PET-Derived Increased Inflammation in Large Vessels is linked to Relapse-Free Survival in Patients with Giant Cell Arteritis

BACKGROUND

 Despite anti-inflammatory treatment, patients with giant cell arteritis (GCA) experience relapse. We aimed to determine respective relapse predictors focusing on [18F]fluorodeoxyglucose ([18F]FDG)-PET-based parameters.

MATERIAL AND METHODS

 21 therapy-naïve GCA patients received [18F]FDG-PET/CT. Patients were divided in two groups: those who relapsed during course of disease and those who did not. Median follow up was 15 months. [18F]FDG-PET/CT was analyzed for visual (PET vascular activity score [VAS]) and quantitative parameters, including Target-to-background-Ratio with liver (TBRliver) and jugular vein (TBRjv) serving as reference tissues. In addition, clinical parameters were tested.

RESULTS

 8/21 (38.1 %) had relapse. Clinical parameters could not significantly discriminate between relapse vs no-relapse, including age (p = 0.9) or blood-based inflammatory markers (white blood cell counts [WBC] and c-reactive protein [CRP], p = 0.72, each). PETVAS score could also not differentiate between respective subgroups (p = 0.59). In a quantitative assessment, TBRjv demonstrated a trend towards significance (p = 0.28). TBRliver, however, separated between patients with and without relapse (p = 0.03).

CONCLUSION

 [18F]FDG PET quantification of vessels may be useful to identify GCA patients prone to relapse during follow-up.

New-Onset Polymyalgia Rheumatica Complicated by Giant Cell Arteritis Following COVID-19 Infection

A 68-year-old female with a past medical history significant for tophaceous gout presented with pain and stiffness in her bilateral shoulders and hip joints for about two weeks after testing positive for COVID-19. Her laboratory results showed an elevated erythrocyte sedimentation rate (ESR) of 74 mm/h and C-reactive protein (CRP) of 25 mg/L. She showed clinical improvement in her symptoms after steroid therapy and was diagnosed with polymyalgia rheumatica (PMR). Despite prompt treatment with steroids, she continued to have persistent joint pain. Also, she developed new bilateral temporal artery tenderness, headaches, blurry vision, and jaw claudication concerning giant cell arteritis (GCA). She was admitted to the hospital for high-dose pulsed IV methylprednisolone and discharged with a steroid taper along with tocilizumab injections. Her symptoms improved rapidly, and she continued to follow up with rheumatology while continuing low-maintenance doses of prednisone. Although the association between PMR and GCA is well-known, the time it takes to reach disease remission, the rate of relapse, and the length of steroid treatment are variable. There are a few COVID-19-associated cases of PMR and GCA; however, the timeline and pathophysiology of this association remain an area for further investigation.

The Relative Frequency of Small Vessel Cerebrovascular Disease and Brain Atrophy in MRI of Patients with Psoriasis

INTRODUCTION

Psoriasis is a systemic autoimmune disease that is associated with numerous comorbidities.

OBJECTIVE

This study aimed to compare the prevalence of small vessel cerebrovascular disease (SVCD) and atrophic brain changes in MRI of patients with psoriasis and normal subjects.

METHODS

This case-control study was performed on 27 patients with psoriasis and 27 normal individuals who were referred to Shohada-e-Tajrish Hospital, Tehran, Iran during 2019 and 2020. Basic demographic and clinical information of participants were recorded. Brain MRI was performed for all individuals to examine the medial temporal atrophy (MTA) score, global cortical atrophy (GCA) score, and Fazekas scale. Finally, the relative frequencies of each parameter between the two groups were compared.

RESULTS

There was no significant difference in the frequency of the Fazekas scale, GCA, and MTA scores between the two groups. However, a mild trend was found for a higher frequency of Fazekas scale, GCA, and MTA scores in controls in comparison with the case group. While there was no significant relationship between the Fazekas scale and disease duration (p=0.16), a significant and positive correlation was found between disease duration and GCA and MTA scores [p<0.001). There was no significant relationship between Fazekas, GCA and MTA status and other parameters.

CONCLUSIONS

The increase in disease duration was significantly associated with an increase in the incidence of cerebral atrophy, which may suggest the need for screening in terms of CNS involvement in psoriasis patients.

Can a Giant Cell Arteritis (GCA) Risk Stratification Score Be Helpful in Clinical Practice?

INTRODUCTION

Giant cell arteritis (GCA) is the most common type of large vessel vasculitis. The diagnosis of GCA is often challenging and there is a difficult balance of over- and underinvestigation. There have been several proposed scoring systems to help clinicians risk stratify patients who may present with suspected GCA.

METHODS

A retrospective cohort study was performed using electronic medical records of patients referred for a temporal artery biopsy (TAB) and temporal artery ultrasound scan (USS) for suspected GCA. All TABs performed at the Royal Wolverhampton NHS Trust between June 2014 and June 2018 and all USS procedures performed between January 2015 and January 2019 were analysed. Patients who undergo a USS for suspected GCA at our centre routinely have scanned bilateral temporal and axillary arteries. Patients were excluded if they already had a previous diagnosis of GCA (and the clinical question was suspected flare), or if there was insufficient information available.

RESULTS

The total number of patients who underwent a confirmatory diagnostic test (either TAB or USS) for suspected GCA was 187. Thirteen of these patients met the exclusion criteria, the remaining 174 patients were included for analysis. A total of 126 of 174 patients underwent a TAB and 63 of 174 had a USS performed; 15 of 174 who had both these were included in the USS cohort because for all these patients, the ultrasound was the first diagnostic test performed. Our results appear to closely mirror the original multi-centre results with regard to the prediction of biopsy-positive GCA, with the centiles closely following those in the inception cohort. Also, 0% of the 'low' risk probability biopsy cohort were misclassified; none had a positive biopsy. However, 8% of the low-risk-probability ultrasound cohort were misclassified, as two had a positive ultrasound.

CONCLUSION

 Our study highlights that a probability score for GCA derived from a large multi-centre cohort of patients who were biopsy positive predicts ultrasound positivity with similar accuracy. Our work reveals that scoring systems are not infallible but can be helpful in guiding clinical decision making.

Giant cell arteritis treatment patterns and rates of serious infections

OBJECTIVES

Giant cell arteritis (GCA) afflicts older adults who may have age- and comorbidity-related risks for infection and is treated with immunosuppressants that increase risk of infection. We examined GCA treatment patterns and rates of serious infections in two real-world cohorts in the U.S.

METHODS

We identified two GCA cohorts using two U.S. health insurance databases, Medicare (public, 2007-2017) and MarketScan (commercial, 2015-2019), by applying a validated claims-based algorithm with positive predictive value 79.0% for GCA. We required age ≥50 years and assessed baseline comorbidities, dispensing of immunosuppressants and prophylactic antibiotics, and vaccine administration. We calculated incidence rates (IR) of serious infections, defined as bacterial or viral infections requiring hospitalisation based on primary inpatient diagnosis code. Multivariable Cox proportional hazards models estimated hazard ratios for risk of serious infection for prespecified covariates.

RESULTS

The Medicare cohort included 734 patients, 28% male, mean age 77.1; the MarketScan cohort included 1022 patients, 30% male, mean age 68.4. More than 85% used prednisone ≥60mg daily at index date and <10% used tocilizumab. Serious infections developed in 27.9% of Medicare and 7.2% of MarketScan patients: IR per 100 person-years = 10.7 (95% CI 9.3, 12.2) in Medicare and 6.3 (95% CI 5.0, 7.9) in MarketScan. Older age and higher frailty score were significantly associated with increased risk for serious infection.

CONCLUSIONS

In these two U.S. GCA cohorts, high-dose glucocorticoids were the most common initial treatment, and over 25% of Medicare and 7% of MarketScan patients developed serious infection during follow-up. Older age and higher frailty score were associated with higher risk of serious infections, though maximum daily prednisone dose was not. Pneumocystis jiroveci pneumonia was rare in two GCA cohorts despite infrequent use of prophylactic antibiotics.

Time Stand Still: Effects of Temporal Window Selection on Eye Tracking Analysis

The number of possible approaches to conducting and analyzing a research study—often referred to as researcher degrees of freedom—has been increasingly under scrutiny as a challenge to the reproducibility of experimental results. Here we focus on the specific instance of time window selection for time series data. As an example, we use data from a visual world eye tracking paradigm in which participants heard a word and were instructed to click on one of four pictures corresponding to the target (e.g., “Click on the hat”). We examined statistical models for a range of start times following the beginning of the carrier phrase, and for each start time a range of window lengths, resulting in 8281 unique time windows. For each time window we ran the same logistic linear mixed effects model, including effects of time, age, noise, and word frequency on an orthogonalized polynomial basis set. Comparing results across these time ranges shows substantial changes in both parameter estimates and p values, even within intuitively “reasonable” boundaries. In some cases varying the window selection in the range of 100–200 ms caused parameter estimates to change from positive to negative. Rather than rush to provide specific recommendations for time window selection (which differs across studies), we advocate for transparency regarding time window selection and awareness of the effects this choice may have on results. Preregistration and multiverse model exploration are two complementary strategies to help mitigate bias introduced by any particular time window choice.

A Case of Giant Cell Arteritis Presenting After COVID-19 Vaccination: Is It Just a Coincidence?

Giant cell arteritis (GCA) is a large vessel vasculitis with variable presentations, including fevers, myalgias, headache, and jaw claudication. A particularly concerning symptom is transient vision loss, which may become irreversible without prompt recognition and treatment. The pathogenesis of GCA is incompletely understood, but it seems that the innate and adaptive immune systems play a key role in vessel inflammation, remodeling, and occlusion. We present a case of a 79-year-old male who developed GCA two days after he received his second dose of a COVID-19 mRNA vaccine. He presented with headaches, fever, and myalgias. Lab workup revealed elevated inflammatory markers, with C-reactive protein (CRP) 272 mg/L (<8.1 mg/L) and erythrocyte sedimentation rate (ESR) 97 mm/hr (0-20mm/hr). Imaging of the head, with CT and MRI, was unremarkable. His headache persisted despite supportive treatment, and he developed new, transient blurred vision, which increased suspicion for GCA. He underwent bilateral temporal artery biopsies, which were consistent with GCA. His symptoms resolved quickly with oral prednisone 60mg daily, and his inflammatory markers returned to normal within a month. A review of the literature revealed several case reports of giant cell arteritis following influenza vaccination. However, no large-scale studies have demonstrated a causal relationship between GCA and immunization. Our case demonstrates the first instance of GCA following a COVID-19 mRNA vaccine. We propose that the upregulated immune response to the vaccine acted as a trigger for GCA in this patient with predisposing factors. While causation cannot be determined based on one case alone, our case demonstrates an opportunity for further research into the relationship between vasculitis and immunizations. Despite this isolated case, the proven benefits of COVID-19 mRNA vaccines significantly outweigh any theoretical risk of immune dysregulation following administration.

Pore diameter mapping using double pulsed-field gradient MRI and its validation using a novel glass capillary array phantom

Double pulsed-field gradient (d-PFG) MRI can provide quantitative maps of microstructural quantities and features within porous media and tissues. We propose and describe a novel MRI phantom, consisting of wafers of highly ordered glass capillary arrays (GCA), and its use to validate and calibrate a d-PFG MRI method to measure and map the local pore diameter. Specifically, we employ d-PFG Spin-Echo Filtered MRI in conjunction with a recently introduced theoretical framework, to estimate a mean pore diameter in each voxel within the imaging volume. This simulation scheme accounts for all diffusion and imaging gradients within the diffusion weighted MRI (DWI) sequence, and admits the violation of the short gradient pulse approximation. These diameter maps agree well with pore sizes measured using both optical microscopy and single PFG diffusion diffraction NMR spectroscopy using the same phantom. Pixel-by-pixel analysis shows that the local pore diameter can be mapped precisely and accurately within a specimen using d-PFG MRI.

Too much of a good thing: underprovision versus overprovision of partner support

We examined whether support underprovision (receiving less support than is desired) and support overprovision (receiving more support than is desired) should be examined as qualitatively distinct forms of inadequate support in marriage. Underprovision of partner support, overprovision of partner support, and marital satisfaction were assessed 5 times over the first 5 years of marriage in a sample of newlywed husbands and wives (N = 103 couples), and were analyzed via actor-partner interdependence modeling (APIM) and growth curve analytic techniques. Increases in underprovision and overprovision of support were each uniquely associated with declines in marital satisfaction over the first 5 years of marriage; however, overprovision of support was a greater risk factor for marital decline than underprovision. Further, when examining support from a multidimensional perspective, overprovision was at least as detrimental, if not more detrimental, than underprovision for each of 4 support types (i.e., informational, emotional, esteem, and tangible support). The present study is the first to examine the utility of differentiating between underprovision and overprovision of partner support. Theoretical, empirical, and clinical implications are discussed.