First experiences of a low-dose protocol for CT-guided musculoskeletal biopsies combining different radiation dose reduction techniques

Background

The use of computed tomography (CT) for image guidance during biopsies is a powerful approach. The method is, however, often associated with a significant level of radiation exposure to the patient and operator.

Purpose

To investigate if a low-dose protocol for CT-guided musculoskeletal (MSK) biopsies, including a combination of different radiation dose (RD) techniques, is feasible in a clinical setting.

Material and Methods

Fifty-seven patients underwent CT-guided fine-needle aspiration cytology (FNAC) utilizing the low-dose protocol (group A). A similar number of patients underwent CT-guided FNAC using the reference protocol (group B). Between-group comparisons comprised radiation dose, success rate, image quality parameters, and workflow.

Results

In group A, the mean total dose-length product (DLP) was 41.2 ± 2.9 mGy*cm, which was statistically significantly lower than of group B (257.4 ± 22.0 mGy*cm), corresponding to a mean dose reduction of 84% ( P<0.001). The mean CTDIvol for the control scans were 1.88 ± 0.09 mGy and 13.16 ± 0.40 mGy for groups A and B, respectively ( P < 0.001). The success rate in group A was 91.2% and 87.9% in group B ( P = 0.56). No negative effect on image-quality parameters, time of FNAC, and number of control scans were found.

Conclusion

We successfully developed a low-dose protocol for CT-guided MSK biopsies that maintains diagnostic accuracy and image quality at a fraction of the RD compared to the reference biopsy protocol at our clinic.

Good clinical and radiographic outcome of cementless metal metaphyseal sleeves in total knee arthroplasty

Background and purpose - The number of revision total knee arthroplasties (TKA) is continuously increasing, leading to a growing need for reliable management of metaphyseal bone loss. We evaluated patients operated with a TKA using metal metaphyseal sleeves for bone defects with a minimum 5-year follow-up. Patients and methods - 37 patients had been operated on. 3 patients died and 3 patients were lost during follow-up. Of the 31 remainders (20 women), 9 had been operated on with a primary TKA and 22 with a revision TKA at the index surgery. The mean age at surgery was 69 (54-89) years and the mean follow-up time was 7.4 (5-12) years. Bone defects were classified according to the Anderson Orthopaedic Research Institute classification (tibia: type I n = 9, type II n = 5 and type III n = 17; femur: type I n = 12, type II n = 3 and type III n = 16). Results - At final follow-up one-third experienced an improvement concerning walking aids and walking distance. Except for 1 patient, all had full extension and a mean knee flexion of 110 (90-140) degrees. VAS pain at rest was 13 (SD 25) and on movement 30 (SD 31). 7 patients were reoperated due to: infection (n = 4), periprosthetic fracture (n = 1), skin necrosis (n = 1), and wound rupture (n = 1). The cumulative 5-year survival rate for reoperation was 77% (CI 63-92) and for revision 97% (CI 91-100). At the time of final follow-up, the sleeves showed good osseointegration with no signs of progressive radiolucency or migration. Interpretation - Titanium sleeves are a promising option in managing difficult cases with metaphyseal bone defects in TKA, providing a stable construct with good medium-term radiographic outcome.

Comparison of metal ion concentrations and implant survival after total hip arthroplasty with metal-on-metal versus metal-on-polyethylene articulations

Background and purpose - Large metal-on-metal (MoM) articulations are associated with metal wear and corrosion, leading to increased metal ion concentrations and unacceptable revision rates. There are few comparative studies of 28-mm MoM articulations with conventional metal-on-polyethylene (MoP) couplings. We present a long-term follow-up of a randomized controlled trial comparing MoM versus MoP 28-mm articulations, focused on metal ions and implant survival. Patients and methods - 85 patients with a mean age of 65 years at surgery were randomized to a MoM (Metasul) or a MoP (Protasul) bearing. After 16 years, 38 patients had died and 4 had undergone revision surgery. 13 patients were unavailable for clinical follow-up, leaving 30 patients (n = 14 MoM and n = 16 MoP) for analysis of metal ion concentrations and clinical outcome. Results - 15-year implant survival was similar in both groups (MoM 96% [95% CI 88-100] versus MoP 97% [95% CI 91-100]). The mean serum cobalt concentration was 4-fold higher in the MoM (1.5 μg/L) compared with the MoP cohort (0.4 μg/L, p < 0.001) and the mean chromium concentration was double in the MoM (2.2 μg/L) compared with the MoP cohort (1.0 μg/L, p = 0.05). Mean creatinine levels were similar in both groups (MoM 93 μmol/L versus MoP 92 μmol/L). Harris hip scores differed only marginally between the MoM and MoP cohorts. Interpretation - This is the longest follow-up of a randomized trial on 28-mm MoM articulations, and although implant survival in the 2 groups was similar, metal ion concentrations remained elevated in the MoM cohort even in the long term.

A new low-dose multi-phase trauma CT protocol and its impact on diagnostic assessment and radiation dose in multi-trauma patients

Purpose

Computed tomography (CT) examinations, often using high-radiation dosages, are increasingly used in the acute management of polytrauma patients. This study compares a low-dose polytrauma multi-phase whole-body CT (WBCT) protocol on a latest generation of 16-cm detector 258-slice multi-detector CT (MDCT) scanner with advanced dose reduction techniques to a single-phase polytrauma WBCT protocol on a 64-slice MDCT scanner.

Methods

Between March and September 2015, 109 polytrauma patients (group A) underwent acute WBCT with a low-dose multi-phase WBCT protocol on a 258-slice MDCT whereas 110 polytrauma patients (group B) underwent single-phase trauma CT on a 64-slice MDCT. The diagnostic accuracy to trauma-related injuries, radiation dose, quantitative and semiquantitative image quality parameters, subjective image quality scorings, and workflow time parameters were compared.

Results

In group A, statistically significantly more arterial injuries (p = 0.04) and arterial dissections (p = 0.002) were detected. In group A, the mean (±SD) dose length product value was 1681 ± 183 mGy*cm and markedly lower when compared to group B (p < 0.001). The SDs of the mean Houndsfield unit values of the brain, liver, and abdominal aorta were lower in group A (p < 0.001). Mean signal-to-noise ratios (SNRs) for the brain, liver, and abdominal aorta were significantly higher in group A (p < 0.001). Group A had significantly higher image quality scores for all analyzed anatomical locations (p < 0.02). However, the mean time from patient registration until completion of examination was significantly longer for group A (p < 0.001).

Conclusions

The low-dose multi-phase CT protocol improves diagnostic accuracy and image quality at markedly reduced radiation. However, due to technical complexities and surplus electronic data provided by the newer low-dose technique, examination time increases, which reduces workflow in acute emergency situations.

Early treatment intensification induces favourable radiographic outcomes according to predicted versus observed radiographic progression in early rheumatoid arthritis: a subanalysis of the randomised FIN-RACo and NEO-RACo trials

OBJECTIVES

Predicted versus observed radiographic progression in early rheumatoid arthritis (POPeRA) was applied to demonstrate how various treatment modalities affect and potentially minimise radiographic progression over time.

METHODS

The POPeRA method utilises the baseline radiographic score and patient-reported symptom duration to predict radiographic outcomes. It was applied at baseline, 2, and 5 years to patients with eRA from the randomised Finnish RA Combination trial (FIN-RACo) (n=144) and New Finnish RA Combination Therapy (NEO-RACo) (n=90) trials. For FIN-RACo, patients were randomised either to a single DMARD (sulfasalazine, with or without prednisolone) or to combination therapy (methotrexate+sulfasalazine+hydroxychloroquine, i.e. triple therapy, with prednisolone). In NEO-RACo, all patients were assigned intensified combination therapy (including 7.5 mg prednisolone/day) plus a randomised 6-month induction of either placebo or anti-TNF treatment (infliximab).

RESULTS

In FIN-RACo, combination versus monotherapy resulted in superior outcomes in the change from predicted progression over 2 and 5 years (mean 35.7% reduction vs. -32.9%, a worsening from predicted, p=0.001; 34.2% vs. -17.8%, p=0.003, respectively). In NEO-RACo, combination+anti-TNF induction led to significantly greater reductions from predicted progression than combination+placebo, both at 2 and 5 years of follow-up (98.5% vs. 83.4%, p=0.005; 92.4% vs. 82.5%, p=0.027, respectively). Importantly, anti-TNF add-on led to superior reductions from predicted among RF-positive patients (2 years: 97.4% vs. 80.4%, p=0.009; 5 years: 90.2% vs. 80.1%, p=0.030), but not among RF-negative patients.

CONCLUSIONS

These results confirm that conventional combination therapy in eRA has a long-term radiographic benefit versus monotherapy. Through POPeRA, it was made evident that anti-TNF induction therapy for 6 months further increases the long-term radiographic benefit of combination therapy in RF-positive patients.

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

Does MIPO of fractures of the distal femur result in more rotational malalignment than ORIF? A retrospective study

PURPOSE

Intraoperative control of rotational malalignment poses a big challenge for surgeons when using modern MIPO (minimally invasive plate osteosynthesis) techniques. We hypothesized that distal femoral fractures treated with MIPO technique are more often fixed in malrotation than those treated with open reduction internal fixation (ORIF).

METHODS

In this retrospective study, we identified 20 patients who met the inclusion criteria and agreed to take part in the study. In ten patients MIPO was applied, in the other ten ORIF was used. Mean age was 44.8 (19-71 years). Functional status was assessed using clinical scores (Harris Hip Score, WOMAC Hip, KS Score, WOMAC Knee, Kujala Score). Rotational alignment was assessed with magnetic resonance imaging and compared to the opposite leg.

RESULTS

We discovered a significant difference in the mean rotational difference between the MIPO group (14.3°) and the ORIF group (5.2°). Functionally, patients in the ORIF group outperformed patients in the MIPO group in all clinical scoring systems although no one proved to be statistically significant. MIPO technique was associated with significantly more rotational malalignment compared to ORIF in distal femur fracture fixation. However, implant failure and nonunion was more common in the ORIF group, with a revision rate of 3 versus 1 in the ORIF group. Clinical scoring did not significantly different between both groups.

CONCLUSION

Taking into account the undisputable advantages of minimally invasive surgery, improved teaching of methods to avoid malrotation as well as regular postoperative investigations to detect any malrotation should be advocated.

EULAR recommendations for the use of imaging in the diagnosis and management of spondyloarthritis in clinical practice

A taskforce comprised of an expert group of 21 rheumatologists, radiologists and methodologists from 11 countries developed evidence-based recommendations on the use of imaging in the clinical management of both axial and peripheral spondyloarthritis (SpA). Twelve key questions on the role of imaging in SpA were generated using a process of discussion and consensus. Imaging modalities included conventional radiography, ultrasound, magnetic resonance imaging, computed tomography (CT), positron emission tomography, single photon emission CT, dual-emission x-ray absorptiometry and scintigraphy. Experts applied research evidence obtained from systematic literature reviews using MEDLINE and EMBASE to develop a set of 10 recommendations. The strength of recommendations (SOR) was assessed by taskforce members using a visual analogue scale. A total of 7550 references were identified in the search process, from which 158 studies were included in the systematic review. Ten recommendations were produced using research-based evidence and expert opinion encompassing the role of imaging in making a diagnosis of axial SpA or peripheral SpA, monitoring inflammation and damage, predicting outcome, response to treatment, and detecting spinal fractures and osteoporosis. The SOR for each recommendation was generally very high (range 8.9–9.5). These are the first recommendations which encompass the entire spectrum of SpA and evaluate the full role of all commonly used imaging modalities. We aimed to produce recommendations that are practical and valuable in daily practice for rheumatologists, radiologists and general practitioners.

Anti-type II collagen immune complex-induced granulocyte reactivity is associated with joint erosions in RA patients with anti-collagen antibodies

Introduction

Rheumatoid arthritis (RA) patients with autoantibodies against collagen type II (CII) are characterized by acute RA onset with elevated inflammatory measures and early joint erosions as well as increased production of tumor necrosis factor-α (ΤΝF-α) by peripheral blood mononuclear cells (PBMC) stimulated by anti-CII immune complexes (IC) in vitro. Polymorphonuclear granulocytes (PMN) are abundant in RA synovial fluids, where they might interact directly with anti-CII IC in the articular cartilage, but no studies have investigated PMN responses towards anti-CII IC. The aim was to investigate whether PMN react towards anti-CII IC, and to what extent such reactivity might relate to the clinical acute onset RA phenotype associated with elevated levels of anti-CII.

Methods

PMN and PBMC isolated from healthy donors were stimulated with IC made with a set of 72 baseline patient sera (24 anti-CII positive, 48 anti-CII negative) chosen from a clinically well-characterized RA cohort with two-year radiological follow-up with Larsen scoring. PMN expression of cluster of differentiation (CD)11b, CD66b, CD16 and CD32 was measured by flow cytometry, whereas PMN production of myeloperoxidase (MPO) and interleukin (IL)-17, and PBMC production of ΤΝF-α was measured with enzyme linked immunosorbent assay.

Results

PMN expression of CD11b, CD66b and MPO, and PBMC production of ΤΝF-α were upregulated whereas PMN expression of CD16 and CD32 were downregulated by anti-CII IC. CD16, CD66b, and MPO production correlated to serum anti-CII levels (Spearman’s ρ = 0.315, 0.675 and 0.253, respectively). CD16 was associated with early joint erosions (P = 0.024, 0.034, 0.046 at baseline, one and two years) and CD66b was associated with changes in joint erosions (P = 0.017 and 0.016, at one and two years compared to baseline, respectively). CD66b was associated with baseline C-reactive protein and PBMC production of ΤΝF-α was associated with baseline erythrocyte sedimentation rate, in accordance with our earlier findings. No clinical associations were observed for MPO or IL-17.

Conclusion

PMN responses against anti-CII IC are more closely associated with early joint erosions than are PBMC cytokine responses. PMN reactivity against anti-CII IC may contribute to joint destruction in newly diagnosed RA patients with high levels of anti-CII.

Sonoelastography: musculoskeletal applications

All participants for image samplings provided written informed consent. Conventional B-mode ultrasonography (US) has been widely utilized for musculoskeletal problems as a first-line approach because of the advantages of real-time access and the relatively low cost. The biomechanical properties of soft tissues reflect to some degree the pathophysiology of the musculoskeletal disorder. Sonoelastography is an in situ method that can be used to assess the mechanical properties of soft tissue qualitatively and quantitatively through US imaging techniques. Sonoelastography has demonstrated feasibility in the diagnosis of cancers of the breast and liver, and in some preliminary work, in several musculoskeletal disorders. The main types of sonoelastography are compression elastography, shear-wave elastography, and transient elastography. In this article, the current knowledge of sonoelastographic techniques and their use in musculoskeletal imaging will be reviewed.

The pattern of acute injuries in patients from alpine skiing accidents has changed during 2000-2011: analysis of clinical and radiological data at a level I trauma center

OBJECTIVES

During the last decade, many educational efforts and technological improvements have been made to protect skiing athletes from injuries. Whether these efforts have changed the pattern of acute injuries from skiing casualties has not yet been shown on a medical basis, which this longitudinal study examines.

METHODS

All patients transferred to the Department of Radiology of our level I trauma center for acute emergency computed tomography (CT) after alpine skiing accidents from 2000 to 2011 were included. We hypothesized that only patients with clinical suspicion for injuries were admitted for acute CT.

RESULTS

Of all acute patients after skiing accidents, 2,252 could be included. From 2000 to 2011, all cerebral injuries and vascular arterial injuries statistically significantly decreased (p < 0.05, respectively). However, extremity fractures, facial fractures, and vertebral fractures increased (p < 0.04, respectively). The number of cerebral hemorrhages, thoracic injuries, and abdominal injuries remained unchanged (p = NS). The mean (SD) number of all initial radiological examinations per victim statistically significantly decreased from 2.3 (0.7) in 2000 to 1.5 (0.6) in 2011, whereas the admissions for acute CT have significantly increased (p < 0.02; respectively).

CONCLUSIONS

Acute radiological evaluation in skiing accidents has changed during the last decade. The decrease in overall cerebral injuries might be a function of the increasing use of skiing helmets. A protection of the extremities, trunk, spine, and face, however, needs further improvements and their radiological assessment with CT warrants attention in skiing casualties.

Very high levels of anti-citrullinated protein antibodies are associated with HLA-DRB1*15 non-shared epitope allele in patients with rheumatoid arthritis

OBJECTIVE

Production of anti-citrullinated protein antibodies (ACPAs) is an important biomarker for rheumatoid arthritis (RA). We undertook this study to determine whether genetic factors (HLA-DRB1 alleles) are associated with extreme ACPA levels in individuals with ACPA-positive RA, and to ascertain whether there are any phenotypic characteristics associated with these subgroups of RA.

METHODS

HLA-DRB1 allelic groups were genotyped in 1,073 ACPA-positive RA patients from the Swedish Epidemiological Investigation of Rheumatoid Arthritis study. We found that 283 patients (26.4%) had high ACPA levels (defined as >1,500 units/ml using the Euro-Diagnostica anti-CCP2 test), while the rest of the patients had moderate ACPA levels and served as the comparison group. A replication group consisted of 235 RA patients.

RESULTS

No significant differences in baseline disease activity were observed between patients with high and those with moderate ACPA levels. However, the HLA-DRB1*15 allele was associated with high ACPA levels (P=0.0002). A similar trend was detected in HLA-DRB1*15-positive patients in the replication cohort, with meta-analysis of the discovery and replication cohorts demonstrating an overall effect of HLA-DRB1*15 on development of high ACPA levels in both the discovery and replication cohorts (P<0.0001 by Mantel-Haenszel test with a fixed-effects model).

CONCLUSION

Our data indicate that HLA-DRB1*15 may promote the production of high ACPA levels. Due to the high value of ACPA level scores in the 2010 American College of Rheumatology/European League Against Rheumatism classification criteria for RA, the presence of HLA-DRB1*15 may, at least in part, contribute to fulfilling the criteria for RA. This illustrates the complex nature of the genetic regulation of ACPA levels. Additional mechanistic studies of the regulation of ACPAs and ACPA-positive RA are pending.

Endovascular popliteal thrombectomy using the self-expanding, retrievable Solitaire recanalization device

PURPOSE

To present an initial peripheral application of the self-expanding, detachable, fully-retrievable Solitaire FR Recanalization Device for endovascular thrombectomy in the lower leg of a patient with acute peripheral limb ischemia.

CASE REPORT

A 79-year-old woman with a long history of peripheral arterial occlusive disease and a femoropopliteal bypass graft presented with sudden grade IIb ischemia of the left lower leg. Conventional antegrade angiography identified total thrombotic occlusion of the tibioperoneal trunk below the distal femoropopliteal bypass anastomosis; the bypass itself was not occluded. When suction thrombectomy was unsuccessful, a 4×20-mm self-expanding, retrievable Solitaire stent was deployed. The thrombus was retrieved, with immediate recanalization of the tibioperoneal trunk and no sequela. Clinical signs of ischemia resolved, and after 6 months of follow-up, no reocclusion had occurred.

CONCLUSION

Developed as a tool to retrieve clots causing acute ischemic stroke, the Solitaire FR Recanalization Device may also have a place in treating patients with acute below-the-knee thrombotic arterial occlusion in whom suction thrombectomy had failed. The Solitaire stent may be an additional endovascular option that can result in successful treatment of acute limb ischemia and avoid more expensive surgical procedures in selected cases.

Anti-type II collagen antibodies are associated with early radiographic destruction in rheumatoid arthritis

Introduction

We have previously reported that high levels of antibodies specific for native human type II collagen (anti-CII) at the time of RA diagnosis were associated with concurrent but not later signs of inflammation. This was associated with CII/anti-CII immune complex (IC)-induced production of pro-inflammatory cytokines in vitro. In contrast, anti-cyclic citrullinated peptide antibodies (anti-CCP) were associated both with late inflammation and late radiological destruction in the same RA cohort. We therefore hypothesized that anti-CII are also associated with early erosions.

Methods

Two-hundred-and-fifty-six patients from an early RA cohort were included. Baseline levels of anti-CII, anti-CCP and anti-mutated citrullinated vimentin were analyzed with ELISA, and rheumatoid factor levels were determined by nephelometry. Radiographs of hands and feet at baseline, after one and after two years were quantified using the 32-joints Larsen erosion score.

Results

Levels of anti-CII were bimodally distributed in the RA cohort, with a small (3.1%, 8/256) group of very high outliers with a median level 87 times higher than the median for the healthy control group. Using a cut-off discriminating the outlier group that was associated with anti-CII IC-induced production of proinflammatory cytokines in vitro, baseline anti-CII antibodies were significantly (p = 0.0486) associated with increased radiographic damage at the time of diagnosis. Anti-CII-positive patient had also significantly increased HAQ score (p = 0.0303), CRP (p = 0.0026) and ESR (p = 0.0396) at the time of diagnosis but not during follow-up. The median age among anti-CII-positive subjects was 12 years higher than among the anti-CII-negative patients.

Conclusion

In contrary to anti-CCP, anti-CII-positive patients with RA have increased joint destruction and HAQ score at baseline. Anti-CII thus characterizes an early inflammatory/destructive phenotype, in contrast to the late appearance of an inflammatory/destructive phenotype in anti-CCP positive RA patients. The anti-CII phenotype might account for part of the elderly acute onset RA phenotype with rather good prognosis.

Contrast-enhanced ultrasonography for the detection of joint vascularity in arthritis--subjective grading versus computer-aided objective quantification

PURPOSE

To compare joint inflammation assessment using subjective grading of power Doppler ultrasonography (PDUS) and contrast-enhanced ultrasonography (CEUS) versus computer-aided objective CEUS quantification.

MATERIALS AND METHODS

37 joints of 28 patients with arthritis of different etiologies underwent B-mode ultrasonography, PDUS, and CEUS using a second-generation contrast agent. Synovial thickness, extent of vascularized pannus and intensity of vascularization were included in a 4-point PDUS and CEUS grading system. Subjective CEUS and PDUS scores were compared to computer-aided objective CEUS quantification using Qontrast® software for the calculation of the signal intensity (SI) and the ratio of SI for contrast enhancement.

RESULTS

The interobserver agreement for subjective scoring was good to excellent (κ = 0.8 - 1.0; P < 0.0001). Computer-aided objective CEUS quantification correlated statistically significantly with subjective CEUS (P < 0.001) and PDUS grading (P < 0.05). The Qontrast® SI ratio correlated with subjective CEUS (P < 0.02) and PDUS grading (P < 0.03). Clinical activity did not correlate with vascularity or synovial thickening (P = N. S.) and no correlation between synovial thickening and vascularity extent could be found, neither using PDUS nor CEUS (P = N. S.).

CONCLUSION

Both subjective CEUS grading and objective CEUS quantification are valuable for assessing joint vascularity in arthritis and computer-aided CEUS quantification may be a suitable objective tool for therapy follow-up in arthritis.

Heat shock protein 60 and immune inflammatory responses in atherosclerosis

Hallmarks of inflammation in various cardiovascular diseases, notably atherosclerosis, have been observed for a long time. However, evidence for an (auto)antigen-driven process at these sites of inflammation has come forward only recently. Heat shock proteins (HSPs) have been identified as playing either immunologically mediated disease promoting or protective roles. HSP60 has been shown to trigger innate and adaptive immune responses that initiate the earliest still reversible inflammatory stage of atherosclerosis. HSP60 is structurally highly conserved and abundantly expressed by prokaryotic and eukaryotic cells under stressful conditions. Beneficial protective immunity to microbial HSP60 acquired by infection or vaccination and bona fide autoimmunity to biochemically altered autologous HSP60 is present in all humans. In vitro and in vivo experiments have demonstrated that classical atherosclerosis risk factors can act as endothelial stressors that provoke the simultaneous expression of adhesion molecules and of HSP60 in mitochondria, in cytoplasm, and on the cell surface, where it acts as a "danger signal" for cellular and humoral immune reactions. Hence, protective, preexisting anti-HSP60 immunity may have to be "paid for" by harmful (auto)immune cross-reactive attack on arterial endothelial cells maltreated by atherosclerosis risk factors. These experimentally and clinically proven findings are the basis for the autoimmune concept of atherosclerosis.

Entrapment neuropathies II: carpal tunnel syndrome

Diagnostic tests in patients complaining of carpal tunnel syndrome (CTS) are based on physical examination, electrodiagnostic tests (EDTs), and diagnostic imaging. Timely diagnosis helps prevent permanent nerve damage and its sequelae in terms of functional impairment. Imaging provides additional information to that obtained from clinical tests and EDTs. By allowing direct visualization of the compressed median nerve (MN), ultrasound (US) and magnetic resonance imaging can depict the causes for secondary CTS and describe anatomical variants, such as a bifid MN or a persistent median artery of the forearm, as well as space-occupying lesions including tenosynovitis and ganglion cysts. In addition, diagnostic imaging is of value for postoperative patients presenting with persistent symptoms. Finally, US is able to add information for EDT-negative symptomatic patients. Over time, US has increased in its sensitivity and specificity so it can be used as the initial test in patients presenting with clinical symptoms of CTS because it is now equivalent to EDT. The use of US as a screening test may reduce the number of EDT examinations in patients with suspected CTS, providing additional valuable anatomical information.

The "Innsbruck Emergency Algorithm" avoids the underdiagnosis of blunt cervical vascular injuries

OBJECTIVES

Blunt cervical vascular injuries (BCVI) from alpine sports accidents bear an increased risk for being underdiagnosed during initial radiological evaluation. At our hospital, the "Innsbruck Emergency Algorithm", which includes assessment of the neck as a computed tomography (CT) angiography during initial whole-body CT, has been introduced to avoid misdiagnoses and optimizes emergency radiology management.

METHODS

Critically injured patients who were admitted for emergency CT after trauma from alpine skiing and mountain-biking accidents and who were reported with BCVI were included in this retrospective study.

RESULTS

During 2003-2009, 36 victims were eligible for inclusion. They presented with a mean (SD) of 4.6 (2.1) diagnoses per patient, of which 3.5 (2.3) were perceptible on radiology examinations only. The "Innsbruck Emergency Algorithm" was performed in 15 individuals while 21 underwent another CT protocol including a native scan of the neck or during a parenchymatous contrast-medium phase only. In addition to BCVI, most patients (71%) were diagnosed with fractures followed by unspecific contusion/s (54%), head injuries (43%), and injuries of parenchymatous organs (19%). In five (14%), BCVI was underdiagnosed during the initial radiological examination. All of the latter had CT during a parenchymatous contrast-medium phase and not according to the "Innsbruck Emergency Algorithm". Four of those patients died during their hospital stay. In 11, cerebral follow-up examinations showed cerebral pathologies considered as results from BCVI.

CONCLUSIONS

The "Innsbruck Emergency Algorithm" in patients with clinically unapparent BCVI after skiing and mountain-biking accidents avoided overlooking vascular injuries, which significantly improved their long-term outcome.

Increased fracture risk in patients with rheumatic disorders and other inflammatory diseases -- a case-control study with 53,108 patients with fracture

OBJECTIVE

To identify the risk of hip and vertebral fractures in patients with rheumatic disorders (RD) and inflammatory bowel diseases (IBD).

METHODS

This population-based case-control study assessed the fracture risk of patients with rheumatoid arthritis, juvenile idiopathic arthritis (JIA), ankylosing spondylitis (AS), systemic lupus erythematosus, polymyositis/dermatomyositis (PM/DM), systemic sclerosis (SSc), Crohn's disease, and ulcerative colitis (UC). The study cohort comprised 53,108 patients with fracture (66% women) and 370,602 age-matched and sex-matched controls. Conditional logistic regression analysis was performed and results were expressed as OR with corresponding 95% CI.

RESULTS

There was a statistically significant increased fracture risk for all RD and for IBD compared with controls. The magnitude of fracture risk was higher for patients with RD (OR 3, 95% CI 2.9-3.2) than for those with IBD (OR 1.6, 1.4-1.8). The OR in RD ranged from 2.6 (1.3-4.9) for SSc to 4 (3.4-4.6) for AS. The largest increased fracture risk for vertebral fractures was seen in AS (OR 7.1, 6-8.4) and for hip fractures in JIA (OR 4.1, 2.4-6.9).

CONCLUSION

Our results highlight the existence of an increased fracture risk from a variety of underlying causes in patients with RD and IBD. In many inflammatory diseases, implementation of fracture prevention strategies may be beneficial.

Enthesiopathy of the flexor carpi ulnaris at the pisiform: findings of high-frequency sonography

OBJECTIVES

Acute or chronic pain at the pisiform may be due to tendinopathy of the flexor carpi ulnaris tendon (FCU) insertion, mechanical overuse, bony fractures, and osteoarthritis of the pisiform-triquetral joint. Enthesiopathy of the FCU at the pisiform might exhibit abnormalities assessable for sonographic characterization. This study aimed to determine the most relevant sonographic features of tendinopathy of the FCU insertion at the pisiform.

MATERIALS AND METHODS

We retrospectively analyzed radiological findings of 9 patients admitted for high-frequency sonographic evaluation of a painful pisiform FCU insertion. The FCU insertion was assessed for active enthesiopathy in terms of tendon thickening and hyperemia, peritendinous effusion, peritendinous hyperemia, peritendinous soft tissue thickening, cystic fluid collections, erosive cortical irregularities, and osteoproliferative alterations at the pisiform.

RESULTS

Of all patients, 5 had inflammatory rheumatic disorders and the remainder had a painful pisiform FCU insertion related to overuse. While peritendinous effusion, pisiform erosive cortical irregularities, and peritendinous soft tissue thickening at the FCU insertion were exclusively found in rheumatic patients, active enthesiopathy of the FCU tendon, pisiform osteoproliferative alterations, and hyperemia of the peritendinous soft tissue were inconsistent and found in both groups. Cystic fluid collections from the pisiform-triquetral joint were only seen in patients with overuse.

CONCLUSIONS

In this small case series of patients with pain at the pisiform FCU insertion, we could reveal several typical sonographic features for insertion tendinopathy. Further studies should prove if these sonographic features could impact on the management of patients with pain at the pisiform.

Adalimumab (Humira®) restores clinical response in patients with secondary loss of efficacy from infliximab (Remicade®) or etanercept (Enbrel®): results from the STURE registry at Karolinska University Hospital

OBJECTIVES

To determine whether the tumour necrosis factor-alpha (TNF-alpha) antagonist adalimumab (Humira) can be efficacious after secondary loss of efficacy (i.e. loss of clinical response in patients who had initially demonstrated clinical response) to infliximab (Remicade) or etanercept (Enbrel).

PATIENTS AND METHODS

We studied 36 patients from the Stockholm TNF-alpha follow-up registry (STURE) who received adalimumab after secondary loss of efficacy to infliximab (group A, n = 27) or etanercept (group B, n = 9), and 26 patients who were started on adalimumab as the first TNF-alpha antagonist (group C).

RESULTS

In group A, the baseline disease activity score 28 (DAS28) at infliximab institution was 5.5+/-0.2. During infliximab treatment, the mean best DAS28 was 3.7+/-0.2 (p<0.001), but increased to 5.2+/-0.3 when infliximab was stopped. After 3 months on adalimumab, the mean DAS28 decreased to 4.5+/-0.3 (p<0.003), and then to 4.2+/-0.2 at 6 months (p<0.001). In group B, the baseline DAS28 at etanercept institution was 6.6+/-0.5. During etanercept treatment, the mean best DAS28 was 4.6+/-0.5 (p<0.01), but increased to 5.7+/-0.4 by the time etanercept was stopped. After 3 months on adalimumab, the mean DAS28 decreased to 4.8+/-0.3 (p<0.005), and to 4.1+/-0.2 at 6 months (p<0.001). In group C, the mean baseline DAS28 was 5.6+/-0.3. After 6 months of adalimumab therapy, the DAS28 decreased to 3.5+/-0.4 (p<0.001). ACR20 responses with adalimumab in groups A, B, and C were similar (70-78%).

CONCLUSIONS

For patients with secondary loss of efficacy from infliximab or etanercept, switching to adalimumab can restore a good clinical response.

Radiological aspects of injuries of avalanche victims

OBJECTIVE

Increasing numbers of avalanche victims with polytrauma have highlighted their need for radiological injury characterisation, which this study examines.

METHODS

People in Tirol injured by avalanche during 1994-2005 and admitted to the Innsbruck Medical University Hospital were included. Data for this retrospective study were obtained from the Austrian avalanche register and local electronic patient files archive.

RESULTS

During the observation period 94 avalanche victims in Tirol were admitted to our hospital, and a mean of 1.5 radiological methods were used per person at presentation. A mean of three diagnoses per victim were recorded, of which one was eligible for radiological examination only. Most victims (56%) were diagnosed with hypothermia, followed by unspecific contusion (54%), injuries of ligaments, tendons or muscles (26%) and fracture (23%); 21 victims died in hospital.

CONCLUSIONS

Emergency radiological examination can discover injuries otherwise not immediately apparent. However, initial use of radiological assessments such as computed tomography for people admitted under cardiopulmonary resuscitation does not always ensure an optimal outcome.

In vivo imaging of the effect of LPS on arterial endothelial cells: molecular imaging of heat shock protein 60 expression

Bacterial endotoxins are known as stress factors for endothelial cells. In 20 normocholesterolemic New Zealand White (NZW) rabbits, endothelial stress was induced by intravenous (i.v.) injection of lipopolysaccharide (LPS), while eight NZW rabbits were sham-treated or served as untreated controls. In vivo molecular imaging was performed using co-registered computer tomography and positron emission tomography 24 h after i.v. injection of (124)I-labeled monoclonal anti-HSP60 or (124)I-radiolabelled isotype control antibodies. Compared to control animals, in vivo images of rabbit aortae revealed significantly increased endothelial binding of (124)I-labeled anti-HSP60 antibodies upon LPS, especially at sites of aortal branching. This was confirmed by immunohistochemistry and autoradiography data. Our results showed, as proof-of-principle, that HSP60-expression in normocholesterolemic rabbits is significantly increased after induction of endothelial stress and that non-invasive in vivo molecular imaging of early aortal HSP60-expression using (124)I-labeled anti-HSP60 monoclonal antibodies is possible.

In vivo molecular imaging of vascular stress

Noninvasive in vivo imaging is an emerging specialty in experimental radiology aiming at developing hardware and appropriate contrast agents to visualize the molecular basis and pathophysiological processes of many pathological conditions, including atherosclerosis. The list of potentially useful tracers and targets for in vivo molecular imaging in the cascade of early atherosclerotic events has been narrowed down to some very promising endothelial factors, i.e., cell adhesion molecules, macrophages, apoptosis, lipoproteins, heat shock proteins, and others. In this review, we will update on the progress of recent developments in the field of noninvasive molecular imaging in experimental atherosclerosis.

Antibodies against citrullinated vimentin in rheumatoid arthritis: higher sensitivity and extended prognostic value concerning future radiographic progression as compared with antibodies against cyclic citrullinated peptides

OBJECTIVE

The Sa autoantigen can be found in inflamed synovium of patients with rheumatoid arthritis (RA), and at least part of the humoral RA-specific anti-Sa response is directed against citrullinated vimentin. This study was undertaken to evaluate the sensitivity, specificity, and prognostic value of determination of levels of antibodies against modified citrullinated vimentin (anti-MCV) as compared with antibodies against cyclic citrullinated peptides (anti-CCP) in an inception cohort of patients with early RA.

METHODS

Clinical data, radiographs, and measurements of levels of anti-MCV and anti-CCP antibodies were obtained in 273 patients with early RA at baseline, after 3 months, and after 1, 2, 3, and 5 years. Autoantibodies were also analyzed in 100 healthy controls.

RESULTS

Of the 273 patients, 193 (70.7%) were anti-MCV positive and 158 (57.9%) were anti-CCP positive at the time of diagnosis, with nearly equal specificities (95% and 96%, respectively). Forty (14.7%) were anti-MCV positive only, and 5 (1.8%) were anti-CCP positive only. Anti-MCV-positive and anti-MCV-negative patients had similar disease activity at baseline, but presence of anti-MCV was predictive of subsequent high disease activity and continued radiographic progression. Changes in anti-MCV level showed stronger correlation with changes in clinical parameters than did changes in anti-CCP level. The subgroup of patients who were anti-MCV positive and anti-CCP negative showed a higher rate of radiographic destruction than did patients who were negative for both anti-MCV and anti-CCP.

CONCLUSION

These findings show that when patients with early RA are compared with healthy controls, analysis of anti-MCV yields greater sensitivity and unchanged specificity as compared with analysis of anti-CCP. Anti-MCV also appears to perform better than anti-CCP in identifying poor radiographic prognosis in patients with early RA.

Decrease of RA-related orthopaedic surgery of the upper limbs between 1998 and 2004: data from 54,579 Swedish RA inpatients

OBJECTIVES

To describe the overall use and temporal trends in orthopaedic upper limb surgery associated with RA on a nation wide basis in Sweden between 1998 and 2004.

METHODS

Data for all inpatient visits during 1998-2004 for patients older than 18 yrs with RA-related diagnoses were extracted from the Swedish National Hospital Discharge Registry (SNHDR). The SNHDR prospectively collects data on all hospital admissions in Sweden according to the International Classification of Diseases (ICD). Data were analysed with respect to orthopaedic surgery of the hand, elbow and shoulder.

RESULTS

During the study period, 54,579 individual RA patients were admitted to a Swedish hospital and 9% of these underwent RA-related surgery of the upper limbs. The RA patient cohort underwent a total of 8251 RA-related upper limb surgical procedures. The hand (77%) was most frequently operated on, followed by the shoulder (13%) and the elbow (10%). There was a statistically significant decrease of 31% for all admissions associated with RA-related upper limb surgery during 1998-2004 (P = 0.001). Some 10% of all RA-related upper limb surgery was due to total joint arthroplasties (TJAs), mostly for the elbow (59%). During 1998-2004, all TJAs, elbow-TJAs and shoulder-TJAs had a stable occurrence. In contrast, the overall numbers of hand-TJAs significantly increased (P = 0.009).

CONCLUSIONS

Rates of RA-related upper limb surgery decreased and TJAs had a stable occurrence in Sweden during 1998-2004. The findings of this study may reflect trends in disease management and health outcomes of RA patients in Sweden.

Initially overseen vertebral body luxation: diagnosed by dynamic fluoroscopy due to delayed dysphagia

This study relates to the case report of a neurologically intact 13-year-old boy with unrecognized traumatic bipedicular vertebral fracture. He was diagnosed complete vertebral body luxation 1 day later by dynamic fluoroscopy, then successfully treated with surgery that resulted in total recovery. The delayed diagnosis highlights the importance of detailed initial clinical and radiology examinations, even when overt symptoms as diagnostic indicators of severe neurological sequelae expected in similar traumatic vertebral fractures are lacking. A 13-year-old boy, who met with a minor bicycle accident, was presented with two small forehead lacerations but without pain or clinical neurological symptoms for radiological examination, which showed no abnormalities. The following day, however, the patient complained about dysphagia and underwent dynamic fluoroscopy for the assessment of deglutition that revealed a total block of contrast medium. Computer tomography (CT) of the cervicothoracic junction showed a bipedicular thoracic vertebral fracture and a hooked vertebral body luxation causing mechanical dysphagia but, surprisingly, without compression of the spinal cord. The patient fully recovered after carefully carried out protracted distension and orthopaedic surgery with vertebral fusion. One year after surgery, the patient had clinically resumed normal function, and CT showed a sufficient vertebral bony consolidation with anatomical alignment. This case exemplifies the importance of careful initial clinical examination and spinal CT after accidents encompassing an increased risk of spinal fractures, even if neurologically unapparent.

Ankle/hindfoot arthrodesis in rheumatoid arthritis improves kinematics and kinetics of the knee and hip: a prospective gait analysis study

OBJECTIVES

To evaluate the effects of ankle/hindfoot arthrodesis in rheumatoid arthritis (RA) patients on gait pattern of the knee and hip.

METHODS

In this prospective follow-up study, 14 RA patients scheduled for ankle/hindfoot arthrodesis (talo-calcaneal, talo-navicular, calcaneo-cuboid and/or talo-crural joints) and 14 age- and sex-matched healthy controls were included. Three-dimensional gait analyses of joint angles, moments and work were performed at the index operation and after 13 months of follow-up. Each patient underwent clinical assessments of pain while walking, overall evaluation of disease activity, Health Related Quality of Life Questionnaire (EQ-5D), activity limitations, maximum walking distance, difficulty with walking surface and gait abnormality. For comparisons of pre- vs post-operative conditions, Wilcoxon's matched pairs test and Friedman ANOVA by rank test were used.

RESULTS

At follow-up after ankle/hindfoot fusion surgery, RA patients demonstrated a statistically significant improvement in mean range of joint motions, moments and work in the overlying joints such as the knee and hip. Moreover, there was significantly less pain, disease activity, activity limitation, difficulty with walking surface and gait abnormality. EQ-5D and maximum walking distance were also significantly improved at follow-up.

CONCLUSIONS

Our results demonstrate that ankle/hindfoot arthrodesis in RA is an effective intervention to reduce pain and to improve Health Related Quality of Life and functional ability. Moreover, the overlying leg joints experience an improvement in joint motion, muscle-generated joint moments and work during walking. Three-dimensional gait analysis may assist future investigations of the effects of orthopaedic surgery on functional mobility in RA to prevent irreversible disablement.

Morphological analysis of human acupuncture points through immunohistochemistry

OBJECTIVE

At present, the functional mechanism of acupuncture is not yet fully understood. Analysis of the subanatomic morphology of acupuncture points (APs) could help compensate for this shortcoming. In immunohistochemistry, the use of specific antibodies enables in situ characterization of the molecular profile of tissue microenvironments. Thus, as proof in principle for the utility of immunohistochemistry, we determined whether the nerve density in biopsies of autopsied skin of a selected standard AP differed from that of a control point (CP).

DESIGN

We analyzed pairs of skin samples from nine autopsy cases and studied the presence and density of soluble protein 100 (S-100), neuron-specific enolase (NSE), and neurofilament (NF) as markers of peripheral nerve structures. Cross-sections of nerves were counted by conventional microscopy and normalized to millimeters squared of subcutaneous fat, followed by statistical analyses for formal comparisons.

RESULTS

Immunohistochemistry could clearly identify myelinated peripheral nerves. The number of nerve structures expressing S-100 protein was significantly reduced in APs compared with CPs (0.020 1 0.005 vs. 0.061 +/- 0.014; P < 0.006). The same pattern was seen in staining of NSE (AP: 0.011 +/- 0.003 vs. CP: 0.045 +/- 0.011) and NF (AP: 0.011 +/- 0.004 vs. CP: 0.054 +/- 0.015; both P < 0.007).

CONCLUSIONS

In this study, we introduce immunohistochemistry as a suitable technology for acupuncture research. In addition, our findings demonstrate that a human AP is not necessarily associated with an increased but, rather, a significantly decreased number and density of subcutaneous nerve structures compared with skin biopsies from locations not recognized as effective for acupuncture. This pilot study, executed on a limited number of individuals and skin samples, justifies the application of immunohistochemistry on a larger collection of biopsy material.

Orthopaedic surgery of the lower limbs in 49,802 rheumatoid arthritis patients: results from the Swedish National Inpatient Registry during 1987 to 2001

OBJECTIVES

To analyse changes in the rates of hospital admission and use of orthopaedic surgery to the lower limbs in Swedish patients with rheumatoid arthritis between 1987 and 2001.

METHODS

Data for all rheumatoid patients admitted to hospital between 1987 and 2001 were abstracted from the Swedish National Hospital Discharge Register (SNHDR). The data in the register are collected prospectively, recording all inpatient admissions throughout Sweden. The SNHDR uses the codes for diagnoses at discharge and surgical procedures according to the Swedish version of the International Classification of Diseases (ICD).

RESULTS

In all, 49,802 individual patients with rheumatoid arthritis were identified, accounting for 159,888 inpatient visits. Hospital admissions for rheumatoid arthritis decreased by 42% (p<0.001) during the period 1987 to 2001. Twelve per cent of all admissions were for a rheumatoid arthritis related surgical procedure to the lower limbs; those admissions decreased markedly (by 16%) between 1987 and 1996, and by 12% between 1997 and 2001, as did the overall number of rheumatoid arthritis related surgical procedures to the lower limbs during both time periods. Between 1997 and 2001, 47% of all rheumatoid arthritis related surgical procedures were total joint arthroplasties. There was an overall trend towards reduced length of hospital stay after orthopaedic surgery to the lower limbs during the study period.

CONCLUSIONS

Rates of hospital admission and rheumatoid arthritis related surgical procedures to the lower limbs in Swedish patients with rheumatoid arthritis decreased between 1987 and 2001. This may reflect trends in disease severity, management, and health outcomes of this disease in Sweden.

Morphological Characterization of Receptor Activator of NFkappaB Ligand (RANKL) and IL-1beta Expression in Rodent Collagen-Induced Arthritis

Bone loss represents a major unsolved problem in rheumatoid arthritis (RA). The receptor activator of nuclear factor-kappaB ligand (RANKL) is essential for the development and activation of osteoclasts, which are key mediators of bone erosions. This study was performed to determine temporal and spatial expression of RANKL compared with the potentially destructive cytokine interleukin-1beta (IL-1beta), related to progression of synovitis and joint destruction in collagen-induced arthritis (CIA), a model of RA. CIA was induced in dark agouti (DA) rats, and tissue specimens were obtained for immunohistochemical analyses at various time points before and after disease onset. Arthritis was monitored visually, and joint pathology was examined histologically. No disease-preceding expression of RANKL was detected. However, a marked increase of both RANKL- and IL-1beta-expressing cells correlated with the progression of synovial inflammation and clinical disease severity. Abundant and concomitant expression of these cytokines was detected at sites of bone erosion, where a colocalization by osteoclast-like multinuclear tartrate-resistant acid phosphatase (TRAP)+ cells was noted. In contrast to the paucity of RANKL expression in cartilage, an abundant expression of IL-1beta was demonstrated, particularly in superficial cartilage layers. These data support the hypothesis that RANKL and IL-1beta are central contributors to joint destruction in CIA.

Clinical and radiological disease-course in a Swedish DMARD-treated early RA-inception cohort: an observational study

OBJECTIVES

Disease-modifying anti-rheumatic drugs (DMARDs) decrease clinical signs and symptoms in rheumatoid arthritis (RA). However, radiographic changes sometimes continue to accrue despite effective suppression of clinical symptoms by therapy. The objective of this study was to identify whether successful clinical disease-control in a Swedish early RA-inception cohort of patients led to an attenuation of radiological progression.

PATIENTS AND METHODS

We analysed clinical data and radiographs of 95 patients who were on a stable treatment regimen [methotrexate (MTX), sulfasalazine (SSZ), oral gold (AUR)] or who had changed between different DMARDs during the 2-year observation period [multiple therapy failures (mTF)]. Radiographs were quantified using the modified Larsen score and 'X-Ray RheumaCoach' software.

RESULTS

Clinical measures improved markedly (p <0.001) from baseline to year 2 under AUR, MTX, and SSZ therapy but not in the mTF group. Similar levels of disease control were seen for each DMARD. During this period, patients treated with AUR had a deltaLarsen score (+ 14.5+/-1.3) similar to mTF patients (+ 15.8+/-1.1) but greater than patients on MTX (+8.6+/-0.8) or SSZ (+9.1+/-0.8).

CONCLUSIONS

This study confirms that radiological progression occurs despite a clinically acceptable disease control, but also shows that, given the same degree of clinical disease control, radiological progression can be different for different DMARDs.

Longitudinal analysis of citrullinated protein/peptide antibodies (anti-CP) during 5 year follow up in early rheumatoid arthritis: anti-CP status predicts worse disease activity and greater radiological progression

OBJECTIVE

To study serum levels of citrullinated protein/peptide antibodies (anti-CP) during up to 5 years' follow up of patients with early rheumatoid arthritis (RA), and to relate serum levels to disease course and to treatments in clinical practice.

METHODS

279 patients with early RA were followed up with clinical investigations, radiographs, and measurement of anti-CP at baseline and after 3 months, 1, 2, 3, and 5 years.

RESULTS

160/279 (57.3%) patients were anti-CP positive at the first visit (mean 5 months after first symptoms). During follow up only 11/279 (3.9%) of the patients changed their anti-CP status. Anti-CP levels fell significantly during the first year, and this drop correlated with the extent of sulfasalazine treatment but not with other drugs or clinical indices. Anti-CP positive and negative patients had similar disease activities at baseline, but during follow up the anti-CP positive patients had worse clinical disease and greater radiological progression, despite at least equally intensive antirheumatic treatment.

CONCLUSIONS

Anti-CP are stable during the first 5 years of RA, suggesting that events before rather than after onset of clinical manifestations of disease determine this phenotype. The presence of anti-CP at diagnosis predicts a less favourable disease course and greater radiological progression despite antirheumatic treatment, but subsequent changes in antibody levels do not reflect changes in disease activity. Taken together, these observations suggest that anti-CP positive RA is a distinct clinical and pathophysiological entity.

Relationship between inflammation and joint destruction in early rheumatoid arthritis: a mathematical description

BACKGROUND

The relationship between inflammation and joint destruction in rheumatoid arthritis (RA) has not been unequivocally characterised. Joint destruction may result from the cumulative inflammatory burden over time, modified by an individual constant factor.

OBJECTIVE

To test the hypothesis that the relationship between radiological progression and inflammation can mathematically be expressed as: [equation: see text] where Re is a factor that varies from person to person.

METHODS

Clinical data and radiographs of 76 patients with early RA receiving different disease modifying antirheumatic drugs were analysed. Radiographs were quantified using the modified Larsen score and the "X-Ray RheumaCoach" software. The cumulative inflammatory burden was estimated by the time integrated 28 joint Disease Activity Score (DAS28), calculated as the area under the curve.

RESULTS

76 patients with early RA who started treatment with methotrexate (n = 20), sulfasalazine (n = 37), or oral gold (n = 19) monotherapy were evaluated. The mean (SEM) DAS28 decreased from 4.6 (0.1) at baseline to 2.3 (0.1) after 2 years. The mean (SEM) DeltaLarsen score from baseline to year 2 was 10.3 (1.5). Correlation between cumulative inflammation and radiographic change was poor. In contrast, when calculating a person's factor Re in year 1 ( Re 1) and year 2 ( Re 2), a strong and significant correlation (r = 0.58, p<0.000001) was seen between Re 1 and Re 2.

CONCLUSIONS

Joint destruction is the result of the cumulative burden of inflammation over time, modified by an individual factor Re that remains relatively constant over the first 2 years of observation. The data support a mathematical model that expresses the interrelationship between inflammation and joint destruction.

Radiological progression of joint damage in a longitudinal cohort of early DMARD-treated rheumatoid arthritis patients followed for 10 years

OBJECTIVE

The efficacy of DMARD therapy in rheumatoid arthritis (RA) can be judged by radiological analysis. This study aimed to determine the time-dependent progression of joint damage, acute-phase response, and rates of radiologic progression in early DMARD-treated RA patients over 10 years.

PATIENTS AND METHODS

We evaluated outpatient records, and radiographs of hands and feet of 54 early RA patients on DMARDs for 10 years. Radiographs were quantified by the Larsen method using recently developed quantification software.

RESULTS

Radiological damage attenuated, with disease progression from baseline to Year 10 [correlation coefficient (r)=0.95, probability (p)<0.001]. Radiographic scores progressed more rapidly during the first 5 years than thereafter. Cumulative erythrocyte sedimentation rate (ESR) was strongly correlated with radiological progression (p<0.001, r=0.88).

CONCLUSION

Our findings reveal a higher amount of radiographic RA progression during the first years of DMARD treatment. Thus, our data provide strong evidence for the importance of both early DMARD therapy and continuous radiographic assessments in RA.

Estimated prediagnosis radiological progression: an important tool for studying the effects of early disease modifying antirheumatic drug treatment in rheumatoid arthritis

OBJECTIVE

To determine if intrapatient comparisons between prediagnosis and subsequent radiological progression could be used to assess effects of DMARDs in an RA inception cohort.

PATIENTS AND METHODS

149 non-randomised patients with newly diagnosed RA in four groups were analysed: patients treated with (a) methotrexate (n = 56); (b) sulfasalazine (n = 55); (c) auranofin (n = 19); and (d) controls who were poor treatment responders (n = 19). Radiographs were quantified using the Larsen erosion score. The prediagnosis radiological progression from the onset of RA symptoms to diagnosis was calculated and compared with the observed progression rate during the first year after diagnosis while receiving DMARD treatment.

RESULTS

Mean (SD) disease duration from onset of symptoms until diagnosis was 6.7 (4.0) months. Mean (SD) baseline Larsen score was 13.2 (9.3), giving a mean (SD) estimated prediagnosis progression rate of 23.6 (12.4) Larsen score units/year. Control and auranofin groups showed radiological progression after diagnosis similar to the progression predicted by prediagnosis progression rates. Patients receiving methotrexate or sulfasalazine showed a marked reduction (71% and 73%, respectively; p<0.001) in radiographic progression compared with prediagnosis progression.

CONCLUSIONS

Prediagnosis rates of radiological progression can be used quantitatively to obtain information on the potential efficacy of DMARDs, and indicate that methotrexate and sulfasalazine, but not auranofin, significantly retard radiographic damage in the first year after diagnosis.