Geert Vanderschueren

Effectiveness of initial treatment allocation based on expert opinion for prevention of rapid radiographic progression in daily practice of an early RA cohort

Objectives To evaluate expert treatment selection for early rheumatoid arthritis and to validate a prediction model for rapid radiographic progression (RRP) in daily practice. Methods Patients received initial combination therapy with steroids (ICTS) or disease-modifying antirheumatic drug monotherapy (IMT) after informal evaluation of prognostic factors, followed by a tight control strategy. Changes in Sharp/van der Heijde score (total Sharp score (TSS)) of >5 units over 1 year (=RRP) were documented. The mean change in TSS and proportion with RRP were compared between groups. Based on the 28 swollen joint count, rheumatoid factor titre and C reactive protein/erythrocyte sedimentation rate, patients were placed in the ASPIRE prediction matrix, yielding a RRP risk. Numbers needed to treat (NNT) intensively to avoid one RRP after 1 year were calculated. Results The mean change in TSS after 1 year and the proportion with RRP was lower in the ICTS group (n=37) than in the IMT group (n=43). The mean calculated risk of RRP was higher in patients with radiographic progression. The mean NNT intensively to prevent RRP was lower in the ICTS group than in the IMT group. The positive predictive value of NNT for RRP prevention was 12.6%, but the negative predictive value reached 100%. Conclusion ICTS seems more effective in preventing RRP than IMT. The predictive matrix model could be helpful in preventing overtreatment in practice.

Postoperative radiograph of the hip arthroplasty: what the radiologist should know

AbstractThis pictorial review aims to provide the radiologist with simple and systematic guidelines for the radiographic evaluation of a hip prosthesis. Currently, there is a plethora of commercially available arthroplasties, making postoperative analysis not always straightforward. Knowledge of the different types of hip arthroplasty and fixating techniques is a prerequisite for correct imaging interpretation. After identification of the type of arthroplasty, meticulous and systematic analysis of the following parameters on an anteroposterior standing pelvic radiograph should be undertaken: leg length, vertical and horizontal centre of rotation, lateral acetabular inclination, and femoral stem positioning. Additional orthogonal views may be useful to evaluate acetabular anteversion. Complications can be classified in three major groups: periprosthetic lucencies, sclerosis or bone proliferation, and component failure or fracture. Teaching Points • To give an overview of the different types of currently used hip arthroplasties. • To provide a simple framework for a systematic approach to postoperative radiographs. • To discuss radiographic findings of the most common complications.

Post-traumatic osteoid osteoma in an 18-year-old adolescent

Osteoid osteoma (OO) is a painful, benign bone-forming lesion, which often poses a diagnostic challenge. The aetiology of OO is still poorly understood. Although not generally accepted, an association with previous trauma or infection has occasionally been suggested. We present a case of an OO 12 years following an ulnar fracture. Radiologists should consider OO as a potential delayed “complication” of a previous fracture. Persistent pain at a previous fracture site should alert the clinician to request cross-sectional imaging. CT scanning plays a pivotal role in the correct diagnosis of OO.

THU0144 Two Year Radiological Follow-Up of Early Rheumatoid Arthritis Patients Treated with Initial Step Up Monotherapy or Initial Step Down Therapy with Glucocorticoids, Followed by a Tight Control Approach

Background Combination therapy with disease-modifying antirheumatic drugs (DMARDs) and glucocorticoids(GCs) or biological agents is superior in achieving clinical response and preventing joint damage compared to DMARD monotherapy in patients with early rheumatoid arthritis (RA). Objectives To compare initial DMARD combination therapy with steroids (ICTS) with DMARD monotherapy (IMT) on the radiologic evolution of patients with early RA over a 2 year treatment period, applying tight control (TC) in daily practice. Methods 74 DMARD-naïve early RA patients received ICTS or IMT in a TC setting, based on the expert opinion of their rheumatologist (n=2) after informal evaluation of prognostic factors. Demographics were registered at baseline and the following clinical characteristics were obtained at baseline, year 1 and year 2: swollen/tender joint counts (TJC, SJC, TJC28 and SJC28), global assessment scores ( PGA, PhGA, pain and fatigue), Health assessment questionnaire ( HAQ), erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) status. Disease activity score based on CRP status (DAS 28(CRP)), EULAR DAS response, clinically meaningful HAQ response, DAS change and HAQ change were calculated from these parameters. Remission was defined as a DAS28 (CRP) score below 2,6. Baseline, year 1 and year 2 X-rays of hands and feet were scored according to Sharp/van der Heijde by 3 readers in consensus: 2 experienced musculoskeletal radiologists (LL and GVDS) and 1 clinical researcher (DDC). Rapid radiographic progression (RRP) was defined as total Sharp score (TSS) of >5 units/year. The mean change in TSS and proportion with RRP were compared between groups. Results At baseline, joint scores and PhGA were significantly higher in the ICTS group. Thus ICTS patients were perceived to have a higher level of RA severity compared with IMT patients. At year 1, both treatment groups achieved 50% remission. At year 2, 37% of IMT and 60% of ICTS patients were in remission, despite ICTS patients having a more severe RA profile at baseline. RRP was found in 4/74 patients at year 1: 3 IMT and 1 ICTS patient. Remarkably, 3 of these 4 patients had no radiographic progression in the second year. 5 Other patients had RRP in the second year: 4 IMT and 1 ICTS patient. 4 Notably young female IMT patients were initially treated with SSZ monotherapy, 2 of which because of pregnancy wish. These patients developed RRP in the second year. Conclusions In a TC setting, ICTS appears to be more effective than IMT in achieving remission and preventing RRP in the daily practice of a Belgian academic hospital over 2 years. Furthermore, risk on RRP is underestimated in certain patient groups which is translated in conservative therapy choices. References Verschueren P, Esselens G, Westhovens R. (2008) Daily practice effectiveness of a step-down treatment in comparison with a tight step-up for early rheumatoid arthritis. Rheumatology (Oxford) 47(1):59-64 Disclosure of Interest None Declared