Imaging

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.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

NEW YORK – When magnetic resonance imaging is used instead of plain x-rays in patients with early inflammatory back pain, the diagnostic accuracy for spondyloarthritis jumps from 25% to 70%, according to Dr. Maxime Dougados, who spoke at a rheumatology meeting sponsored by New York University.

"Seventy-five percent of the time, you cannot make the diagnosis with plain x-rays," said Dr. Dougados, professor of rheumatology at Paris-Descartes University/Cochin Hospital in Paris and the president-elect of EULAR. He presented the Ira Goldstein Memorial Lecture at the meeting, focusing on spondyloarthritis (SpA).

Dr. Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain that was initiated by the French Society of Rheumatology. Patients were recruited between December 2007 and April 2010 if they had inflammatory back pain lasting more than 3 months and less than 3 years. The group will be followed for 10 years in the ongoing study. At baseline, the mean age was 35 years, 54% were female and 57% were HLA-B27 positive (Joint Bone Spine 2011 March 30 [doi: 10.1016/j.jbspin.2011.01.013]).

Looking at radiological sacroiliac changes, the diagnosis was "obvious" for 25.6% of the cohort, "doubtful" for 21.3%, and "normal" for 53.1%. "These results indicate that at the first clinical visit, the interview is very important to pick up other clinical symptoms," said Dr. Dougados. In fact, about 80% were found to have non-axial clinical manifestations, including articular peripheral involvement, enthesopathy, dactylitis, anterior chest wall pain, uveitis, or psoriasis.

Using MRI, 70% of the cohort were determined to have "obvious" sacroiliitis, about 20% had a "doubtful" diagnosis and about 10% were thought to be "normal."

"These results indicate that you can detect early abnormalities of the sacroiliac joint on MRI even if x-rays are normal," he said.

According to Dr. Dougados, these imaging findings fit well with recent results from the DECLIC study, in which 163 rheumatologists were asked to diagnose 472 patients with early inflammatory back pain, including 161 patients with spondyloarthritis, according to four different sets of criteria. The specificity of the modified New York criteria, which relies on radiographic signs of sacroiliitis (unilateral grade III or bilateral grade II), fell well below that of the modified Amor criteria, the modified ESSG (European Spondyloarthropathy Study Group) criteria, and the ASAS (Assessment of Spondyloarthritis International Society) criteria. The latter three criteria include the option of diagnosing sacroiliitis with MRI.

In the new classification criteria from the ASAS, separate criteria are listed for patients with axial SpA with and without peripheral manifestations and patients with peripheral manifestations only. For axial SpA, one diagnostic pathway requires sacroiliitis on imaging plus one or more SpA feature. Sacroiliitis on MRI is given as much weight as is sacroiliitis on radiographs (Best Pract. Res. Clin. Rheumatol. 2010;24:589-604). The other pathway requires HLA-B27 positivity plus two or more SpA features. In patients with peripheral manifestations only, the requirements include peripheral arthritis, enthesitis or dactylitis plus one or more SpA features, including sacroiliitis on imaging.

Dr. Dougados also spoke about recent findings showing that patients with SpA were more likely to have distinct noninflammatory spinal MRI lesions (known as Fatty Romanus lesions) than were patients with degenerative arthritis or spinal malignancy (Ann. Rheum. Dis. 2010; 69:891-94).

"As MRI is becoming more important, rheumatologists should be trained to interpret MRIs," he said. "You don’t need to be a specialist in radiology."

Dr. Dougados has received grants for research projects and/or honorarium fees for participation at advisory boards/symposiums from Abbott, Bristol-Myers Squibb, Merck, Pfizer, Sanofi, and UCB.

LAKE BUENA VISTA, FLA.  – Serial computed tomography scans commonly used to monitor patients following endovascular aneurysm repair may be unnecessary after 6 years, according to the findings of a retrospective study of 2,965 scans in 608 EVAR patients.

Furthermore, such scans are more likely to detect a clinically significant incidental finding that warrants further workup than to find a problem with the endograft, Dr. Elizabeth L. Detschelt said at the annual meeting of the Society for Clinical Vascular Surgery.

The average annual rate of detection of EVAR-related findings was 4% (range 2%-5%), which remained constant over the first 6 years of follow-up, and the rate after 6 years was 0%. However, the annual detection rate for new clinically significant incidental findings on these scans was 25% (range 14%-32%), which remained constant for more than 10 years, said Dr. Detschelt of Allegheny General Hospital, Pittsburgh.

On multivariate analysis, predictors of detection of new clinically significant findings included age over 65 years, glomerular filtration rate less than 60 mL/min per 1.73 m², and tobacco use. No predictors were identified for EVAR-related findings, she noted.

The patients underwent EVAR for infrarenal aneurysm at a single institution between Dec. 1, 1999, and Nov. 30, 2009, and were followed for a mean of 32 months. These results are particularly relevant, Dr. Detschelt said, because risks from repeated scans, which are commonly used for serial imaging in EVAR patients to monitor for endoleak and other problems, are currently a topic of intense debate.

"Recently, the literature has really been inundated with concerns about the cumulative effects of such radiation exposure by these CT scan protocols, and in addition there’s a fair amount of literature to cite a very high rate of incidental findings that we detect on this follow-up with CT protocol," said Dr. Detschelt. Although such findings require follow-up, the literature suggests that this often falls through the cracks, she added.

In this study, EVAR-related findings included endoleak, limb occlusion, and endograft migration. Clinically significant incidental findings were varied, with the most common occurring in the broad categories of genitourinary findings, hepatobiliary findings, hernias, pulmonary neoplasms, and other vascular and cardiac lesions.

Not only do the findings suggest that serial imaging is not needed for EVAR-related concerns after 6 years, but they also underscore the importance of carefully evaluating post-EVAR CT scans for clinically significant incidental findings.

"As the ordering physicians of these CT scans, it is our legal responsibility to ensure that they have appropriate workup, so this is going to mean that not only do we have to look at the scans to assess the status of our aneurysm repair, but we also have to read the radiologist’s report to make sure we’re not missing something," she said.

That’s particularly true for patients who are older, who smoke, and who have a degree of renal insufficiency, she added.

The findings also raise the question of whether post-EVAR patients should undergo monitoring using other imaging techniques such as ultrasound, or whether a less frequent CT scan protocol can be used to reduce patient exposure to radiation and reduce patient costs.

These questions – along with the bigger question of whether it is more prudent to not use CT scans in order to reduce radiation exposure or to continue with CT monitoring to pick up findings that potentially could save or improve lives – require better data to inform decision making, she concluded.

During a discussion period after Dr. Detschelt’s talk, one audience member cautioned against suggesting that CT monitoring be considered for the purpose of detecting incidental nonvascular issues, saying that raises the argument of whether the general population aged 65-75 years should also undergo serial CT scans to find incidental nonvascular issues. He also noted that at his institution, the concerns about serial CT monitoring post EVAR are addressed in part by using duplex ultrasound in the immediate postoperative period, with follow-up by duplex ultrasound in those patients with no problems detected on the initial ultrasound.

He said findings from his experience and others have been published, and show that this is approach is "probably safe and effective." Dr. Detschelt responded that while duplex ultrasound is not used immediately postoperatively at her institution, there has been a move toward using it for long-term follow-up there. At many institutions, however, workforce issues come into play, because the duplex studies are more time intensive and require specially trained vascular staff, she said.

Dr. Detschelt had no disclosures.

LAKE BUENA VISTA, FLA.  – Serial computed tomography scans commonly used to monitor patients following endovascular aneurysm repair may be unnecessary after 6 years, according to the findings of a retrospective study of 2,965 scans in 608 EVAR patients.

Furthermore, such scans are more likely to detect a clinically significant incidental finding that warrants further workup than to find a problem with the endograft, Dr. Elizabeth L. Detschelt said at the annual meeting of the Society for Clinical Vascular Surgery.

The average annual rate of detection of EVAR-related findings was 4% (range 2%-5%), which remained constant over the first 6 years of follow-up, and the rate after 6 years was 0%. However, the annual detection rate for new clinically significant incidental findings on these scans was 25% (range 14%-32%), which remained constant for more than 10 years, said Dr. Detschelt of Allegheny General Hospital, Pittsburgh.

On multivariate analysis, predictors of detection of new clinically significant findings included age over 65 years, glomerular filtration rate less than 60 mL/min per 1.73 m², and tobacco use. No predictors were identified for EVAR-related findings, she noted.

The patients underwent EVAR for infrarenal aneurysm at a single institution between Dec. 1, 1999, and Nov. 30, 2009, and were followed for a mean of 32 months. These results are particularly relevant, Dr. Detschelt said, because risks from repeated scans, which are commonly used for serial imaging in EVAR patients to monitor for endoleak and other problems, are currently a topic of intense debate.

"Recently, the literature has really been inundated with concerns about the cumulative effects of such radiation exposure by these CT scan protocols, and in addition there’s a fair amount of literature to cite a very high rate of incidental findings that we detect on this follow-up with CT protocol," said Dr. Detschelt. Although such findings require follow-up, the literature suggests that this often falls through the cracks, she added.

In this study, EVAR-related findings included endoleak, limb occlusion, and endograft migration. Clinically significant incidental findings were varied, with the most common occurring in the broad categories of genitourinary findings, hepatobiliary findings, hernias, pulmonary neoplasms, and other vascular and cardiac lesions.

Not only do the findings suggest that serial imaging is not needed for EVAR-related concerns after 6 years, but they also underscore the importance of carefully evaluating post-EVAR CT scans for clinically significant incidental findings.

"As the ordering physicians of these CT scans, it is our legal responsibility to ensure that they have appropriate workup, so this is going to mean that not only do we have to look at the scans to assess the status of our aneurysm repair, but we also have to read the radiologist’s report to make sure we’re not missing something," she said.

That’s particularly true for patients who are older, who smoke, and who have a degree of renal insufficiency, she added.

The findings also raise the question of whether post-EVAR patients should undergo monitoring using other imaging techniques such as ultrasound, or whether a less frequent CT scan protocol can be used to reduce patient exposure to radiation and reduce patient costs.

These questions – along with the bigger question of whether it is more prudent to not use CT scans in order to reduce radiation exposure or to continue with CT monitoring to pick up findings that potentially could save or improve lives – require better data to inform decision making, she concluded.

During a discussion period after Dr. Detschelt’s talk, one audience member cautioned against suggesting that CT monitoring be considered for the purpose of detecting incidental nonvascular issues, saying that raises the argument of whether the general population aged 65-75 years should also undergo serial CT scans to find incidental nonvascular issues. He also noted that at his institution, the concerns about serial CT monitoring post EVAR are addressed in part by using duplex ultrasound in the immediate postoperative period, with follow-up by duplex ultrasound in those patients with no problems detected on the initial ultrasound.

He said findings from his experience and others have been published, and show that this is approach is "probably safe and effective." Dr. Detschelt responded that while duplex ultrasound is not used immediately postoperatively at her institution, there has been a move toward using it for long-term follow-up there. At many institutions, however, workforce issues come into play, because the duplex studies are more time intensive and require specially trained vascular staff, she said.

Dr. Detschelt had no disclosures.

LAKE BUENA VISTA, FLA.  – Serial computed tomography scans commonly used to monitor patients following endovascular aneurysm repair may be unnecessary after 6 years, according to the findings of a retrospective study of 2,965 scans in 608 EVAR patients.

Furthermore, such scans are more likely to detect a clinically significant incidental finding that warrants further workup than to find a problem with the endograft, Dr. Elizabeth L. Detschelt said at the annual meeting of the Society for Clinical Vascular Surgery.

The average annual rate of detection of EVAR-related findings was 4% (range 2%-5%), which remained constant over the first 6 years of follow-up, and the rate after 6 years was 0%. However, the annual detection rate for new clinically significant incidental findings on these scans was 25% (range 14%-32%), which remained constant for more than 10 years, said Dr. Detschelt of Allegheny General Hospital, Pittsburgh.

On multivariate analysis, predictors of detection of new clinically significant findings included age over 65 years, glomerular filtration rate less than 60 mL/min per 1.73 m², and tobacco use. No predictors were identified for EVAR-related findings, she noted.

The patients underwent EVAR for infrarenal aneurysm at a single institution between Dec. 1, 1999, and Nov. 30, 2009, and were followed for a mean of 32 months. These results are particularly relevant, Dr. Detschelt said, because risks from repeated scans, which are commonly used for serial imaging in EVAR patients to monitor for endoleak and other problems, are currently a topic of intense debate.

"Recently, the literature has really been inundated with concerns about the cumulative effects of such radiation exposure by these CT scan protocols, and in addition there’s a fair amount of literature to cite a very high rate of incidental findings that we detect on this follow-up with CT protocol," said Dr. Detschelt. Although such findings require follow-up, the literature suggests that this often falls through the cracks, she added.

In this study, EVAR-related findings included endoleak, limb occlusion, and endograft migration. Clinically significant incidental findings were varied, with the most common occurring in the broad categories of genitourinary findings, hepatobiliary findings, hernias, pulmonary neoplasms, and other vascular and cardiac lesions.

Not only do the findings suggest that serial imaging is not needed for EVAR-related concerns after 6 years, but they also underscore the importance of carefully evaluating post-EVAR CT scans for clinically significant incidental findings.

"As the ordering physicians of these CT scans, it is our legal responsibility to ensure that they have appropriate workup, so this is going to mean that not only do we have to look at the scans to assess the status of our aneurysm repair, but we also have to read the radiologist’s report to make sure we’re not missing something," she said.

That’s particularly true for patients who are older, who smoke, and who have a degree of renal insufficiency, she added.

The findings also raise the question of whether post-EVAR patients should undergo monitoring using other imaging techniques such as ultrasound, or whether a less frequent CT scan protocol can be used to reduce patient exposure to radiation and reduce patient costs.

These questions – along with the bigger question of whether it is more prudent to not use CT scans in order to reduce radiation exposure or to continue with CT monitoring to pick up findings that potentially could save or improve lives – require better data to inform decision making, she concluded.

During a discussion period after Dr. Detschelt’s talk, one audience member cautioned against suggesting that CT monitoring be considered for the purpose of detecting incidental nonvascular issues, saying that raises the argument of whether the general population aged 65-75 years should also undergo serial CT scans to find incidental nonvascular issues. He also noted that at his institution, the concerns about serial CT monitoring post EVAR are addressed in part by using duplex ultrasound in the immediate postoperative period, with follow-up by duplex ultrasound in those patients with no problems detected on the initial ultrasound.

He said findings from his experience and others have been published, and show that this is approach is "probably safe and effective." Dr. Detschelt responded that while duplex ultrasound is not used immediately postoperatively at her institution, there has been a move toward using it for long-term follow-up there. At many institutions, however, workforce issues come into play, because the duplex studies are more time intensive and require specially trained vascular staff, she said.

Dr. Detschelt had no disclosures.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.

NEW YORK – Imaging seems to be the sine qua non of determining cardiovascular disease risk in patients with rheumatoid arthritis.

Dr. Jeffrey D. Greenberg noted that, over the last 10-15 years, epidemiologic studies have shown patients with rheumatoid arthritis (RA) have a twofold increase in the risk of myocardial infarction and stroke and an increase in cardiovascular-related deaths. "An important issue we face is how can we risk stratify our patients to predict who will develop cardiovascular disease? Imaging is a promising area that may help us develop biomarkers of risk or better understand pathophysiological mechanisms of RA."

The need for precise tools with which to predict risk has become more urgent with the recently published findings that carotid ultrasound measurement of carotid intima-media thickness has been found to predict coronary events in patients with RA, independent of traditional cardiovascular risk factors and manifestations of RA.

The study, conducted by Dr. Matthew R. Evans and his associates at Brooke Army Medical Center, Fort Sam Houston, Tex., found that there appears to be a dose-dependent relationship between plaque and risk, with a 2.5-fold increase with unilateral plaque and 4.3-fold increase with bilateral carotid plaque, suggesting that atherosclerosis plays a significant role in acute coronary events in patients with RA (Arthritis Rheum. 2011 [doi:10.1002/art.30265]).

In discussing Dr. Evans’s research at his presentation at a rheumatology meeting sponsored by New York University, Dr. Greenberg said that this is the first study to demonstrate the predictive value of measuring carotid intima-media thickness and plaque for cardiovascular events in RA patients.

In the Evans study, carotid ultrasounds were performed on 636 RA patients as part of the prospective ORALE (Outcome of Rheumatoid Arthritis Longitudinal Evaluation) study. These patients were followed for 3,402 person-years and, during that time, 84 patients experienced 121 new or recurrent acute coronary syndrome (ACS) events, such as myocardial infarction, unstable angina, cardiac arrest, or death from ischemic heart disease. The rate of ACS events was 3.5/100 patient-years for this group. If only those without a prior history of ACS were analyzed, this group had 66 ACS events, with an incidence of 2.1 ACS/100 person-years.

Multivariate analysis of baseline factors associated with incident or recurrent acute coronary syndromes revealed that two markers of atherosclerosis were independent predictors of a subsequent coronary event. Having a past cardiovascular event raised the risk almost threefold (hazard ratio, 2.87 [1.75, 4.73]; P = .001) and carotid intima-media thickness also raised the risk significantly (HR, 1.61 [1.24, 2.08]; P = .001). After substituting carotid plaque for intima-media thickness, the investigators found a 2.5-fold increase in risk for unilateral plaque and almost a sixfold increase in risk for bilateral plaque.

The findings confirmed that traditional demographic and cardiovascular risk factors also predict coronary events as would be expected. These include male gender (HR, 1.94 [1.11, 3.39]; P =.05), diabetes (HR, 2.24 [1.44, 3.50]; P = .001), and hypertension (HR=1.56 [1.00, 2.44]; P =.05). Measures of RA severity, such as swollen joint counts (HR, 1.03 [1.01, 1.06]; P = .01) and cumulative prednisone dose of 20 g (HR, 2.12, [1.32, 3.42]; P = .01), also had predictive value.

Dr. Greenberg, who is director of the Arthritis Translational Registry and Biorepository at NYU Hospital for Joint Diseases, is involved in ongoing studies using advanced MRI and PET techniques to visualize and quantify some of key histologic features of plaque that are most likely to rupture, which he calls "vulnerable plaque." These histologic features include macrophage content, plaque neovascularization, a lipid-rich necrotic core, and a thin fibrous cap.

Dr. Greenberg receives consulting fees from Genentech Inc.