MRI bone oedema has been observed in early and advanced RA and may represent a cellular infiltrate (osteitis) in subchondral bone. We studied MRI scans from RA patients undergoing surgery, seeking to identify regions of bone oedema and examine its histopathological equivalent in resected bone.Preoperative contrast-enhanced MRI scans were obtained in 11 RA patients scheduled for orthopaedic surgery to the hands/wrists or feet. In 9, MRI scans were scored by 2 readers for bone oedema (RAMRIS system). Its distribution with respect to surgical site was investigated. In 4 patients, 7 bone samples were examined for a cellular infiltrate, and this was compared with MRI bone oedema, scored for spatial extent and intensity.Inter-reader intraclass correlation coefficients for bone oedema were 0.51 (all sites) and 0.98 (bone samples for histology). Bone oedema was observed at 60% of surgical sites vs 38% of non-surgical sites. High-grade bone oedema (score >/=50% maximum) was strongly associated with the surgical field (OR 9.3 (3.5 to 24.2), p<0.0001). Bone oedema scores correlated with pain (r = 0.67, p = 0.048) and CRP (r = 0.86, p = 0.01). In 4 of the 7 bone samples, there was concordance between bone oedema and subchondral osteitis. In 3, there was no MRI bone oedema, and osteitis was "slight".High-grade MRI bone oedema was common within the field of intended surgery and associated with pain. There was concordance between the presence and severity of MRI bone oedema and osteitis on histology, with an MRI threshold effect due to differences in image resolution.
Background Dual-energy computed tomography (DECT) has recently been described as a sensitive method to detect urate deposits in patients with gout. Objectives The aim of this study was to compare the reproducibility of DECT with various physical measurement methods of tophus size assessment. Methods Sixty-four tophi from 25 patients were analyzed. Each tophus was assessed by 2 independent observers using Vernier calipers and tape measure. All patients proceeded to DECT scanning of both feet. Urate volume within index tophi was assessed by 2 independent observers using automated DECT volume assessment software (n = 55 tophi). Five patients returned within 1 week for repeat physical assessment of tophus size. Dual-energy computed tomography scans from the returning patients were scored twice by both observers. Intraobserver and interobserver reproducibility was assessed by intraclass correlation coefficient (ICC) and limits-of-agreement analysis. Results Overall, DECT was more reproducible than the physical methods with interobserver ICCs for DECT of 0.95, for calipers 0.78, and for tape measurement 0.88, and intraobserver ICCs for DECT of 1.00, for calipers 0.75, and for tape measurement 0.91. Vernier caliper and tape measurements correlated highly with each other (rs = 0.84, P < 0.0001) but less well with DECT (for index tophi, rs = 0.46, P = 0.004 for both). Large variation was observed in the amount of urate deposits documented by DECT in tophi of similar physical size. Conclusions Dual-energy computed tomography scanning is a highly reproducible method for measuring urate deposits within tophi. This imaging modality reveals the composition of tophi that contain variable urate deposits embedded within soft tissue.
Objective. To determine the reliability and feasibility of a new magnetic resonance imaging (MRI) score to quantify bone marrow edema (BME), synovitis, and erosions in the cervical spine of patients with rheumatoid arthritis (RA); and to investigate the correlations among neck pain, clinical markers of RA disease activity, and MRI features of disease activity in the cervical spine. Methods. Thirty patients with RA (50% with neck pain) and a Disease Activity Score 28-joint count > 3.2 had an MRI scan of their cervical spine. STIR, VIBE, and T1-weighted postcontrast sequences were used to quantify BME. MRI scans were scored for total BME, synovitis, and erosions using a new scoring method developed by the authors and assessed for reliability and feasibility. Associations between neck pain and clinical markers of disease activity were investigated. Results. BME was present in 14/30 patients; 9/14 (64%) had atlantoaxial BME, 10/14 (71%) had subaxial BME, and 5/14 (36%) had both. Interobserver reliability for total cervical BME score was moderate [intraclass correlation coefficient (ICC) = 0.51]. ICC improved to 0.67 if only the vertebral bodies and dens were considered. There was no correlation between neck pain or clinical measures of RA disease activity and the presence of any MRI features including BME, synovitis, or erosions. Conclusion. Current RA disease activity scores do not identify activity in the cervical spine. An MRI score that quantifies BME, synovitis, and erosions in the cervical spine may provide useful information regarding inflammation and damage. This could alert clinicians to the presence of significant pathology and influence management.
The OMERACT RA MRI scoring system (RAMRIS) evaluates bone erosions, bone edema, and synovitis. The system is validated and increasingly used as an outcome measure in RA clinical trials. However, joint space narrowing (JSN), reflecting cartilage damage, is an important aspect of the joint damage in RA, and reliable assessment of this could constitute a useful additional outcome measure in RA clinical trials.
Objectives
The aim of the present OMERACT initiative was to validate the newly proposed MRI scoring system for JSN [1].
Methods
Fourteen RA patients’ and one healthy control’s 2nd-5th metacarpophalangeal joints (MCP2-5) and wrist on one hand were assessed for JSN on MRI and CT by three experienced readers. Images were read twice with different identification numbers for blinding.
Results
Patient demographics: 71% female, age median 61 years (range 31-78), disease duration 5 (1-20), 71% IgM rheumatoid factor positive, Sharp/van der Heijde X-ray scores: Total 75 (3-106), joint space narrowing 40 (1-70), erosion 27 (2-44)). On both MRI and CT, high intrareader (ICCs ≥0.91) and interreader (ICCs ≥0.89) reliability were found for total assessment of JSN (see table). The agreement was generally lower for MCP joints than the wrist, particularly for CT.
Conclusions
High intra- and interreader reliabilty was obtained by three readers assessing JSN on MRI and CT using the OMERACT JSN MRI scoring system. The score may be a useful outcome measure in RA clinical trials.
References
Østergaard M, et al.: Development and preliminary validation of a magnetic resonance imaging joint space narrowing score for use in rheumatoid arthritis: potential adjunct to the OMERACT RA MRI scoring system. J.Rheumatol. 2011;38:2045-50.
There is new evidence that B-cell depletion could be an effective intervention in patients with SSc. Observational case–control study data from the European League Against Rheumatism Scleroderma Trials and Research group has suggested that rituximab therapy may reduce progression of skin thickening and lung fibrosis, especially in a subgroup with early dcSSc. These positive data remain preliminary and need to be viewed with caution, recognizing the spontaneous regression of skin thickening that may occur during early disease. In this review, we summarize the clinical evidence for the therapeutic use of rituximab in SSc as well as the basic science evidence suggesting that B cells and autoantibodies are the primary drivers of fibrosis in skin and lung tissue. We have also reviewed the parallels between SSc and the other CTDs where B-cell depletion therapy is efficacious.
To define a minimum acceptable total squamous cellularity for (ThinPrep) liquid-based cervical cytology (LBC) specimens using quality control techniques.Two hundred LBC preparations were made containing varying numbers (<200) of severely dyskaryotic squamous cells and with varying total cellularities.Ninety-eight per cent of the LBC preparations that were missed by one or more of three cytoscreeners had fewer than 16 abnormal objects (single dyskaryotic cells or clumps of cells) and 87 dyskaryotic cells. The minimum ratio of dyskaryotic to total squamous cells that, in a preparation of 5000 squamous cells has a probability of at least 0.98 that 87 or more dyskaryotic cells will be present is 1:47. Twenty-three preparations diagnosed as abnormal had ratios of dyskaryotic to total squamous cells of between 1:2.5 and 1:4596. There is thus no feasible minimum acceptable squamous cellularity that will give an acceptable probability of detection of all specimen vials containing abnormal cells in the observed proportions.It is suggested that the minimum acceptable cellularity for LBC specimens is set pragmatically by the screening programme to give a feasible percentage of repeat tests.
Objectives To develop and test an MRI cartilage scoring system for use at the wrist in rheumatoid arthritis (RA). Methods MRI scans were obtained using a 3T MRI scanner with dedicated wrist coil in 22 early and 16 established RA patients plus 22 controls. Axial and coronal T1-weighted (precontrast and postcontrast) and T2-weighted turbo spin echo sequences were obtained. Eight wrist joints were scored for cartilage narrowing: distal radioulnar, radiolunate, radioscaphoid, triquetrum-hamate, capitate-lunate, scaphotrapezoid, second metacarpal base-trapezoid and third metacarpal base-capitate, using a system based on the Sharp van der Heijde x-ray joint space narrowing (JSN) score by three radiologists. Fifteen sites at the wrist were also scored for synovitis, bone oedema and erosion using the RA MRI score. Results Interobserver (three-reader) and intraobserver reliability (readers 1 and 2) for the cartilage score were excellent: intraclass correlations (ICC (95% CI)) 0.91, (0.86 to 0.94), 0.98 (0.96 to 1.00) and 0.94 (0.87 to 1.00), respectively. Cartilage scores (median, range) were higher in the established RA group (11.9, 2.3–27.3) than the early RA group (2.15, 0–6) (p≤0.001) but early RA scores did not differ from healthy controls (2.3, 1–8.7). Cartilage scores correlated with synovitis (R=0.52), bone oedema (R=0.63) and erosion scores (R=0.66), p<0.001 for all, and with x-ray JSN scores (R=0.68 to 0.78). Conclusion This MRI cartilage score demonstrated excellent reliability when tested in a three-reader system. However, cartilage loss in early RA could not be distinguished from that seen in healthy controls.
Natural killer (NK) cells are vital effector cells of innate immunity because of their rapid cytotoxic and cytokine‐producing responses to cell stress or infection. A distinguishing feature of NK cells is the ability to balance these signals with those of normal homeostasis through the expression of an array of inhibitory and activating receptors. Two functional subsets of NK cells exist: the more mature CD56 dim population is potently cytotoxic, whereas CD56 bright NK cells have low cytotoxicity but produce much greater amounts of cytokines, and express homing molecules for secondary lymphoid organs and sites of inflammation. NK cells have been identified as important modulatory cells in shaping adaptive immune responses by interacting with dendritic cells (DCs) and T cells. NK cells also interact with cells of the innate immune system such as monocytes and macrophages. This review outlines the biology of NK cells and the potential role of NK cells in modulating gouty inflammation.
Objective. To develop and validate a magnetic resonance imaging (MRI) method of assessment of joint space narrowing (JSN) in rheumatoid arthritis (RA). Methods. Phase A: JSN was scored 0–4 on MR images of 5 RA patients and 3 controls at 15 wrist sites and 2nd–5th metacarpophalangeal (MCP) joints by 8 readers (7 once, one twice), using a preliminary scoring system. Phase B: Image review, discussion, and consensus on JSN definition, and revised scoring system. Phase C: MR images of 15 RA patients and 4 controls were scored using revised system by 5 readers (4 once, one twice), and results compared with radiographs [Sharp-van der Heijde (SvdH) method]. Results. Phase A: Intraobserver agreement: intraclass correlation coefficient (ICC) = 0.99; smallest detectable difference (SDD, for mean of readings) = 2.8 JSN units (4.9% of observed maximal score). Interobserver agreement: ICC = 0.93; SDD = 6.4 JSN units (9.9%). Phase B: Agreement was reached on JSN definition (reduced joint space width compared to normal, as assessed in a slice perpendicular to the joint surface), and revised scoring system (0–4 at 17 wrist sites and 2nd–5th MCP; 0: none; 1: 1–33%; 2: 34–66%; 3: 67–99%; 4: ankylosis). Phase C: Intraobserver agreement: ICC = 0.90; SDD = 6.8 JSN units (11.0%). Interobserver agreement: ICC = 0.92 and SDD = 6.2 JSN units (8.7%). The correlation (ICC) with the SvdH radiographic JSN score of the wrist/hand was 0.77. Simplified approaches evaluating fewer joint spaces demonstrated similar reliability and correlation with radiographic scores. Conclusion. An MRI scoring system of JSN in RA wrist and MCP joints was developed and showed construct validity and good intra- and interreader agreements. The system may, after further validation in longitudinal data sets, be useful as an outcome measure in RA.
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