Magnetic resonance imaging characteristics in patients with spondyloarthritis and clinical diagnosis of heel enthesitis: post hoc analysis from the phase 3 ACHILLES trial.

OBJECTIVE: To investigate the imaging characteristics and clinically assess heel enthesitis in spondyloarthritis (SpA) by applying in a post hoc analysis the Heel Enthesitis Magnetic Resonance Imaging Scoring system (HEMRIS) in blinded and centrally-read MRI data from the ACHILLES trial (NCT02771210). METHODS: ACHILLES included patients (≥18 years) with active psoriatic arthritis or axial SpA with clinical and MRI-positive heel enthesitis refractory to standard treatment. Patients were randomized to receive subcutaneous secukinumab 150/300 mg or placebo. At week 24, patients on placebo were switched to secukinumab treatment. MRI-positive heel enthesitis was confirmed in all patients by local investigators. MRIs were performed at 3 timepoints: screening and weeks 24 and 52. In the present analysis, all MRIs were re-evaluated by 2 blinded central readers in a consensus read fashion for a priori defined MRI parameters based on HEMRIS. RESULTS: At screening, 171/204 (83.8%) of patients presented with entheseal inflammation and/or structural damage, considering both the Achilles tendon and plantar fascia. Pathologies were more evident in the Achilles tendon area compared to the plantar aponeurosis. The most frequent pathologies were intra-tendon hypersignal and retrocalcaneal bursitis. The mean total entheseal inflammation score at screening in the Achilles tendon area was 2.99 (N=204) and the mean change (standard deviation [SD]) from screening to weeks 24 and 52 was - 0.91 (1.99) and - 0.83 (2.12) in the secukinumab group vs - 0.48 (1.86) and - 0.80 (1.98) in the placebo-secukinumab group, respectively. The mean total structural damage score at screening was 1.36 (N=204) and the mean change (SD) from screening to weeks 24 and 52 was 0.00 (0.65) and - 0.06 (0.56) in the secukinumab group vs 0.08 (0.48) and 0.04 (0.75) in the placebo-secukinumab group, respectively. CONCLUSIONS: Based on the newly developed HEMRIS, entheseal inflammation and/or structural damage was confirmed in 83.3% of ACHILLES patients. Pathologies were more evident in the Achilles tendon area compared to plantar fascia, with the inflammatory parameters being more responsive with secukinumab treatment compared to placebo. The present analysis, with detailed information on individual MRI parameters, contributes to the scientific debate on heel enthesitis. TRIAL REGISTRATION: ClinicalTrials.gov NCT02771210 .

Mission statement from rheumatologists in the German Society of Rheumatology (DGRh e. V.) : We live rheumatology.

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.

[Mission statement from rheumatologists in the German Society of Rheumatology (DGRh e. V.) : We live rheumatology. German version]. / Leitbild der Rheumatologinnen und Rheumatologen in der Deutschen Gesellschaft für Rheumatologie e. V. (DGRh e. V.) : Wir sind die Rheumatologie.

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.

[Current guidance of the German Society of Rheumatology for the care of patients with rheumatic diseases during the SARS-CoV-2/Covid 19 pandemic]. / Aktuelle Handlungsempfehlungen der Deutschen Gesellschaft für Rheumatologie für die Betreuung von Patienten mit rheumatischen Erkrankungen während der SARS-CoV­2/Covid 19-Pandemie.

In the current SARS-CoV-2 pandemic there are many questions regarding the safe treatment of patients with inflammatory rheumatic diseases. Many of these questions cannot yet be answered on an evidence-based basis and this does not make patient care easy. The German Society for Rheumatology (DGRh) hopes that these initial recommendations will provide support for specific issues in the care of patients with inflammatory rheumatic diseases in view of the current threat posed by SARS-CoV-2. In order to take advantage of the dynamic worldwide gain in knowledge for our patients, the recommendations will be updated regularly. The updated versions of the recommendations are deposited on the homepage of the DGRh.

[Imaging of psoriatic arthritis and aspects of radiographic progression]. / Bildgebung bei der Psoriasisarthritis und Aspekte der röntgenologischen Progression.

Psoriatic arthritis (PsA) is a heterogeneous multifactorial disease with musculoskeletal involvement, which can be manifested as monoarthritis, oligoarthritis or polyarthritis and in some patients can also affect the axial skeleton. The most frequent indications of inflammation are bone marrow edema and enthesitis. The early and differential diagnosis of PsA is a clinical challenge, particularly as a differential diagnosis from other inflammatory or degenerative diseases of joints. Inflammatory joint and tendon alterations in the region of the extremities and the spine can be visualized with high sensitivity by the use of magnetic resonance imaging (MRI), musculoskeletal sonography (US) and fluorescence optical imaging (FOI). The use of MRI has a prognostic value with respect to the further radiographic course of the disease, particularly in the initial stages of the disease. Structural damage can be specifically and also partially demonstrated 3­dimensionally in peripheral joints and the spine by the use of computed tomography (CT) and conventional X­ray imaging. High-resolution peripheral quantitative CT (HR-pQCT) in particular, can visualize pathophysiological processes and the morphological consequences even in early stages of the disease. The values of conventional X­ray diagnostics, CT, MRI, musculoskeletal US and alternative imaging procedures are presented with respect to the diagnostics and prognosis of the progression of patients with PsA.

[Specialist training quo vadis?] / Facharztweiterbildung quo vadis?

BACKGROUND: In May 2018 a revision of the training regulations for German doctors (MWBO) was passed which will significantly impact the medical training for German rheumatologists. The goal of this paper was to create an overview of the status quo in advanced medical training in this field. METHODS: A quantitative and qualitative analysis was conducted to identify the strengths and weaknesses of the current continuous education in the field of rheumatology in Germany. The number of newly trained specialists in rheumatology in the years 2015 to 2017 was determined from the regional medical associations. Furthermore, an online survey assessing the training conditions of assistant physicians was conducted. 71 physicians participated in the nationwide survey. RESULTS: In 2015 (53 specialists), in 2016 (43 specialists) and in 2017 (43 specialists) completed their training in the field of rheumatology. The online survey of assistant physicians found that the medical training was graded 3.1 on a scale of 1 to 6 (SD ± 1.1). 19.4% of respondents reported that they had regular mentoring, and 41.7% had on-the-job evaluations. Deficits were evident concerning practical diagnostic skills: 22.8% of the physicians were not practicing joint ultrasonography and another 20% performed it only once a month. As points of criticism 46.6% mentioned a missing structure in training programme and 33.3% noted a lack of supervision. The majority of respondents wanted more training options, supervision and better practical training in ultrasound diagnostics. CONCLUSION: The nationwide number of newly acquired specialist qualifications (between 2015 and 2017) showed a decreasing trend. It is to be feared that the numbers will continue to stagnate, which increases the importance to invest further in medical education. The online survey also showed that the current medical training in Germany has deficits. Here, the new MWBO could create better guidelines for a structured training, which should be guided by the principle of "Teach to Target".

[Use of medical apps and online platforms among German rheumatologists : Results of the 2016 and 2018 DGRh conference surveys and research conducted by rheumadocs]. / Nutzung von Medizin-Apps und Online-Plattformen unter deutschen Rheumatologen : Ergebnisse der rheumadocs-Recherche und DGRh-Kongress-Umfragen von 2016 und 2018.

BACKGROUND: Apps and online platforms play an ever increasing role in the daily work routine of physicians. The aim of this study was to investigate which medical apps and online platforms are used by German rheumatologists for certain tasks and to identify usage trends. METHODS: Data were collected via a SurveyMonkey survey conducted by members of rheumadocs (Young German Rheumatology Association) at the 2016 and 2018 German Society for Rheumatology (DGRh) conferences. RESULTS: In 2016 and 2018 the survey was completed by 75 and 84 assistant and specialist rheumatologists, respectively. In 2016, 37% of rheumatologists were using medical apps in routine care which changed to 49% in 2018. In 2016, 47% compared to 68% in 2018, planned to integrate medical apps into routine care. In total, 20 different medical apps were recommended for colleagues to use; however only 2 of these apps were specific for rheumatology. In contrast to 52 app recommendations for colleagues, only 8 app recommendations for patients were recorded. Most recommendations to physicians received the app "Arznei aktuell" (21%). "Embryotox" was the app, most recommended to patients (38%). In 2016 the online database PubMed was most popular and 97% of participants were familiar with it. Use of other online platforms showed great age dependency in 2016: Amboss (a digital learning platform) was used by 31% of the age group 21-30 years and was not used at all by the age group 51-60 years. DISCUSSION: Use of medical apps and planned integration of medical apps into routine care is increasing among German rheumatologists. On the other hand, recommendable rheumatological apps for rheumatologists and especially for patients are currently largely unknown to rheumatologists.

[MRI diagnostics in inflammatory joint and spinal diseases: protocols and special sequences: when and for what?] / MRT-Diagnostik bei entzündlichen Gelenk- und Wirbelsäulenerkrankungen: Protokolle und Spezialsequenzen: Wann und wozu?

Magnetic resonance imaging (MRI) is an important component in rheumatology for imaging diagnostics and therapy monitoring of inflammatory and non-inflammatory diseases of the spine and peripheral joints. The correct selection of suitable and practical MRI protocols and sequences represents a great challenge for physicians with respect to requesting and interpreting the indications for MRI investigations. This review article provides recommendations and suggestions for MRI investigation protocols for clinical utilization and practice. New sequences are evaluated and assessed in order to generate the best possible standardized and comparable examinations for rheumatology in the future and therefore optimize the quality of radiological interventions.

[Biomarkers and imaging for diagnosis and stratification of rheumatoid arthritis and spondylarthritis in the BMBF consortium ArthroMark]. / Biomarker und Bildgebung zur Diagnose und Stratifizierung der rheumatoiden Arthritis und Spondylarthritis im BMBF-Verbund ArthroMark.

Rheumatic diseases are among the most common chronic inflammatory disorders. Besides severe pain and progressive destruction of the joints, rheumatoid arthritis (RA), spondyloarthritides (SpA) and psoriatic arthritis (PsA) impair working ability, reduce quality of life and if treated insufficiently may enhance mortality. With the introduction of biologics to treat these diseases, the demand for biomarkers of early diagnosis and therapeutic stratification has been growing continuously. The main goal of the consortium ArthroMark is to identify new biomarkers and to apply modern imaging technologies for diagnosis, follow-up assessment and stratification of patients with RA, SpA and PsA. With the development of new biomarkers for these diseases, the ArthroMark project contributes to research in chronic diseases of the musculoskeletal system. The cooperation between different national centers will utilize site-specific resources, such as biobanks and clinical studies for sharing and gainful networking of individual core areas in biomarker analysis. Joint data management and harmonization of data assessment as well as best practice characterization of patients with new imaging technologies will optimize quality of marker validation.

Intra-individual assessment of inflammatory severity and cartilage composition of finger joints in rheumatoid arthritis.

OBJECTIVE: To intra-individually assess the association of inflammation severity and cartilage composition measured by RAMRIS synovitis sub-score and delayed gadolinium-enhanced magnetic resonance imaging of the cartilage (dGEMRIC) of metacarpophalangeal (MCP) joints in patients with rheumatoid arthritis (RA). METHODS: Forty-three patients with RA according to ACR/EULAR classification criteria (age 52.9 ± 14.5 years, range, 18-77 years) were included in this study. All study participants received 3-T MRI scans of the metacarpophalangeal joints of the second and third finger (MCP 2 and 3). The severity of synovitis was scored according to the RAMRIS synovitis sub-score by two readers in consensus. In the cases with identical synovitis sub-scores, two radiologists decided in consensus on the joint with more severe synovitis. Cartilage composition was assessed with dGEMRIC. To test the association of inflammation severity and cartilage damage and in order to eliminate inter-patient confounders, each patient's MCP 2 and 3 were dichotomized into the joint with more severe synovitis versus the joint with less severe synovitis for a paired Wilcoxon test of dGEMRIC value. RESULTS: There was a significant difference of dGEMRIC value (median of difference: 47.12, CI [16.6; 62.76]) between the dichotomized MCPs (p = 0.0001). There was a significant correlation between dGEMRIC value and RAMRIS synovitis grading of the joint with more severe synovitis (r = 0.5; p < 0.05) and the joint with less severe synovitis (r = 0.33; p < 0.05). CONCLUSIONS: Our data concur with the concept that synovitis severity is associated with cartilage damage. The local inflammatory status on a joint level correlated significantly with the extent of cartilage degradation in biochemical MRI.

[New imaging procedures in rheumatology: from bench to bedside]. / Neue bildgebende Verfahren in der Rheumatologie: From bench to bedside.

Modern imaging procedures play an import role in diagnostic and therapy-control in rheumatic diseases. Reasons are the continuous development, the evaluation and the implementation in local / international guidelines and classification criteria. According to new therapeutic goals and the aim of clinical and radiological remission the early diagnosis and sufficient therapy-control is unalterable. The ultrasound is today an inherent tool in the early diagnosis of joint- and vascular diseases and is used comprehensively in rheumatic diseases. Beside the highly sensitive detection of inflammation the MRI might depict bone erosions and bone marrow oedema, which is highly predictive for the development of erosions, clearly earlier than conventional x-rays. Due to its advantages the MRI is used frequently in the early diagnosis of spondyloarthritis (ASAS-guidelines). Moreover the capillary microscopy is - due to the rapid performance, the absence of radiation and the high sensitivity - applied in the early diagnosis and therapy-control of connective tissue diseases (e.g systemic sclerosis). New innovative imaging technics find increasing acceptance in the diagnostic algorithm in rheumatic disease. Hence the DECT can detect monosodium urate (MSU) crystals without the need of a joint puncture. Hybrid imaging technics like PET-CT / PET-MRI combine the high sensitivity of the PET and the accurate solution of the CT / MRI. These advantages lead to increasing importance in diagnostic imaging.

[Eosinophilic granulomatosis with polyangiitis presenting as livedo racemosa]. / Livedo racemosa als kutane Manifestation bei eosinophiler Granulomatose mit Polyangiitis.

As a rare antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, eosinophilic granulomatosis with polyangiitis (EGPA, formerly Churg-Strauss syndrome) is characterized by asthma, severe peripheral eosinophilia and the presence of extravascular granulomas. Cutaneous involvement usually includes palpable purpura or cutaneous to subcutaneous nodes. We present the case of a 43-year-old woman with EPGA and the unusual cutaneous manifestation of livedo racemosa.

[Case-based interactive PACS learning: introduction of a new concept for radiological education of students]. / Fallbasiertes interaktives "PACS-learning": Vorstellung eines neuen studentischen Lehrkonzepts für die Radiologie.

PURPOSE: Medical curricula are currently being reformed in order to establish superordinated learning objectives, including, e.g., diagnostic, therapeutic and preventive competences. This requires a shifting from traditional teaching methods towards interactive and case-based teaching concepts. Conceptions, initial experiences and student evaluations of a novel radiological course Co-operative Learning In Clinical Radiology (CLICR) are presented in this article. MATERIALS AND METHODS: A novel radiological teaching course (CLICR course), which combines different innovative teaching elements, was established and integrated into the medical curriculum. Radiological case vignettes were created for three clinical teaching modules. By using a PC with PACS (Picture Archiving and Communication System) access, web-based databases and the CASUS platform, a problem-oriented, case-based and independent way of learning was supported as an adjunct to the well established radiological courses and lectures. Student evaluations of the novel CLICR course and the radiological block course were compared. RESULTS: Student evaluations of the novel CLICR course were significantly better compared to the conventional radiological block course. Of the participating students 52% gave the highest rating for the novel CLICR course concerning the endpoint overall satisfaction as compared to 3% of students for the conventional block course. The innovative interactive concept of the course and the opportunity to use a web-based database were favorably accepted by the students. Of the students 95% rated the novel course concept as a substantial gain for the medical curriculum and 95% also commented that interactive working with the PACS and a web-based database (82%) promoted learning and understanding. CONCLUSION: Interactive, case-based teaching concepts such as the presented CLICR course are considered by both students and teachers as useful extensions to the radiological course program. These concepts fit well into competence-oriented curricula.

Utilize your dental X-ray set better.

The dental X-ray set should not be used in a stereotyped way, but should be regarded as an instrument with a wealth of potential. For its optimal utilization the operator should be familiar with the principles of projection geometry and of image formation. The diagnostic problem should be analysed so that the determination of projections and angulations of the X-ray beam will result in the maximum information. To ascertain true morphology and interpret the radiographic images three-dimensionally multiple views are required. Distortion is a disturbing factor in radiographic image formation and methods minimizing distortion are to be preferred. The benefits of occlusal radiography are emphasized. In order to limit the detrimental effects of ionizing radiation X-ray examinations should not be used unless the outcome represents a net benefit to the patient. However, it is wrong policy to restrict the number of radiographs in dental practice if substantial indications for radiography exist.