Massimiliano Parodi

Dynamic magnetic resonance of the wrist in psoriatic arthritis reveals imaging patterns similar to those of rheumatoid arthritis

This dynamic magnetic resonance imaging (MRI) study is concerned with a prospective evaluation of wrist synovitis in patients with psoriatic arthritis (PsA) in comparison with patients with rheumatoid arthritis (RA) and healthy controls. Fifteen consecutive patients with PsA, 49 consecutive patients with RA, 30 RA patients matched for disease severity with those with PsA, and 8 healthy controls were studied. MRI was performed with a low-field (0.2T), extremity-dedicated machine. After an intravenous bolus injection of gadolinium-diethylenetriaminepentaacetic acid, 20 consecutive fast spin-echo axial images of the wrist were obtained every 18 s. The enhancement ratio was calculated both as rate of early enhancement (REE), which shows the slope of the curve of contrast uptake per second during the first 55 s, and as relative enhancement (RE), which indicates the steady state of enhancement. The REE was 1.0 ± 0.6 in patients with PsA, 1.6 ± 0.7 in consecutive patients with RA, and 0.1 ± 0.1 in controls (p <0.001). The RE was 87.1 ± 39.2 in patients with PsA, 125.8 ± 48.0 in consecutive RA patients, and 15.5 ± 19.2 in controls (p <0.001). However, the same figures in matched RA patients were 1.3 ± 0.7 and 107.3 ± 48.2, respectively (not significant in comparison with PsA). Rheumatoid-like PsA and oligoarticular PsA did not differ from each other in terms of synovial enhancement. Dynamic MRI shows the same pattern of synovitis in patients with PsA and RA when the two groups are matched for disease severity. This technique cannot be used to differentiate PsA from RA. However, REE and RE were significantly higher in PsA than in normal controls, with only one instance of overlap between values found for the two groups.

Is the Course of Steroid‐Treated Polymyalgia Rheumatica More Severe in Women?

Abstract:  Polymyalgia rheumatica (PMR) has a marked preponderance in women. The female sex has been claimed to be a risk factor for longer‐course corticosteroid therapy and to be associated with more severe systemic symptoms and lower hemoglobin levels. Eighty consecutive patients affected by PMR, seen at two tertiary referral centers, were followed‐up for a mean period of 14.9 months after initiating corticosteroid treatment. At presentation, women had longer disease duration and lower hemoglobin levels (both P= 0.05) than men. In contrast, their systemic signs of PMR were less common (P= 0.01). Women were treated with a slightly higher mean daily dose of prednisone (P= 0.055), and assumed a significantly higher cumulative dosage of the drug (P= 0.01). Accordingly, the mean number of steroid‐related side effects was higher among women (P= 0.003). The number of relapses during steroid treatment (P= 0.02), but not that of recurrences, was increased in women. ESR, which was raised at presentation, significantly declined during follow‐up to normal values in both subgroups (P < 0.00001 by analysis of variance [ANOVA]). Its decrease was significantly more pronounced in men than in women. Hemoglobin at follow‐up was significantly higher in men than in women at any given time point. In conclusion, sex is probably modulating the response to corticosteroids. This finding emphasizes the need to consider differences between males and females in the clinical and therapeutic approach to PMR patients.

The correct prednisone starting dose in polymyalgia rheumatica is related to body weight but not to disease severity

Backgroundthe mainstay of treatment of polymyalgia rheumatica (PMR) is oral glucocorticoids, but randomized controlled trials of treatment are lacking. As a result, there is no evidence from controlled studies on the efficacy of different initial doses or glucocorticoid tapering. The aim of this study is to test if 12.5 mg prednisone/day is an adequate starting dose in PMR and to evaluate clinical predictors of drug response.Methods60 consecutive PMR patients were treated with a starting dose of 12,5 mg/day prednisone. Clinical, laboratory, and, in a subset of 25 patients, ultrasonographic features were recorded as possible predictors of response to prednisone. Remission was defined as disappearance of at least 75% of the signs and symptoms of PMR and normalization of ESR and CRP within the first month, a scenario allowing steroid tapering.Results47/60 (78.3%) patients responded to 12.5 mg of prednisone after a mean interval of 6.6 ± 5.2 days. In univariate analysis, body weight and gender discriminated the two groups. In multivariate analysis, the only factor predicting a good response was low weight (p = 0.004); the higher response rate observed in women was explained by their lower weight. The mean prednisone dose per kg in the responders was 0.19 ± 0.03 mg in comparison with 0.16 ± 0.03 mg for non responders (p = 0.007).Conclusions12.5 mg prednisone is a sufficient starting dose in ¾ of PMR patients. The main factor driving response to prednisone in PMR was weight, a finding that could help in the clinical care of PMR patients and in designing prospective studies of treatment.Trial RegistrationClinicalTrials.gov: NCT01169597

Dynamic Contrast-enhanced Magnetic Resonance Imaging of Articular and Extraarticular Synovial Structures of the Hands in Patients with Psoriatic Arthritis

Objective. Dynamic, contrast-enhanced magnetic resonance imaging (DCE-MRI), the quantification of enhancement within the synovial membrane and bone by extracting curves using fast T1-weighted sequences during intravenous administration of contrast agent, evaluates synovitis and bone marrow edema in psoriatic arthritis (PsA). In this pilot study, we looked at possible differences between joint synovitis and tenosynovitis in PsA as compared with rheumatoid arthritis (RA). Methods. Seven patients with PsA and 10 with RA were studied. After DCE-MRI was performed on 3 axial slices of the wrist, the enhancement ratio was calculated on 6 different regions of interest (ROI) of the synovial membrane outlined by the operator: the wrist compartment, 3 extensor tendon compartments, and 2 flexor compartments. DCE-MRI results were quantitatively analyzed using the Dynamika software, a computer-aided semiautomated method. Results. In PsA, the area of the ROI outlined around the first and second extensor compartments was larger than in RA; the opposite was true for the extensor carpi ulnaris region. The volume of inflammation was significantly higher in RA than in PsA for all the extensor compartments except the second, and in the joint synovial membrane. The DCE-MRI indicators of the degree of inflammation were higher for PsA in the joint synovial membrane (p = 0.002 and p < 0.001, respectively). There was a significant correlation between volume of inflammation but not its degree and 28-joint Disease Activity Score at the level of the wrist joint (r = 0.6; p = 0.01). Conclusion. DCE-MRI can reveal useful and potentially clinically important information on the characteristics of different types of arthritis.

Comparison of the manual and computer-aided techniques for evaluation of wrist synovitis using dynamic contrast-enhanced MRI on a dedicated scanner

OBJECTIVE Traditional methods for assessment of synovial inflammation in rheumatoid arthritis such as clinical examination, immunohistology of bioptic samples, scintigraphy, and radiography have several limitations, including lack of sensitivity, need of invasive techniques, and administration of radioactive material. MRI lacks on standardisation and the data are often analysed using laborious, relatively rigid scoring methods. MATERIALS AND METHODS This study introduces a standardized computer-aided method for quantitative analysis of MRI of the wrist on a dedicated scanner. Assessment of the synovial inflammation was performed using a semi-automated model-based method in conjunction with patient motion reduction algorithms. Further, the new method was compared with the traditional user-dependent ROI-based technique. RESULTS The computer-aided technique generated robust and reproducible results. Application of motion reduction algorithms allowed for significant improvements of the signal to noise ratio, which is especially important in the datasets acquired with low-field scanners. CONCLUSION The use of the computer software can be beneficial for diagnostic decision in cross sectional as well as longitudinal MRI examinations of the wrist in rheumatoid arthritis.

Magnetic Resonance Imaging of the Hand in Psoriatic Arthritis

Although magnetic resonance imaging (MRI) studies of psoriatic arthritis (PsA) are fewer than those of rheumatoid arthritis (RA), interest in this field is growing. The type and site of the lesions, rather than the mere severity of synovitis, can help differentiate PsA from other arthritides. Extracapsular enhancement and enthesitis are features emphasized as typical of PsA, but their relevance for the diagnosis is more quantitative than qualitative. Erosions in PsA are probably less frequent and progressive than in RA. Bone edema is unlikely to predict the appearance of erosions in patients with PsA. The Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) system has been adapted to peripheral PsA, but standardization is still in progress. Dactylitis is a relatively specific feature of PsA. Its pathogenic mechanisms have been investigated with MRI. MRI evaluation of PsA may facilitate diagnosis, evaluation of treatment effects, and understanding of associated mechanisms.

Changes in adiponectin and leptin concentrations during glucocorticoid treatment: a pilot study in patients with polymyalgia rheumatica

This study is concerned with an evaluation of the effects of glucocorticoids (GC) on adiponectin and leptin concentrations in patients with polymyalgia rheumatica (PMR). Seven patients diagnosed with PMR were studied at baseline and after one and three months of prednisone treatment. Serum leptin and adiponectin, serum glucose and insulin, erythrocyte sedimentation rate, C‐reactive protein, and IL‐6 were all measured by commercial assays. The treatment with GC normalized inflammation markers and significantly increased adiponectin and leptin concentrations without any impairment of insulin sensitivity measured by HOMA‐IR. Adiponectin significantly increased only between baseline and 1 month (P= 0.013). A significant correlation was found between adiponectin and leptin concentrations both at baseline and after 3 months of treatment (both rho = 0.89, P= 0.03). In addition, adiponectin correlated also with serum glucose at baseline (rho = 0.81, P= 0.047). According to our results, adiponectin concentrations seem to be driven by inflammation, whereas leptin seems to be increased directly by the use of steroids.

Changes in adiponectin and leptin concentrations during glucocorticoid treatment: A pilot study in patients with polymyalgia rheumatica: Annals of the New York Academy of Sciences

This study is concerned with an evaluation of the effects of glucocorticoids (GC) on adiponectin and leptin concentrations in patients with polymyalgia rheumatica (PMR). Seven patients diagnosed with PMR were studied at baseline and after one and three months of prednisone treatment. Serum leptin and adiponectin, serum glucose and insulin, erythrocyte sedimentation rate, C‐reactive protein, and IL‐6 were all measured by commercial assays. The treatment with GC normalized inflammation markers and significantly increased adiponectin and leptin concentrations without any impairment of insulin sensitivity measured by HOMA‐IR. Adiponectin significantly increased only between baseline and 1 month (P= 0.013). A significant correlation was found between adiponectin and leptin concentrations both at baseline and after 3 months of treatment (both rho = 0.89, P= 0.03). In addition, adiponectin correlated also with serum glucose at baseline (rho = 0.81, P= 0.047). According to our results, adiponectin concentrations seem to be driven by inflammation, whereas leptin seems to be increased directly by the use of steroids.

Polymyalgia rheumatica is associated with extensor tendon tenosynovitis but not with synovitis of the hands: a magnetic resonance imaging study

OBJECTIVES To study with MRI the hands of consecutive PMR patients, who were not selected on the basis of peripheral arthritis, with a correlation to clinical and laboratory findings. METHODS Twenty-six hands of 15 PMR patients and 26 hands of 13 healthy controls were studied by extremity-dedicated MRI for the presence of synovitis, tenosynovitis, soft-tissue oedema, bone marrow oedema and erosions. RESULTS Sixteen (61.6%) of the 26 PMR hands and 4 (15.4%) of the 26 control hands showed tenosynovitis (P = 0.001). Extensor tendon tenosynovitis was seen in 9 (34.6%) of the 26 PMR hands, but in only 1 (3.8%) control hand (P = 0.002) and flexor tenosynovitis was seen in 12 (46.1%) of the 26 PMR hands and in 4 (15.4%) of the 26 control hands (P = 0.03). All other features were similar in the two groups. CONCLUSIONS Our data support the view that tenosynovitis, especially of the extensor tendons, is a frequent event in PMR, unrelated to clinical involvement of the hand. This finding is in agreement with the concept of PMR as a disease of extra-articular structures.

Bone ankylosis of the wrist as a possible indicator of treatment efficacy in rheumatoid arthritis

crystalline fashion. It is not clear if these two types of pigmentation are directly related, with the smaller granules representing nucleation points for the process of polymerization that leads to complete encrusting of fibres in ochronotic pigment. Alternatively, two or more independent mechanisms of pigment formation and deposition may overlap in soft or joint tissues. Pigmentation was not uniform at all levels within the tissue and it is not clear why some of the collagen fibres were unaffected. The results confirm that the presence of HGA cannot be the sole factor in pigmentation; other local factors must promote or inhibit nucleation and deposition of ochronotic pigment, such as pH, redox potential or the presence of other currently unidentified factors. The small nucleating pigment appears as a regular pattern and may provide clues to the exact point to which the HGA is attracted in these tissues and could be used in the future to elucidate the binding mechanism as a therapeutic target.