Correlation of high-resolution computed tomography and immunological bronchoalveolar lavage in interstitial lung disease at the onset of inflammatory rheumatic diseases: implications for diagnosis and therapeutic strategies.

OBJECTIVES: Inflammatory rheumatic diseases (IRD) are often associated with interstitial lung disease (ILD). The aim of the present study was to establish a correlation between the findings on HRCT and the immunological bronchoalveolar lavage (BAL). METHODS: The study included 74 patients with newly diagnosed IRD and evidence of ILD on HRCT with the following pattern: ground-glass opacities (GGO), non-specific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP). Patients with other HRCT pattern were excluded. No patient received any immunosuppressive therapy. In addition to HRCT, immunological BAL was performed and the American Thoracic Society clinical practice guideline were used to define BAL patterns (lymphocytic cellular pattern, neutrophilic cellular pattern, eosinophilic cellular pattern and unspecified pattern). RESULTS: The main HRCT patterns were NSIP (47.3%), GGO (33.8%), and UIP (18.9%). BAL patterns showed the following distribution: 41.9% lymphocytic cellular pattern, 23.0% neutrophilic cellular pattern, 18.9% eosinophilic cellular pattern, and 16.2% unspecific cellular pattern. Placing these data in the context of the HRCT findings, the lymphocytic cellular BAL pattern (48%) was most commonly BAL pattern associated with GGO pattern in HRCT, whereas neutrophilic and lymphocytic cellular BAL patterns were the dominant feature in NSIP and UIP. CONCLUSION: In patients with new-onset IRD and ILD, inflammatory pulmonary changes are predominate, reflected by GGO on HRCT and a mainly lymphocytic cell profile in the immunological BAL. In NSIP or UIP on HRCT, the percentages of lymphocytes and neutrophils were higher in BAL fluid, representing a fibrotic component in addition to the inflammation. Consequently, patients with evidence of GGO on HRCT should primarily be treated with anti-inflammatory/immunosuppressive therapy, whereas in patients with NSIP and UIP a combination of anti-inflammatory and anti-fibrotic agents would be the appropriate treatment.

[Imaging of congenital heart defects with a focus on magnetic resonance imaging and computed tomography]. / Bildgebung angeborener Herzfehler mit Fokus auf Magnetresonanz- und Computertomographie.

CLINICAL ISSUE: Due to advances in diagnostics and therapy, the survival rate of patients with congenital heart defects is continuously increasing. The aim of this review is to compare various imaging modalities that are used in the diagnosis of congenital heart defects. METHODS: Transthoracic echocardiography is the imaging method of choice in the presence of a congenital heart defect because of its wide availability and non-invasiveness. It can be complemented by transesophageal echocardiography, cardiac catheterization, computed tomography (CT), and magnetic resonance imaging (MRI) of the heart and vessels close to the heart. METHODICAL INNOVATIONS: The radiation exposure of CT examinations of the heart is continuously decreasing because of improved technologies. MRI is also being continuously optimized, e.g., by the acquisition of MR angiographies without contrast medium application or a thin three-dimensional (3D) visualization of the entire heart with the possibility of reconstruction in all spatial planes (whole-heart technique) as well as 2D to 4D flow. PRACTICAL RECOMMENDATION: Due to the complexity of congenital heart defects and the variety of possible pathologies, the choice of imaging modality and its exact performance has to be coordinated in an interdisciplinary context and individually adapted.

[Is JAK inhibition an option in the treatment of interstitial lung disease in rheumatoid arthritis?] / Ist JAK-Hemmung eine Option in der Behandlung der interstitiellen Lungenerkrankung bei einer rheumatoiden Arthritis?

A 69-year-old male patient with seropositive erosive rheumatoid arthritis (RA) presented to our clinic due to progressive dyspnea. High-resolution computed tomography (HRCT) and immunological bronchioalveolar lavage revealed ground-glass opacities and a lymphocytic alveolitis caused by interstitial lung disease (ILD) in RA. Considering previous forms of treatment, disease-modifying antirheumatic drug (DMARD) treatment was switched to tofacitinib. Tofacitinib treatment demonstrated a 33% reduction in ground-glass opacities by artificial intelligence-based quantification of pulmonary HRCT over the course of 6 months, which was associated with an improvement in dyspnea symptoms. In conclusion, tofacitinib represents an effective anti-inflammatory therapeutic option in the treatment of RA-ILD.

The relationship between structural analysis of the hand and clinical characteristics in psoriatic arthritis.

Up to now, there is only limited information available on a possible relationship between clinical characteristics and the mineralization of metacarpal bones and finger joint space distance (JSD) in patients with psoriatic arthritis (PsA). Computerized digital imaging techniques like digital X-ray radiogrammetry (DXR) and computer-aided joint space analysis (CAJSA) have significantly improved the structural analysis of hand radiographs and facilitate the recognition of radiographic damage. The objective of this study was to evaluate clinical features which potentially influence periarticular mineralization of the metacarpal bones and finger JSD in PsA-patients. 201 patients with PsA underwent computerized measurements of the metacarpal bone mineral density (BMD) with DXR and JSD of all finger joints by CAJSA. DXR-BMD and JSD were compared with clinical features such as age and sex, disease duration, C-reactive protein (CRP) as well as treatment with prednisone and disease-modifying antirheumatic drugs (DMARDs). A longer disease duration and an elevated CRP value were associated with a significant reduction of DXR-BMD, whereas JSD-parameters were not affected by both parameters. DXR-BMD was significantly reduced in the prednisone group (-0.0383 g/cm²), but prednisone showed no impact on finger JSD. Patients under the treatment with bDMARDs presented significant lower DXR-BMD (-0.380 g/cm²), JSDMCP (-0.0179 cm), and JSDPIP (-0.0121 cm) values. Metacarpal BMD was influenced by inflammatory activity, prednisone use, and DMARDs. In contrast, finger JSD showed only a change compared to baseline therapy. Therefore, metacarpal BMD as well as finger JSD represent radiographic destruction under different aspects.

Assessing the diagnostic value of a potential screening tool for detecting early interstitial lung disease at the onset of inflammatory rheumatic diseases.

BACKGROUND: Interstitial lung disease (ILD) is a severe pulmonary complication in inflammatory rheumatic diseases (IRD) and associated with significantly increased morbidity and mortality. That is why ILD screening at a very early stage, at the onset of IRD, is essential. The objective of the present study was to evaluate the diagnostic value and utility of a stepwise approach as a potential ILD screening tool in patients with newly diagnosed IRD. METHODS: Consecutively, 167 IRD patients were enrolled. To homogenize the study cohort, an age and gender matching was performed. The case-control study included 126 patients with new onset of IRD (mainly connective tissue diseases [CTD], small vessel vasculitis, and myositis). We applied a stepwise screening algorithm in which all patients underwent pulmonary function testing (PFT) and/or additional chest radiography. If there was at least one abnormal finding, pulmonary high-resolution computed tomography (HRCT) was subsequently performed. RESULTS: With our stepwise diagnostic approach, we identified 63 IRD patients with ILD (ILD group) and 63 IRD patients without ILD (non-ILD group). A reduced diffusing capacity for carbon monoxide (DLCO) < 80% showed a sensitivity of 83.6% and a specificity of 45.8% compared to chest X-ray with 64.2% and 73.6%, respectively, in detecting ILD. The combination of reduced DLCO and chest X-ray revealed a sensitivity of 95.2% and a specificity of 38.7%. The highest sensitivity (95.2%) and specificity (77.4%) were observed for the combination of reduced DLCO, chest X-ray, and pulmonary HRCT. The most common pulmonary abnormalities on HRCT were ground-glass opacities (GGO; 36.5%), followed by non-specific interstitial pneumonia (NSIP; 31.8%) and usual interstitial pneumonia (UIP; 9.5%). CONCLUSIONS: The combination of reduced DLCO (< 80%), chest X-ray, and pulmonary HRCT yielded the highest sensitivity and specificity in detecting ILD at the onset of IRD. Therefore, this stepwise approach could be a new screening algorithm to identify IRD patients with pulmonary involvement already at the time of the initial IRD diagnosis.

[Chest X-rays in children and adolescents : Indications and limitations]. / Röntgenuntersuchungen des Thorax bei Kindern und Jugendlichen : Indikationen und Limitationen.

CLINICAL ISSUE: Chest X­ray is the most commonly performed X­ray examination in children and adolescents. The aim of this review is to present the benefit of this radiologic modality, but also its limitations. METHODS: Compared with older children, most X­ray examinations of the chest were performed in newborns. After the neonatal period, this review focusses on the diagnosis of inflammatory pulmonary changes, foreign body aspiration, detection of pulmonary nodules, and cystic fibrosis. METHODOLOGICAL INNOVATIONS: The radiation exposure of X­ray examinations is continuously decreasing due to technical innovations. However, other imaging modalities were also continuously being optimized; therefore, alternatives without radiation exposure, i.e., magnetic resonance imaging [MRI] and ultrasound, should be considered in case of specific clinical indications. PRACTICAL RECOMMENDATION: Even if the diagnostic performance of chest X­ray examinations is often minor compared to computed tomography or MRI, chest X­ray still has a high value in children and adolescents, due to its ubiquitous availability and the relatively simple acquisition.

[Need for and predictability of magnetic resonance imaging examinations in patients with implanted neurostimulators]. / Bedarf und Vorhersagbarkeit von Magnetresonanztomographieuntersuchungen bei Patienten mit implantiertem Neurostimulator.

BACKGROUND: With an increasing number of magnetic resonance imaging (MRI) examinations in the general population, there are no data available regarding the requirements of patients with implanted neurostimulators in Germany. Published data from the United States of America suggest a high need. The limited approval for MRI scans of implants are a common problem. OBJECTIVE: The focus is on the MRI needs of these pain patients and the predictability at the time of implantation. MATERIAL AND METHOD: We carried out a retrospective evaluation of the database of our hospital information system. We searched for all MRI requests for patients with an implanted neurostimulator between November 2011 and March 2019. In addition, we compared these data with the implantation of neurostimulators in the same period. RESULTS: We identified 171 MRI examinations and 22 requests without a subsequent examination. Out of 294 (28%) patients implanted in our center 83 had at least 1 MRI scan in our hospital. We observed a steadily increasing demand. In 111 of 171 (65%) performed examinations, there was no association between the indications leading to neurostimulator implantation and to MRI. A predictability could only be assumed for 43 of 193 (22%) MRI requests. CONCLUSION: In Germany, patients with an implanted neurostimulator have a high need for MRI diagnostics which cannot be predicted at the time of implantation. Therefore, only MRI-conditional systems should be implanted. The manufacturers need to adapt the implants and their approval to requirements.

Impact of a Heutagogical, Multimedia-Based Teaching Concept to Promote Self-Determined, Cooperative Student Learning in Clinical Radiology.

PURPOSE: To date, didactic lecturing is a common method of university medical training. However, higher levels of competence to solve complex issues are hardly to be achieved with a largely passive learning style. We established and evaluated a heutagogical blended learning concept to investigate self-determined learning with a multimedia-based, interactive approach in the lecture room to teach clinical radiology. MATERIALS AND METHODS: In the 2019/2020 winter semester, we included 266 medical students in their fourth academic year in our prospective, observational study. Students participated in a series of 11 radiological lectures given by 10 lecturers. They were requested to prepare for lectures by watching learning videos. During the lecture, students had to answer key-feature questions (KFQ) in small groups and to jointly submit their answers by means of an audience response system (ARS). After each lecture and the exam, we conducted surveys and compared results with a historical control group. A focus group interview with lecturers was performed after conclusion of the lecture series. RESULTS: The students' overall impression of the "flipped classroom" concept and their examination grades were superior to historical controls (overall impression: 1.5 [95 % CI 1.4-1.6] vs. 2.7 [95 % CI 2.5-2.9] rated on a scale from 1 to 6, p < 0.001; examination grades: 1.8 [95 % CI 1.7-1.9] vs. 2.0 [95 % CI 1.9-2.0] rated on a scale from 1 to 5, p < 0.001). Most students agreed that learning videos (76.6 %), ARS (88.5 %), KFQ (76.5 %), and solution-oriented small group discussions (83.7 %) were useful. Lecturers stated an improved convergence of demands on learning and clinical competence. However, they also emphasized an increased initial effort for implementation. CONCLUSION: Students rated the overall benefit from the heutagogical "flipped classroom" concept as high. Examination grades improved. According to lecturers, the "flipped classroom" concept better matched later professional demands than traditional lectures. KEY POINTS: · The benefit of the "flipped classroom" concept for radiological lectures was rated high by students.. · Most students were satisfied with the multimedia and interactive elements of lectures.. · Lecturers considered heutagogical learning demands as appropriate for later clinical requirements.. CITATION FORMAT: · Teichgräber U, Ingwersen M, Mentzel H et al. Impact of a Heutagogical, Multimedia-Based Teaching Concept to Promote Self-Determined, Cooperative Student Learning in Clinical Radiology. Fortschr Röntgenstr 2021; 193: 701 - 711.

Radiographic remission in rheumatoid arthritis quantified by computer-aided joint space analysis (CASJA): a post hoc analysis of the RAPID 1 trial.

BACKGROUND: The reduction of finger joint space width (JSW) in patients with rheumatoid arthritis (RA) is strongly associated with joint destruction. Treatment with certolizumab pegol (CZP), a PEGylated anti-TNF, has been proven to be effective in RA patients. The computer-aided joint space analysis (CAJSA) provides the semiautomated measurement of joint space width at the metacarpal-phalangeal joints (MCP) based on hand radiographs. The aim of this post hoc analysis of the RAPID 1 trial was to quantify MCP joint space distance (JSD-MCP) measured by CAJSA between baseline and week 52 in RA patients treated with certolizumab pegol (CZP) plus methotrexate (MTX) compared with MTX/placebo. METHODS: Three hundred twenty-eight patients were included in the post hoc analysis and received placebo plus MTX, CZP 200 mg plus MTX and CZP 400 mg plus MTX. All patients underwent X-rays of the hand at baseline and week 52 as well as assessment of finger joint space narrowing of the MCP using CAJSA (Version 1.3.6; Sectra; Sweden). The joint space width (JSW) was expressed as mean joint space distance of the MCP joints I to V (JSD-MCPtotal). RESULTS: The MTX group showed a significant reduction of joint space of - 4.8% (JSD-MCPtotal), whereas in patients treated with CZP 200 mg/MTX and CZP 400 mg/MTX a non-significant change (JSD-MCPtotal + 0.6%) was observed. Over 52 weeks, participants with DAS28 remission (DAS28 ≤ 2.6) exhibited a significant joint space increase of + 3.3% (CZP 200 mg plus MTX) and + 3.9% (CZP pegol 400 mg plus MTX). CONCLUSION: CZP plus MTX did not reduce JSD-MCPtotal estimated by CAJSA compared with MTX/placebo. Furthermore, clinical remission (DAS28 ≤ 2.6) in patients treated with CZP plus MTX was associated with an increasing JSD, indicating radiographic remission in RA.

MR imaging of pulmonary lung nodules during one lung flooding: first morphological evaluation using an ex vivo human lung model.

OBJECTIVES: Magnetic resonance imaging in pulmonary oncology is limited because of unfavourable physical and physiological conditions in ventilated lung. Previous work showed operability of One Lung Flooding using saline in vivo in MR units, and that valuable conditions for ultrasound and thermal-based interventions exist. Therefore, this study investigates the morphological details of human lung during Lung Flooding to evaluate its further value focusing on MR-guided interventions. MATERIALS AND METHODS: MR imaging was performed on 20 human lung lobes containing lung cancer and metastases. Lobes were intraoperatively flooded with saline and imaged using T1w Gradient Echo and T2 Spin Echo sequences at 1.5 T. Additionally, six patients received pre-operative MRI. RESULTS: During lung flooding, all lung tumours and metastases were visualized and clearly demarked from the surrounding lung parenchyma. The tumour mass appeared hyperintense in T1w and hypointense in T2w MR imaging. Intra-pulmonary bronchial structures were well differentiated in T2w and calcification in T1w MR sequences. CONCLUSION: Superior conditions with new features of lung MRI were found during lung flooding with an unrestricted visualization of malignant nodules and clear demarcation of intra-pulmonary structures. This could lead to new applications of MR-based pulmonary interventions such as laser or focused ultrasound-based thermal ablations.

Assessment of MR imaging during one-lung flooding in a large animal model.

OBJECTIVE: Magnetic resonance imaging (MRI) of the lung remains challenging due to the low tissue density, susceptibility artefacts, unfavourable relaxation times and motion. Previously, we demonstrated in vivo that one-lung flooding (OLF) with saline is a viable and safe approach. This study investigates the feasibility of OLF in an MRI environment and evaluates the flooding process on MR images. METHODS: OLF of the left lung was performed on five animals using a porcine model. Before, during and after OLF, standard T2w and T1w spin-echo (SE) and gradient-echo (GRE) sequences were applied at 3 T. RESULTS: The procedure was successfully performed in all animals. On T1w MRI, the flooded lung appeared homogenous and isointense with muscle tissue. On T2w images, vascular structures were highly hypointense, while the bronchi were clearly demarcated with hypointense wall and hyperintense lumen. The anatomical demarcation of the flooded lung from the surrounding organs was superior on T2w images. No outflow effects were seen, and no respiration triggering was required. DISCUSSION: OLF can be safely performed in an MR scanner with highly detailed visualization of the pulmonary structures on T2w images. The method provides new approaches to MRI-based image-guided pulmonary interventions using the presented experimental model.

Patient radiation dose in percutaneous biliary interventions: recommendations for DRLs on the basis of a multicentre study.

OBJECTIVE: Percutaneous biliary interventions (PBIs) can be associated with a high patient radiation dose, which can be reduced when national diagnostic reference levels (DRLs) are kept in mind. The aim of this multicentre study was to investigate patient radiation exposure in different percutaneous biliary interventions, in order to recommend national DRLs. METHODS: A questionnaire asking for the dose area product (DAP) and the fluoroscopy time (FT) in different PBIs with ultrasound- or fluoroscopy-guided bile duct punctures was sent to 200 advanced care hospitals. Recommended national DRLs are set at the 75th percentile of all DAPs. RESULTS: Twenty-three facilities (9 interventional radiology depts. and 14 gastroenterology depts.) returned the questionnaire (12%). Five hundred sixty-five PBIs with 19 different interventions were included in the analysis. DAPs (range 4-21,510 cGy·cm2) and FTs (range 0.07-180.33 min) varied substantially depending on the centre and type of PBI. The DAPs of initial PBIs were significantly (p < 0.0001) higher (median 2162 cGy·cm2) than those of follow-up PBIs (median 464 cGy·cm2). There was no significant difference between initial PBIs with ultrasound-guided bile duct puncture (2162 cGy·cm2) and initial PBIs with fluoroscopy-guided bile duct puncture (2132 cGy·cm2) (p = 0.85). FT varied substantially (0.07-180.33 min). CONCLUSIONS: DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. PBI with US-guided bile duct puncture did not reduce DAP, when compared to PBI with fluoroscopy-guided bile duct puncture. National DRLs of 4300 cGy·cm2 for initial PBIs and 1400 cGy·cm2 for follow-up PBIs are recommended. KEY POINTS: • DAPs and FTs in percutaneous biliary interventions showed substantial variations depending on the centre and the type of PBI. • PBI with US-guided bile duct puncture did not reduce DAP when compared to PBI with fluoroscopy-guided bile duct puncture. • DRLs of 4300 cGy·cm2for initial PBIs (establishing a transhepatic tract) and 1400 cGy·cm2for follow-up PBIs (transhepatic tract already established) are recommended.

Inhibition of periarticular bone loss is associated with clinical remission and ACR70-Response in rheumatoid arthritis.

The aim of this study, based on a post hoc analysis of the data set used in the RAPID 1 trial, focuses on the associations between metacarpal bone mineral density, as estimated by digital X-ray radiogrammetry (DXR), and clinical remission as well as ACR70-Response in rheumatoid arthritis (RA) patients treated with certolizumab pegol (CZP). The trial evaluates a total of 345 RA patients treated with methotrexate versus CZP 200 mg versus CZP 400 mg. All patients underwent X-rays of the hand at baseline and week 52 as well as computerized calculations of bone mineral density (BMD) by DXR. Clinical remission was defined as DAS28 < 2.6. ACR70-Response was also evaluated. The radiological assessment of disease progression was estimated using the modified total Sharp Score. The mean difference for DAS28 was observed for patients treated with CZP 400 mg (median: - 3.53, minimum: - 6.77; maximum: + 0.48) and CZP 200 mg (median: - 3.13, minimum: - 6.37; maximum: - 0.52) compared to the methotrexate group (median - 2.41, minimum: - 4.76; maximum: + 0.31). The DXR-BMD showed a minor bone loss for the treatment groups undergoing therapy with CZP 200 mg (median: - 0.009 g/cm2, minimum: - 0.059 g/cm2; maximum: + 0.095 g/cm2) and CZP 400 mg (median: - 0.008 g/cm2, minimum: - 0.064 g/cm2; maximum: + 0.080 g/cm2). The methotrexate group presented an advanced periarticular metacarpal bone loss as measured by DXR-BMD (median: - 0.024 g/cm2, minimum: - 0.102 g/cm2; maximum: + 0.057 g/cm2). In the case of clinical remission and ACR70-Response, no significant change of the DXR-BMD was observed for both CZP groups. The study highlights that patients treated with CZP show a less accentuated periarticular bone loss as estimated by DXR in comparison to patients with methotrexate plus placebo. In addition, patients with clinical remission and ACR70-Response revealed no periarticular demineralisation.

Comparison of Unenhanced T1-Weighted Signal Intensities Within the Dentate Nucleus and the Globus Pallidus After Serial Applications of Gadopentetate Dimeglumine Versus Gadobutrol in a Pediatric Population.

OBJECTIVE: The aim of this study was to evaluate and compare changes in T1-weighted signal intensity (SI) within the dentate nucleus (DN) and globus pallidus (GP) in a pediatric population after serial applications of the linear gadolinium-based magnetic resonance contrast medium gadopentetate dimeglumine and the more stable macrocyclic agent gadobutrol. MATERIALS AND METHODS: Institutional review board approval was obtained. Two similar pediatric patient cohorts who underwent at least 3 serial contrast-enhanced magnetic resonance imaging (MRI) examinations with sole application of gadopentetate dimeglumine or gadobutrol were analyzed. All MRI examinations were performed on a 1.5 T system acquiring unenhanced T1-weighted spin echo sequences, which were evaluated on the baseline MRI and after the contrast medium administrations. For analysis of SI changes in the DN, the ratios of the DN to the pons (P) and to the middle cerebellar peduncle (MCP) were assessed. The GP was compared with the thalamus (TH) by dividing the SIs between GP and TH (GP-to-TH ratio). RESULTS: Twenty-eight patients (13 boys, 15 girls; mean age, 8.4 ± 6.8 years) who received at least 3 applications of gadopentetate dimeglumine and 25 patients (13 boys, 12 girls; mean age, 9.7 ± 5.4 years) with 3 or more gadobutrol injections were included. After 3 administrations of gadopentetate dimeglumine, the T1-weighted SI ratios significantly increased: mean difference value of 0.036 ± 0.031 (DN-to-P; P < 0.001), 0.034 ± 0.032 (DN-to-MCP; P < 0.001), and 0.025 ± 0.025 (GP-to-TH; P = 0.001). In a subanalysis of 12 patients with more than 3 injections of gadopentetate dimeglumine, the mean differences of the SI ratios were slightly higher: 0.043 ± 0.032 (DN-to-P; P = 0.001), 0.041 ± 0.035 (DN-to-MCP; P = 0.002), and 0.028 ± 0.025 (GP-to-TH; P = 0.003). In contrast, gadobutrol did not show a significant influence on the SI ratios, neither after 3 nor after more than 3 applications. CONCLUSIONS: The T1-weighted SI increase within the DN and GP after serial administrations of the linear contrast medium gadopentetate dimeglumine, but not after serial applications of the macrocyclic agent gadobutrol, found in a pediatric population, is consistent with results published for adult patients. The clinical impact of the intracranial T1-hyperintensities is currently unclear. However, in accordance with the recent decision of the Pharmacovigilance and Risk Assessment Committee of the European Medicines Agency, intravenous macrocyclic agents should be preferred and MR contrast media should be used with caution and awareness of the pediatric brain development in children and adolescents.

Metacarpal bone loss in patients with rheumatoid arthritis estimated by a new Digital X-ray Radiogrammetry method - initial results.

BACKGROUND: The Digital X-ray Radiogrammetry (DXR) method measures the cortical bone thickness in the shafts of the metacarpals and has demonstrated its relevance in the assessment of hand bone loss caused by rheumatoid arthritis (RA). The aim of this study was to validate a novel approach of the DXR method in comparison with the original version considering patients with RA. METHOD: The study includes 49 patients with verified RA. The new version is an extension of the BoneXpert method commonly used in pediatrics which has these characteristics: (1) It introduces a new technique to analyze the images which automatically validates the results for most images, and (2) it defines the measurement region relative to the ends of the metacarpals. The BoneXpert method measures the Metacarpal Index (MCI) at the metacarpal bone (II to IV). Additionally, the MCI is quantified by the DXR X-posure System. RESULTS: The new version correctly analyzed all 49 images, and 45 were automatically validated. The standard deviation between the MCI results of the two versions was 2.9% of the mean MCI. The average Larsen score was 2.6 with a standard deviation of 1.3. The correlation of MCI to Larsen score was -0.81 in both versions, and there was no significant difference in their ability to detect erosions. CONCLUSION: The new DXR version (BoneXpert) validated 92% of the cases automatically, while the same good correlation to RA severity could be presented compared to the old version.

Digital X-ray radiogrammetry and its sensitivity and specificity for the identification of rheumatoid arthritis-related cortical hand bone loss.

Digital X-ray radiogrammetry (DXR) is a computer-assisted diagnosis technique for quantifying cortical hand bone mineral density (BMD) as well as the metacarpal index (MCI) in the metacarpal bones from radiographs. The objective was to compare DXR-BMD and DXR-MCI between healthy individuals and patients with rheumatoid arthritis (RA) and verify the sensitivity and specificity of this technique for the identification of cortical hand bone loss as an additional diagnostic approach in RA. 618 patients were enrolled and divided into two groups: those with RA (n = 309) and a healthy control group (n = 309) as a reference database. DXR-BMD and the DXR-MCI were measured by DXR using hand radiographs. The severity of RA was evaluated by the modified Larsen score. Mean values for DXR-BMD and DXR-MCI in RA patients were significantly lower compared to healthy subjects (-20.7 and -21.1 %, respectively). Depending on the severity of RA-related joint damage, DXR-BMD revealed a significant reduction of -28.1 % and DXR-MCI -28.2 %, comparing score 1 and score 5 of the modified Larsen score. Both DXR-BMD and DXR-MCI had a high sensitivity (DXR-BMD 91 %, DXR-MCI 87 %) and a moderate specificity (DXR-BMD 47 %, DXR-MCI 49 %) to identify RA-related cortical hand bone loss. The DXR technique seems to be able to quantify RA-related periarticular bone loss as a characteristic feature in the course of RA. Consequently, periarticular osteoporosis seems to function as a reliable diagnostic approach comparable to erosions and joint space narrowing in the diagnosis of RA and as a surrogate marker for the progression of bone loss in RA.

Psoriatic arthritis is associated with bone loss of the metacarpals.

BACKGROUND: BoneXpert (BX) is a newly developed medical device based on digital X-ray radiogrammetry to measure human cortical bone thickness. The aim of this study was to quantify cortical bone loss of the metacarpals in patients with psoriatic arthritis (PsA) and compare these findings with other radiological scoring methods. METHODS: The study includes 104 patients with verified PsA. The BX method was used to measure the Metacarpal Index (MCI) at the metacarpal bones (II-IV). Additionally, the T-score of the MCI (T-scoreMCI) was calculated. Radiographic severity was determined by the Psoriatic Arthritis Ratingen Score (Proliferation Score and Destruction Score) as published by Wassenberg et al. and the Psoriatic Arthritis modified van der Heijde Sharp Score (Joint Space Narrowing Score and Erosion Score). RESULTS: For the total PsA study cohort, the T-scoreMCI was significantly reduced by -1.289 ± 1.313 SD. The MCI negatively correlated with the Proliferation Score (r = -0.732; p < 0.001) and the Destruction Score (r = -0.771; p < 0.001) of the Psoriatic Arthritis Ratingen Score. Lower coefficients of correlations were observed for the Psoriatic Arthritis modified van der Heijde Sharp Score. In this context, a severity-dependent and PsA-related periarticular demineralisation as measured by the MCI was quantified. The strongest reduction of -30.8 % (p < 0.01) was observed for the MCI in the Destruction Score. CONCLUSIONS: The BX MCI score showed periarticular demineralisation and severity-dependent bone loss in patients with PsA. The measurements of the BX technique were able to sensitively differentiate between the different stages of disease manifestation affecting bone integrity and thereby seem to achieve the potential to be a surrogate marker of radiographic progression in PsA.

A new implementation of digital X-ray radiogrammetry and reference curves of four indices of cortical bone for healthy European adults.

UNLABELLED: Digital X-ray radiogrammetry performs measurements on a hand radiograph in digital form. We present an improved implementation of the method and provide reference curves for four indices for the amount of bone. We collected 1662 hand radiographs of healthy subjects of age 9-100 years. PURPOSE: The digital X-ray radiogrammetry (DXR) method has been shown to be efficient for diagnosis of osteoporosis and for assessment of progression of rheumatoid arthritis. The aim of this work is to present a new DXR implementation and reference curves of four indices of cortical bone and to compare their relative SDs in healthy subjects at fixed age and gender. MATERIALS AND METHODS: A total of 1662 hand radiographs of healthy subjects of age 9-100 years were collected in Jena in 2001-2005. We also used a longitudinal study of 116 Danish children born in 1952 with on average 11 images taken over the age range 7 to 40 years. The new DXR method reconstructs the whole metacarpal contour so that the metacarpal lengths can be measured and used in two of the indices. The new DXR method automatically validates 97 % of the images and is implemented as a local server for PACS users. RESULTS: The Danish bone health index (BHI) data are consistent with the Jena data and also with the published BHI reference for healthy children. BHI is found to have smaller relative SD than the other three indices in the Jena cohort over the age range 20-80 years. CONCLUSION: The new DXR method is an extension of the existing BoneXpert method for children, which allows patients to be followed from childhood into adulthood with the same method. By making all four indices of cortical bone available within the same medical device, it becomes possible to decide which index has the best relation to fracture risk in future studies.

Reference values for digital X-ray radiogrammetry parameters in children and adolescents in comparison to estimates in patients with distal radius fractures.

The first objective of this study was to determine normative digital X-ray radiogrammetry (DXR) values, based on original digital images, in a pediatric population (aged 6-18 years). The second aim was to compare these reference data with patients suffering from distal radius fractures, whereas both cohorts originated from the same geographical region and were evaluated using the same technical parameters as well as inclusion and exclusion criteria. DXR-BMD and DXR-MCI of the metacarpal bones II-IV were assessed on standardized digital hand radiographs, without printing or scanning procedures. DXR parameters were estimated separately by gender and among six age groups; values in the fracture group were compared to age- and gender-matched normative data using Student's t tests and Z scores. In the reference cohort (150 boys, 138 girls), gender differences were found in bone mineral density (DXR-BMD), with higher values for girls from 11 to 14 years and for boys from 15 to 18 years (p < 0.05). Girls had higher normative metacarpal index (DXR-MCI) values than boys, with significant differences at 11-14 years (p < 0.05). In the case-control investigation, the fracture group (95 boys, 69 girls) presented lower DXR-BMD at 15-18 years in boys and 13-16 years in girls vs. the reference cohort (p < 0.05); DXR-MCI was lower at 11-18 years in boys and 11-16 years in girls (p < 0.05). Mean Z scores in the fracture group for DXR-BMD were -0.42 (boys) and -0.46 (girls), and for DXR-MCI were -0.51 (boys) and -0.53 (girls). These findings indicate that the fully digital DXR technique can be accurately applied in pediatric populations ≥ 6 years of age. The lower DXR-BMD and DXR-MCI values in the fracture group suggest promising early identification of individuals with increased fracture risk, without the need for additional radiation exposure, enabling the initiation of prevention strategies to possibly reduce the incidence of osteoporosis later in life.