Prostate positioning errors associated with two automatic registration based image guidance strategies.

Daily image guidance for helical tomotherapy prostate patients is based on the registration of pre-treatment megavoltage CT (MVCT) images and the original planning CT. The goal of registration, whether manual or automatic, is the overlap of the prostate; otherwise prostate misplacement may compromise the efficacy of treatment or lead to increased toxicity. A previous study demonstrated that without the aid of implanted fiducials, manual registration results in inaccurate prostate positioning. The objective of this work is to quantify prostate misplacement that results from automatic bone matching (BM) and image matching (IM) registration algorithms. 204 MVCT images from 8 high risk tomotherapy prostate patients were incorporated into this retrospective study. BM and IM registration algorithms--based on maximization of mutual information of bony anatomy only and the entire image, respectively--were used to independently register MVCT images to their respective planning images. A correlation coefficient based algorithm that uses known planning CT contour information was used for automatic prostate localization in each MVCT image. Daily prostate misplacement was determined by repositioning as calculated from the BM and the IM algorithms. Mean (+/- SD) and maximum 3D prostate positioning errors were 3.7 +/- 2.1 mm and 11.8 mm for bone matching and 4.6 +/- 2.3 mm and 11.5 mm for image matching. In terms of translational directions, IM would lead to prostate positioning error > or = 3 mm in any of the LR, AP or SI directions in 62% of treatment fractions. The corresponding value for BM is 51%. The values for positioning errors > or = 5 mm were 29% and 17% for IM and BM, respectively. This data suggests automatic daily image guidance for tomotherapy prostate patients should be based on bone matching instead of image matching.

Validation of a Systemic Lupus Activity Questionnaire (SLAQ) for population studies.

The goal of this work was to develop an economical way of tracking disease activity for large groups of systemic lupus erythematosus (SLE) patients in clinical studies. A Systemic Lupus Activity Questionnaire (SLAQ) was developed to screen for possible disease activity using items from the Systemic Lupus Activity Measure (SLAM) and tested for its measurement properties. The SLAQ was completed by 93 SLE patients just prior to a scheduled visit. At the visit, a rheumatologist, blinded to SLAQ results, examined the subject and completed a SLAM. Associations among SLAQ, and SLAM (omitting laboratory items) and between individual items from each instrument were assessed with Pearson correlations. Correlations between pairs of instruments were compared using Student's t-tests. The mean score across all 24 SLAQ items was 11.5 (range 0-33); mean SLAM without labs was 3.0 (range 0-13). The SLAQ had a moderately high correlation with SLAM-nolab (r = 0.62, P < 0.0001). Correlations between patient-clinician matched pairs of items ranged from r = 0.06 to 0.71. Positive predictive values for the SLAQ ranged from 56 to 89% for detecting clinically significant disease activity. In studies of SLE, symptoms suggesting disease can be screened by self-report using the SLAQ and then verified by further evaluation.

Association between clinical factors, socioeconomic status, and organ damage in recent onset systemic lupus erythematosus.

OBJECTIVE: To determine the prevalence and socioeconomic and clinical predictors of early organ damage in a cohort of patients with systemic lupus erythematosus (SLE) of 2-7 years' duration randomly sampled at 5 centers and balanced by socioeconomic status and race. METHODS: The Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) Damage Index was measured in 200 patients who met the ACR criteria for SLE with a mean disease duration of 3.8 years. The SLICC/ACR scores for each organ system and the prevalence of damage within organ systems were assessed. Logistic regression analyses evaluated the simultaneous effects of age at diagnosis, disease duration, disease activity, and sociodemographic factors. RESULTS: Sixty-one percent of the patients had damage within 7 years of onset (mean 3.8 yrs). Neuropsychiatric (20.5%) and musculoskeletal (18.5%) systems were the most frequently involved, followed by renal (15.5%) and skin (12.5%) systems, all with median SLICC/ACR organ system scores of 1. In multivariate models, African-American race was associated with skin damage but not with damage in other specific organ systems. Socioeconomic status was not associated with organ system damage. Older age at diagnosis correlated with cardiovascular, musculoskeletal, gastrointestinal, ocular, and pulmonary damage. Clinical factors such as longer disease duration correlated with higher renal and cardiovascular damage, and greater disease activity at diagnosis of SLE correlated with greater renal, musculoskeletal, and pulmonary damage. CONCLUSION: There is evidence of organ system damage in SLE within a mean of 3.8 years after onset. We found little evidence for differences in early organ damage according to race or socioeconomic status. Damage to most organ systems was related to age at diagnosis of SLE and clinical factors such as disease duration.

Effects of epidural steroid injection on pain due to lumbar spinal stenosis or herniated disks: a prospective study.

OBJECTIVES: To describe the extent of pain relief two weeks after an epidural steroid injection in patients with herniated disks and lumbar spinal stenosis, and to identify predictors of changes in pain ratings in each population. METHODS: The study design was a prospective evaluation of patients with lumbar spinal stenosis (LSS) and herniated disks (HDs) referred to a hospital-based pain clinic for an epidural steroid injection (ESI). A complete history, detailed physical examination, comprehensive pain questionnaire, and Brief Symptom Inventory were obtained for all patients. Pain was assessed at baseline and two weeks following a single ESI using a visual analog scale. RESULTS: Two hundred twelve patients (mean age 54 years) were enrolled, and 78 of these provided pain ratings before and two weeks after the injection. LSS patients improved less two weeks following the ESI than HD patients (P = 0.04). Just 38% of LSS patients reported improvement in pain score compared with 61% of HD patients. In analyses that combined LSS and HD patients, predictors of worse response included a report of health problems and a diagnosis of LSS. CONCLUSIONS: LSS patients have worse response to ESIs than HD patients. The poor response to ESI in patients with LSS underscores the need for randomized controlled trials of ESI in this population.

Focal myositis presenting as pseudothrombophlebitis of the neck in a patient with mixed connective tissue disease.

This report describes a case of focal myositis in a patient with mixed connective tissue disease. The patient presented with diffuse neck swelling and pseudothrombophlebitis of the left internal jugular vein. Other clinical features included a high fever, elevated erythrocyte sedimentation rate, and prompt improvement after administration of high-dose intravenous corticosteroid therapy. Criteria for polymyositis were absent, serum levels of creatine kinase remained normal, and there was no sign of recurrence during 3 years of followup. Results of immunoprecipitation for anti-Jo-1 and other myositis-specific autoantibodies remained negative in serial serum samples obtained before, during, and after the episode.

Lambda light chain deposition disease presenting as an amyloid-like arthropathy.

We describe a case of lambda light chain deposition disease (LCDD) which presented with symmetric, seronegative, nonerosive arthritis associated with skin nodules and widespread, progressive soft tissue induration. Multiple biopsies disclosed Congo red nonbirefringent deposits which stained strongly with lambda light chain antiserum, allowing distinction from amyloid arthropathy. This is the first report of musculoskeletal involvement in LCDD.

A simple severity of disease index for systemic lupus erythematosus.

Although indices of activity for systemic lupus erythematosus have been developed and validated, a disease staging system requires the measurement of severity as well. We have constructed such a scale, the Lupus Severity of Disease Index (Lupus SDI). Accepted clinical, pathologic and physiologic classification schemes were employed to validate this index at two separate research institutions. The Lupus SDI allows homogenization of patient populations for the purposes of research and, possibly, for case mix adjustment.

Acute polyarthritis associated with birefringent lipid microspherules occurring in a patient with longstanding rheumatoid arthritis.

We describe a 52-year-old patient with longstanding rheumatoid arthritis (RA) who developed an acute polyarthritis of her hands and wrists. Synovial fluid analysis revealed the presence of intra and extracellular lipid microspherules with the typical appearance of Maltese crosses under polarized light microscopy. No other specific cause could be identified. This is the first description of an acute polyarthritis associated with lipid microspherules in RA.