99; smallest detectable difference (SDD, for mean of readings) = 2.8 JSN units (4.9% of observed maximal score). Interobserver agreement: ICC = 0.93; SDD = 6.4 JSN units (9.9%). Phase B: Agreement was reached on JSN definition (reduced joint space width compared to normal, as assessed in a slice perpendicular to the joint surface), and revised scoring system (0–4 at 17 wrist sites and 2nd–5th MCP; 0: none; 1: 1–33%; 2: 34–66%; 3: 67–99%; 4: ankylosis). Phase C: Intraobserver agreement: ICC = 0.90; SDD = 6.8 JSN units (11.0%). Interobserver agreement: ICC = 0.92 and SDD = 6.2 JSN units (8.7%). The correlation (ICC) with the SvdH radiographic JSN score of the wrist/hand was 0.77. Simplified approaches evaluating fewer joint spaces demonstrated similar reliability and correlation with radiographic scores.Conclusion.An MRI scoring system of JSN in RA wrist and MCP joints was developed and showed construct validity and good intra- and interreader agreements. The system may, after further validation in longitudinal data sets, be useful as an outcome measure in RA.

The bone mineral density (BMD) measurement of the hand in rheumatoid arthritis (RA) patients is no standard measurement method as yet. The aim was to contribute to the standardization of the hand BMD measurement, especially of periarticular regions. As results, we found best precision values for the wrist and a significant correlation between hand and spine/femur BMD depending on disease activity and disease duration. This study was conducted to investigate (i) the precision of periarticular hand BMD measuring, (ii) the periarticular demineralization of the hand, (iii) the correlation between periarticular hand BMD and spine/femur BMD, and (iv) the correlation of hand BMD to hand synovitis. A number of 52 RA patients were examined by BMD measurement of the femoral neck, spine, whole hand, metacarpophalangeal (MCP) joints II–V, personal identity profile (PIP) joints II–V, and wrist using dual-energy X-ray absorptiometry (DXA). Synovitis of the hand was examined by ultrasonography and magnetic resonance imaging (MRI). Three subgroups were further analyzed: early RA, established RA with moderate and with high disease activity. Early RA and established RA patients with high disease activity were Followed up after 12 months. We found (1) best precision of BMD measurement for the wrist, (2) BMD in RA significantly reduced if compared to normal controls, (3) a highly significant positive correlation between hand and spine/femur BMD and the power of correlation to depend on disease activity and disease duration (high correlation in RA with moderate disease activity and early RA, very high correlation in RA with high disease activity), (4) a negative correlation between hand BMD and hand synovitis in RA with high disease activity, and (5) a significant reduction of synovitis but no change in hand BMD after 12 months, respectively. This study shows a highly significant correlation between hand BMD and spine/femur BMD in RA patients depending on disease activity and disease duration. We conclude to measure BMD at different sites including hands in order to quantify bone loss in RA patients most properly.

Objective To investigate the relationship of circulating biomarkers of inflammation (C-reactive protein [CRP], interleukin-6 [IL-6], and YKL-40), angiogenesis (vascular endothelial growth factor), cartilage turnover (C-terminal crosslinking telopeptide of type II collagen [CTX-II], total aggrecan, matrix metalloproteinase 3 [MMP-3], and cartilage oligomeric matrix protein [COMP]), and bone turnover (CTX-I and osteocalcin) to inflammation on magnetic resonance imaging (MRI) and radiographic progression in patients with axial spondylarthritis (SpA) beginning tumor necrosis factor α (TNFα) inhibitor therapy. Methods MRIs were evaluated according to the Berlin sacroiliac (SI) joint and spine inflammation scoring method at baseline, week 22, and week 46. Radiographs were evaluated using the modified Stoke Ankylosing Spondylitis Spine Score at baseline and week 46. Patients with new syndesmophytes were identified. Biomarker levels in patients were compared to levels in healthy subjects. Results Higher pretreatment MRI inflammation scores for SI joints and/or lumbar spine were associated with higher baseline CTX-II levels, but not with higher levels of biomarkers of inflammation and bone turnover. During treatment with TNFα inhibitors, a decrease in MRI inflammation scores from baseline to week 22 was associated with larger percentage decreases in and a normalization of CRP and IL-6 levels as compared to an increase or no change in MRI scores. Development of new syndesmophytes was associated with larger percentage decreases in CRP and IL-6 levels and an increase in osteocalcin level, and with normalization of CRP and IL-6 levels from baseline to week 22. Persistent systemic inflammation was associated with radiographic nonprogression. Conclusion Our findings indicate that inflammation on baseline MRI is associated with higher CTX-II levels. Radiographic progression is associated with decreased systemic inflammation, as assessed by IL-6 and CRP levels and MRI, supporting the notion of a link between the resolution of inflammation and new bone formation in SpA patients during anti-TNFα therapy.

Objective To study the relationship between spinal mobility, radiographic damage of the spine and spinal inflammation as assessed by MRI in patients with ankylosing spondylitis (AS). Methods In this subanalysis of the Ankylosing Spondylitis Study for the Evaluation of Recombinant Infliximab Therapy cohort, 214 patients, representing an 80% random sample, were investigated. Only baseline data were used. MRI inflammation was assessed by the AS spinal MRI activity (ASspiMRI-a) score, structural damage by the modified Stoke AS Spine Score (mSASSS) and spinal mobility by the linear definition of the Bath Ankylosing Spondylitis Metrology Index (BASMI). Univariate correlations were calculated on baseline values using Spearman rank correlation. Independent associations between the variables of interest were investigated by multivariate linear regression analysis. Associations with clinical disease activity, C-reactive protein, disease duration, age, gender, body mass index and HLA-B27 status were also investigated. Subanalyses were performed according to disease duration. Results BASMI correlated moderately well with mSASSS (Spearman's rho = 0.6) and weakly with ASspiMRI-a (rho = 0.3). A best-fit model for BASMI included both mSASSS (regression coefficient (B) = 0.865, p 3 years B was greater for mSASSS than for ASspiMRI-a (0.924 vs 0.156). Conclusion Spinal mobility impairment in AS is independently determined both by irreversible spinal damage and by reversible spinal inflammation. Spinal mobility impairment is more influenced by spinal inflammation in early disease, and by structural damage in later disease.

Objective.Magnetic resonance imaging (MRI) is increasingly used to measure articular inflammation and damage in patients with psoriatic arthritis (PsA). We evaluated the reliability of a new OMERACT PsA MRI scoring system, PsAMRIS, in PsA fingers.Methods.In 2 separate studies, MRI scans were obtained from patients with clinical evidence of synovitis or dactylitis of the fingers. For the first cross-sectional study, images were obtained at one timepoint. For the second longitudinal study, images were obtained at 2 timepoints, 6 weeks apart. Scans were scored using PsAMRIS in an international multireader setting, for synovitis, tenosynovitis, periarticular inflammation, bone edema, bone erosions, and bone proliferation.Results.Global status scores from both datasets revealed moderate to high reliability for scoring most features, although reliability was poor for periarticular inflammation in the cross-sectional study. Change scores that reflected inflammatory activity also exhibited moderate to good reliability in the longitudinal exercise, despite there being very little absolute change in MRI synovitis or tenosynovitis observed in this dataset. At the distal interphalangeal joints, reliability for change scores was acceptable only for synovitis and tenosynovitis.Conclusion.Further development and testing of the PsAMRIS is planned to improve its performance as a clinical and research tool to identify and measure pathology in peripheral joint PsA.

This article describes a preliminary OMERACT psoriatic arthritis magnetic resonance image scoring system (PsAMRIS) for evaluation of inflammatory and destructive changes in PsA hands, which was developed by the international OMERACT MRI in inflammatory arthritis group. MRI definitions of important pathologies in peripheral PsA and suggestions concerning appropriate MRI sequences for use in PsA hands are also provided.

Acute rehabilitation refers to the multidisciplinary rehabilitative treatment of patients in continuing need of integrated acute and rehabilitative longterm care. As a result of the advances in acute rheumatology and improved emergency services, an increasing number of patients survive episodes of severe disease and complications of immunosuppressive therapy. These patients require not only treatment of their acute medical problems but also specialized multidisciplinary acute rehabilitation starting as early as possible during their hospital stay. We describe 4 typical cases from the major fields of rheumatology. (1) Acute rehabilitation of a 63-year-old woman with rheumatoid arthritis after replacement of both preexisting knee endoprostheses in one session and removal of the left hip endoprosthesis due to infection and sepsis. (2) Rehabilitation of a 29-year-old man with a 7-year history of ankylosing spondylitis who lived in an adjustable easy chair for 2 years due to severe pain prior to admission. (3) A 61-year-old woman with active refractory Wegener’s granulomatosis who developed respiratory insufficiency due to aspergillus and pseudomonas pneumonia. (4) The acute rehabilitation of a 21-year-old woman with systemic lupus erythematosus and a history of 14 laparotomies due to severe acute pancreatitis and multiple gut perforations. Acute rehabilitation was complicated by a large defect of the abdominal wall and significant critical illness polyneuropathy. Our report points out differences between acute, postacute, and longterm rehabilitation, describes the mobilization of patients in acute rheumatology units, and defines specific problems encountered in acute hospital-based rehabilitation of rheumatological patients.