Imaging

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

Right ventricular mass, volume, and ejection fraction differ significantly according to patient age, sex, and race, according to a prospective imaging study of more than 4,000 healthy people that was reported in Circulation on June 6.

Moreover, the effect of these patient characteristics on the right ventricle is independent of body size, blood pressure level, diabetes status, and other conventional cardiovascular risk factors that are known to be associated with right ventricular morphology, said Dr. Steven M. Kawut of the Penn Cardiovascular Institute at the University of Pennsylvania, Philadelphia, and his associates.

Right ventricular structure and function have been "challenging" to measure with standard echocardiography techniques, and to date studies examining possible determinants of RV morphology have been small, have focused on young adults of homogeneous ethnicity, and have produced mixed findings, the investigators said.

In what they described as "the largest study of RV morphology ever performed," Dr. Kawut and his colleagues used cardiac MRI to assess ventricular morphology in a subset of subjects participating in MESA (Multi-Ethnic Study of Atherosclerosis). Their ancillary study specifically included a large number of subjects (4,123) from six communities across the United States who were of four major ethnicities and who ranged in age from 45 to 84 years.

The investigators found a consistent, approximately 5% decrease in RV mass for every 10-year increase in patient age, with men showing significantly larger age-related decrements in RV mass (1.0 g per decade) than did women (0.8 g per decade). These findings "may be surprising," as previous studies have been all over the map, with reports that aging increases, decreases, or makes no changes in RV mass, the investigators said.

Older age also was associated with smaller RV volume, and again the decreases in volume were greater among men than among women. Increasing age also was associated with increasing right ventricular ejection fraction of approximately 1% per decade (in all ethnicities except white), and decreasing right ventricular stroke volume of approximately 3% per decade.

It is possible that both the loss of cardiac myocytes and diminished quality of cardiac myocytes occur with aging, and may account for these changes, they said.

Sex also was independently associated with RV morphology. Men had approximately 8% higher RV mass than did women, as well as approximately 10% larger RV end-diastolic volume, approximately 4% lower RV ejection fraction, and approximately 7% larger RV stroke volume.

These sex differences "appeared to persist despite adjustment for the respective left ventricular parameter, suggesting that these findings were not solely due to secondary effects from the left ventricle or residual confounding by body size or composition." It seems likely that hormonal influences play a role in these sex-based differences, the researchers added.

"To our knowledge, ours is the first study to examine differences in RV morphology between races and ethnicities," they noted.

Blacks and Chinese Americans had a lower RV mass than did whites, whereas Hispanics had higher RV mass. Blacks had smaller RV end-diastolic volume than did whites, whereas Hispanics had larger RV end-diastolic volume than whites. Similarly, RV stroke volume was smallest in blacks, intermediate in whites, and larger in Hispanics. These differences could be the result of genetic variation among ethnic groups and may explain the poorer outcomes that are noted in blacks who have cardiopulmonary disease.

Based on their findings, Dr. Kawut and his associates devised new normative equations for measures of right ventricular morphology based on patient age, sex, and race. When these new equations were applied to the entire study cohort, they "were effective at indexing right ventricular measures to body size, [which is] important for clinical care and research since the outcomes of patients with congestive heart failure and pulmonary arterial hypertension depend on RV morphology and function," they said.

The new equations must be validated in other populations before they can be used clinically, the investigators noted.

This study was limited in that many subjects in MESA were unable to tolerate cardiac MRI, and many of the results for subjects who did undergo the procedure were "uninterpretable," they added.

The authors had no disclosures.

LONDON – A single 5-mg infusion of zoledronic acid, a bisphosphonate, in patients with knee osteoarthritis led to significant pain reduction and shrinkage of bone marrow lesions in a randomized, placebo-controlled study with 59 patients.

The zoledronic acid treatment led to an average 15-point drop in pain (on a visual analog scale of 0-100) beyond what occurred in the placebo group, and the active treatment was also linked with an average 170-mm² reduction in maximal bone marrow lesion (BML) area beyond the placebo-treated patients, which was a cut in BML area of about 37%, compared with the starting BML area, Dr. Graeme Jones said at the annual European Congress of Rheumatology. Dr. Jones visualizes BMLs using MRI knee scans.

"This is the first intervention shown to work on BMLs" in patients with osteoarthritis (OA), said Dr. Jones, professor of rheumatology and epidemiology and head of the musculoskeletal unit at the Menzies Research Institute Tasmania, Hobart, Australia.

"This is exciting for treating existing OA. It is one of the first positive structure modification trials," commented Dr. Philip Conaghan, professor and chairman of musculoskeletal medicine at the University of Leeds (England).

"Results from several studies have linked BMLs with pain and cartilage damage in OA patients. The larger the BML, the faster the cartilage loss and the worse the pain," Dr. Jones said in an interview. Based on studies his group has done, about 20% of BMLs that are associated with knee OA spontaneously enlarge over the course of 3 years, another 20% shrink in size, and about 60% remain the same, he said. Their earlier research findings also showed that BMLs are independently linked with fast progression of OA and the need for knee replacement. "If you reduce BMLs, it should produce good outcomes in patients," he said.

"The next step is to show that treatment with zoledronic acid not only reduces BML size but also slows cartilage loss. Sixty patients followed for 12 months were not enough to assess cartilage. We will need about 400 patients followed for 2 years," Dr. Jones added.

Despite not yet having information on cartilage effects, he said that his results so far have convinced him that treatment with zoledronic acid is reasonable for patients with painful knee OA and BMLs.

"I use it off label. Patients need to know it’s off label, and they [therefore] must be willing to pay for it, but I use it. It’s been shown to work, and nothing else works. Zoledronic acid [Reclast] is available, we know about its safety, and it’s been used for a long time to treat osteoporosis and cancers. If you have OA patients with BMLs, this is something to actively consider for them. Patients with OA have very limited treatment options. This can make a large difference in their pain, and it has long-lasting benefit so it can be given once a year," Dr. Jones said.

He recommended an infusion of 5 mg of zoledronic acid for patients who are at least 50 years old with knee OA that fulfills the American College of Rheumatology clinical criteria, and knee BMLs that are visible on an MRI scan of the affected knee. In his experience, 88% of these knee OA patients have BMLs. Dr. Jones noted that he does not use a maximal BML area threshold for initiating treatment, although in his study the average maximal BML area was about 465 mm². About one-third of people aged 50 years or older with no clinical evidence of OA also have BMLs, he noted.

The benefits of zoledronic acid that were seen in his study might be a class effect that may be replicated by treatment with another bisphosphonate, but zoledronic acid is more potent than oral bisphosphonates and hence the drug’s beneficial effect on pain and BML shrinkage may exceed the effect that other bisphosphonates might have, he said.

The pain benefit appeared to start wearing off about a year after the zoledronic acid injection. Dr. Jones said that he has a small number of patients whom he has infused a second time, which produced a second round of pain reduction. He has not yet given any OA patients a third dose of the drug.

The 59 patients who were enrolled in the study had an average age of about 60 years, with an average knee pain score of about 52 on the visual analog scale; all patients had BMLs as seen on MRI scans of their affected knees. In all, 31 patients received a 5-mg infusion of zoledronic acid and 28 patients received a placebo infusion. All patients also continued their conventional pain medication regimens. The zoledronic acid infusion was well tolerated: Although infusion reactions were reported in 90% of the patients who received the drug and in 43% of the placebo patients, serious adverse effects occurred in only 19% of the patients who received zoledronic acid and in 4% of the placebo patients.

The Food and Drug Administration has approved zoledronic acid under a number of brand names to prevent or treat osteoporosis in postmenopausal women or patients who are at risk for osteoporosis because they are taking or have taken corticosteroid therapy; to manage Paget disease; and to prevent chemotherapy-induced bone fractures or fractures in patients with multiple myeloma or cancer that has metastasized to the bones from other locations.

The study was funded by Novartis, which markets zoledronic acid (Reclast). Dr. Jones and Dr. Conaghan said that they had no disclosures.

*Correction, 6/6/2011: An earlier version of this story incorrectly stated that Dr. Jones had no disclosures. Dr. Jones has received speaker fees, travel sponsorship, and research support from Novartis and from several other drug companies.

 

LONDON – A single 5-mg infusion of zoledronic acid, a bisphosphonate, in patients with knee osteoarthritis led to significant pain reduction and shrinkage of bone marrow lesions in a randomized, placebo-controlled study with 59 patients.

The zoledronic acid treatment led to an average 15-point drop in pain (on a visual analog scale of 0-100) beyond what occurred in the placebo group, and the active treatment was also linked with an average 170-mm² reduction in maximal bone marrow lesion (BML) area beyond the placebo-treated patients, which was a cut in BML area of about 37%, compared with the starting BML area, Dr. Graeme Jones said at the annual European Congress of Rheumatology. Dr. Jones visualizes BMLs using MRI knee scans.

"This is the first intervention shown to work on BMLs" in patients with osteoarthritis (OA), said Dr. Jones, professor of rheumatology and epidemiology and head of the musculoskeletal unit at the Menzies Research Institute Tasmania, Hobart, Australia.

"This is exciting for treating existing OA. It is one of the first positive structure modification trials," commented Dr. Philip Conaghan, professor and chairman of musculoskeletal medicine at the University of Leeds (England).

"Results from several studies have linked BMLs with pain and cartilage damage in OA patients. The larger the BML, the faster the cartilage loss and the worse the pain," Dr. Jones said in an interview. Based on studies his group has done, about 20% of BMLs that are associated with knee OA spontaneously enlarge over the course of 3 years, another 20% shrink in size, and about 60% remain the same, he said. Their earlier research findings also showed that BMLs are independently linked with fast progression of OA and the need for knee replacement. "If you reduce BMLs, it should produce good outcomes in patients," he said.

"The next step is to show that treatment with zoledronic acid not only reduces BML size but also slows cartilage loss. Sixty patients followed for 12 months were not enough to assess cartilage. We will need about 400 patients followed for 2 years," Dr. Jones added.

Despite not yet having information on cartilage effects, he said that his results so far have convinced him that treatment with zoledronic acid is reasonable for patients with painful knee OA and BMLs.

"I use it off label. Patients need to know it’s off label, and they [therefore] must be willing to pay for it, but I use it. It’s been shown to work, and nothing else works. Zoledronic acid [Reclast] is available, we know about its safety, and it’s been used for a long time to treat osteoporosis and cancers. If you have OA patients with BMLs, this is something to actively consider for them. Patients with OA have very limited treatment options. This can make a large difference in their pain, and it has long-lasting benefit so it can be given once a year," Dr. Jones said.

He recommended an infusion of 5 mg of zoledronic acid for patients who are at least 50 years old with knee OA that fulfills the American College of Rheumatology clinical criteria, and knee BMLs that are visible on an MRI scan of the affected knee. In his experience, 88% of these knee OA patients have BMLs. Dr. Jones noted that he does not use a maximal BML area threshold for initiating treatment, although in his study the average maximal BML area was about 465 mm². About one-third of people aged 50 years or older with no clinical evidence of OA also have BMLs, he noted.

The benefits of zoledronic acid that were seen in his study might be a class effect that may be replicated by treatment with another bisphosphonate, but zoledronic acid is more potent than oral bisphosphonates and hence the drug’s beneficial effect on pain and BML shrinkage may exceed the effect that other bisphosphonates might have, he said.

The pain benefit appeared to start wearing off about a year after the zoledronic acid injection. Dr. Jones said that he has a small number of patients whom he has infused a second time, which produced a second round of pain reduction. He has not yet given any OA patients a third dose of the drug.

The 59 patients who were enrolled in the study had an average age of about 60 years, with an average knee pain score of about 52 on the visual analog scale; all patients had BMLs as seen on MRI scans of their affected knees. In all, 31 patients received a 5-mg infusion of zoledronic acid and 28 patients received a placebo infusion. All patients also continued their conventional pain medication regimens. The zoledronic acid infusion was well tolerated: Although infusion reactions were reported in 90% of the patients who received the drug and in 43% of the placebo patients, serious adverse effects occurred in only 19% of the patients who received zoledronic acid and in 4% of the placebo patients.

The Food and Drug Administration has approved zoledronic acid under a number of brand names to prevent or treat osteoporosis in postmenopausal women or patients who are at risk for osteoporosis because they are taking or have taken corticosteroid therapy; to manage Paget disease; and to prevent chemotherapy-induced bone fractures or fractures in patients with multiple myeloma or cancer that has metastasized to the bones from other locations.

The study was funded by Novartis, which markets zoledronic acid (Reclast). Dr. Jones and Dr. Conaghan said that they had no disclosures.

*Correction, 6/6/2011: An earlier version of this story incorrectly stated that Dr. Jones had no disclosures. Dr. Jones has received speaker fees, travel sponsorship, and research support from Novartis and from several other drug companies.

 

LONDON – A single 5-mg infusion of zoledronic acid, a bisphosphonate, in patients with knee osteoarthritis led to significant pain reduction and shrinkage of bone marrow lesions in a randomized, placebo-controlled study with 59 patients.

The zoledronic acid treatment led to an average 15-point drop in pain (on a visual analog scale of 0-100) beyond what occurred in the placebo group, and the active treatment was also linked with an average 170-mm² reduction in maximal bone marrow lesion (BML) area beyond the placebo-treated patients, which was a cut in BML area of about 37%, compared with the starting BML area, Dr. Graeme Jones said at the annual European Congress of Rheumatology. Dr. Jones visualizes BMLs using MRI knee scans.

"This is the first intervention shown to work on BMLs" in patients with osteoarthritis (OA), said Dr. Jones, professor of rheumatology and epidemiology and head of the musculoskeletal unit at the Menzies Research Institute Tasmania, Hobart, Australia.

"This is exciting for treating existing OA. It is one of the first positive structure modification trials," commented Dr. Philip Conaghan, professor and chairman of musculoskeletal medicine at the University of Leeds (England).

"Results from several studies have linked BMLs with pain and cartilage damage in OA patients. The larger the BML, the faster the cartilage loss and the worse the pain," Dr. Jones said in an interview. Based on studies his group has done, about 20% of BMLs that are associated with knee OA spontaneously enlarge over the course of 3 years, another 20% shrink in size, and about 60% remain the same, he said. Their earlier research findings also showed that BMLs are independently linked with fast progression of OA and the need for knee replacement. "If you reduce BMLs, it should produce good outcomes in patients," he said.

"The next step is to show that treatment with zoledronic acid not only reduces BML size but also slows cartilage loss. Sixty patients followed for 12 months were not enough to assess cartilage. We will need about 400 patients followed for 2 years," Dr. Jones added.

Despite not yet having information on cartilage effects, he said that his results so far have convinced him that treatment with zoledronic acid is reasonable for patients with painful knee OA and BMLs.

"I use it off label. Patients need to know it’s off label, and they [therefore] must be willing to pay for it, but I use it. It’s been shown to work, and nothing else works. Zoledronic acid [Reclast] is available, we know about its safety, and it’s been used for a long time to treat osteoporosis and cancers. If you have OA patients with BMLs, this is something to actively consider for them. Patients with OA have very limited treatment options. This can make a large difference in their pain, and it has long-lasting benefit so it can be given once a year," Dr. Jones said.

He recommended an infusion of 5 mg of zoledronic acid for patients who are at least 50 years old with knee OA that fulfills the American College of Rheumatology clinical criteria, and knee BMLs that are visible on an MRI scan of the affected knee. In his experience, 88% of these knee OA patients have BMLs. Dr. Jones noted that he does not use a maximal BML area threshold for initiating treatment, although in his study the average maximal BML area was about 465 mm². About one-third of people aged 50 years or older with no clinical evidence of OA also have BMLs, he noted.

The benefits of zoledronic acid that were seen in his study might be a class effect that may be replicated by treatment with another bisphosphonate, but zoledronic acid is more potent than oral bisphosphonates and hence the drug’s beneficial effect on pain and BML shrinkage may exceed the effect that other bisphosphonates might have, he said.

The pain benefit appeared to start wearing off about a year after the zoledronic acid injection. Dr. Jones said that he has a small number of patients whom he has infused a second time, which produced a second round of pain reduction. He has not yet given any OA patients a third dose of the drug.

The 59 patients who were enrolled in the study had an average age of about 60 years, with an average knee pain score of about 52 on the visual analog scale; all patients had BMLs as seen on MRI scans of their affected knees. In all, 31 patients received a 5-mg infusion of zoledronic acid and 28 patients received a placebo infusion. All patients also continued their conventional pain medication regimens. The zoledronic acid infusion was well tolerated: Although infusion reactions were reported in 90% of the patients who received the drug and in 43% of the placebo patients, serious adverse effects occurred in only 19% of the patients who received zoledronic acid and in 4% of the placebo patients.

The Food and Drug Administration has approved zoledronic acid under a number of brand names to prevent or treat osteoporosis in postmenopausal women or patients who are at risk for osteoporosis because they are taking or have taken corticosteroid therapy; to manage Paget disease; and to prevent chemotherapy-induced bone fractures or fractures in patients with multiple myeloma or cancer that has metastasized to the bones from other locations.

The study was funded by Novartis, which markets zoledronic acid (Reclast). Dr. Jones and Dr. Conaghan said that they had no disclosures.

*Correction, 6/6/2011: An earlier version of this story incorrectly stated that Dr. Jones had no disclosures. Dr. Jones has received speaker fees, travel sponsorship, and research support from Novartis and from several other drug companies.

 

Two measures of fracture risk – bone mineral density T score and FRAX score – are clinically useful in patients with type 2 diabetes, even though they tend to underestimate the increased fracture risk in this patient population, according to the results of a large study reported in the June 1 issue of JAMA.

But to be more accurate for older adults with diabetes, these treatment and diagnostic algorithms should undergo "refinements," said Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics, University of California, San Francisco, and her associates (JAMA 2011;305:2184-92).

Type 2 diabetes is known to be associated with a higher bone mineral density (BMD) but, paradoxically, also with a higher risk of fracture. There has been concern that established methods for predicting fractures "may not perform adequately in patients with type 2 diabetes," the researchers said.

In what they described as the first study to prospectively examine the relationship between BMD and fractures in older adults with type 2 diabetes, Dr. Schwartz and her colleagues analyzed data from three large, prospective, observational studies that all used radiology reports and radiographs to confirm fracture diagnoses. The three studies also ascertained subjects’ diabetes status.

The Study of Osteoporotic Fractures (SOF) involved 7,926 white women at four U.S. clinical centers who underwent femoral neck-hip BMD measurement and were followed for the occurrence of fractures from 1988 through 2008. The Osteoporotic Fractures in Men Study (MrOS) involved 5,994 men at six U.S. clinical centers who underwent hip BMD measurement and were followed from 2000 through 2009. And the Health, Aging, and Body Composition (Health ABC) study involved 1,523 women and 1,442 men in their 70s, approximately half of whom were white and half black, who underwent hip BMD measurement and were followed from 1997 through 2007.

The FRAX (Fracture Risk Algorithm) scores were calculated for subjects in the SOF and MrOS studies by the World Health Organization (WHO) Collaborating Center for Metabolic Bone Disease, but not for subjects in the Health ABC study.

Dr. Schwartz and her associates found that both low BMD T score and high FRAX score were predictive of hip and nonspinal fracture in patients with diabetes. "However, for a given T score and age, those adults with diabetes had a higher risk of fracture than those without diabetes," they said.

For example, the risk of hip fracture in a woman with diabetes was equivalent to that of a nondiabetic woman with a T score of about 0.5 units lower.

The subjects with diabetes showed higher rates of fracture at any given FRAX score than did subjects who didn’t have diabetes, they noted.

"Interpretation of T score or FRAX score in an older patient with diabetes must take into account the higher fracture risk associated with diabetes. For example, ... a T score in a woman with diabetes is associated with hip fracture risk equivalent to a woman without diabetes with a T score of approximately 0.5 units lower," the investigators said.

"The FRAX score has been incorporated into U.S. guidelines for prevention and treatment of osteoporosis. The FRAX algorithm does not currently include type 2 diabetes as a risk factor for fracture, and our results indicate that use of the FRAX score in patients with diabetes will likely underestimate risk.

"An adjustment of this algorithm for type 2 diabetes seems justified, given the prevalence of diabetes among older adults," Dr. Schwartz and her associates said.

The reason diabetes raises fracture risk even as it appears to protect against loss of BMD is not understood. "Bone strength may be compromised through changes that are not captured with dual-energy x-ray absorptiometry, such as higher levels of advanced glycation end products in bone collagen. More frequent falls in older adults with diabetes could also increase fracture risk for a given BMD," they said.

This study was funded by an investigator-initiated grant from Amgen to Dr. Schwartz. She and her associates also reported receiving support from Novartis, Merck, Pfizer, Nycomed, and Roche.

Two measures of fracture risk – bone mineral density T score and FRAX score – are clinically useful in patients with type 2 diabetes, even though they tend to underestimate the increased fracture risk in this patient population, according to the results of a large study reported in the June 1 issue of JAMA.

But to be more accurate for older adults with diabetes, these treatment and diagnostic algorithms should undergo "refinements," said Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics, University of California, San Francisco, and her associates (JAMA 2011;305:2184-92).

Type 2 diabetes is known to be associated with a higher bone mineral density (BMD) but, paradoxically, also with a higher risk of fracture. There has been concern that established methods for predicting fractures "may not perform adequately in patients with type 2 diabetes," the researchers said.

In what they described as the first study to prospectively examine the relationship between BMD and fractures in older adults with type 2 diabetes, Dr. Schwartz and her colleagues analyzed data from three large, prospective, observational studies that all used radiology reports and radiographs to confirm fracture diagnoses. The three studies also ascertained subjects’ diabetes status.

The Study of Osteoporotic Fractures (SOF) involved 7,926 white women at four U.S. clinical centers who underwent femoral neck-hip BMD measurement and were followed for the occurrence of fractures from 1988 through 2008. The Osteoporotic Fractures in Men Study (MrOS) involved 5,994 men at six U.S. clinical centers who underwent hip BMD measurement and were followed from 2000 through 2009. And the Health, Aging, and Body Composition (Health ABC) study involved 1,523 women and 1,442 men in their 70s, approximately half of whom were white and half black, who underwent hip BMD measurement and were followed from 1997 through 2007.

The FRAX (Fracture Risk Algorithm) scores were calculated for subjects in the SOF and MrOS studies by the World Health Organization (WHO) Collaborating Center for Metabolic Bone Disease, but not for subjects in the Health ABC study.

Dr. Schwartz and her associates found that both low BMD T score and high FRAX score were predictive of hip and nonspinal fracture in patients with diabetes. "However, for a given T score and age, those adults with diabetes had a higher risk of fracture than those without diabetes," they said.

For example, the risk of hip fracture in a woman with diabetes was equivalent to that of a nondiabetic woman with a T score of about 0.5 units lower.

The subjects with diabetes showed higher rates of fracture at any given FRAX score than did subjects who didn’t have diabetes, they noted.

"Interpretation of T score or FRAX score in an older patient with diabetes must take into account the higher fracture risk associated with diabetes. For example, ... a T score in a woman with diabetes is associated with hip fracture risk equivalent to a woman without diabetes with a T score of approximately 0.5 units lower," the investigators said.

"The FRAX score has been incorporated into U.S. guidelines for prevention and treatment of osteoporosis. The FRAX algorithm does not currently include type 2 diabetes as a risk factor for fracture, and our results indicate that use of the FRAX score in patients with diabetes will likely underestimate risk.

"An adjustment of this algorithm for type 2 diabetes seems justified, given the prevalence of diabetes among older adults," Dr. Schwartz and her associates said.

The reason diabetes raises fracture risk even as it appears to protect against loss of BMD is not understood. "Bone strength may be compromised through changes that are not captured with dual-energy x-ray absorptiometry, such as higher levels of advanced glycation end products in bone collagen. More frequent falls in older adults with diabetes could also increase fracture risk for a given BMD," they said.

This study was funded by an investigator-initiated grant from Amgen to Dr. Schwartz. She and her associates also reported receiving support from Novartis, Merck, Pfizer, Nycomed, and Roche.

Two measures of fracture risk – bone mineral density T score and FRAX score – are clinically useful in patients with type 2 diabetes, even though they tend to underestimate the increased fracture risk in this patient population, according to the results of a large study reported in the June 1 issue of JAMA.

But to be more accurate for older adults with diabetes, these treatment and diagnostic algorithms should undergo "refinements," said Ann V. Schwartz, Ph.D., of the department of epidemiology and biostatistics, University of California, San Francisco, and her associates (JAMA 2011;305:2184-92).

Type 2 diabetes is known to be associated with a higher bone mineral density (BMD) but, paradoxically, also with a higher risk of fracture. There has been concern that established methods for predicting fractures "may not perform adequately in patients with type 2 diabetes," the researchers said.

In what they described as the first study to prospectively examine the relationship between BMD and fractures in older adults with type 2 diabetes, Dr. Schwartz and her colleagues analyzed data from three large, prospective, observational studies that all used radiology reports and radiographs to confirm fracture diagnoses. The three studies also ascertained subjects’ diabetes status.

The Study of Osteoporotic Fractures (SOF) involved 7,926 white women at four U.S. clinical centers who underwent femoral neck-hip BMD measurement and were followed for the occurrence of fractures from 1988 through 2008. The Osteoporotic Fractures in Men Study (MrOS) involved 5,994 men at six U.S. clinical centers who underwent hip BMD measurement and were followed from 2000 through 2009. And the Health, Aging, and Body Composition (Health ABC) study involved 1,523 women and 1,442 men in their 70s, approximately half of whom were white and half black, who underwent hip BMD measurement and were followed from 1997 through 2007.

The FRAX (Fracture Risk Algorithm) scores were calculated for subjects in the SOF and MrOS studies by the World Health Organization (WHO) Collaborating Center for Metabolic Bone Disease, but not for subjects in the Health ABC study.

Dr. Schwartz and her associates found that both low BMD T score and high FRAX score were predictive of hip and nonspinal fracture in patients with diabetes. "However, for a given T score and age, those adults with diabetes had a higher risk of fracture than those without diabetes," they said.

For example, the risk of hip fracture in a woman with diabetes was equivalent to that of a nondiabetic woman with a T score of about 0.5 units lower.

The subjects with diabetes showed higher rates of fracture at any given FRAX score than did subjects who didn’t have diabetes, they noted.

"Interpretation of T score or FRAX score in an older patient with diabetes must take into account the higher fracture risk associated with diabetes. For example, ... a T score in a woman with diabetes is associated with hip fracture risk equivalent to a woman without diabetes with a T score of approximately 0.5 units lower," the investigators said.

"The FRAX score has been incorporated into U.S. guidelines for prevention and treatment of osteoporosis. The FRAX algorithm does not currently include type 2 diabetes as a risk factor for fracture, and our results indicate that use of the FRAX score in patients with diabetes will likely underestimate risk.

"An adjustment of this algorithm for type 2 diabetes seems justified, given the prevalence of diabetes among older adults," Dr. Schwartz and her associates said.

The reason diabetes raises fracture risk even as it appears to protect against loss of BMD is not understood. "Bone strength may be compromised through changes that are not captured with dual-energy x-ray absorptiometry, such as higher levels of advanced glycation end products in bone collagen. More frequent falls in older adults with diabetes could also increase fracture risk for a given BMD," they said.

This study was funded by an investigator-initiated grant from Amgen to Dr. Schwartz. She and her associates also reported receiving support from Novartis, Merck, Pfizer, Nycomed, and Roche.

Magnetic resonance imaging is at least as sensitive as other modalities at predicting treatment response in patients with new onset spondyloarthritis, according to data presented on May 25 by Dr. Mikkel Østergaard at the annual European Congress of Rheumatology.

In discussing research that pointed to the usefulness of MRI in managing patients with ankylosing spondylitis (SpA), Dr. Østergaard reviewed the varied manifestations SpA can take on MRI, and how imaging can be a useful tool for predicting the formation of new bone.

“MRI has brought a major improvement in the evaluation and management of patients with spondyloarthritis,” he said. “It allows earlier detection of sacroiliitis than [does] any other modality, and has thereby enabled physicians to diagnose spondyloarthritis up to 5-10 years earlier than they could before.” He added that MRI provides physicians with an objective way to monitor disease activity in SpA.

Dr. Østergaard explained how to use MRI to identify disease in the sacroiliac joints, the spine, and the peripheral joints. “Given the major improvement in evaluation and management of spondyloarthritis patients that MRI has brought, it is very important that rheumatologists are aware of the findings that indicate actual spondyloarthritis and of the advantages of MRI so that they can order the correct examinations,” he said.

“It is important that not only rheumatologists but also radiologists are aware of the large impact of early diagnosis and treatment of patients with SpA concerning pain relief and better function,” he noted. Radiologists should prioritize to do early and adequate MRI examinations in patients with suspected spondyloarthritis. Ordering MRI “at an earlier and more appropriate phase in the patient’s disease” could help those patients get a quick diagnosis and allow early initiation of the relevant therapy, Dr. Østergaard added.

He discussed a study in which he participated that involved 50 patients with SpA who had an MRI done once at baseline and again on follow-up at an average of 19.2 months later. Patients also underwent spinal radiography at baseline and follow-up more than 2 years later. The goal of the study was to use imaging to evaluate the effectiveness of anti–tumor necrosis factor (TNF)–alpha agents for treatment of vertebral corner inflammatory lesions. The study aimed to evaluate whether MRI could be used to predict the growth of new syndesmophytes after anti-TNF-alpha therapy, said Dr. Østergaard of the department of rheumatology at the University of Copenhagen and Glostrup (Denmark) Hospital, who was a coauthor.

The study showed that in patients who receive anti-TNF-alpha therapy, new syndesmophytes developed more frequently from vertebral corners where follow-up MRI had shown a completely resolved corner inflammatory lesion, compared with vertebral corners with no inflammatory lesions (42.9 % vs. 2.4 %). For patients who received standard treatment, the study reported a similar pattern (20 % vs. 3.3 %), he added.

The study findings indicated that MRI can predict new bone formation on radiograph, and supported the theory that anti-TNF-alpha acts to inhibit new bone formation. However, because the sample size was so small, further study will be needed to validate these findings, Dr. Østergaard said.

Dr. Østergaard had no disclosures to report.

Magnetic resonance imaging is at least as sensitive as other modalities at predicting treatment response in patients with new onset spondyloarthritis, according to data presented on May 25 by Dr. Mikkel Østergaard at the annual European Congress of Rheumatology.

In discussing research that pointed to the usefulness of MRI in managing patients with ankylosing spondylitis (SpA), Dr. Østergaard reviewed the varied manifestations SpA can take on MRI, and how imaging can be a useful tool for predicting the formation of new bone.

“MRI has brought a major improvement in the evaluation and management of patients with spondyloarthritis,” he said. “It allows earlier detection of sacroiliitis than [does] any other modality, and has thereby enabled physicians to diagnose spondyloarthritis up to 5-10 years earlier than they could before.” He added that MRI provides physicians with an objective way to monitor disease activity in SpA.

Dr. Østergaard explained how to use MRI to identify disease in the sacroiliac joints, the spine, and the peripheral joints. “Given the major improvement in evaluation and management of spondyloarthritis patients that MRI has brought, it is very important that rheumatologists are aware of the findings that indicate actual spondyloarthritis and of the advantages of MRI so that they can order the correct examinations,” he said.

“It is important that not only rheumatologists but also radiologists are aware of the large impact of early diagnosis and treatment of patients with SpA concerning pain relief and better function,” he noted. Radiologists should prioritize to do early and adequate MRI examinations in patients with suspected spondyloarthritis. Ordering MRI “at an earlier and more appropriate phase in the patient’s disease” could help those patients get a quick diagnosis and allow early initiation of the relevant therapy, Dr. Østergaard added.

He discussed a study in which he participated that involved 50 patients with SpA who had an MRI done once at baseline and again on follow-up at an average of 19.2 months later. Patients also underwent spinal radiography at baseline and follow-up more than 2 years later. The goal of the study was to use imaging to evaluate the effectiveness of anti–tumor necrosis factor (TNF)–alpha agents for treatment of vertebral corner inflammatory lesions. The study aimed to evaluate whether MRI could be used to predict the growth of new syndesmophytes after anti-TNF-alpha therapy, said Dr. Østergaard of the department of rheumatology at the University of Copenhagen and Glostrup (Denmark) Hospital, who was a coauthor.

The study showed that in patients who receive anti-TNF-alpha therapy, new syndesmophytes developed more frequently from vertebral corners where follow-up MRI had shown a completely resolved corner inflammatory lesion, compared with vertebral corners with no inflammatory lesions (42.9 % vs. 2.4 %). For patients who received standard treatment, the study reported a similar pattern (20 % vs. 3.3 %), he added.

The study findings indicated that MRI can predict new bone formation on radiograph, and supported the theory that anti-TNF-alpha acts to inhibit new bone formation. However, because the sample size was so small, further study will be needed to validate these findings, Dr. Østergaard said.

Dr. Østergaard had no disclosures to report.

Magnetic resonance imaging is at least as sensitive as other modalities at predicting treatment response in patients with new onset spondyloarthritis, according to data presented on May 25 by Dr. Mikkel Østergaard at the annual European Congress of Rheumatology.

In discussing research that pointed to the usefulness of MRI in managing patients with ankylosing spondylitis (SpA), Dr. Østergaard reviewed the varied manifestations SpA can take on MRI, and how imaging can be a useful tool for predicting the formation of new bone.

“MRI has brought a major improvement in the evaluation and management of patients with spondyloarthritis,” he said. “It allows earlier detection of sacroiliitis than [does] any other modality, and has thereby enabled physicians to diagnose spondyloarthritis up to 5-10 years earlier than they could before.” He added that MRI provides physicians with an objective way to monitor disease activity in SpA.

Dr. Østergaard explained how to use MRI to identify disease in the sacroiliac joints, the spine, and the peripheral joints. “Given the major improvement in evaluation and management of spondyloarthritis patients that MRI has brought, it is very important that rheumatologists are aware of the findings that indicate actual spondyloarthritis and of the advantages of MRI so that they can order the correct examinations,” he said.

“It is important that not only rheumatologists but also radiologists are aware of the large impact of early diagnosis and treatment of patients with SpA concerning pain relief and better function,” he noted. Radiologists should prioritize to do early and adequate MRI examinations in patients with suspected spondyloarthritis. Ordering MRI “at an earlier and more appropriate phase in the patient’s disease” could help those patients get a quick diagnosis and allow early initiation of the relevant therapy, Dr. Østergaard added.

He discussed a study in which he participated that involved 50 patients with SpA who had an MRI done once at baseline and again on follow-up at an average of 19.2 months later. Patients also underwent spinal radiography at baseline and follow-up more than 2 years later. The goal of the study was to use imaging to evaluate the effectiveness of anti–tumor necrosis factor (TNF)–alpha agents for treatment of vertebral corner inflammatory lesions. The study aimed to evaluate whether MRI could be used to predict the growth of new syndesmophytes after anti-TNF-alpha therapy, said Dr. Østergaard of the department of rheumatology at the University of Copenhagen and Glostrup (Denmark) Hospital, who was a coauthor.

The study showed that in patients who receive anti-TNF-alpha therapy, new syndesmophytes developed more frequently from vertebral corners where follow-up MRI had shown a completely resolved corner inflammatory lesion, compared with vertebral corners with no inflammatory lesions (42.9 % vs. 2.4 %). For patients who received standard treatment, the study reported a similar pattern (20 % vs. 3.3 %), he added.

The study findings indicated that MRI can predict new bone formation on radiograph, and supported the theory that anti-TNF-alpha acts to inhibit new bone formation. However, because the sample size was so small, further study will be needed to validate these findings, Dr. Østergaard said.

Dr. Østergaard had no disclosures to report.

Magnetic resonance imaging is an important tool for detecting subclinical arthritis in children with juvenile idiopathic arthritis. In addition, MRI is a useful way to determine if there is disease persistence or silent progression before discontinuing treatment, according to a study of children who have clinically inactive JIA or are in remission on medication, according to Dr. Nikolay Tzaribachev.

All of the patients with clinically defined persistent oligoarticular juvenile idiopathic arthritis (JIA) were found to have polyarticular disease on MRI, according to Dr. Tzaribachev, head of the pediatric rheumatology department at the Center for Rheumatic Diseases in Bad Bramstedt, Germany.

Photo credit: Courtesy Dr. Nikolay Tzaribachev

"JIA tends to have an insidious onset and disease course. Subclinical JIA can elude the human tactile senses and clinical capacity to detect arthritis. In patients who are on drug treatment, symptoms may drop beyond clinical activity and disease may only become detectable by imaging techniques," said Dr. Tzaribachev in an interview.

"Remission criteria appear to be insufficient to detect the real extent of disease, which is of high importance to prevent joint damage, especially in growing children, who are supposed to become healthy adults.

"Furthermore, differentiation between oligo- and polyarticular disease at the first clinical evaluation after onset of symptoms is indispensable, since according to the ACR 2011 treatment guidelines [Arthritis Care Res. (Hoboken) 2011;63:465-82], oligo- and polyarticular disease have different treatment approaches," he noted.

During the last few years, silent arthritis in adults with RA has been detected only through the use of different imaging techniques, according to Dr. Tzaribachev. This fact led him and his colleagues to speculate that silent arthritis might also be the cause of the high percentage of disabilities in young adults with JIA, and that the clinical criteria for inactive disease and remission in JIA might be inadequate for detecting silent arthritis.

"We saw the huge discrepancy between clinical examination and MRI results, and understood the urgent need for more knowledge about the real extent of disease and silent disease progression, in order to protect the children from joint damage," said Dr. Tzaribachev.

The study included 21 patients with JIA (median age, 10.2 years at enrollment), who were on medications including NSAIDs, methotrexate, and/or tumor necrosis factor antagonists.

Clinically inactive disease or remission on medication were defined according to the Wallace criteria (J. Rheumatol. 2006;33:789-95). Patients underwent clinical examination, laboratory tests, and MRIs, and were asked to fill out a child health assessment questionnaire at every visit. The joints examined included wrists, knees, and ankles. Clinical and MRI exams and laboratory investigations were performed on the same day. Joint counts included those done clinically, as well as those based on MRI findings.

JIA subtype distribution included persistent oligoarticular (five patients), extended oligoarticular (four), polyarthritis (six), psoriatic arthritis (five), and undifferentiated arthritis (one). The median follow up time was 2.5 years.

Overall, 45 events were documented, 29 of which involved silent arthritis.

In all events, MRI revealed the following findings: 36 events with joint effusion, 39 with synovitis, 42 with synovial hypertrophy, 15 with bone marrow edema, 14 with osteitis, 15 with erosions, and 3 with tenosynovitis. All the silent arthritis events involved signs of arthritis that could be seen on MRI. Silent arthritis events were followed after a delay by clinical activity, according to the study.

In patients with JIA who present with clinically inactive disease or remission on medication, flares are preceded by arthritis detected on MRI. "In those cases, clinical examination and laboratory parameters remain normal despite ongoing disease activity, and remission criteria fail to show the real extent of disease," said Dr. Tzaribachev. "The lack of symptoms may also lead to silent disease progression, explaining the high percentage of physical disabilities in young adults with JIA. Imaging seems to be an important tool for defining disease activity, which should be included in the remission criteria and performed before treatment discontinuation."

The JIA classification probably needs to be redefined and remission criteria need to be reviewed to allow for the use of MRI and ultrasound, said Dr. Tzaribachev. Imaging techniques and protocols also need to be improved to become more child friendly, he noted. In addition, more studies are needed to define normal findings with respect to the growing musculoskeletal system in children and to allow for differentiation from mild pathology, especially for new imaging techniques like Xiralite. "Last, but not least, as in adult rheumatology, imaging should probably find its place in all clinical trials of children with inflammatory arthritis," he said.

Dr. Tzaribachev has received a research grant from Pfizer on temporomandibular joint arthritis in patients with JIA. His coauthors reported no disclosures.

Magnetic resonance imaging is an important tool for detecting subclinical arthritis in children with juvenile idiopathic arthritis. In addition, MRI is a useful way to determine if there is disease persistence or silent progression before discontinuing treatment, according to a study of children who have clinically inactive JIA or are in remission on medication, according to Dr. Nikolay Tzaribachev.

All of the patients with clinically defined persistent oligoarticular juvenile idiopathic arthritis (JIA) were found to have polyarticular disease on MRI, according to Dr. Tzaribachev, head of the pediatric rheumatology department at the Center for Rheumatic Diseases in Bad Bramstedt, Germany.

Photo credit: Courtesy Dr. Nikolay Tzaribachev

"JIA tends to have an insidious onset and disease course. Subclinical JIA can elude the human tactile senses and clinical capacity to detect arthritis. In patients who are on drug treatment, symptoms may drop beyond clinical activity and disease may only become detectable by imaging techniques," said Dr. Tzaribachev in an interview.

"Remission criteria appear to be insufficient to detect the real extent of disease, which is of high importance to prevent joint damage, especially in growing children, who are supposed to become healthy adults.

"Furthermore, differentiation between oligo- and polyarticular disease at the first clinical evaluation after onset of symptoms is indispensable, since according to the ACR 2011 treatment guidelines [Arthritis Care Res. (Hoboken) 2011;63:465-82], oligo- and polyarticular disease have different treatment approaches," he noted.

During the last few years, silent arthritis in adults with RA has been detected only through the use of different imaging techniques, according to Dr. Tzaribachev. This fact led him and his colleagues to speculate that silent arthritis might also be the cause of the high percentage of disabilities in young adults with JIA, and that the clinical criteria for inactive disease and remission in JIA might be inadequate for detecting silent arthritis.

"We saw the huge discrepancy between clinical examination and MRI results, and understood the urgent need for more knowledge about the real extent of disease and silent disease progression, in order to protect the children from joint damage," said Dr. Tzaribachev.

The study included 21 patients with JIA (median age, 10.2 years at enrollment), who were on medications including NSAIDs, methotrexate, and/or tumor necrosis factor antagonists.

Clinically inactive disease or remission on medication were defined according to the Wallace criteria (J. Rheumatol. 2006;33:789-95). Patients underwent clinical examination, laboratory tests, and MRIs, and were asked to fill out a child health assessment questionnaire at every visit. The joints examined included wrists, knees, and ankles. Clinical and MRI exams and laboratory investigations were performed on the same day. Joint counts included those done clinically, as well as those based on MRI findings.

JIA subtype distribution included persistent oligoarticular (five patients), extended oligoarticular (four), polyarthritis (six), psoriatic arthritis (five), and undifferentiated arthritis (one). The median follow up time was 2.5 years.

Overall, 45 events were documented, 29 of which involved silent arthritis.

In all events, MRI revealed the following findings: 36 events with joint effusion, 39 with synovitis, 42 with synovial hypertrophy, 15 with bone marrow edema, 14 with osteitis, 15 with erosions, and 3 with tenosynovitis. All the silent arthritis events involved signs of arthritis that could be seen on MRI. Silent arthritis events were followed after a delay by clinical activity, according to the study.

In patients with JIA who present with clinically inactive disease or remission on medication, flares are preceded by arthritis detected on MRI. "In those cases, clinical examination and laboratory parameters remain normal despite ongoing disease activity, and remission criteria fail to show the real extent of disease," said Dr. Tzaribachev. "The lack of symptoms may also lead to silent disease progression, explaining the high percentage of physical disabilities in young adults with JIA. Imaging seems to be an important tool for defining disease activity, which should be included in the remission criteria and performed before treatment discontinuation."

The JIA classification probably needs to be redefined and remission criteria need to be reviewed to allow for the use of MRI and ultrasound, said Dr. Tzaribachev. Imaging techniques and protocols also need to be improved to become more child friendly, he noted. In addition, more studies are needed to define normal findings with respect to the growing musculoskeletal system in children and to allow for differentiation from mild pathology, especially for new imaging techniques like Xiralite. "Last, but not least, as in adult rheumatology, imaging should probably find its place in all clinical trials of children with inflammatory arthritis," he said.

Dr. Tzaribachev has received a research grant from Pfizer on temporomandibular joint arthritis in patients with JIA. His coauthors reported no disclosures.

Magnetic resonance imaging is an important tool for detecting subclinical arthritis in children with juvenile idiopathic arthritis. In addition, MRI is a useful way to determine if there is disease persistence or silent progression before discontinuing treatment, according to a study of children who have clinically inactive JIA or are in remission on medication, according to Dr. Nikolay Tzaribachev.

All of the patients with clinically defined persistent oligoarticular juvenile idiopathic arthritis (JIA) were found to have polyarticular disease on MRI, according to Dr. Tzaribachev, head of the pediatric rheumatology department at the Center for Rheumatic Diseases in Bad Bramstedt, Germany.

Photo credit: Courtesy Dr. Nikolay Tzaribachev

"JIA tends to have an insidious onset and disease course. Subclinical JIA can elude the human tactile senses and clinical capacity to detect arthritis. In patients who are on drug treatment, symptoms may drop beyond clinical activity and disease may only become detectable by imaging techniques," said Dr. Tzaribachev in an interview.

"Remission criteria appear to be insufficient to detect the real extent of disease, which is of high importance to prevent joint damage, especially in growing children, who are supposed to become healthy adults.

"Furthermore, differentiation between oligo- and polyarticular disease at the first clinical evaluation after onset of symptoms is indispensable, since according to the ACR 2011 treatment guidelines [Arthritis Care Res. (Hoboken) 2011;63:465-82], oligo- and polyarticular disease have different treatment approaches," he noted.

During the last few years, silent arthritis in adults with RA has been detected only through the use of different imaging techniques, according to Dr. Tzaribachev. This fact led him and his colleagues to speculate that silent arthritis might also be the cause of the high percentage of disabilities in young adults with JIA, and that the clinical criteria for inactive disease and remission in JIA might be inadequate for detecting silent arthritis.

"We saw the huge discrepancy between clinical examination and MRI results, and understood the urgent need for more knowledge about the real extent of disease and silent disease progression, in order to protect the children from joint damage," said Dr. Tzaribachev.

The study included 21 patients with JIA (median age, 10.2 years at enrollment), who were on medications including NSAIDs, methotrexate, and/or tumor necrosis factor antagonists.

Clinically inactive disease or remission on medication were defined according to the Wallace criteria (J. Rheumatol. 2006;33:789-95). Patients underwent clinical examination, laboratory tests, and MRIs, and were asked to fill out a child health assessment questionnaire at every visit. The joints examined included wrists, knees, and ankles. Clinical and MRI exams and laboratory investigations were performed on the same day. Joint counts included those done clinically, as well as those based on MRI findings.

JIA subtype distribution included persistent oligoarticular (five patients), extended oligoarticular (four), polyarthritis (six), psoriatic arthritis (five), and undifferentiated arthritis (one). The median follow up time was 2.5 years.

Overall, 45 events were documented, 29 of which involved silent arthritis.

In all events, MRI revealed the following findings: 36 events with joint effusion, 39 with synovitis, 42 with synovial hypertrophy, 15 with bone marrow edema, 14 with osteitis, 15 with erosions, and 3 with tenosynovitis. All the silent arthritis events involved signs of arthritis that could be seen on MRI. Silent arthritis events were followed after a delay by clinical activity, according to the study.

In patients with JIA who present with clinically inactive disease or remission on medication, flares are preceded by arthritis detected on MRI. "In those cases, clinical examination and laboratory parameters remain normal despite ongoing disease activity, and remission criteria fail to show the real extent of disease," said Dr. Tzaribachev. "The lack of symptoms may also lead to silent disease progression, explaining the high percentage of physical disabilities in young adults with JIA. Imaging seems to be an important tool for defining disease activity, which should be included in the remission criteria and performed before treatment discontinuation."

The JIA classification probably needs to be redefined and remission criteria need to be reviewed to allow for the use of MRI and ultrasound, said Dr. Tzaribachev. Imaging techniques and protocols also need to be improved to become more child friendly, he noted. In addition, more studies are needed to define normal findings with respect to the growing musculoskeletal system in children and to allow for differentiation from mild pathology, especially for new imaging techniques like Xiralite. "Last, but not least, as in adult rheumatology, imaging should probably find its place in all clinical trials of children with inflammatory arthritis," he said.

Dr. Tzaribachev has received a research grant from Pfizer on temporomandibular joint arthritis in patients with JIA. His coauthors reported no disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.

Asymptomatic, low-risk patients with abnormal results on screening coronary computed tomographic angiography tend to undergo further invasive procedures and to initiate medical therapy, but don’t show better outcomes at 18 months than do those who aren’t screened, according to a report published online May 23 in Archives of Internal Medicine.

In addition, patients who receive normal results on CCTA screening tend to discontinue aspirin or statin use. "Whether this will prove to be cost effective or potentially harmful owing to a false sense of reassurance is currently unknown," according to Dr. John W. McEvoy of Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, and his associates.

Both findings demonstrate that physicians and patients sometimes "dramatically change practice based on CCTA findings," so rigorous randomized controlled trials that closely examine the usefulness of this imaging technique are called for, they added.

The investigators "sought to evaluate the downstream implications of CCTA testing" in what they described as the first study to examine the issue in a large matched cohort. They used data from a group of 1,000 asymptomatic, low-risk South Korean adults who had already undergone CCTA as part of a 6-month health-promotion effort at Seoul National University Bundang Hospital, as well as 1,000 matched subjects who declined to have CCTA in that promotion.

The mean age of the study population was 50 years, and 63% of the subjects were men.

The majority, 79%, had normal CCTA results; 21% had abnormal results. This included 7% who were found to have significant coronary artery stenosis.

Significantly more (5.5%) of the subjects who underwent CCTA were referred for further testing, including myocardial single-photon emission CT (SPECT) and coronary angiography, compared with subjects who did not have CCTA (2.2%). Yet the percentage of abnormal SPECT results was the same in both groups.

Revascularization procedures also were more common in the CCTA group (13 subjects) than in the control group (1 subject), "despite their asymptomatic status and low Framingham Risk Score." Twelve patients underwent PCI and 1 underwent CABG in the CCTA group.

However, the rate of major coronary events was extremely low (0.1%) and identical between the two study groups, regardless of CCTA screening status.

"This raises great concern regarding the use of CCTA imaging in low-risk groups," Dr. McEvoy and his associates said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.204]).

"Our data concur with the prevailing notion that screening CCTA does not have a role in low-risk patients."

Subjects who underwent CCTA had increased rates of statin use compared with those who did not, both at 90 days (34% vs. 8%) and 18 months (20% vs. 6%). The odds ratio for statin use among subjects who had abnormal CCTA results was 4.6, compared with subjects who did not undergo CCTA.

Abnormal CCTA results also were associated with an increased use of aspirin. The odds ratio for aspirin use among subjects who had abnormal CCTA findings was 6.8 at 90 days and 4.2 at 18 months, compared with subjects who did not undergo CCTA.

It was interesting to note that the use of both medications decreased markedly over time in both groups. This "serves as a reminder that medication compliance is a complex phenomenon determined only in part by a single health care intervention (such as an imaging test like CCTA)," the investigators noted.

Overall, the study findings "highlight the need to consider the pretest probability of disease before performing imaging tests in patients who may be subsequently exposed to potentially harmful downstream procedures with questionable prognostic benefit," they said.

In an accompanying editorial, Dr. Michael S. Lauer wrote: "The report by McEvoy et al. serves as a powerful reminder of the two-edged effects of screening."

"Overdiagnosis is threatening to become an increasingly important public health problem because of the enthusiasm for and proliferation of unproven screening tests," he said (Arch. Intern. Med. 2011 May 23 [doi:10.1001/archinternmed.2011.205]).

"If we are going to prevent an epidemic of coronary pseudodisease, we as a profession will have to muster the courage, imagination, and discipline to design and perform the needed large-scale trials" to determine whether CCTA actually improves patient outcomes, said Dr. Lauer of the National Heart, Lung, and Blood Institute.

Dr. McEvoy and Dr. Lauer reported no relevant financial disclosures.