Is there a preferred method for scoring activity of the spine by magnetic resonance imaging in ankylosing spondylitis?

This report summarizes the discussion during a module update at OMERACT 8 on scoring methods for activity in the spine on magnetic resonance imaging. The conclusion was that the 3 available scoring methods are all very good with respect to discrimination and feasibility: the Ankylosing Spondylitis spine MRI score for activity (ASspiMRI-a), the Berlin method (a modification of the ASspiMRI-a), and the Spondyloarthritis Research Consortium of Canada Magnetic Resonance Imaging Index for Assessment of Spinal Inflammation in AS (SPARCC). All 3 methods were judged to be similar with respect to responsiveness and discrimination, although the differences in between-reader intraclass correlation coefficients (ICC) were judged to be relevant (the SPARCC method provided consistently higher ICC). The Berlin and SPARCC methods were preferred most frequently. The development of a new method combining the best elements of all methods is an additional possibility.     

Edema and fibrosis imaging by cardiovascular magnetic resonance: How can the experience of Cardiology be best utilized in rheumatological practice?

Objectives

CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis.

Method

CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies.

Results

Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs.

Conclusion

The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.     

Is there a place for cardiovascular magnetic resonance imaging in the evaluation of cardiovascular involvement in rheumatic diseases?

Cardiovascular magnetic resonance (CMR) is a noninvasive, nonradiating imaging technique, which provides novel information for the evaluation of cardiovascular diseases. Until now it has been successfully used for the evaluation of congenital and acquired heart diseases, cardiac tumors-mass, iron overload, and myocardial fibrosis detection. Recently, its diagnostic capabilities have been extended to the evaluation of myocardial inflammation and myocardial perfusion. Currently, it is considered the gold standard for the evaluation of volumes, mass, ejection fraction of atriums and ventricles, quantification of iron overload in different organs, detection and follow-up of myocardial inflammation, myocardial infarction and its complications, evaluation of the aorta, detection of anomalous coronary arteries, and ectatic or aneurysmatic coronary arteries. All the above applications and mainly the CMR ability to detect myocardial inflammation, perfusion defects, fibrosis, coronary and great arteries aneurysms make it a valuable tool for cardiovascular system assessment, commonly affected during the course of rheumatic diseases. The technique has been already successfully used in the evaluation of vasculitides, systemic lupus erythematosus, myositis, and scleroderma. However, further studies are needed to evaluate its usefulness as a diagnostic and monitoring tool of cardiovascular involvement in rheumatic patients.     

A high‐resolution magnetic resonance imaging study of distal interphalangeal joint arthropathy in psoriatic arthritis and osteoarthritis: Are they the same?

Objective

Distal interphalangeal (DIP) joint arthropathy is characteristic of both psoriatic arthritis (PsA) and osteoarthritis (OA), but the microanatomic basis for DIP joint localization is poorly understood. This study used high‐resolution magnetic resonance imaging (MRI) to investigate the basis for hand disease localization in both conditions.

Methods

Twenty patients matched for disease duration (10 with DIP joint PsA and 10 with DIP joint OA) and 10 normal control subjects were scanned with a 1.5T MRI scanner utilizing a high‐resolution 23‐mm diameter surface coil with displayed pixel dimensions of 80–100 μm. Images were obtained precontrast and postcontrast, and all joint structures, including ligaments, tendons, and entheses, were evaluated by 2 independent assessors.

Results

PsA could be distinguished from OA on the basis of more severe inflammation in the collateral ligaments and the extensor tendons and more severe changes at the corresponding DIP joint entheseal insertions. A much greater degree of extracapsular enhancement, with diffuse involvement of the nailbed and diffuse bone edema without cartilage damage, was also typical of PsA. Compared with the normal controls, the OA cohort exhibited prominent ligament and entheseal changes, but with much less contrast enhancement than in PsA and less bone involvement at the insertions.

Conclusion

These findings suggest prominent inflammatory changes in ligament, tendon, enthesis, and adjacent bone in the DIP joint disease of PsA patients. Involvement of the same structures is common in the DIP joints of OA patients, but inflammatory changes are much less marked. These findings are potentially important for a better understanding of arthritis in humans.

     

Is magnetic resonance imaging useful for the management of patients with rectal villous adenoma? A study of 45 consecutive patients treated by transanal endoscopic microsurgery

Purpose

Very few data are available about the clinical relevance of magnetic resonance (MR) imaging in preoperative evaluation of rectal villous adenoma. The aim is to evaluate the impact of MR imaging for the surgical management of rectal villous adenoma treated by transanal endoscopic microsurgery (TEM).

Methods

All patients with histologically proven rectal villous tumours operated by TEM who had a preoperative MR imaging between 2009 and 2017 were retrospectively reviewed. All patients underwent TEM because preoperative evaluation suggested systematically usT0 or usT1 tumour. Pathological stage was blindly compared to preoperative MR imaging (location according to the anal verge and the peritoneal reflection, amount of circumferential involvement, tumour size and staging) and preoperative transrectal ultrasonography (TRUS) results.

Results

Forty-five patients were included (24 men, mean age 65?±?8 years) with TRUS data available only in 37. Pathologic results were pT0-pTis in 32, pT1 in 10 and pT2 in 3. TRUS diagnosed correctly 36/37 lesions (97%) and understaged one pT2 tumour. A significant correlation between TRUS and pathologic results was noted (r?=?0.99; p?=?0.01). MR imaging diagnosed correctly 19/42 pTis-T1 and 1/3 pT2 tumours (46%). Overstaging by MR imaging was noted in 25 cases (54%). No correlation between MR imaging and pathologic results was noted (r?=?0.7; p?=?0.3).

Conclusion

Preoperative evaluation of rectal villous adenoma is overstaged by MRI in more than half of the patients. This study suggests that the indication of local excision by TEM for rectal villous adenoma should be based on TRUS rather than on MRI.

     

Diffusion-weighted magnetic resonance imaging of parotid glands before and after abatacept therapy in patients with Sjögren’s syndrome associated with rheumatoid arthritis: Utility to evaluate and predict response to treatment

Objective: To compare parotid diffusion-weighted images (DWIs) taken before and after abatacept therapy in patients with Sjögren’s syndrome (SS) associated with rheumatoid arthritis (RA) and to examine the utility in evaluation and prediction of response to therapy.

Methods: DWIs of the parotid glands taken at baseline and 52 weeks after initiation of abatacept were analyzed in nine SS patients with RA using relative standard deviation (RSD) of the entire glands and signal intensity ratio (SIR) within the residual parenchyma. The correlation between changes in RSD and SIR and changes in salivary secretion based on Saxon’s test was examined. Furthermore, baseline characteristics were compared in patients with increased and decreased salivary secretion after treatment. The predictive power of the parameter at baseline was examined using receiver operating characteristic (ROC) analysis.

Results: Abatacept improved salivary secretion from 2076?±?1535 at baseline to 2857?±?1431?mg/2?min at 52 weeks (n?=?9, p?=?.05). Increase of salivary secretion was significantly higher in patients with decreased RSD (n?=?6) than increased RSD (n?=?3) (1241?±?713, –137?±?142?mg/2?min, p?=?.02). The increase and decrease in RSD completely accorded with those of salivary secretion. Furthermore, SIR was the only parameter that was significantly different between patients with posttreatment increase and decrease in salivary secretion (p?=?.04). ROC analysis showed the sensitivity and specificity of SIR at baseline of ≥13.0?×?10^?2 for the prediction of the response to abatacept were 75.0% and 83.3%, respectively.

Conclusions: Parotid DWI seems to be useful for evaluating and predicting the response in salivary secretion to abatacept in SS patients with RA.     

Role of ultrasound and magnetic resonance imaging in systemic lupus erythematosus erosive arthritis treatment response prediction. Correspondence on: “Ultrasonographic non-radiographic erosions could predict the efficacy of belimumab in articular systemic lupus erythematosus”

Clinical Rheumatology -     

Reply to: Comment on “Comparison of MMP-3 levels in rheumatoid arthritis after treatment with tocilizumab or infliximab for 12 weeks” by Yokoe et al.

Modern Rheumatology -     

Documenting damage progression in a two‐year longitudinal study of rheumatoid arthritis patients with established disease (the DAMAGE study cohort): Is there an advantage in the use of magnetic resonance imaging as compared with plain radiography?

Objective

In early rheumatoid arthritis (RA), longitudinal studies have demonstrated that magnetic resonance imaging (MRI) is more sensitive than radiography in demonstrating progressive erosive joint damage. The present study evaluated the progression of erosive damage in patients with established RA by using limited field of view MRI and comparing the results with those obtained by radiography.

Methods

MRI and radiographic studies were available from 47 of 60 patients enrolled in a 2‐year RA observational study. MRI of the metacarpophalangeal (MCP) joints was performed at baseline and 2 years later, and a single observer scored all of the MR images with the use of an MRI scoring method developed by the Outcome Measures in Rheumatology Clinical Trials MRI RA study group. MR images from 14 patients were reread by the same observer after 1 week to assess intraobserver reliability. Radiographs were obtained at baseline and at 2 years, and were scored by an observer using the Scott modification of the Larsen score. Radiographs from 14 patients were reread after 1 week to assess the intraobserver reliability. The smallest detectable difference (SDD) was calculated for the MRI scores, the total Larsen scores, and the Larsen scores of the dominant‐hand MCP joints (MCPs 2–5) for direct comparison with the MRI results.

Results

The median disease duration was 5.1 years (range 0.5–29 years). Evidence of erosion progression was identified by MRI in 30 patients (64%). The SDD based on the intraobserver scores was calculated as ±3.25 units. Using this result, 11 patients (23%) showed evidence of erosion progression on MRI that was greater than the SDD. The SDD for progression based on the intraobserver total Larsen radiographic scores was 0.77 units, and the SDD for the Larsen scores of the dominant‐hand MCP joints was 1.55 units. On the basis of these results, radiographic progression was noted in 19 patients (40%) by the total Larsen score and 7 patients (15%) by the dominant‐hand MCP Larsen score. The most striking finding was that although MRI and radiograph scores identified a similar group of patients as having progression of joint damage, the radiographs of both hands appeared to be more responsive to change, albeit with the caveat that radiographic progression was most marked outside the dominant‐hand MCP joints.

Conclusion

There was no clear advantage of MRI with a limited field of view as compared with radiographic imaging of both hands in detecting progression of joint damage over 2 years in this group of patients with established RA. The conclusion drawn from this study is not that radiographs are better than MRI or vice versa, but that careful analysis is required to determine the optimal imaging method, or combination of imaging methods, for each study population, depending on the objective and duration of the study.

     

Impact of Early (≤24 h) Versus Delayed (>24 h) Intervention in Patients With Non-ST Segment Elevation Myocardial Infarction: An Observational Study of 20,882 Patients From the London Heart Attack Group

IntroductionWe aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention in non-ST-segment elevation acute myocardial infarction (NSTEMI) patients.MethodsWe examined the impact of early (≤24 h) versus delayed (>24 h) intervention in a large observational cohort of 20,882 consecutive NSTEMI patients treated with PCI between 2005 and 2015 at 8 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching.ResultsMean age was 64.5 ± 12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24 h. Patients treated within 24 h were slightly younger (62.8 ± 12.8 vs. 65.2 ± 12.6, p < 0.001), most commonly male (76% vs. 72.9%, p < 0.001) and were more frequently ventilated (2.3% vs. 1.4%, p < 0.001) and in cardiogenic shock (3.6% vs. 1.4%, p < 0.001) with dynamic changes on their ECG (84.5% vs. 76.1% p < 0.001). At a median follow up of 4.2 years (interquartile range 1.8 to 7) 17.7% of patients had died. Estimated 5-year survival in patients treated within 24 h was 84.6% vs. 81% for those treated >24 h following their presentation (p < 0.001). This survival benefit remained following adjustment for confounders; HR_{(delayed vs. early management)} 1.11 (95%CI 1.003 to 1.23, p = 0.046). In the propensity matched cohort of 4356 patients in each group, there remained a trend for higher survival in the early intervention group (p = 0.061).ConclusionsNotwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24 h) may improve mid-term survival.     

Erratum to: Reply to: Comment on ‘‘Comparison of MMP-3 levels in rheumatoid arthritis after treatment with tocilizumab or infliximab for 12 weeks’’ by Yokoe et al.

Modern Rheumatology -     

Documenting damage progression in a two-year longitudinal study of rheumatoid arthritis patients with established disease (the DAMAGE study cohort): is there an advantage in the use of magnetic resonance imaging as compared with plain radiography?

OBJECTIVE: In early rheumatoid arthritis (RA), longitudinal studies have demonstrated that magnetic resonance imaging (MRI) is more sensitive than radiography in demonstrating progressive erosive joint damage. The present study evaluated the progression of erosive damage in patients with established RA by using limited field of view MRI and comparing the results with those obtained by radiography. METHODS: MRI and radiographic studies were available from 47 of 60 patients enrolled in a 2-year RA observational study. MRI of the metacarpophalangeal (MCP) joints was performed at baseline and 2 years later, and a single observer scored all of the MR images with the use of an MRI scoring method developed by the Outcome Measures in Rheumatology Clinical Trials MRI RA study group. MR images from 14 patients were reread by the same observer after 1 week to assess intraobserver reliability. Radiographs were obtained at baseline and at 2 years, and were scored by an observer using the Scott modification of the Larsen score. Radiographs from 14 patients were reread after 1 week to assess the intraobserver reliability. The smallest detectable difference (SDD) was calculated for the MRI scores, the total Larsen scores, and the Larsen scores of the dominant-hand MCP joints (MCPs 2-5) for direct comparison with the MRI results. RESULTS: The median disease duration was 5.1 years (range 0.5-29 years). Evidence of erosion progression was identified by MRI in 30 patients (64%). The SDD based on the intraobserver scores was calculated as +/-3.25 units. Using this result, 11 patients (23%) showed evidence of erosion progression on MRI that was greater than the SDD. The SDD for progression based on the intraobserver total Larsen radiographic scores was 0.77 units, and the SDD for the Larsen scores of the dominant-hand MCP joints was 1.55 units. On the basis of these results, radiographic progression was noted in 19 patients (40%) by the total Larsen score and 7 patients (15%) by the dominant-hand MCP Larsen score. The most striking finding was that although MRI and radiograph scores identified a similar group of patients as having progression of joint damage, the radiographs of both hands appeared to be more responsive to change, albeit with the caveat that radiographic progression was most marked outside the dominant-hand MCP joints. CONCLUSION: There was no clear advantage of MRI with a limited field of view as compared with radiographic imaging of both hands in detecting progression of joint damage over 2 years in this group of patients with established RA. The conclusion drawn from this study is not that radiographs are better than MRI or vice versa, but that careful analysis is required to determine the optimal imaging method, or combination of imaging methods, for each study population, depending on the objective and duration of the study.     

Comparison of left ventricular ejection fraction and volumes in heart failure by echocardiography, radionuclide ventriculography and cardiovascular magnetic resonance; are they interchangeable?

AIMS: To prospectively compare the agreement of left ventricular volumes and ejection fraction by M-mode echocardiography (echo), 2D echo, radionuclide ventriculography and cardiovascular magnetic resonance performed in patients with chronic stable heart failure. It is important to know whether the results of each technique are interchangable, and thereby how the results of large studies in heart failure utilizing one technique can be applied using another. Some studies have compared cardiovascular magnetic resonance with echo or radionuclude ventriculography but few contain patients with heart failure and none have compared these techniques with the current fast breath-hold acquisition cardiovascular magnetic resonance. METHODS AND RESULTS: Fifty two patients with chronic stable heart failure taking part in the CHRISTMAS Study, underwent M-mode echo, 2D echo, radionuclude ventriculography and cardiovascular magnetic resonance within 4 weeks. The scans were analysed independently in blinded fashion by a single investigator at three core laboratories. Of the echocardiograms, 86% had sufficient image quality to obtain left ventricular ejection fraction by M-mode method, but only 69% by 2D Simpson's biplane analysis. All 52 patients tolerated the radionuclude ventriculography and cardiovascular magnetic resonance, and all these scans were analysable. The mean left ventricular ejection fraction by M-mode cube method was 39+/-16% and 29+/-15% by Teichholz M-mode method. The mean left ventricular ejection fraction by 2D echo Simpson's biplane was 31+/-10%, by radionuclude ventriculography was 24+/-9% and by cardiovascular magnetic resonance was 30+/-11. All the mean left ventricular ejection fractions by each technique were significantly different from all other techniques (P<0.001), except for cardiovascular magnetic resonance ejection fraction and 2D echo ejection fraction by Simpson's rule (P=0.23). The Bland-Altman limits of agreement encompassing four standard deviations was widest for both cardiovascular magnetic resonance vs cube M-mode echo and cardiovascular magnetic resonance vs Teichholz M-mode echo at 66% each, and was 58% for radionuclude ventriculography vs cube M-mode echo, 44% for cardiovascular magnetic resonance vs Simpson's 2D echo, 39% for radionuclide ventriculography vs Simpson's 2D echo, and smallest at 31% for cardiovascular magnetic resonance-radionuclide ventriculography. Similarly, the end-diastolic volume and end-systolic volume by 2D echo and cardiovascular magnetic resonance revealed wide limits of agreement (52 ml to 216 ml and 11 ml to 188 ml, respectively). CONCLUSION: These results suggest that ejection fraction measurements by various techniques are not interchangeable. The conclusions and recommendations of research studies in heart failure should therefore be interpreted in the context of locally available techniques. In addition, there are very wide variances in volumes and ejection fraction between techniques, which are most marked in comparisons using echocardiography. This suggests that cardiovascular magnetic resonance is the preferred technique for volume and ejection fraction estimation in heart failure patients, because of its 3D approach for non-symmetric ventricles and superior image quality.     

Conformational state of the MscS mechanosensitive channel in solution revealed by pulsed electron–electron double resonance (PELDOR) spectroscopy

The heptameric mechanosensitive channel of small conductance (MscS) provides a critical function in Escherichia coli where it opens in response to increased bilayer tension. Three approaches have defined different closed and open structures of the channel, resulting in mutually incompatible models of gating. We have attached spin labels to cysteine mutants on key secondary structural elements specifically chosen to discriminate between the competing models. The resulting pulsed electron–electron double resonance (PELDOR) spectra matched predicted distance distributions for the open crystal structure of MscS. The fit for the predictions by structural models of MscS derived by other techniques was not convincing. The assignment of MscS as open in detergent by PELDOR was unexpected but is supported by two crystal structures of spin-labeled MscS. PELDOR is therefore shown to be a powerful experimental tool to interrogate the conformation of transmembrane regions of integral membrane proteins.