Periodontitis and rheumatoid arthritis-Global efforts to untangle two complex diseases.

Understanding the impact of oral health on rheumatoid arthritis (RA) will inform how best to manage patients with both periodontitis and RA. This review seeks to provide an update on interventional and mechanistic investigations, including a brief summary of European Research programs investigating the link between periodontitis and RA. Recent clinical studies are described that evaluate how the treatment of one disease impacts on the other, as are studies in both humans and animal models that have sought to identify the potential mechanisms linking the two diseases.

Outcomes of periodontal therapy in rheumatoid arthritis: The OPERA feasibility randomized trial.

AIM: Periodontitis is independently associated with rheumatoid arthritis (RA); however, there is limited data on whether periodontal treatment improves overall RA disease activity. We conducted a pilot feasibility randomized controlled clinical trial to test whether intensive periodontal therapy reduces RA disease activity in patients with active RA and periodontitis. MATERIALS AND METHODS: The following inclusion criteria were applied: patients with RA and periodontitis, aged 18+, stable on treatment with disease-modifying anti-rheumatic drugs for ≥3 months, disease activity score (DAS28) ≥3.2, and DAS28 >5.1 only if patient unwilling to take biologics. Participants meeting the inclusion criteria were randomized to immediate intensive periodontal therapy or to delayed therapy (control group) administered by a dental hygienist in a secondary care setting. Data were collected at baseline and at 3 and 6 months of follow-up. Participants randomized to the control group (delayed therapy) received the standard of care for the duration of the trial, including oral hygiene instructions delivered by a dental hygienist, and the same periodontal therapy as the intervention group after study completion (i.e., 6 months after randomization). The periodontal inflammation surface area was calculated using clinical attachment loss (CAL), periodontal probing pocket depth, and bleeding on probing. Cumulative probing depth was also measured. We examined the effect of periodontal therapy on periodontal outcomes and on clinical markers of disease activity in RA, as measured by the DAS28-C-reactive protein score as well as musculo-skeletal ultrasound grey scale and power Doppler scores. RESULTS: A total of 649 patients with RA were invited to participate in the study. Of these, 296 (46%) consented to participate in the screening visit. A sample of 201 patients was assessed for eligibility, of whom 41 (20%) did not meet the RA inclusion criteria and 100 (50%) did not meet the periodontal disease criteria. Among the 60 (30%) eligible participants, 30 were randomized to immediate periodontal therapy and 30 were allocated to the control group. The loss to follow-up was 18% at the end of the trial. There were no major differences with regard to baseline characteristics between the groups. Periodontal therapy was associated with reduced periodontal inflamed surface area, cumulative probing depths, RA disease activity scores, and ultrasound scores over the course of the trial. There was no change in CAL. CONCLUSIONS: Overall, the trial was feasible and acceptable to the study participants. Recruitment to and satisfactory retention in a randomized controlled trial on the effect of periodontal treatment on RA patients is possible, albeit challenging. In this feasibility study of patients with RA and periodontitis, periodontal treatment resulted in significant improvements in periodontal disease outcomes and overall RA disease activity, although complete resolution of periodontal inflammation was difficult to achieve in some cases.

Periodontitis and rheumatoid arthritis: An update 2012-2017.

Rheumatoid arthritis and chronic periodontitis are both chronic inflammatory diseases characterized by an exacerbated inflammatory reaction that leads to destruction of bone and other connective tissue. Owing to these similarities, the relationship between these two diseases has been investigated for over two decades. In the 2013 proceedings from a workshop jointly held by the European Federation of Periodontology and American Academy of Periodontology in 2012 it was concluded that there was at least minimal evidence of an association between periodontitis and rheumatoid arthritis. In this review, we consider publications in the field over the past 5 years and determine whether the evidence for this relationship has increased.

What is the added sensitivity of non-lateral cervical spine radiographs in the evaluation of acute cervical spine trauma?

PURPOSE: Plain radiography of the cervical spine is used as a screening test for trauma patients. We evaluated the diagnostic yield of performing anteroposterior (AP), odontoid, and oblique views in addition to the lateral view in the current era when radiographs are performed only on low-risk patients. METHODS: All imaging reports from cervical spine radiography studies on patients aged 18 years and older in the emergency room of a major academic medical center between November 22, 2003, and January 17, 2012, were retrospectively reviewed. For the clinical workflow employed at the time of study acquisition, radiologists prospectively reviewed the lateral projection and subsequently reviewed the entirety of the images obtained. Exam reports and, when necessary, images were reviewed to determine which patients had fractures and on which projection the fractures were identified. RESULTS: Six fractures were detected in 7218 exams. Three of these fractures were identified on the lateral radiograph, and three of these fractures were visualized on the additional projections (two on oblique and one on odontoid views). The yield of the additional projections is one fracture per 9713 radiographic projections (90% confidence interval of one fracture per 1245-47,946 examinations). For two of the patients with fractures identified on the lateral projection, an additional fracture was seen when CT was then performed. CONCLUSIONS: Performing additional radiographs of the cervical spine including AP, odontoid, and bilateral oblique projections in trauma patients with low pretest probability of fracture augments the diagnostic yield of lateral radiographs. Considering the potential for devastating neurological outcomes from missed cervical fractures, addition of AP, odontoid, and oblique projections continues to detect fractures at a low rate.

Asymptomatic adult intrapericardial diaphragmatic hernia detected on cardiac SPECT CT.

An 83-year-old man underwent exercise stress test with single photon emission computed tomography (SPECT) myocardial perfusion imaging for new electrocardiogram (EKG) changes. The stress EKG did not show any significant changes. Myocardial perfusion imaging with SPECT demonstrated an inferior wall defect and extracardiac uptake of nuclear tracer. Simultaneous cardiac computed tomography performed for attenuation correction showed presence of intrapericardial hepatic tissue in an anterior diaphragmatic hernia. The herniated tissue was noted to influence the perfusion image and cause the defect. To date, this is a unique finding based on review of literature.

Translation of First North American 50 and 70 cc Total Artificial Heart Virtual and Clinical Implantations: Utility of 3D Computed Tomography to Test Fit Devices.

Since the creation of SynCardia's 50 cc Total Artificial Hearts (TAHs), patients with irreversible biventricular failure now have two sizing options. Herein, a case series of three patients who have undergone successful 50 and 70 cc TAH implantation with complete closure of the chest cavity utilizing preoperative "virtual implantation" of different sized devices for surgical planning are presented. Computed tomography (CT) images were used for preoperative planning prior to TAH implantation. Three-dimensional (3D) reconstructions of preoperative chest CT images were generated and both 50 and 70 cc TAHs were virtually implanted into patients' thoracic cavities. During the simulation, the TAHs were projected over the native hearts in a similar position to the actual implantation, and the relationship between the devices and the atria, ventricles, chest wall, and diaphragm were assessed. The 3D reconstructed images and virtual modeling were used to simulate and determine for each patient if the 50 or 70 cc TAH would have a higher likelihood of successful implantation without complications. Subsequently, all three patients received clinical implants of the properly sized TAH based on virtual modeling, and their chest cavities were fully closed. This virtual implantation increases our confidence that the selected TAH will better fit within the thoracic cavity allowing for improved surgical outcome. Clinical implantation of the TAHs showed that our virtual modeling was an effective method for determining the correct fit and sizing of 50 and 70 cc TAHs.

Volumetric MRI of the lungs during forced expiration.

PURPOSE: Lung function is typically characterized by spirometer measurements, which do not offer spatially specific information. Imaging during exhalation provides spatial information but is challenging due to large movement over a short time. The purpose of this work is to provide a solution to lung imaging during forced expiration using accelerated magnetic resonance imaging. The method uses radial golden angle stack-of-stars gradient echo acquisition and compressed sensing reconstruction. METHODS: A technique for dynamic three-dimensional imaging of the lungs from highly undersampled data is developed and tested on six subjects. This method takes advantage of image sparsity, both spatially and temporally, including the use of reference frames called bookends. Sparsity, with respect to total variation, and residual from the bookends, enables reconstruction from an extremely limited amount of data. RESULTS: Dynamic three-dimensional images can be captured at sub-150 ms temporal resolution, using only three (or less) acquired radial lines per slice per timepoint. The images have a spatial resolution of 4.6×4.6×10 mm. Lung volume calculations based on image segmentation are compared to those from simultaneously acquired spirometer measurements. CONCLUSION: Dynamic lung imaging during forced expiration is made possible by compressed sensing accelerated dynamic three-dimensional radial magnetic resonance imaging. Magn Reson Med 75:2295-2302, 2016. © 2015 Wiley Periodicals, Inc.

Identification of 4th intercostal space using sternal notch to xiphoid length for accurate electrocardiogram lead placement.

OBJECTIVE: Precordial ECG lead placement is difficult in obese patients with increased chest wall soft tissues due to inaccurate palpation of the intercostal spaces. We investigated whether the length of the sternum (distance between the sternal notch and xiphoid process) can accurately predict the location of the 4th intercostal space, which is the traditional location for V1 lead position. MATERIALS AND METHODS: Fifty-five consecutive adult chest computed tomography examinations were reviewed for measurements. RESULTS: The sternal notch to right 4th intercostal space distance was 67% of the sternal notch to xiphoid process length with an overall correlation of r=0.600 (p<0.001). CONCLUSION: The above measurement may be utilized to locate the 4th intercostal space for accurate placement of the precordial electrodes in adults in whom the 4th intercostal space cannot be found by physical exam.

The wonderful world of the windpipe: a review of central airway anatomy and pathology.

A variety of pathologic processes can involve the central airways. Abnormalities may either diffusely or focally involve the tracheal or mainstem bronchial walls. Diseases that diffusely involve the tracheal wall can be subclassified as sparing the membranous trachea or circumferentially involving the tracheal wall. Focal diseases of the trachea and mainstem bronchi include benign and malignant causes. Additionally, congenital and acquired morphologic abnormalities of the trachea will be reviewed.

A tour of the thymus: a review of thymic lesions with radiologic and pathologic correlation.

The thymus is routinely encountered on cross-sectional imaging studies of the chest. It has a variable appearance, undergoes dynamic changes during periods of stress, and demonstrates numerous different pathologic lesions. Understanding the imaging characteristics of these different lesions facilitates accurate radiographic diagnosis and can prevent unnecessary follow-up imaging and intervention. This article will review normal thymic anatomy and development, thymic hyperplasia and associated medical conditions, and the imaging and pathologic features of various benign and malignant thymic lesions.

Management of pneumothoraces detected on chest computed tomography: can anatomical location identify patients who can be managed expectantly?

BACKGROUND: Pneumothorax (PTX) can be readily detected by computed tomography (CT) or ultrasound. However, management of PTX in hemodynamically stable patients remains controversial. STUDY OBJECTIVES: We sought to investigate whether a distinct anatomical distribution of PTX along prespecified chest zones as detected by CT can be described in patients with or without subsequent chest tube thoracotomy (CTT), thus potentially allowing the extended focused assessment with sonography for trauma (EFAST) ultrasound examination to guide PTX management. METHODS: We performed a retrospective review of chest CT scans performed in the emergency department (ED) of a Level I trauma center. CT scans were analyzed for PTX distribution according to a chest zone model. Medical records of subjects with PTX were reviewed for subsequent CTT. RESULTS: Of 3636 chest CT scans performed, 183 PTX (156 patients) were detected without CTT at the time of CT scan (69% male, mean age 42 years). Of these, 66 subjects (40%) underwent CTT; 43 chest tubes (63%) were placed in the ED, 9 (13%) during hospitalization and 9 (13%) in the operating room. Median time to CTT was 140 min (interquartile range 52-199). Initial hemodynamic parameters, need for surgery, and need for mechanical ventilation were similar in both groups (p > 0.05 for all). Anatomical distribution and size of PTX were similar in the two groups. CONCLUSION: Although the majority of patients with traumatic PTX could be managed conservatively, we did not identify a characteristic anatomical PTX pattern, which could identify subjects who may not require CTT.

ACR Appropriateness Criteria ® imaging of mesenteric ischemia.

Mesenteric ischemia is a rare disease associated with high morbidity and mortality. Acute mesenteric ischemia is most commonly secondary to embolism followed by arterial thrombosis, nonocclusive ischemia, and less commonly venous thrombosis. Chronic mesenteric ischemia is almost always caused by atherosclerotic disease, with rare causes including fibromuscular dysplasia and vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Patients with mesenteric ischemia usually present with nonspecific abdominal symptoms and laboratory findings. This document evaluates and rates the appropriateness of imaging to evaluate patients with clinically suspected mesenteric ischemia. While catheter-based angiography has been considered the reference standard and enables diagnosis and treatment, advances in computed tomography have made it a first-line test in many patients because it is a fast, widely available, and noninvasive study. Abdominal radiographs and ultrasound have a limited role in diagnosing mesenteric ischemia but are commonly the first ordered tests in patients with abdominal pain and may diagnose more common pathologies.

Detection of hepatic steatosis on contrast-enhanced CT images: diagnostic accuracy of identification of areas of presumed focal fatty sparing.

OBJECTIVE: The purpose of this article is to determine the diagnostic accuracy of identifying focal areas of increased density along the gallbladder fossa or in the periphery of segment IV for diagnosing hepatic steatosis. MATERIALS AND METHODS: Five hundred consecutive three-phase CT examinations were retrospectively evaluated. Two reference standards for hepatic steatosis were determined using the unenhanced CT examination: a liver-spleen attenuation difference of greater than 10 HU and the absolute attenuation of the liver less than 40 HU. The portal venous phase was independently analyzed by two radiologists. Hepatic steatosis was diagnosed on the contrast-enhanced images if there was increased attenuation in the liver, either at the gallbladder fossa or in the posterior medial aspect of segment IV, when compared with background liver parenchyma. RESULTS: The criterion of relative liver-spleen attenuation difference diagnosed 38 cases. The criterion of absolute liver attenuation less than 40 HU diagnosed 44 cases. Of these cases, hepatic steatosis was diagnosed on the portal venous phase in 23 cases (κ = 1.0), with no false-positive cases. The criterion of relative liver-spleen attenuation difference yielded sensitivity, specificity, positive predictive value, and negative predictive value of 60.5%, 100%, 100%, and 96.9%, respectively. The criterion of absolute liver attenuation less than 40 HU yielded sensitivity, specificity, positive predictive value, and negative predictive value of 52.5%, 100%, 100%, and 95.7%, respectively. CONCLUSION: Qualitative evaluation of the liver on a portal venous phase contrast-enhanced CT is highly specific for the diagnosis of hepatic steatosis; the sensitivity of the method, however, is rather low.

Anatomical distribution of traumatic pneumothoraces on chest computed tomography: implications for ultrasound screening in the ED.

OBJECTIVES: We sought to assess the anatomical distribution of traumatic pneumothoraces (PTXs) on chest computed tomography (CT) to develop an optimized protocol for PTX screening with ultrasound in the emergency department (ED). METHODS: We performed a retrospective review of all chest CTs performed in one ED between January 2005 and December 2008 according to presence, location, and size of PTX. Pneumothoraces were then measured and categorized into 14 anatomical regions for each hemithorax. RESULTS: A total of 277 (3.8%) PTXs were identified, with 26 bilateral PTX, on 3636 chest CTs performed during the study period. Etiology was blunt (85%) or penetrating trauma (15%). Eighty-three (45%) PTXs were radiographically occult on initial chest x-ray. One hundred eighty-three (66%) PTX had no chest tube at the time of CT. For both hemithoraces, the distribution demonstrated increasing PTX frequency and size from lateral to medial and from superior to inferior. Region 12 (parasternal, intercostal spaces [ICS] 7-8) was involved in 68% of PTX on either side; region 9 (parasternal, ICS 5-6), in 67% on the left and in 52% on the right; and region 11 (lateral to midclavicular line, ICS 7-8), in 46% on the left and in 53% on the right. The largest anterior-to-posterior PTX dimension was seen in region 12. CONCLUSIONS: Our results indicate that 80.4% of right- and 83.7% of left-sided traumatic PTXs would be identified by scanning regions 9, 11, and 12. These findings suggest that a standardized protocol for PTX screening with ultrasound should include these regions.

ACR Appropriateness Criteria(®) blunt chest trauma--suspected aortic injury.

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

Contrast opacification using a reduced volume of iodinated contrast material and low peak kilovoltage in pulmonary CT angiography: Objective and subjective evaluation.

OBJECTIVE: The purpose of our study was to evaluate whether a reduced volume of iodinated contrast material for pulmonary CT angiography (CTA) using a low peak kilovoltage (kVp) technique yields equivalent opacification in all vessels. MATERIALS AND METHODS: Four hundred fifty-two consecutive pulmonary CTA patients (265 women and 187 men; age range, 18-91 years; mean age, 56.2 years) were retrospectively evaluated. Patients were grouped into those receiving 125 mL (n = 229) and 75 mL (n = 223) of 370 mg I/mL iodinated contrast material. Low kVp was used in all patients. Hounsfield units were measured at lobar, posterobasal segment, posterobasal ramus, and medial basal subsegmental ramus in the left lower lobe. Three thoracic radiologists blinded to contrast dose independently and randomly evaluated the quality of enhancement using a 3-point scale at the same levels. The two-sample Student's t test was used to compare contrast opacification between groups; Spearman's correlation and the C-statistic were used to assess objective and subjective measurements. Interreader agreement was measured using Kendall's coefficient. RESULTS: Mean contrast opacification differences between 125 mL versus 75 mL were not statistically significant (p > 0.21) at the lobar, segmental, and posterior basal rami, although the mean trended (p = 0.07) toward higher opacification of the medial basal ramus among 75 mL patients. Across all four pulmonary artery segments, there was good concordance between subjective and objective measurements, significantly higher than the null value of 0.50 (p > 0.05). For subsegmental arteries, concordance between objective and subjective measures was greater for the 75 mL group (p < 0.05). There was good interreader concordance, with a concordance coefficient of 0.70 (95% CI, 0.66-0.74). CONCLUSION: Both objective and subjective measures of contrast opacification support a reduction from 125 to 75 mL of contrast medium required for pulmonary CTA.

Preoperative Risk Stratification of Right Ventricular Function Utilizing Cardiac Magnetic Resonance Imaging Compared With Echocardiographic and Hemodynamic Parameters.

Accurate right ventricle functional analysis prior to mechanical circulatory support continues to be valuable for preoperative stratification of patients at risk for developing right ventricular (RV) failure. While cardiac magnetic resonance imaging (CMR) remains the gold standard, CMR is limited by availability and patient-specific contraindications. Further investigation of other imaging modalities would be beneficial as it may serve as a surrogate to identifying RV systolic dysfunction. A single-center, retrospective study including 29 patients with advanced heart failure was performed. All patients underwent ventricular functional analysis with both CMR and echocardiography, and 19 patients underwent right heart catheterization. Predictability with multimodal assessment of RV function was determined using logistic regression methods. Of the 29 participants, 10 had severe RV dysfunction. Tricuspid annular plane of systolic excursion was a modest predictor of RV dysfunction with odd ratio (OR) of 0.07 (0.01-0.72) and c-statistic of 0.79. Invasive hemodynamic measurement of cardiac index by thermodilution method was also predictive of RV dysfunction but failed to reach statistical significance (OR of 0.03, <0.001-1.28) with c-statistic of 0.83. The role of invasive hemodynamic data in predicting RV function compared with CMR should be further explored among patients with advanced heart failure.

Vascular enhancement and image quality of MDCT pulmonary angiography in 400 cases: comparison of standard and low kilovoltage settings.

OBJECTIVE: The purpose of this study was to investigate the vascular enhancement and image quality of pulmonary CT angiography performed with lower peak kilovoltage settings in a large patient sample. MATERIALS AND METHODS: This retrospective study was approved by our institutional review board, which waived the requirement for informed consent. Four hundred patients believed to have a pulmonary embolism were studied. All patients underwent 16- or 64-MDCT with automatic tube current modulation. The 200 patients in the standard peak kilovoltage group (mean age, 57 years; range, 22-95 years) underwent MDCT at 130 or 120 kVp. The 200 patients in the low peak kilovoltage group (mean age, 56 years; range, 21-92 years) underwent MDCT at 110 or 100 kVp. Vascular enhancement was evaluated by measurement of the attenuation value in the main pulmonary artery and segmental and subsegmental arteries. Image noise was quantified by measurement of the SD of the attenuation value in the main pulmonary artery. One blinded radiologist assessed image quality using visual scores. Wilcoxon's rank test was used to evaluate differences between the groups. RESULTS: Mean vascular enhancement in the main pulmonary artery had significantly higher attenuation values in the low peak kilovoltage group (376.1 +/- 102.9 HU) than in the standard peak kilovoltage group (309.2 +/- 94.8 HU) (p < 0.0001). Mean attenuation values in all measured segmental and subsegmental arteries were significantly higher in the low peak kilovoltage group than in the standard peak kilovoltage group (p < 0.0001). Image noise in the low peak kilovoltage group was significantly higher than in the standard peak kilovoltage group (p < 0.0001). There was no significant difference in the image quality scores of the two groups (p = 0.116). CONCLUSION: Lowering kilovoltage improved vascular enhancement without deterioration of image quality. The results of our study confirm previously reported preliminary findings.

Gums and joints: is there a connection? Part two: the biological link.

Rheumatoid arthritis (RA) and periodontitis (PD) are inflammatory diseases characterised by an exacerbated immune-inflammatory reaction that leads to the destruction of bone and other connective tissues that share numerous similarities. Although a significant and independent association between these two conditions has been described, the pathophysiological processes that may explain this relationship remain unknown and multiple theories have been proposed. This review presents the most important theories currently proposed to explain the biological link between RA and PD.