Imaging

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 Dougados presented the as yet unpublished results from the DESIR cohort, a large French national multicenter database of long-term follow-up of 708 patients presenting with early inflammatory back pain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.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

SAN DIEGO – The manifestations of chronic venous insufficiency generally increase with higher body mass index, results from a national screening program demonstrated.

However, venous abnormalities on screening duplex ultrasound were not correlated with increasing BMI.

"We did not find an increase in obstruction or venous reflux in higher-BMI individuals, which leads us to believe that obesity in and of itself is a contributor to chronic venous disease in the absence of valvular insufficiency," Dr. Colleen Moore said at the annual meeting of the American Venous Forum.

To determine differences in venous disease across a spectrum of BMI, Dr. Moore and her associates analyzed results from the National Venous Screening program. The program, launched by the American Venous Forum in 2005, was designed to educate participants about venous thromboembolism (VTE) risk, varicose veins, and chronic venous insufficiency through screening, literature, promotional materials, and an interview with a venous expert.

"The program strives to identify those at risk for VTE, the presence of venous obstruction or reflux on a modified duplex ultrasound, and the presence of chronic venous insufficiency based on a quick leg inspection," said Dr. Moore, of the vascular surgery department at Southern Illinois University, Springfield. "It then empowers individuals to go forth and inform their primary care providers and family of their risk of venous disease and the presence of venous disease."

Dr. Moore and her colleagues divided participants into six BMI categories: underweight (less than 18.5 kg/m²), normal weight (18.5-24.9), overweight (25-29.9), obese (30-34.9), morbidly obese (35-39.9), and supermorbidly obese (greater than 40).

The researchers collected several data points for comparison, including demographic and health information, a VTE risk assessment, venous quality of life with the Chronic Venous Insufficiency Questionnaire 2 (CIVIQ2), and an abbreviated duplex ultrasound. Participants in the screening program also underwent a lower-extremity inspection and were assigned a CEAP classification (based on clinical severity, etiology or cause, anatomy, and pathophysiology).

Dr. Moore presented findings from 7,227 people who have been screened since 2005. Of these, 1.3% were underweight, 34.9% were normal weight, 34.8% were overweight, 16.6% were obese, 7.7% were morbidly obese, and 4.7% were supermorbidly obese.

The prevalence of diabetes significantly increased incrementally with BMI (from 4.9% in the normal-weight group to 25.2% in the supermorbidly obese group), as did the prevalence of hypertension (from 22.9% in the normal-weight group to 54.3% in the supermorbidly obese group).

Mean VTE risk-assessment scores significantly increased incrementally with BMI (from 3.3 in the normal-weight group to 4.1 in the supermorbidly obese group), as did mean quality-of-life scores (from 20.3 in the normal-weight group to 29.0 in the supermorbidly obese group). "We looked at social activities such as the ability to play sports or do housework," Dr. Moore said. "As you become heavier those scores increase, indicating a worse quality of life, and are statistically significant, compared with the normal-weight individuals."

Quality-of-life assessments regarding physical function such as the ability to walk briskly or climb stairs yielded similar results.

Mean CEAP scores significantly increased incrementally with BMI (from 1.4 in the normal-weight group to 1.9 in the supermorbidly obese group), as did mean venous clinical severity scores (from 2.6 in the normal-weight group to 4.3 in the supermorbidly obese group).

Dr. Moore also reported that evidence of venous obstruction on duplex examination appeared to increase across the BMI spectrum, but this did not reach statistical significance. The same association was seen for venous reflux as assessed by duplex examination.

Dr. Moore said that she had no relevant financial conflicts to disclose.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW ORLEANS – Using speckle tracking echocardiography to guide pacemaker lead placement improved the outcomes of cardiac resynchronization therapy for patients with severe heart failure in TARGET, said to be the first randomized clinical trial to study the feasibility and outcomes of a targeted approach to left ventricular lead placement.

When speckle-tracking echocardiography (STE) was used to identify target sites for pacemaker lead placement for individual patients, leads were more likely to be placed at concordant sites. The result was improved echocardiographic response at 6 months – defined as a greater than 15% change in left ventricular end systolic volume (LVESV) from baseline to 6-month follow-up. The STE group had a 70% response as compared with a 55% response in the group with conventional lead placement without echocardiography guidance (P = .031), reported Dr. Fakhar Z. Khan, of Cambridge (U.K.) University, who reported the results of TARGET on April 5 at the annual meeting of the American College of Cardiology.

Lower rates were also seen with STE for the combined end point of all-cause mortality and heart failure hospitalization. The difference was primarily driven by fewer heart failure hospitalizations. Looking at mortality alone at a mean follow-up of 400 days, the two groups did not significantly differ.

"This is a well-designed, well-conducted study with impressive differences in clinical outcomes," said Dr. Byron Kwock Lee, who is with the University of California, San Francisco, and chaired the session where the TARGET results were presented. "Other studies have shown echocardiographic outcomes but have had difficulty showing clinical differences."

"I am impressed that the modest echocardiographic changes translated to dramatic clinical effects," commented Dr. Michael Crawford, also of the University of California, San Francisco, and a panelist at the presentation of the study results.

Up to 40% of patients fail to gain significant clinical benefit from cardiac resynchronization therapy, Dr. Khan noted. The position of the left ventricular lead has emerged as an important determinant of response, with better results achieved when pacing at the latest site of contraction and lesser responses noted when pacing areas of scar.

Speckle tracking radial strain imaging correlates with delayed enhanced cardiac MRI for determination of scar, Dr. Khan said. In patients undergoing cardiac resynchronization therapy, less than 10% amplitude of radial strain at the left ventricular pacing site has a high negative predictive value (91%) for response.

Using STE, "we found that concordant lead placement, baseline dyssynchrony, and pacing away from areas of scar are strongly related to improved outcomes," he said.

The single blinded, randomized, controlled trial enrolled 220 patients recruited from three different hospitals in the U.K. Participants were in sinus rhythm, had severe heart failure (NYHA Class III/IV), left ventricular ejection fractions less than 35%, and QRS intervals greater than 120 msec. Patients were randomized in a 1:1 ratio to receive either standard lead placement without the benefit of echocardiographic guidance or targeted lead placement using STE to position the lead at the latest site of contraction and away from areas of scar. Following implantation, all devices were optimized using echocardiography.

Concordant lead placement was achieved in 61% of the STE group vs. 45% of control group. Placement was adjacent in 25% of the STE group and 28% of the control group, and was remote in 10% and 24%, respectively.

At baseline, both groups were comparable in demographic and disease characteristics. Mean age was about 70 years, about 86% were male, about 94% had NYHA Class III heart failure, and 56% had underlying ischemic cardiomyopathy.

Both groups had a 14% rate of implant-related complications. Procedural length of time was similar for both groups.

In addition to the primary end point improvements in echocardiographic response at 6-month follow-up, the STE group also had significantly improved clinical end points, compared with the standard placement group. Statistically significant differences from baseline to follow-up for the STE group vs. the standard placement group included improvement in heart failure class (P = .002), 6-mile walk test results (P = .01), and quality-of-life scores. (P = .02).

Patients in the study will continue to have ongoing follow-up.

"STE software can be applied to any existing echocardiographic image at no additional risk to the patient," Dr. Khan said. "STE makes targeting of the lead feasible at any facility that performs echocardiography and has the software available to analyze their images, so it is widely accessible at smaller centers and nonacademic hospitals where more and more pacemakers are being implanted. That being said, it requires training and experience."

Dr. Khan had no relevant financial disclosures.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.

NEW YORK – Using ultrasound to guide the diagnosis and treatment of rheumatologic conditions has been the standard of care in Europe for several years, and now the practice is becoming more common in the United States, according to Dr. Jonathan Samuels.

In 2008, Dr. Samuels and his colleagues at New York University surveyed members of the American College of Rheumatology and rheumatology fellow trainees across the country. They found that although about 20% said they were currently using ultrasound, more than 75% said it should be a standard clinical tool in the specialty (Bull. NYU Hosp. Jt. Dis. 2010;68:292-8). This suggests a trend that more rheumatologists are using ultrasound than a decade ago, said Dr. Samuels at a rheumatology meeting sponsored by NYU.

Ultrasound is also being introduced into many U.S. fellowship programs and academic departments for both clinical and research purposes, he said, adding that physicians have an increasing number of opportunities to train in the best ways to use ultrasound for rheumatologic conditions. There are now a number of weekend courses sponsored by universities that rheumatologists can take. And the ACR has launched its own series of courses on using ultrasound. Rheumatologists can also get online education and guidance through the USSONAR (Ultrasound School of North American Rheumatologists). For the last 2 years, this institution has conducted an annual competency exam.

Meanwhile, the issue of certification remains up in the air. The ACR Musculoskeletal Ultrasound Task Force has been working to determine if and how it should certify its members in the use of ultrasound. ACR officials are currently surveying their members on this issue, said Dr. Samuels, a rheumatologist at New York University.

According to another source, the ACR is being forced into undertaking the credentialing of musculoskeletal ultrasound, if only because there is no one else to step up to do it.

Dr. Samuels said that for rheumatologists who use ultrasound in the office, this particular imaging technology offers a number of advantages. The procedure is painless, and there’s no claustrophobia or anxiety associated with it, as there may be with other imaging modalities. There’s also no need for patients to be still for long periods of time and no radiation exposure. Ultrasound is much less expensive than other imaging alternatives.

Ultrasound also allows physicians to perform a dynamic assessment, he said. With ultrasound, physicians can move the probe from side to side and patients can view the assessment as it happens rather than looking at a still image later. Another advantage is that physicians can evaluate multiple joints from multiple views in a single imaging session. In some cases, ultrasound can eliminate the need to perform an MRI, but it can also be supplemental, Dr. Samuels said.

There are a number of potential uses for ultrasound in rheumatology, such as in diagnosing and evaluating treatment for inflammatory arthritis, crystal disease, and osteoarthritis. "If used properly, ultrasound can be an extension of our clinical exam," Dr. Samuels said.

In inflammatory arthritis, ultrasound can help with diagnosis and prognosis by detecting erosions, synovitis, effusions, tenosynovitis, enthesopathy, and productive changes such as nodules and tophi. Rheumatologists can also evaluate treatment response by rescanning after prolonged treatment, he said.

In rheumatoid arthritis, clinicians can easily use ultrasound to look for erosions, Dr. Samuels said, and it is more sensitive than using conventional radiography. A study published in 2000 shows that in 40 patients with early RA, the number of erosions detected was more than sixfold greater with ultrasound than with x-ray (Arthritis. Rheum. 2000;43:2762-70). And a review of available evidence on ultrasound in rheumatoid arthritis found that it is comparable to MRI in terms of both inflammatory and destructive changes in RA finger and toe joints (Scand. J. Rheumatol. 2003;32:63-73).

Ultrasound can help to detect RA earlier by investigating synovitis. The ultrasound allows the physicians to identify synovitis through synovial fluid, synovial hypertrophy, and power Doppler signal, Dr. Samuels said.

Ultrasound can also be used to help with aspiration and injections. For example, rheumatologists can use ultrasound to detect whether they need to aspirate an effusion in patients with knee osteoarthritis. It can also help to guide injections that might otherwise be contraindicated if they were to be done blindly in the office, such as hip injections.

Dr. Samuels reported that he had no financial conflicts of interest.