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The rapid development of COVID-19 vaccines in the wake of the COVID-19 pandemic has led to an equally expediently deployed vaccination campaign with more than 12 billion vaccinations administered worldwide. Reports of vaccine-associated adverse reactions (VAARs) have ranged from headaches and pain at the injection site to potentially life-threatening events such as cerebral venous sinus thrombosis. The heart has also not been spared of VAARs, as vaccine-associated myocardial infarction and more commonly, albeit still rare, myocarditis and perimyocarditis have been reported in predominantly young male recipients.Cardiac magnetic resonance imaging findings of vaccine-associated myocarditis such as prolonged T1 and T2 relaxation times, increased T2 signal intensity ratio, and subepicardial late gadolinium enhancement have been demonstrated to be similar to those in virus-induced myocarditis, enabling the use of the modified 2018 Lake Louise Criteria for diagnostic purposes to confirm vaccination-associated myocardial inflammation. Other reported cardiac findings such as cardiomyopathies and arrhythmias were confined to case reports. The incidence of myocardial infarction was not noted to be higher than in the overall population.The overall preliminary prognosis of vaccine- associated myocarditis seems to be good as suggested by initial reports, but long-term follow-up is needed to sufficiently assess possible sequelae and consequences.HINTERGRUND: Die rasche Entwicklung von COVID-19-Impfstoffen im Rahmen der COVID-19-Pandemie hat zu einer zügigen Impfkampagne geführt, im Rahmen derer mehr als 12 Mrd. Impfungen weltweit durchgeführt wurden. Die Berichte über Impfnebenwirkungen („vaccine-associated adverse reactions“, VAAR) reichen dabei von Kopfschmerzen und Schmerzen an der Injektionsstelle bis hin zu potenziell lebensbedrohlichen Ereignissen wie zerebrale Venen- und Sinusthrombosen. Auch kardiale Impfnebenwirkungen wurden beschrieben. Solche kardialen VAAR scheinen überwiegend junge Männer zu betreffen. Obwohl diese kardialen Impfnebenwirkungen sehr selten sind, gibt es einige Berichte über Myokarditiden und Perimyokarditiden nach Impfung.Die Magnetresonanztomographie(MRT)-Befunde der impfassoziierten Myokarditis, wie verlängerte T1- und T2-Relaxationszeiten, fokale T2-Signalerhöhungen und ein subepikardiales Late-Gadolinium-Enhancement ähneln nachweislich denen der virusinduzierten Myokarditis, sodass die modifizierten Lake-Louise-Kriterien 2018 für diagnostische Zwecke zum Nachweis einer impfassoziierten myokardialen Inflammation verwendet werden können. Sonstige kardiale Befunde wie Kardiomyopathien und Arrhythmien beschränken sich aktuell auf Fallberichte. Berichte über Myokardinfarkte nach Impfung sind ebenfalls sehr selten. Die Inzidenz von Myokardinfarkten ist nicht höher als in der Gesamtbevölkerung.Die vorläufige Gesamtprognose der impfstoffassoziierten Myokarditis scheint den ersten Berichten zufolge gut zu sein, doch sind langfristige Nachuntersuchungen erforderlich, um mögliche Folgeerkrankungen und Konsequenzen ausreichend bewerten zu können.

Objectives To find simple imaging-based features on cardiac magnetic resonance (CMR) that are associated with major adverse cardiovascular events (MACE) in takotsubo syndrome (TTS). Methods Patients with TTS referred for CMR between 2007 and 2021 were retrospectively evaluated. Besides standard CMR analysis, commonly known complications of TTS based on expert knowledge were assessed and summarised via a newly developed PE2RT score (one point each for pleural effusion, pericardial effusion, right ventricular involvement, and ventricular thrombus). Clinical follow-up data was reviewed up to three years after discharge. The relationship between PE2RT features and the occurrence of MACE (cardiovascular death or new hospitalisation due to acute myocardial injury, arrhythmia, or chronic heart failure) was examined using Cox regression analysis and Kaplan–Meier estimator. Results Seventy-nine patients (mean age, 68 ± 14 years; 72 women) with TTS were included. CMR was performed in a median of 4 days (IQR, 2–6) after symptom onset. Over a median follow-up of 13.3 months (IQR, 0.4–36.0), MACE occurred in 14/79 (18%) patients: re-hospitalisation due to acute symptoms (9/79, 11%) or chronic heart failure symptoms (4/79, 5%), and cardiac death (1/79, 1%). Patients with MACE had a higher PE2RT score (median [IQR], 2 [2–3] vs 1 [0–1]; p 2RT score was associated with MACE on Cox regression analysis (hazard ratio per PE2RT feature, 2.44; 95%CI: 1.62–3.68; p 2RT complications were strongly associated with the occurrence of MACE (log-rank p Conclusions The introduced PE2RT complication score might enable an easy-to-assess outcome evaluation of TTS patients by CMR. Key Points • Complications like pericardial effusion, pleural effusion, right ventricular involvement, and ventricular thrombus (summarised as PE2RT features) are relatively common in takotsubo syndrome. • The proposed PE2RT score (one point per complication) was associated with the occurrence of major adverse cardiac events on follow-up. • Complications easily detected by cardiac magnetic resonance imaging can help clinicians derive long-term prognostic information on patients with takotsubo syndrome.

Abstract Objectives To analyse the diagnostic impact of dual energy computed tomography (DECT) in acute gout flares and acute calcium pyrophosphate (CPP) crystal arthritis when compared to the gold standard of arthrocentesis with compensated polarised light microscopy. Microscopy results were also compared to musculoskeletal ultrasound (MUS), conventional radiographs, and the suspected clinical diagnosis (SCD). Methods Thirty-six patients with a suspected gout flare (n = 24) or acute CPP crystal arthritis (n = 11, n = 1 suffered from neither) who received a DECT and underwent arthrocentesis were included. Two independent readers assessed DECT images for signs of monosodium urate crystals or calcium pyrophosphate deposition. Results Sensitivity of DECT for gout was 63% (95% CI 0.41–0.81) with a specificity of 92% (0.41–0.81) while sensitivity and specificity for acute CPP arthritis were 55% (0.23–0.83) and 92% (0.74–0.99), respectively. MUS had the highest sensitivity of all imaging modalities with 92% (0.73–0.99) and a specificity of 83% (0.52–0.98) for gout, while sensitivity and specificity for acute CPP crystal arthritis were 91% (0.59–1.00) and 92% (0.74–0.99), respectively. Conclusion DECT is an adequate non-invasive diagnostic tool for acute gout flares but might have a lower sensitivity than described by previous studies. Both MUS and SCD had higher sensitivities than DECT for acute gout flares and acute CPP crystal arthritis. Key Points• DECT offers a lower sensitivity for acute gout flares than previously described.• DECT sensitivity for acute CPP crystal arthritis is less than the already validated ultrasound.

Aims The exact role of portal hypertension in cirrhotic cardiomyopathy remains unclear, and it is uncertain whether cardiac abnormalities also occur in non-cirrhotic portal hypertension (NCPH). This magnetic resonance imaging (MRI) study aimed to evaluate the presence of subclinical myocardial dysfunction, oedema, and fibrosis in NCPH. Methods and results In this prospective study (2018–2022), participants underwent multiparametric abdominal and cardiac MRI including assessment of cardiac function, myocardial oedema, late gadolinium enhancement (LGE), and abdominal and cardiac mapping [T1 and T2 relaxation times, extracellular volume fraction (ECV)]. A total of 111 participants were included [44 participants with NCPH (48 ± 15 years; 23 women), 47 cirrhotic controls, and 20 healthy controls]. The cirrhotic group was dichotomized (Child A vs. Child B/C). NCPH participants demonstrated a more hyperdynamic circulation compared with healthy controls (cardiac index: 3.7 ± 0.6 vs. 3.2 ± 0.8 L/min/m², P = 0.004; global longitudinal strain: −27.3 ± 4.6 vs. −24.6 ± 3.5%, P = 0.022). The extent of abnormalities indicating myocardial fibrosis and oedema in NCPH was comparable with Child A cirrhosis (e.g. LGE presence: 32 vs. 33 vs. 69%, P = 0.004; combined T1 and T2 elevations: 46 vs. 27 vs. 69%, P = 0.017; NCPH vs. Child A vs. Child B/C). Correlations between splenic T1 and myocardial T1 values were found (r = 0.41; P = 0.007). Splenic T1 values were associated with the presence of LGE (odds ratio, 1.010; 95% CI: 1.002, 1.019; P = 0.013). Conclusion MRI parameters of myocardial fibrosis and oedema were altered in participants with NCPH to a similar extent as in compensated cirrhosis and were associated with splenic markers of portal hypertension, indicating specific portal hypertensive cardiomyopathy.

The aim of this study was to compare a new compressed sensing (CS) method for T2-weighted propeller acquisitions (T2CS) with conventional T2-weighted propeller sequences (T2conv) in terms of achieving a higher image quality, while reducing the acquisition time.Male participants with a clinical suspicion of prostate cancer were prospectively enrolled and underwent prostate magnetic resonance imaging at 3 T. Axial and sagittal images of the T2conv sequence and the T2CS sequence were acquired. Sequences were qualitatively assessed by 2 blinded radiologists concerning artifacts, image-sharpness, lesion conspicuity, capsule delineation, and overall image quality using 5-point Likert items ranging from 1 (nondiagnostic) to 5 (excellent). The apparent signal-to-noise ratio and apparent contrast-to-noise ratio were evaluated. PI-RADS scores were assessed for both sequences. Statistical analysis was performed by using Wilcoxon signed rank test and paired samples t test. Intrarater and interrater reliability of qualitative image evaluation was assessed using intraclass correlation coefficient (ICC) estimates.A total of 29 male participants were included (mean age, 66 ± 8 years). The acquisition time of the T2CS sequence was respectively 26% (axial plane) and 24% (sagittal plane) shorter compared with the T2conv sequence (eg, axial: 171 vs 232 seconds; P0.001). In the axial plane, the T2CS sequence had fewer artifacts (4 [4-4.5] vs 4 [3-4]; P0.001), better image-sharpness (4 [4-4.5] vs 3 [3-3.5]; P0.001), better capsule delineation (4 [3-4] vs 3 [3-3.5]; P0.001), and better overall image quality (4 [4-4] vs 4 [3-4]; P0.001) compared with the T2conv sequence. The ratings of lesion conspicuity were similar (4 [4-4] vs 4 [3-4]; P = 0.166). In the sagittal plane, the T2CS sequence outperformed the T2conv sequence in the categories artifacts (4 [4-4] vs 3 [3-4]; P0.001), image sharpness (4 [4-5] vs 4 [3-4]; P0.001), lesion conspicuity (4 [4-4] vs 4 [3-4]; P = 0.002), and overall image quality (4 [4-4] vs 4 [3-4]; P = 0.002). Capsule delineation was similar between both sequences (3 [3-4] vs 3 [3-3]; P = 0.07). Intraobserver and interobserver reliability for qualitative scoring were good (ICC intra: 0.92; ICC inter: 0.86). Quantitative analysis revealed a higher apparent signal-to-noise ratio (eg, axial: 52.2 ± 9.7 vs 22.8 ± 3.6; P0.001) and a higher apparent contrast-to-noise ratio (eg, axial: 44.0 ± 9.6 vs 18.6 ± 3.7; P ≤ 0.001) of the T2CS sequence. PI-RADS scores were the same for both sequences in all participants.CS-accelerated T2-weighted propeller acquisition had a superior image quality compared with conventional T2-weighted propeller sequences while significantly reducing the acquisition time.

PURPOSE: To evaluate the diagnostic performance of layer-specific cardiac MRI feature-tracking (FT) strain analysis in patients with acute myocarditis. MATERIALS AND METHODS: Seventy patients (mean age, 43 years ± 19 [SD]; 46 men) with clinically defined acute myocarditis and 42 healthy controls who underwent cardiac MRI from March 2014 to November 2018 were retrospectively analyzed. FT-based left ventricular peak systolic global longitudinal strain (GLS) and global circumferential strain (GCS) were assessed at subendocardial, midmyocardial, and subepicardial layers. The 2018 Lake Louise criteria (LLC) were assessed. Patients with myocarditis were dichotomized into two groups: those with preserved and those with reduced ejection fraction. For statistical analysis, unpaired t test, one-way analysis of variance, Pearson correlation, and receiver operating characteristic analysis were used. RESULTS: GLS and GCS values of all layers (eg, midmyocardial GCS: −21.3% ± 5.5 vs −28.0% ± 4.3; P < .001) were impaired in patients with myocarditis compared with controls. Only subepicardial GLS (−20.0% ± 3.3 vs −17.5% ± 3.3; P < .001) and midmyocardial GCS values (−28.0% ± 4.3 vs −23.1% ± 4.3; P < .001) could differentiate between controls and patients with preserved ejection fraction. Midmyocardial GCS correlated with inflammatory myocardial parameters (eg, late gadolinium enhancement percentage, r = 0.48, P < .001). Midmyocardial GCS (area under the receiver operating characteristic curve [AUC], 0.82) and subepicardial GLS (AUC, 0.77) had the highest diagnostic performance for acute myocarditis diagnosis (P < .05 against all other strain parameters). The diagnostic performance of the 2018 LLC was significantly improved by inclusion of these two strain parameters (AUC, 0.92 vs 0.97; P = .04). CONCLUSION: Diagnostic performance of cardiac MRI FT strain was different between myocardial layers in acute myocarditis, with midmyocardial GCS and subepicardial GLS providing the highest diagnostic performance. Keywords: MRI, Cardiac, Heart, Left Ventricle, Inflammation, Tissue Characterization, MR–Functional Imaging, Feature-Tracking Strain, Acute Myocarditis Supplemental material is available for this article. © RSNA, 2022

To evaluate cardiac MRI characteristics in patients with suspected hypersensitivity myocarditis following mRNA COVID-19 vaccination.Patients clinically suspected of acute myocarditis after COVID-19 vaccination were retrospectively analyzed and compared against a healthy control group. Cardiac MRI protocol included parameters such as T1 and T2 relaxation times, extracellular volume (ECV), T2 signal intensity ratio, and late gadolinium enhancement (LGE). Lymph node size was assessed in the patient group on the injection side. Student t-test, analyses of variance (ANOVA) with Tukey post-hoc test, and χ20 patients with clinically suspected post-vaccine myocarditis (28 ± 12 years; 12 men) and 40 controls (31 ± 11 years; 25 men) were evaluated. According to the 2018 Lake Louise criteria (LLC), patients with clinically suspected myocarditis were further subdivided into an LLC-positive group (n = 9) and an LLC-negative group (n = 11). The mean time of symptom onset after vaccination was 1.1 ± 1.2 days (LLC-positive) and 6.5 ± 9.2 days (LLC-negative). Group differences in inflammatory variables between myocarditis patients and control subjects were more pronounced in the LLC-positive group (e. g., T1 relaxation time: 1041 ± 61 ms [LLC positive] vs. 1008 ± 79 ms [LLC-negative] vs. 970 ± 25 ms [control]; p .001; or T2 signal intensity ratio 2.0 ± 0.3 vs. 1.6 ± 0.3 [LLC-negative] and vs. 1.6 ± 0.3 [control], p = .012). LLC-positive patients were significantly faster in receiving an MRI after initial symptom onset (8.8 ± 6.1 days vs. 52.7 ± 33.4 days; p = .001) and had higher troponin T levels (3938 ± 5850 ng/l vs. 9 ± 11 ng/l; p .001). LGE lesions were predominantly located at the subepicardium of the lateral wall. Axillary lymphadenopathy was more frequent in the LLC-positive group compared to the LLC-negative group (8/9 [89 %] vs. 0/11 [0 %], p 0.001).Vaccine-induced myocarditis should be considered in patients with acute symptom onset after mRNA vaccination, especially if elevated serum troponin T is observed. Imaging findings of vaccine-induced myocarditis are similar to virus-induced myocarditis, allowing for the use of the Lake Louise Criteria for diagnostic purposes.· Vaccine-induced hypersensitivity myocarditis can be confirmed with cardiac MRI. · Especially patients with sudden onset of symptoms and elevated serum troponin T had positive cardiac MRI findings. · Cardiac MRI characteristics of vaccine-induced myocarditis are similar to those in virus-induced myocarditis.· Kravchenko D, Isaak A, Mesropyan N et al. Cardiac MRI in Suspected Acute Myocarditis After COVID-19 mRNA Vaccination. Fortschr Röntgenstr 2022; 194: 1003 - 1011.ZIEL: Analyse der kardialen MRT-Befunde bei Patienten mit Hypersensitivitätsmyokarditis nach mRNA-COVID-19-Impfung.Patienten mit klinischem Verdacht auf akute Myokarditis nach mRNA-COVID-19-Impfung wurden retrospektiv analysiert und mit einer gesunden Kontrollgruppe verglichen. Das Herz-MRT-Protokoll enthielt Parameter wie T1- und T2-Relaxationszeiten, extrazelluläres Volumen (EZV), die T2-Signalintensitätsratio und Late Gadolinium Enhancement (LGE). Die axilläre Lymphknotengröße bei den Patienten wurde auf der Impfseite bestimmt. Für die statistische Analyse wurden der Student-t-Test, Varianzanalysen (ANOVA) mit Tukey-Post-hoc-Test und der χ20 Patienten mit Verdacht auf Myokarditis nach Impfung (28 ± 12 Jahre; 12 Männer) und 40 Kontrollen (31 ± 11 Jahre; 25 Männer) wurden analysiert. Gemäß der 2018er Lake-Louise-Kriterien (LLC) wurden die Patienten in eine LLC-positive Gruppe (n = 9) und eine LLC-negative Gruppe (n = 11) unterteilt. Die mittlere Zeit nach Impfung bis zum Symptombeginn betrug 1,1 ± 1,2 Tage (LLC-positiv) bzw. 6,5 ± 9,2 Tage (LLC-negativ). Die Gruppenunterschiede der Entzündungsparameter zwischen Myokarditispatienten und Kontrollen waren in der LLC-positiven Gruppe ausgeprägter (z. B. T1-Relaxationszeit: 1041 ± 61 ms [LLC-positiv] vs. 1008 ± 79 ms [LLC-negativ] vs. 970 ± 25 ms [Kontrolle], p ,001; oder T2-Signalintensitätsratio 2.0 ± 0.3 vs. 1.6 ± 0.3 [LLC negativ] und vs. 1.6 ± 0.3 [Kontrolle], p = ,012). LLC-positive Patienten erhielten nach Symptombeginn schneller ein MRT (8,8 ± 6,1 Tage vs. 52,7 ± 33,4 Tage; p = ,001) und hatten höhere Troponin T-Werte (3938 ± 5850 ng/l vs. 9 ± 11 ng/l; p ,001). LGE-Läsionen waren überwiegend subepikardial in der Lateralwand lokalisiert. Axilläre Lymphadenopathien waren in der LLC-positiven Gruppe häufiger als in der LLC-negativen Gruppe (8/9 [89 %] vs. 0/11 [0 %] p ,001).Eine Myokarditis nach mRNA-Impfung sollte bei akutem Auftreten von Symptomen vermutet werden, insbesondere bei erhöhten Troponin-Werten. Die MRT-Befunde einer impfinduzierten Myokarditis sind mit denen einer virusinduzierten Myokarditis vergleichbar, sodass die Lake-Louise-Kriterien zur Diagnosebestätigung angewendet werden können.· Hypersensitivitätsmyokarditiden nach stattgehabter mRNA-Impfung können mit der kardialen MRT bestätigt werden. · Insbesondere Patienten mit plötzlichem Symptombeginn und erhöhtem Troponin T hatten auffällige MRT-Befunde. · Die MRT-Befunde einer impfungsinduzierten Myokarditis waren vergleichbar mit denen viraler Myokarditiden.

We aimed to investigate the diagnostic utility of MRI extracellular volume fraction (ECV) for the assessment of liver cirrhosis severity as defined by Child-Pugh class. In this retrospective study, 90 patients (68 cirrhotic patients and 22 controls), who underwent multiparametric liver MRI, were identified. Hepatic T1 relaxation times and ECV were assessed. Clinical scores of liver disease severity were calculated. One-way analysis of variance (ANOVA) followed by Tukey's multiple comparison test, Spearman's correlation coefficient, and receiver operating characteristic (ROC) analysis were used for statistical analysis. In cirrhotic patients, hepatic native T1 increased depending on Child-Pugh class (620.5 ± 78.9 ms (Child A) vs. 666.6 ± 73.4 ms (Child B) vs. 828.4 ± 91.2 ms (Child C), P 0.001). ECV was higher in cirrhotic patients compared to the controls (40.1 ± 11.9% vs. 25.9 ± 4.5%, P 0.001) and increased depending of Child-Pugh class (33.3 ± 6.0% (Child A) vs. 39.6 ± 4.9% (Child B) vs. 52.8 ± 1.2% (Child C), P 0.001). ECV correlated with Child-Pugh score (r = 0.64, P 0.001). ECV allowed differentiating between Child-Pugh classes A and B, and B and C with an AUC of 0.785 and 0.944 (P 0.001, respectively). The diagnostic performance of ECV for differentiating between Child-Pugh classes A and B, and B and C was higher compared to hepatic native T1 (AUC: 0.651 and 0.910) and MELD score (AUC: 0.740 and 0.795) (P 0.05, respectively). MRI-derived ECV correlated with Child-Pugh score and had a high diagnostic performance for the discrimination of different Child-Pugh classes. ECV might become a valuable non-invasive biomarker for the assessment of liver cirrhosis severity.

Introduction To evaluate treatment response of uterine fibroids after ultrasound guided high-intensity focused ultrasound (USgHIFU) with a special focus on fibroid size and characterization based on Funaki classification scheme, as well as clinical response to treatment of leading fibroid-associated symptoms. Materials and methods Uterine fibroids treated by USgHIFU were assigned to Funaki type 1–3 based on T2-w-MRI. Differences in size, non-perfused volume ratio (NPVR) and volume reduction over time were determined using T1-/T2-w MRI sequences and contrast-enhanced sonography. Treatment effects on three leading fibroid-associated symptoms were also evaluated. Measurements were compared by mixed model, Bland–Altman’s plot and Spearman’s correlation. Results In this prospective single-center study, 35 patients with 44 symptomatic uterine fibroids were treated by USgHIFU (n = 22, n = 12 and n = 10 assigned to Funaki type 1, 2 and 3, respectively). NPVRs of Funaki type 1 and 2 fibroids were significantly higher compared to type 3 (p = .0023). A significant fibroid shrinkage was observed independent of Funaki type compared to baseline: 38.8 ± 26.9%, 46.7 ± 30.3% and 54.5 ± 29.3% at 3, 6 and 12 months, respectively (each p

Background Myocardial injury and inflammation at cardiac MRI in patients with COVID-19 have been described in recent publications. Concurrently, a chronic COVID-19 syndrome (CCS) after SARS-CoV-2 infection has been observed and manifests with symptoms such as fatigue and exertional dyspnea. Purpose To explore the relationship between CCS and myocardial injury and inflammation as an underlying cause of the persistent complaints in previously healthy individuals. Materials and Methods In this prospective study from January 2021 to April 2021, study participants without known cardiac or pulmonary diseases prior to SARS-CoV-2 infection who had persistent CCS symptoms such as fatigue or exertional dyspnea after convalescence and healthy control participants underwent cardiac MRI. The cardiac MRI protocol included evaluating the T1 and T2 relaxation times, extracellular volume, T2 signal intensity ratio, and late gadolinium enhancement (LGE). Student t tests, Mann-Whitney U tests, and χ2 tests were used for statistical analysis. Results Forty-one participants with CCS (mean age, 39 years ± 13 [standard deviation]; 18 men) and 42 control participants (mean age, 39 years ± 16; 26 men) were evaluated. The median time between the initial incidence of mild to moderate COVID-19 not requiring hospitalization and undergoing cardiac MRI was 103 days (interquartile range, 88-158 days). Troponin T levels were normal. Parameters indicating myocardial inflammation and edema were comparable between participants with CCS and control participants (T1 relaxation times: 978 msec ± 23 vs 971 msec ± 25 [P = .17]; T2 relaxation times: 53 msec ± 2 vs 52 msec ± 2 [P = .47]; T2 signal intensity ratios: 1.6 ± 0.2 vs 1.6 ± 0.3 [P = .10]). Visible myocardial edema was present in none of the participants. Three of 41 (7%) participants with CCS demonstrated nonischemic LGE, whereas no participants in the control group demonstrated nonischemic LGE (0 of 42 [0%]; P = .07). None of the participants fulfilled the 2018 Lake Louise criteria for the diagnosis of myocarditis. Conclusion Individuals with chronic COVID-19 syndrome who did not undergo hospitalization for COVID-19 did not demonstrate signs of active myocardial injury or inflammation at cardiac MRI. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Lima and Bluemke in this issue.

Clinical differentiation between gout, osteoarthritis (OA), and calcium pyrophosphate deposition disease (CPPD) remains a hurdle in daily practice without imaging or arthrocentesis. We performed a retrospective analysis of consecutive patients with gout, CPPD, and OA at a tertiary rheumatology center. A total of 277 patients were enrolled, with 164 suffering from gout, 76 from CPPD, and 37 from OA. We used ANOVA and conditional inference tree analysis (Ctrees) to find associations between clinical, laboratory, and imaging data and gout, OA, and CPPD. The sonographic double contour sign was unable to differentiate gout from CPPD. Ctrees were able to exclude OA and CPPD as possible differentials based on elevated uric acid, C-reactive protein (CRP), presence of arterial hypertension, and sex, diagnosing gout with a sensitivity and specificity of 95.1% and 41.6%, respectively. Elevated CRP was observed using simple linear regressions in patients with type II diabetes, higher cumulative joint scores, increased number of affected joints, as well as elevated uric acid, erythrocyte sedimentation rate, and leukocyte count. Ctrees were able to differentiate gout, OA, and CPPD based on just four characteristics. Inflammatory response correlated with type II diabetes, more or larger joint involvement, and elevated uric acid levels.

Background: Despite ultrasound being an inherent part of medical education, only a few German medical schools have established a comprehensive ultrasound curriculum. This study aimed to explore medical students' perspectives on ultrasound in medical education (USMed).Results: Between January 1st, 2019 und June 30th, 2019, an online survey was conducted among German medical students via the students' associations and their respective teaching facilities. The survey consisted of 17 items regarding USMed. Statements were rated on a 4-point Likert scale for agreement. In total, 1040 students from 31 German medical faculties participated. The majority (1021, 98.2%) reported a very high to high interest in curricular USMed. Students agreed (n = 945, 90.9%) that USMed would be helpful along their entire course of medical studies. Considering the best starting time for USMed, the opinions of German medical students diverged: students studying in a model curriculum preferred to start in the second year (40.7%) while 49% of the students studying in a traditional curriculum preferred to start in the third year (p ≤ 0.001). An insufficient allotment of time for USMed in the planned curriculum (675, 65%) and a lack of courses run by medical faculty (305, 29.4%) were listed as perceived significant barriers to the participation in USMed. Peer teaching was regarded as an effective method in realizing USMed by 731 (70.3%) students.Conclusion: German medical students are very interested and willing to participate in USMed. There appears to be a high demand for US courses offered by medical schools.

Non-opioid analgesics are widely used for pain relief in palliative medicine. However, there is a lack of evidence-based recommendations addressing the efficacy, tolerability, and safety of non-opioids in this field. A comprehensive systematic review and meta-analysis on current evidence can provide a basis for sound recommendations in clinical practice. A database search for controlled trials on the use of non-opioids in adult palliative patients was performed in Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, and EMBASE from inception to 18 February 2018. Endpoints were pain intensity, opioid-sparing effects, safety, and quality of life. Studies with similar patients, interventions, and outcomes were included in the meta-analyses. Our systematic search was able to only identify studies dealing with cancer pain. Of 5991 retrieved studies, 43 could be included (n = 2925 patients). There was no convincing evidence for satisfactory pain relief by acetaminophen alone or in combination with strong opioids. We found substantial evidence of moderate quality for a satisfactory pain relief in cancer by non-steroidal anti-inflammatory drugs (NSAIDs), flupirtine, and dipyrone compared with placebo or other analgesics. There was no evidence for a superiority of one specific non-opioid. There was moderate quality of evidence for a similar pain reduction by NSAIDs in the usual dosage range compared with up to 15 mg of morphine or opioids of equianalgesic potency. The combination of NSAID and step III opioids showed a beneficial effect, without a decreased tolerability. There is scarce evidence concerning the combination of NSAIDs with weak opioids. There are no randomized-controlled studies on the use of non-opioids in a wide range of end-stage diseases except for cancer. Non-steroidal anti-inflammatory drugs, flupirtine, and dipyrone can be recommended for the treatment of cancer pain either alone or in combination with strong opioids. The use of acetaminophen in the palliative setting cannot be recommended. Studies are not available for long-term use. There is a lack of evidence regarding pain treatment by non-opioids in specific cancer entities.

BACKGROUND There is currently a lack of studies that evaluate the effects of matrix electrode neuromodulation on acute pain. In this prospective and randomized cross-over study, we investigated the efficacy of 4 Hz-matrix stimulation on venipuncture-induced pain in 30 healthy subjects. METHODS We compared two conditions of neurostimulation: in EC1 (experimental condition 1), we performed venipuncture during stimulation, with 2.5 min of prestimulation with 600 stimuli; in EC2 (experimental condition 2), the length of stimulation was 5 min, at 1200 stimuli, with subsequent venipuncture. A group with no stimulation was used as control condition. RESULTS The EC2 group did not only show a 77% reduction in puncture pain when compared to the control group (p < 0.001; effect size [ES] d = 1.45), but also had a significant effect compared with EC1 (p < 0.001; ES d = 1.33). EC1, on the other hand, did not demonstrate a significant difference to the control group. The status of the veins was evaluated based on visibility and did not differ significantly between the conditions. CONCLUSION The results of this study showed for the first time that pre-emptive matrix stimulation could be an effective way to reduce acute pain. The duration of stimulation seems to play a key role in the effectiveness of the neurophysiological mechanism of action. Matrix stimulation is a therapeutic intervention with very few side effects, which could, in the future, expand our pain-management options for the treatment of acute pain.

Background:The clinical differentiation between gout, osteoarthritis (OA), and calcium pyrophosphate deposition disease (CPPD) still remains a hurdle in daily practice without imaging or arthrocentesis. Although a plethora of clinical data exists, reliable predictor biomarkers for all but gout are still missing.Objectives:To explore an association between common physical examination, ultrasound and laboratory findings and gout, OA, and CPPD, which can in turn provide reliable diagnostic predictions.Methods:277 patients were retrospectively analysed using ANOVA with Scheffe’s post hoc tests and conditional inference trees regarding biomarkers such as age, sex, body mass index, hypertension, renal status, cumulative affected joint size, number of afflicted joints, double contour sign, intracartiliginous double contour sign, degree of vascularization on ultrasound (DoV), uric acid, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), ferritin, and leucocyte count. Simple linear regressions were carried out to explore associations between increased inflammatory parameters and the above-mentioned biomarkers. Statistically significant associations were defined as p values < 0.05.Results:The male sex was associated with gout (p value < 0.05 vs CPPD and < 0.05 vs OA). OA affected younger patients than CPPD (mean 64.5 vs 73.1 years, p < 0.05). Hypertension was correlated with gout (p < 0.05) and CPPD (p < 0.05), impaired renal status with gout when compared to OA (p < 0.05) but not compared to CPPD (p 0.21). A higher number of involved joints was associated with gout (mean 2.2 joints) compared to OA (1.0, p < 0.05) and CPPD (1.6, p 0.01). The double contour sign was not able to differentiate gout and CPPD with a sensitivity/specificity of 71%/55% for gout and 59%/39% for CPPD. The intracartilaginous double contour sign was specific for CPPD (99%) but with a low sensitivity of 26%. DoV was significantly associated with gout (vs OA, p < 0.05) and CPPD (vs OA, p < 0.05). Unsurprisingly, uric acid was associated with gout while ESR and CRP were increased in gout and CPPD, but not in OA. Some associations were statistically significant but arguably clinically unimportant. Conditional inference trees were able to exclude OA (specificity 97.5%) and CPPD (specificity 94.0%) as possible differentials based on just uric acid, CRP, hypertension, and sex, and diagnose gout with a sensitivity of 95.1%, summarized in Figure 1. Linear regressions demonstrated an elevated CRP response in people suffering from type II diabetes, higher cumulative joint points score, number of affected joints, as well as elevated uric acid, ESR, and leucocyte count.Figure 1.Conditional inference tree using unbiased recursive partitioning to reliably differentiate between gout, osteoarthritis, and calcium pyrophosphate deposition disease.Conclusion:Gout can be reliably diagnosed, simultaneously excluding OA and CPPD as differential diagnoses by conditional inference trees using just four biomarkers. A correlation between inflammatory reaction severity based on CRP levels was found in patients suffering from type II diabetes, more or larger joint involvement and elevated uric acid levels. The double contour sign remains a questionable differentiator between gout and CPPD with a sensitivity/specificity of 71%/55% for gout and 59%/39% for CPPD, similar to findings reported by Löffler et al (1) with a sensitivity/specificity of only 64%/52% for gout.References:[1]Löffler C, Sattler H, Peters L, Löffler U, Uppenkamp M, Bergner R. Distinguishing gouty arthritis from calcium pyrophosphate disease and other arthritides. J Rheumatol 2015; 42(3):513–20.Disclosure of Interests:Dmitrij Kravchenko Shareholder of: Pfizer, Raoul Bergner: None declared, Charlotte Behning: None declared, Valentin Schäfer Speakers bureau: AbbVie, Novartis, BMS, Chugai, Celgene, Medac, Sanofi, Lilly, Hexal, Pfizer, Janssen, Roche, Schire, Onkowissen, Royal College London, Consultant of: Novartis, Chugai, AbbVie, Celgene, Sanofi, Lilly, Hexal, Pfizer, Amgen, BMS, Roche, Gilead, Medac, Grant/research support from: Novartis, Hexal, Lilly, Roche, Celgene, Universität Bonn.

Background:Differentiation of gout and calcium pyrophosphate deposition disease (CPPD) is sometimes difficult as patients often present with a similar clinical picture. Arthrocentesis and subsequent polarization microscopy (PM) remains the gold standard but novel diagnostic approaches such as non-invasive dual energy computed tomography (DECT) have recently been validated for gout. Currently, limited data is available on DECT in patients with CPPD.Objectives:To analyse the diagnostic impact of DECT in gout and CPPD when compared to the gold standard of PM. We further compared the results of PM to ultrasound (US), conventional radiographs (CR), and suspected clinical diagnosis (SCD). Additionally, 15 laboratory parameters were analysed.Methods:Twenty-six patients diagnosed with gout (n = 18) or CPPD (n = 8) who received a DECT and underwent arthrocentesis were included. Two independent readers assessed colour coded, as well as 80 and 120 kV DECT images for signs of monosodium urate (MSU) crystals or CPP deposition. US and CR from the patient’s initial visit along with the SCD were also compared to PM. US examinations were performed by certified musculoskeletal ultrasound specialists. The association of up to 15 laboratory parameters such as uric acid, thyroid stimulating hormone, and C-reactive protein (CRP) with the PM results was analysed.Results:Sensitivity of DECT for gout was 67% (95% CI 0.41-0.87) with a specificity of 88% (95% CI 0.47-1.0). Concerning CPPD, the sensitivity and specificity of DECT was 63% (95% CI 0.25-0.91) and 83% (95% CI 0.59-0.96) respectively. US had the highest sensitivity of 89% (95% CI 0.65-0.99) with a specificity of 75% (95% CI 0.35-0.97) for gout, while the sensitivity and specificity for CPPD were 88% (95% CI 0.47-1.0) and 89% (95% CI 0.65-0.99) respectively. The SCD had the second highest sensitivity for gout at 78% (95% CI 0.52-0.94) with a comparable sensitivity of 63% (95% CI 0.25-0.92) for CPPD. Uric acid levels were elevated in 33% of gout patients and 25% of CPPD patients. While elevated CRP levels were observed in 59% of gout patients and in 88% of CPPD patients, none of the 15 analysed laboratory parameters were found to be significantly linked.Conclusion:DECT provides a non-invasive diagnostic tool for gout but might have a lower sensitivity than suggested by previous studies (67% vs 90%1). DECT sensitivity for CPPD was 63% (95% CI 0.25-0.91) in a sample group of eight patients. Both US and the SCD had higher sensitivities than DECT for gout and CPPD. Further studies with larger patient cohorts are needed in order to determine the diagnostic utility of DECT in CPPD.References:[1]Bongartz, Tim; Glazebrook, Katrina N.; Kavros, Steven J.; Murthy, Naveen S.; Merry, Stephen P.; Franz, Walter B. et al. (2015): Dual-energy CT for the diagnosis of gout: an accuracy and diagnostic yield study. InAnnals of the rheumatic diseases74 (6), pp. 1072–1077. DOI: 10.1136/annrheumdis-2013-205095.Disclosure of Interests:None declared

European journal of pain : EJP 22(1), 58-71 (2018). doi:10.1002/ejp.1089, Published by Wiley-Blackwell, Malden, Mass. [u.a.]

Background Rare rheumatic diseases are challenging for both patients and clinicians. This problem is further propelled by the scarce number of approved treatment regimens. Therapy is often limited to immunosuppression with corticosteroids or off-label use of drugs for common rheumatic diseases. Objectives We have recently described a set of 82 classified rare diseases in rheumatology [1]. In this systematic review, we analysed the evidence for therapeutic regimens from randomized clinical trials of rare rheumatic diseases. Methods For this systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PUBMED and SCOPUS, up to 20th of October 2016. To validate the search strategy, we selected sentinel references. We included randomized controlled trials regarding rare rheumatic diseases and put a focus on pharmacological treatment compared with placebo, application of two drugs, or standard therapy. The term “rare” was defined by the European Union as a condition that occurs in no more than 1 in 2,000 individuals. Two review authors independently assessed trial quality and extracted the data. We screened the search results and included studies if they met the selection criteria. If we identified two or more trials that investigated the same rare disease and used the same assessment tools we performed a meta-analysis. Results 135 studies were screened, of which 34 met the inclusion criteria. In total, we analysed data on 11 different orphan diseases, encompassing 2,324 participants. There was a high degree of statistical and clinical heterogeneity in these trials. Several sources of potential bias were identified in the included studies, for example, a lack of description of the blinding methods and allocation concealment, as well as the small size of the study populations. We included studies such as rituximab against cyclophosphamide in ANCA-associated vasculitis. These studies demonstrated a non-inferiority of rituximab. The meta-analysis resulted a combined odds ratio (OR) of 1.42 in favour of rituximab (95% CI). Further meta-analyses were possible for another 22 studies involving, among others, Behcet9s disease, systemic sclerosis, cryopyrin-associated periodic syndromes, and giant cell arteritis. Compounds studied were immunosuppressants like corticosteroids, methotrexate and azathioprine, or biologicals such as rilonacept, infliximab, and canakinumab. Conclusions A high degree of evidence is hampered by the limited number of study participants in each trial. On the other hand, diseases such as systemic sclerosis, ANCA-associated vasculitides, or Behcet9s disease had more high quality trials available. The amount of data for most other rare disease remains unsatisfactory. References Leyens J, Stieber C, Bender TTA, Mucke M, Seidel MF. (2016) Classification of rare diseases in rheumatology demonstrates a combined prevalence double to the prevalence of ankylosing spondylitis. Ann. Rheum. Dis. 75(Suppl2): 618. Disclosure of Interest None declared