Feasibility and reproducibility of the PsAMRIS-H score for psoriatic arthritis in low-field-strength dedicated extremity magnetic resonance imaging.

OBJECTIVES: The psoriatic arthritis magnetic resonance imaging scoring system (PsAMRIS-H) for the evaluation of inflammatory and destructive changes in PsA hands was validated on 0.6-T scanners. The applicability of the PsAMRIS-H on a low-field MRI system as a well-accepted, low-cost imaging modality was evaluated. METHOD: In 65 consecutive patients (31 males, median age 52 years), 73 scans on a 0.2-T dedicated extremity MRI system were obtained for evaluation of PsA. Images were scored for synovitis, tenosynovitis, periarticular enhancement, bone erosion, bone oedema, and proliferation, and the PsAMRIS-H score was calculated. The intraclass correlation coefficient (ICC) was calculated and the paired t-test conducted. RESULTS: Intra-reader reliability for the total PsAMRIS-H score was good, with an ICC of 0.81 and 0.77 for readers 1 and 2, respectively, and inter-reader agreement was moderate (0.57 for each reader). However, the PsAMRIS-H score differed significantly between the two readers (22 vs. 31; p < 0.05). When individual components of the PsAMRIS were evaluated, intra- and inter-reader agreement was poor to moderate, especially for tenosynovitis and periarticular inflammation. CONCLUSIONS: Low-field 0.2-T MRI is capable of quantifying the PsAMRIS-H with good intra-reader reproducibility. However, low signal-to-noise ratio (SNR), low spatial resolution, and system artefacts limit the application of the PsAMRIS-H, leading to low inter- and intra-reader agreement for individual features.

[Vasculitis in the trunk: Imaging patterns of typical organ manifestations due to primary vasculitis of small and medium sized vessels]. / Vaskulitiden am Körperstamm: Bildgebende Diagnostik typischer Organmanifestationen der primären Vaskulitiden mittelgroßer und kleiner Gefäße.

Vasculitis of small and medium sized vessels mostly affects several organ systems and causes unspecific symptoms. The trunk, lungs, heart and the gastrointestinal and urogenital tracts are most frequently involved. Due to an unclear clinical picture imaging is part and parcel of diagnostics. The knowledge of typical and rare imaging patterns as well as knowledge of the correct imaging method is crucial for classification. Projection radiography is still the gold standard for imaging of the lungs. Using computed tomography discrete ground-glass pattern opacities, nodules and consolidations can be depicted. In the abdomen computed tomography and magnetic resonance imaging can depict swelling of the intestinal wall. Digital subtraction angiography may contribute to further differentiation and reveal microaneurysms in cases of polyarteriitis nodosa.

Pulmonary radiological characteristics in patients with HIV infection at the time of highly active antiretroviral therapy (HAART).

OBJECTIVE: To report on radiological and epidemiological characteristics of pulmonary disease in patients with HIV infection in times of highly active antiretroviral therapy (HAART). METHODS: Clinical data of 130 HIV infected adults with acute pulmonary symptoms were compared with findings in chest radiography (n = 130) and computed tomography (CT, n = 42). Presence and distribution of consolidation, interstitial changes, pleural effusion, and adenopathy were evaluated. Results were compared to findings from sputum, bronchoalveolar lavage, transbronchial biopsy, or empirical therapy results. RESULTS: 48% of patients presented pathologic findings. Overall sensitivity for the detection of pulmonary involvement was 0.87 (chest radiography) vs. 0.97 (CT). Disease specific sensitivity was 0.33 compared to 0.70. Bacterial pneumonia (BP, n = 26, 20%) was the most frequent diagnosis, followed by pneumocystis jiroveci pneumonia (PJP, n = 17, 13%), mycobacterium avium complex (MAC, 6%), Kaposi's sarcoma and lymphoma (KS and NHL, each 4%), fungal pneumonia (2%), and tuberculosis (TBC, 1%). Focal pulmonary infiltration was predominantly present in BP (50%, n = 13). Reticular (35%; n = 6) and micronodular (35%; n = 6) infiltration were predominantly found in PJP. CONCLUSIONS: Despite HAART, lung involvement is still common. Only contrast-enhanced computed tomography shows an acceptable disease-specific sensitivity. In unclear cases, CT should be performed.

[Imaging in the early diagnosis of changes in the hand of patients suffering from rheumatoid arthritis. Is ultrasound a true alternative for low-field magnetic resonance scanning, 3-phase bone scintigraphy and conventional x-rays?]. / Bildgebende Verfahren in der Frühdiagnostik rheumatischer Veränderungen der Hände. Ist die Sonographie eine echte Alternative zur Niederfeld-MRT, 3-Phasen-Skelettszintigraphie und Projektionsradiographie?

PURPOSE: Besides the use of conventional x-rays in the diagnostic work-up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of ultrasound of the hands with proven methods such as conventional x-rays, low-field MRI and 3P-Sz. METHODS: A total of 30 patients were studied using a 1 day protocol with ultrasound, 3P-Sz, MRI and x-ray of the hands. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA typical and non-RA typical changes. All methods were compared to the summarized findings interpreted by a rheumatologist after 2 years. RESULTS: Of the 30 patients, 19 presented with clinical symptoms of initial changes due to rheumatoid arthritis. Ultrasound revealed 14/19 patients with the correct diagnosis. Conventional x-rays indicated 11/19 patients, while 3P-Sz (100%) and low-field MRI (95%) showed high sensitivity. It was possible to differentiate between inflammation and inconspicuous findings. CONCLUSIONS: An experienced examiner can use ultrasound effectively for the initial diagnosis of RA. Based on its low cost, ultrasound is a valid alternative to conventional x-rays.

[Soft tissue manifestations of early rheumatic disease: imaging with MRI]. / Frühmanifestationen rheumatischer Gelenkerkrankungen an den Weichgewebestrukturen der Hand: Nachweis mit der MRT.

PURPOSE: The aim of this study was to evaluate typical magnetic resonance imaging (MRI) findings in early rheumatic diseases manifesting at the soft tissues of the hand using a retrospective analysis. MATERIAL AND METHODS: A total of 186 MRI examinations of patients with clinical suspicion of a rheumatic disease were evaluated in a consensus reading by two experienced radiologists. All imaging patterns were assessed with respect to their type and localization. Under blinded and non-blinded conditions diagnoses were correlated with final clinical diagnosis. RESULTS: The most frequent diagnoses were rheumatoid arthritis (RA, 45.7%) and psoriatic arthritis (PsA, 15.6%). The mean correlation between clinical and MRI diagnosis (r) was 0.75 in blinded and 0.853 in non-blinded reading (p <0.001). The following extra-articular imaging patterns were found: synovitis (59.1%), tendovaginitis (91.4%), dactylitis (14.5%), and bone marrow edema (18.3%). Only dactylitis was specific for a particular rheumatic disease (PsA; r=0.934; sensitivity 84.9%, specificity 82.4%). CONCLUSION: Inflammatory conditions of the hand can be reliably detected with MRI. In many cases the definite diagnosis can only be made when taking clinical, serological, and radiographic results into account (+13.7% increase of significance).

[Inflammatory spine disease as a cause of back pain]. / Entzündliche Wirbelsäulenerkrankungen als Ursache für Rückenschmerzen.

PURPOSE: The aim of this review is to evaluate the role of inflammatory spine disease in patients with chronic back pain. The contribution of imaging modalities for the diagnostic evaluation of back pain is discussed. MATERIAL AND METHODS: A systematic literature search based on the classification of seronegative spondyloarthropathies and rheumatoid arthritis was performed. The results of this search and the experiences in a large collective of rheumatological patients are analyzed. RESULTS: The prevalence of rheumatoid arthritis (1-2%) is comparable to that of spondyloarthropathies (1.9%). The etiology of these entities is not fully elucidated. Magnetic resonance imaging is increasingly used for early detection and surveillance of therapy with TNF-alpha antagonists. DISCUSSION: Bone marrow edema, which is only detectable with MRI, represents an early sign of inflammation. Therapy with TNF-alpha antagonists is based on clinical and laboratory criteria, and signs of inflammation in MRI. MRI is useful for assessment of the effectiveness of anti-inflammatory therapy.

[Pulmonary manifestations in rheumatic systemic diseases]. / Pulmonale Manifestationen bei Erkrankungen des rheumatischen Formenkreises.

Collagen based vascular diseases with pulmonary involvement comprise rheumatoid arthritis, systemic lupus erythematosus, progressive systemic sclerosis, dermatomyositis and polymyositis, ankylosing spondylitis, Sjögren's syndrome, and mixed connective tissue diseases. The different characteristics of pulmonary involvement are described. In such circumstances, early recognition of lung involvement is of considerable significance and the relationship to the corresponding disease has to be made. Frequently unrecognised pulmonary involvement ends up as fibrosis with irreversible deficits in respiratory function.

[Diagnosis of initial changes in patients suffering from rheumatoid arthritis. Two years follow up control with a low-field magnetic resonance scanner, 3-phase bone scintigraphy and conventional x-ray]. / Frühdiagnostik rheumatischer Veränderungen der Hände: Verlaufsbeobachtung über 2 Jahre mittels Niederfeld-Magnetresonanztomographie, 3-Phasen-Skelettszintigraphie und Projektionsradiographie.

UNLABELLED: Besides conventional x-ray, in the diagnostic work up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The AIM of this study was to compare the diagnostic value of a newly developed low field MRI with proven methods such as conventional x-ray and 3P-Sz. PATIENTS, METHODS: 42 patients were studied using a one days protocol with 3P-Sz, MRI, and x-ray of the hands with yearly follow up examinations. Images were visually assessed by two blinded nuclear medicine physicians and radiologists and classified as RA-typical and non-RA-typical changes. All methods were compared to the summarised findings interpreted by a rheumatologist in consideration of the Ritchie articular index as gold-standard. RESULTS: 24/42 patients presented with clinical symptoms of initial changes by rheumatoid arthritis. Conventional x-ray revealed in 20/24 patients within the correct diagnosis in the study period. On the other hand 3P-Sz and low field MRI concordantly showed all 24 patients with initial changes due to RA. Time of detection showed variations with a tendency to later findings by conventional x-ray. CONCLUSIONS: In the diagnostic work up of initial changes conventional x-ray should be the first choice in imaging. Our findings suggest that MRI represents an equally sensitive method for the diagnosis of initial changes due to RA in the region of the hands as compared to the 3P-Sz. The limitation of the low field MRI is the small field of view, so we prefer 3P-Sz or high field MRI in the diagnosis of patients with suspected RA.

[Systematic characterization of sonomorphological changes in the early stage of rheumatoid arthritis]. / Systematische Charakterisierung der sonomorphologischen Veränderungen in den Frühstadien der rheumatoiden Arthritis.

AIM: The early stage of rheumatoid arthritis (RA) is primarily manifested in the soft tissue of the hand. Although ultrasound (US) is regarded as an important imaging process in diagnostic medicine, precise characterization of sonomorphological changes has not yet been undertaken. METHOD: 20 patients with RA were examined with US. Two radiologists described semiquantitatively the characteristics of synovial changes in the hand in a consensus-based process and measured the synovial width. Statistical methods were used to determine whether the various synovial changes differed significantly and to identify the most frequent locations of changes. RESULTS: On the basis of the significant differences in morphology and synovial width, it is possible to distinguish between unremarkable findings, pannus tissue and band-like synovitis. Pannus tissue is most frequently found on the finger flexor tendons (FFT), the metacarpophalangeal joints (MCP) and the tendon of M. extensor carpi ulnaris (ECU). Band-like synovitis exhibits an uncharacteristic distribution pattern with a slight propensity to favour these locations. CONCLUSION: The FFT, MCP joints and ECU tendons are particularly important in systematic US screening of the hand for the purpose of establishing reliable evidence of inflammatory changes. Different stages of RA can be identified on the basis of the characteristic types of synovitis and the number of joints and tendons affected.

[Diagnosis of initial changes in the hand of patients with rheumatoid arthritis--comparison between low-field magnetic resonance imaging, 3-phase bone scintigraphy and conventional x-ray]. / Diagnostik initialer Veränderungen an der Hand bei rheumatoider Arthritis--Vergleich der Niederfeld-Magnetresonanz-Tomographie mit 3-Phasen-Skelettszinti-graphie und Projektionsradiographie.

UNLABELLED: Besides conventional X-rays, in the diagnostic work up of initial changes in patients suffering from rheumatoid arthritis (RA), 3-phase bone scintigraphy (3P-Sz) is as well established as magnetic resonance imaging (MRI). The aim of this study was to compare the diagnostic value of the newly developed low field MRI with the proven methods X-rays and 3P-Sz. METHODS: 65 patients (47f, 18m; 20-86 yrs) were studied on a one day protocol with 3P-Sz (550 MBq Tc-99m DPD), MRI and X-rays of the hands. Images were visually analysed by two blinded nuclear medicine physicians and radiologists and classified as a) RA-typical, b) inflammatory, non-RA-typical and c) non inflammatory changes. All methods were compared to 3P-Sz as golden standard. RESULTS: In comparison to 3P-Sz, low field MRI presents with almost equal sensitivity and specificity in rheumatoid-typical and inflammatory changes. Conventional X-rays revealed in arthritis-typical changes as well as in inflammatory changes a significantly lower sensitivity and also a lower negative predictive value while specificity equals the one of MRI. Quantitative analysis of 3P-Sz using ROI-technique unveiled significantly higher values in patients with rheumatoid arthritis than in those with no inflammatory changes. CONCLUSION: MRI represents an equally sensitive method in the initial diagnosis of rheumatoid-typical and inflammatory changes in the region of the hands as compared to the 3P-Sz. Besides the basic diagnosis with conventional X-rays, 3P-Sz is still the recommended method of choice to evaluate the whole body when RA is suspected. Additionally, quantitative analysis of the 3P-Sz using the ROI technique in the region of the hands reveals statistically significant results and should therefore be taken into account in the assessment of inflammatory changes.

[Differential radiologic diagnosis of HIV-associated lung diseases]. / Radiologische Differentialdiagnostik HIV-assoziierter Lungenerkrankungen.

In 1993 in Germany an estimated number of 50,000-70,000 individuals were infected with the human immunodeficiency virus (HIV), WHO estimations ranged up to 14 million HIV-positive individuals including 1 million children. AIDS-related diseases frequently occur in the lung. 65% of all AIDS-defining illnesses begin with life-threatening pulmonary infections. Most frequently HIV-positive patients present with Pneumocystis carinii pneumonia, followed by atypical mycobacteriosis, bacterial infections, Kaposi's sarcoma and non-Hodgkin lymphoma. The purpose of this article is to identify pulmonary HIV-associated diseases by focusing on radiological patterns and correlating them with clinical findings.

[Sonographic diagnosis of liver tumors. Results of comparative studies of ultrasound, computerized tomography, laparoscopy, biopsy and scintigraphy in 413 patients]. / Sonographische Diagnostik von Lebertumoren. Ergebnisse vergeichender Untersuchungen von Ultraschall, Computertomographie, Laparoskopie, Biopsie und Szintigraphie bei 413 Patienten.

Based on a retrospective study of 413 patients, the accuracy of sonography compared to CT, laparoscopy, biopsy and scintigraphy in the primary diagnosis of liver masses is shown. False positive sonographic reports are analysed in retrospect. 190 of 338 solid space-occupying growths of the liver have sonographically been called definite growths and 148 have been considered suspicious of being such growths. 49 of the cystic lesions were considered definitely cystic and 26 suspicious. Sonography made correct positive diagnoses in 91.8% of the cysts and in 88.9% of the solid growths. The diagnostic accuracy of solid growths (without further specification) was 90%. Among the sonographically suspicious ones the specific diagnosis was correct in 80.8% of the cystic lesions and in 44.5% of the solid lesions and a correct diagnosis without further specification was made in 55.4%. The majority of false positive diagnoses corresponded to normal findings in other methods. The number of false positive diagnoses in sonography in contrast to CT depends to a high degree on the experience of the physician. Before the use of other more invasive methods the sonographically suspicious findings should therefore be double-checked by an experienced colleague with several years of sonographic experience.