Gender differences in vascular aging and in coronary artery disease pathophysiology

Women have a clinical advantage over men in relation to atherosclerotic cardiovascular disease (CVD) (morbidity and mortality). This advantage disappears once women become older, and in their seventh decade, the risk to develop CVD equals men at that age. There have been several theories about this gender difference that were related to hormones, and the different morphology and physiology that characterize the cardiovascular system in women. In this review, the different mechanisms will be reviewed and discussed.

Intercarpal arthrodesis: A systematic review

Intercarpal arthrodesis is a well-established option to treat various disorders of the carpus, such as localized osteoarthritis, carpal instability, and Kienböck's disease. This is a non-conservative procedure aimed at obtaining a stable and congruent interface between the radius and the proximal carpal row, which restores wrist function by minimizing pain and restoring grip strength. These procedures generally yield good predictable results that are maintained over time. However, all intracarpal arthrodesis procedures cause a loss of wrist range of motion. To optimize outcomes and minimize complications, especially nonunion, this surgery may require a learning curve. A precise surgical technique for preparing the bone surfaces, bringing enough bone graft, and using reliable fixation is essential. Since the late 1960s, several intracarpal arthrodesis procedures have been described. Commonly used fusions target the scaphotrapeziotrapezoid, scaphocapitate, four corners, capitolunate or capitohamatolunate regions. Lesser used fusions focus on specific lesions such as the scapholunate, scapholunocapitate, lunotriquetral and triquetrohamate. Here, we propose a systematic review of the various types of intercarpal arthrodesis procedures described in the literature. After having described each arthrodesis, we specify their indications, the variations of the surgical techniques, and then present an overview of the results and complications. Finally, we discuss how these surgeries affect wrist biomechanics. LEVEL OF EVIDENCE: III.

Man against machine reloaded: performance of a market-approved convolutional neural network in classifying a broad spectrum of skin lesions in comparison with 96 dermatologists working under less artificial conditions

BACKGROUND

Convolutional neural networks (CNNs) efficiently differentiate skin lesions by image analysis. Studies comparing a market-approved CNN in a broad range of diagnoses to dermatologists working under less artificial conditions are lacking.

MATERIALS AND METHODS

One hundred cases of pigmented/non-pigmented skin cancers and benign lesions were used for a two-level reader study in 96 dermatologists (level I: dermoscopy only; level II: clinical close-up images, dermoscopy, and textual information). Additionally, dermoscopic images were classified by a CNN approved for the European market as a medical device (Moleanalyzer Pro, FotoFinder Systems, Bad Birnbach, Germany). Primary endpoints were the sensitivity and specificity of the CNN's dichotomous classification in comparison with the dermatologists' management decisions. Secondary endpoints included the dermatologists' diagnostic decisions, their performance according to their level of experience, and the CNN's area under the curve (AUC) of receiver operating characteristics (ROC).

RESULTS

The CNN revealed a sensitivity, specificity, and ROC AUC with corresponding 95% confidence intervals (CI) of 95.0% (95% CI 83.5% to 98.6%), 76.7% (95% CI 64.6% to 85.6%), and 0.918 (95% CI 0.866-0.970), respectively. In level I, the dermatologists' management decisions showed a mean sensitivity and specificity of 89.0% (95% CI 87.4% to 90.6%) and 80.7% (95% CI 78.8% to 82.6%). With level II information, the sensitivity significantly improved to 94.1% (95% CI 93.1% to 95.1%; P < 0.001), while the specificity remained unchanged at 80.4% (95% CI 78.4% to 82.4%; P = 0.97). When fixing the CNN's specificity at the mean specificity of the dermatologists' management decision in level II (80.4%), the CNN's sensitivity was almost equal to that of human raters, at 95% (95% CI 83.5% to 98.6%) versus 94.1% (95% CI 93.1% to 95.1%); P = 0.1. In contrast, dermatologists were outperformed by the CNN in their level I management decisions and level I and II diagnostic decisions. More experienced dermatologists frequently surpassed the CNN's performance.

CONCLUSIONS

Under less artificial conditions and in a broader spectrum of diagnoses, the CNN and most dermatologists performed on the same level. Dermatologists are trained to integrate information from a range of sources rendering comparative studies that are solely based on one single case image inadequate.

3D reconstructions, 4D imaging and postprocessing with CT in musculoskeletal disorders: Past, present and future

Three-dimensional (3D) imaging and post processing are common tasks used daily in many disciplines. The purpose of this article is to review the new postprocessing tools available. Although 3D imaging can be applied to all anatomical regions and used with all imaging techniques, its most varied and relevant applications are found with computed tomography (CT) data in musculoskeletal imaging. These new applications include global illumination rendering (GIR), unfolded rib reformations, subtracted CT angiography for bone analysis, dynamic studies, temporal subtraction and image fusion. In all of these tasks, registration and segmentation are two basic processes that affect the quality of the results. GIR simulates the complete interaction of photons with the scanned object, providing photorealistic volume rendering. Reformations to unfold the rib cage allow more accurate and faster diagnosis of rib lesions. Dynamic CT can be applied to cinematic joint evaluations a well as to perfusion and angiographic studies. Finally, more traditional techniques, such as minimum intensity projection, might find new applications for bone evaluation with the advent of ultra-high-resolution CT scanners. These tools can be used synergistically to provide morphologic, topographic and functional information and increase the versatility of CT.

Sleep disorders and vascular responsiveness in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is the most common systemic autoimmune disease characterized by chronic systemic inflammation. Half of the deaths of patients with RA are due to cardiovascular diseases (CVD), considered to be 1.5 to -2.0-fold that in the general population. Patients with RA also experience poor sleep, which by itself is associated with endothelial dysfunction, CVD events and sudden death. Our aim was to study the mechanistic pathways and the correlations between sleep efficiency and vascular reactivity of patients with RA.

METHODS AND RESULTS

A prospective study that evaluated quality of sleep using ACTi Graphs, vascular inflammation and endothelial function of 18 patients with RA. Inflammation was studied by levels of E-selectin, intercellular adhesion molecule 1 (ICAM-1) and NO in serum. Endothelial function was studied using the brachial artery plethysmography method. Eighteen RA patients (aged 57.56 ± 13.55 years; 16 women) with a long-standing active RA: Eight patients had impaired sleep efficiency and 10 had a good sleep efficiency. Those who had an impaired sleep had larger baseline diameters of the brachial artery (0.39 ± 0.08 cm vs. 0.32 ± 0.04 cm; P = 0.02). Negative correlations were found between baseline brachial artery diameter and sleep efficiency (P = 0.01), and with NO level (P = 0.04). Stepwise regression found that brachial artery diameter at baseline and NO level could predict sleep efficiency (r²  = 0.543, P = 0.01).

CONCLUSION

Vascular reactivity could predict quality of sleep in patients with RA. Quality of sleep may serve as an independent CVD risk factor in patients with RA.

[Artificial intelligence and smartphone program applications (Apps) : Relevance for dermatological practice]

ADVANTAGES OF ARTIFICIAL INTELLIGENCE (AI)

With responsible, safe and successful use of artificial intelligence (AI), possible advantages in the field of dermato-oncology include the following: (1) medical work can focus on skin cancer patients, (2) patients can be more quickly and effectively treated despite the increasing incidence of skin cancer and the decreasing number of actively working dermatologists and (3) users can learn from the AI results. POTENTIAL DISADVANTAGES AND RISKS OF AI USE: (1) Lack of mutual trust can develop due to the decreased patient-physician contact, (2) additional time effort will be necessary to promptly evaluate the AI-classified benign lesions, (3) lack of adequate medical experience to recognize misclassified AI decisions and (4) recontacting a patient in due time in the case of incorrect AI classifications. Still problematic in the use of AI are the medicolegal situation and remuneration. Apps using AI currently cannot provide sufficient assistance based on clinical images of skin cancer.

REQUIREMENTS AND POSSIBLE USE OF SMARTPHONE PROGRAM APPLICATIONS

Smartphone program applications (apps) can be implemented responsibly when the image quality is good, the patient's history can be entered easily, transmission of the image and results are assured and medicolegal aspects as well as remuneration are clarified. Apps can be used for disease-specific information material and can optimize patient care by using teledermatology.

SAT0459 EVALUATION OF THE PREVALENCE AND THE MANAGEMENT OF OSTEOPOROTIC FRACTURES IN PATIENTS HOSPITALIZED AT NANCY UNIVERSITY HOSPITAL (FRANCE) IN 2017

Background:

Osteoporotic fractures are a major public health concern because of their consequences in morbidity, costs and mortality. In the meantime, historically postfracture osteoporosis medication use rates have been poor.

Objectives:

The aim is to analyze the management of osteoporosis in patients hospitalized for osteoporotic fractures (OF) at Nancy University Hospital (France) in 2017.

Methods:

Total number of hospitalized patients and hospital stays were extracted by the Department of Medical Information (DIM) which selected departments with at least forty hospitalizations with Medical Unit Summary related to a diagnosis of fracture or osteoporosis. Hospitalizations not concerned by a recent OF were excluded. Data on fractures, patient characteristics, risk factors for OF and fall, management of osteoporosis, discharge status, stay duration, were studied from patient medical records. Prevalence of OF stays, management of osteoporosis and factors associated with duration of stay were analyzed.

Results:

Out of a total of 153,840 hospitalizations, 918 hospitalizations (844 patients, mean age 74.5 years ± 13.6, 74.5% women) concern an OF. The prevalence of hospitalizations for OF was 0.6% of total hospitalizations and 17.9% of total hospitalizations for fractures. Among the 844 patients, 85.7% had a severe fracture (vertebral fracture: 56.2%, hip fracture: 24.1%), 16.5% had a non-severe fracture, and 8.5% had a fracture cascade in the year. At discharge from hospital, 11.7% of patients received a specific treatment for osteoporosis. Longer stay duration was associated with age, severe fractures, Groll index and discharge status.

Conclusion:

Nearly one hospitalized fracture in five is osteoporotic, while only one in ten patients is treated for osteoporosis. Stay duration increased with age and comorbidities. This encourages the development of early prevention, screening and treatment strategies for osteoporosis.

References:

[1]Hernlund E, Svedbom A, Ivergård M, Compston J, Cooper C, Stenmark J, et al. Osteoporosis in the European Union: medical management, epidemiology and economic burden. A report prepared in collaboration with the International Osteoporosis Foundation (IOF) and the European Federation of Pharmaceutical Industry Associations (EFPIA). Arch Osteoporos. 2013;8:136.

[2]Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int. 2006 Oct 19;17(12):1726–33.

[3]Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility Fractures and the Osteoporosis Care Gap: An International Phenomenon. Semin Arthritis Rheum. 2006 Apr;35(5):293–305.

Disclosure of Interests:

None declared

Dermatoskopie, sequenzielle Videodermatoskopie, Ganzkörperfotografie, künstliche Intelligenz – was bringt uns die Zukunft?

Die Dermatoskopie ist mittlerweile ein fester Bestandteil einer jeden dermatologischen Untersuchung. Mit dieser Technik konnten die Früherkennung von Malignomen der Haut und deren Vorstufen deutlich verbessert und unnötige Exzisionen benigner Hautläsionen reduziert werden. Der Einsatz der Dermatoskopie umfasst mittlerweile auch die Beurteilung von entzündlichen und parasitären Dermatosen sowie Haarerkrankungen. Bei definierten Risikogruppen für ein Melanom sollte der Zwei-Schritte-Algorithmus, bestehend aus Ganzkörperfotografie und Videodermatoskopie, in entsprechenden Zeitintervallen zur Anwendung kommen. Mit dieser Methode können Melanome meist in einem sehr frühen Stadium entdeckt werden, da Veränderungen bestehender Muttermale sowie neu entstandene Läsionen früher festgestellt werden. In den letzten Jahren konnten mehrere Studien nachweisen, dass speziell geschulte neuronale Netzwerke Malignome der Haut, insbesondere Melanome, mit einer sehr hohen Treffsicherheit diagnostizieren können. Wie diese Computer-gestützte Diagnostik mithilfe einer künstlichen Intelligenz in den klinischen Alltag integriert werden kann und welche Vorteile sich hiervon ableiten lassen, ist derzeit noch nicht geklärt.

Diagnostic performance of a deep learning convolutional neural network in the differentiation of combined naevi and melanomas

BACKGROUND

Deep learning convolutional neural networks (CNN) may assist physicians in the diagnosis of melanoma. The capacity of a CNN to differentiate melanomas from combined naevi, the latter representing well-known melanoma simulators, has not been investigated.

OBJECTIVE

To assess the diagnostic performance of a CNN when used to differentiate melanomas from combined naevi in comparison with dermatologists.

METHODS

In this study, a CNN with regulatory approval for the European market (Moleanalyzer-Pro, FotoFinder Systems GmbH, Bad Birnbach, Germany) was used. We attained a dichotomous classification (benign, malignant) in dermoscopic images of 36 combined naevi and 36 melanomas with a mean Breslow thickness of 1.3 mm. Primary outcome measures were the CNN's sensitivity, specificity and the diagnostic odds ratio (DOR) in comparison with 11 dermatologists with different levels of experience.

RESULTS

The CNN revealed a sensitivity, specificity and DOR of 97.1% (95% CI [82.7-99.6]), 78.8% (95% CI [62.8-89.1.3]) and 34 (95% CI [4.8-239]), respectively. Dermatologists showed a lower mean sensitivity, specificity and DOR of 90.6% (95% CI [84.1-94.7]; P = 0.092), 71.0% (95% CI [62.6-78.1]; P = 0.256) and 24 (95% CI [11.6-48.4]; P = 0.1114). Under the assumption that dermatologists use the CNN to verify their (initial) melanoma diagnosis, dermatologists achieve an increased specificity of 90.3% (95% CI [79.8-95.6]) at an almost unchanged sensitivity. The largest benefit was observed in 'beginners', who performed worst without CNN verification (DOR = 12) but best with CNN verification (DOR = 98).

CONCLUSION

The tested CNN more accurately classified combined naevi and melanomas in comparison with trained dermatologists. Their diagnostic performance could be improved if the CNN was used to confirm/overrule an initial melanoma diagnosis. Application of a CNN may therefore be of benefit to clinicians.

Man against machine: diagnostic performance of a deep learning convolutional neural network for dermoscopic melanoma recognition in comparison to 58 dermatologists

Background

Deep learning convolutional neural networks (CNN) may facilitate melanoma detection, but data comparing a CNN's diagnostic performance to larger groups of dermatologists are lacking.

Methods

Google's Inception v4 CNN architecture was trained and validated using dermoscopic images and corresponding diagnoses. In a comparative cross-sectional reader study a 100-image test-set was used (level-I: dermoscopy only; level-II: dermoscopy plus clinical information and images). Main outcome measures were sensitivity, specificity and area under the curve (AUC) of receiver operating characteristics (ROC) for diagnostic classification (dichotomous) of lesions by the CNN versus an international group of 58 dermatologists during level-I or -II of the reader study. Secondary end points included the dermatologists' diagnostic performance in their management decisions and differences in the diagnostic performance of dermatologists during level-I and -II of the reader study. Additionally, the CNN's performance was compared with the top-five algorithms of the 2016 International Symposium on Biomedical Imaging (ISBI) challenge.

Results

In level-I dermatologists achieved a mean (±standard deviation) sensitivity and specificity for lesion classification of 86.6% (±9.3%) and 71.3% (±11.2%), respectively. More clinical information (level-II) improved the sensitivity to 88.9% (±9.6%, P = 0.19) and specificity to 75.7% (±11.7%, P < 0.05). The CNN ROC curve revealed a higher specificity of 82.5% when compared with dermatologists in level-I (71.3%, P < 0.01) and level-II (75.7%, P < 0.01) at their sensitivities of 86.6% and 88.9%, respectively. The CNN ROC AUC was greater than the mean ROC area of dermatologists (0.86 versus 0.79, P < 0.01). The CNN scored results close to the top three algorithms of the ISBI 2016 challenge.

Conclusions

For the first time we compared a CNN's diagnostic performance with a large international group of 58 dermatologists, including 30 experts. Most dermatologists were outperformed by the CNN. Irrespective of any physicians' experience, they may benefit from assistance by a CNN's image classification.

Clinical trial number

This study was registered at the German Clinical Trial Register (DRKS-Study-ID: DRKS00013570; https://www.drks.de/drks_web/).

Influenza virus and atherosclerosis

Influenza viruses infect the upper respiratory system, causing usually a self-limited disease with mild respiratory symptoms. Acute lung injury, pulmonary microvascular leakage and cardiovascular collapse may occur in severe cases, usually in the elderly or in immunocompromised patients. Acute lung injury is a syndrome associated with pulmonary oedema, hypoxaemia and respiratory failure. Influenza virus primarily binds to the epithelium, interfering with the epithelial sodium channel function. However, the main clinical devastating effects are caused by endothelial dysfunction, thought to be the main mechanism leading to pulmonary oedema, respiratory failure and cardiovascular collapse. A significant association was found between influenza infection and acute myocardial infarction (AMI). The incidence of admission due to AMI during an acute viral infection was six times as high during the 7 days after laboratory confirmation of influenza infection as during the control interval (10-fold in influenza B, 5-fold in influenza A, 3.5-fold in respiratory syncytial virus and 2.7-fold for all other viruses). Our review will focus on the mechanisms responsible for endothelial dysfunction during influenza infection leading to cardiovascular collapse and death.

Imaging appearance and prevalence of the anteromedial meniscofemoral ligament: A potential pitfall to anterior cruciate ligament analysis on MRI

PURPOSE

To describe the aspect of the anteromedial meniscofemoral ligament on MRI and to assess its prevalence.

METHOD

One thousand five hundred sixty knee MRI studies were retrospectively evaluated for the presence of an anteromedial meniscofemoral ligament. In addition to these studies, nine full MRI studies from our department's image archive were also analysed. The anteromedial meniscofemoral ligament length, thickness, and angle with respect to the tibial plateau were evaluated independently by two radiologists. For comparison purposes, the anterior cruciate ligament was assessed in the same manner.

RESULTS

There was a 0.77% prevalence of the anteromedial meniscofemoral ligament in the study population. Compared to the anterior cruciate ligament, the anteromedial meniscofemoral ligament was 80.6%-83.8% thinner according to both observers (P =  0.0002), with a mean thickness of 1.53 ± 0.47 mm and 1.80 ± 0.66 mm determined by observers 1 and 2, respectively. The anteromedial meniscofemoral ligament angles were 15%-17.7% lower than the anterior cruciate ligament angles (P <  0.003). Interobserver reproducibility was considered excellent for the length and angle measurements (ICCs varying from 0.85-0.97) and good for the thickness measurements (ICCs 0.66-0.77).

CONCLUSIONS

The anteromedial meniscofemoral ligament is a rare structure that can be differentiated from the anterior cruciate ligament based on morphologic criteria.

Gender differences in cardiovascular risk of patients with rheumatoid arthritis

BACKGROUND

Rheumatoid Arthritis (RA) is a chronic inflammatory disease, affecting women more than men, with a more aggressive course in women.

DESIGN

A prospective study that recruited 58 patients (46 women aged 56 ± 12 years) with active long-standing RA disease (>12 months). Our goals were to measure their endothelial function, part of the cardiovascular risk assessment.

METHODS

The Brachial Artery method measured endothelial function (the flow mediated percent change [FMD percentage] of the brachial artery diameter). A senior Rheumatologist clinically evaluated all subjects. Mann Whitney rank sum test estimated gender differences among the RA patients.

RESULTS

Median FMD% change for men was -6.07%, while median FMD% change for women was 0.44% (Z = 2.38, P = 0.01). Baseline Brachial artery diameter was larger in men (Z = 2.52, P = 0.01); however, tender joints count and BMI were greater in women (Z=-2.24, P = 0.01; Z=-3.99, P = 0.001), respectively.

CONCLUSIONS

Women with RA have significantly better endothelial function than men with RA. It means that even though RA is 3-fold more prevalent in women, women are more protected from atherosclerotic coronary artery disease and cardiac events.

Evidence-based MR imaging follow-up strategy for desmoid-type fibromatosis

OBJECTIVES

To propose a follow-up strategy for desmoid-type fibromatosis (DF) based on tumor growth behavior and the signal on T2-weighted MRI.

METHODS

We retrospectively reviewed 296 MRI studies of 34 patients with histologically proven DF. In each study, tumor volume and T2 signal relatively normal striated muscle were assessed. Volume variation and monthly growth rates were analyzed to determine lesion growth behavior (progressing versus stable/regressing lesions). Growth behavior was correlated with T2 signal, tumor location, β-catenin status, treatment strategy, and follow-up duration. Interobserver variability of volume measurements and interobserver measurement variation ratio were assessed.

RESULTS

There were 25 women and 9 men with a mean age of 39.9 ± 19 (4-73) years. Mean follow-up time in the patients included was 55 ± 41 (12-148) months. In progressing lesions, the mean average monthly growth ratio was 10.9 ± 9.2 (1.1-42.5) %. Interobserver variability of volume measurements was excellent (ICC = 0.96). Mean interobserver measurement variation ratio was 20.4 ± 23.6%. The only factor correlated with tumor growth behavior was T2 signal ratio (p < 0.0001). Seventeen out of 34 (50%) patients presented a signal change over the threshold of 1 during follow-up. There were five occurrences of secondary growth after a period of stability with a mean delay until growth of 38.2 ± 44.2 (17-116) months.

CONCLUSION

DF growth rate was quantitatively assessed. A threshold for volume variation detection was established. DF growth behavior was significantly related to T2 signal. An evidence-based follow-up strategy is proposed.

KEY POINTS

• In progressing desmoid fibromatosis, the mean average monthly growth ratio was 10.9 ± 9.2%. • Lesions with muscle/tumor T2 signal ratios lower than 1 tended to be stable or regress over time. • Given the interobserver measurement variability and MRI in-plane spatial resolution, a variation higher than 42.6% in tumor volume is required to confirm punctual progression.

Standardization of dermoscopic terminology and basic dermoscopic parameters to evaluate in general dermatology (non-neoplastic dermatoses): an expert consensus on behalf of the International Dermoscopy Society

BACKGROUND

Over the last few years, several articles on dermoscopy of non-neoplastic dermatoses have been published, yet there is poor consistency in the terminology among different studies.

OBJECTIVES

We aimed to standardize the dermoscopic terminology and identify basic parameters to evaluate in non-neoplastic dermatoses through an expert consensus.

METHODS

The modified Delphi method was followed, with two phases: (i) identification of a list of possible items based on a systematic literature review and (ii) selection of parameters by a panel of experts through a three-step iterative procedure (blinded e-mail interaction in rounds 1 and 3 and a face-to-face meeting in round 2). Initial panellists were recruited via e-mail from all over the world based on their expertise on dermoscopy of non-neoplastic dermatoses.

RESULTS

Twenty-four international experts took part in all rounds of the consensus and 13 further international participants were also involved in round 2. Five standardized basic parameters were identified: (i) vessels (including morphology and distribution); (ii) scales (including colour and distribution); (iii) follicular findings; (iv) 'other structures' (including colour and morphology); and (v) 'specific clues'. For each of them, possible variables were selected, with a total of 31 different subitems reaching agreement at the end of the consensus (all of the 29 proposed initially plus two more added in the course of the consensus procedure).

CONCLUSIONS

This expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This tool, if adopted by clinicians and researchers in this field, is likely to enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology. What's already known about this topic? Over the last few years, several papers have been published attempting to describe the dermoscopic features of non-neoplastic dermatoses, yet there is poor consistency in the terminology among different studies. What does this study add? The present expert consensus provides a set of standardized basic dermoscopic parameters to follow when evaluating inflammatory, infiltrative and infectious dermatoses. This consensus should enhance the reproducibility and comparability of existing and future research findings and uniformly expand the universal knowledge on dermoscopy in general dermatology.

Inhibition of endothelial progenitor cells may explain the high cardiovascular event rate in patients with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) patients may suffer cardiovascular (CV) events much more than the general population, and CV disease is the leading cause of death in patients with RA. Our hypothesis was that impaired function of endothelial progenitor cells may contribute to endothelial dysfunction and the clinical CV events of patients with RA.

METHODS

About 27 RA patients (9 males and 18 females) with an active disease and 13 healthy subjects who served as the control group (nine males and four females) were enrolled to this prospective study. The ability to grow in culture colony-forming units of endothelial progenitor cells (CFU-EPCs) was measured, as well as their endothelial function using high-resolution ultrasonography of the brachial artery, and levels of C reactive protein (CRP) in the serum. For statistical analysis, we used the Student's t-test.

RESULTS

As a group, patients with RA were older (P < 0.0001), had severe endothelial dysfunction (P<0.0001), with impaired ability to grow CFU-EPCs (P<0.0001), and a higher inflammatory state (P = 0001). No difference was observed in BMI. All RA patients had an active disease (DAS28 3.9 ± 0.9) for 9.2 ± 6.5 years. The same differences were observed in both genders.

CONCLUSIONS

Patients with RA had an impaired ability to grow EPCs and severe endothelial dysfunction. Inability to grow colonies of EPCs reflects the impaired regenerative capacity of patients with RA and may explain the endothelial dysfunction and the high CV event rate among patients with RA.

Endothelial function in rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) patients are at higher risk of accelerated atherosclerosis.

AIMS

To assess endothelial dysfunction in RA to find a possible mechanistic pathway that will explain the clinical phenomenon.

METHODS

A prospective study recruited 44 RA patients with an active long standing (>12 months) disease. All underwent a detailed assessment of disease activity. To estimate the endothelial function the brachial artery method was performed, measuring flow mediated diameter percent (FMD%) change. Clustering analyses (hierarchical and k-means) were performed. Patients were compared to healthy subjects.

RESULTS

Forty four RA patients (54.42 ± 11.14 years, females (72.7%)) with co-morbidities (70.5%), not taking tumor necrosis factor-blockers or disease modifying anti rheumatic drugs (63.6%). Only 6 (13.6%) had a normal endothelial function. Hierarchical and k-means clustering techniques showed statistically significant differences among the three clusters concerning disease activity score-28 (DAS-28)- erythrocyte sedimentation rate (ESR) (P = 0.000), DAS-28- C-reactive protein (CRP; P = 0.001), clinical disease activity index (P = 0.002), simplified disease activity index (P = 0.001), ESR (P = 0.000), (CRP) (P = 0.003) and FMD% (P = 0.009). The group with the highest FMD% values exhibited the lowest clinical scores and laboratory parameters. Patients with the lowest FMD% values co-clustered with subjects with positive but low FMD% changes and elevated clinical and laboratory parameters.

CONCLUSIONS

Our study confirmed the feasibility of exploiting endothelial function in clinical practice as an early predictor of atherosclerosis in RA patients.

Impaired ability to grow colonies of endothelial stem cells could be the mechanism explaining the high cardiovascular morbidity and mortality of patients with depression

BACKGROUND

Subjects with depression are more prone to develop cardiovascular complications. Severity of depression is associated with higher rates of cardiovascular mortality and morbidity. Several mechanisms were suggested including accelerated atherosclerosis, alteration of the cardiac autonomic response with a decrease in heart rate variability. There is evidence that circulating endothelial progenitor cells (EPCs) are decreased in patients with major depression. Our hypothesis was that patients with depression would have an impaired ability to build colonies of EPCs.

METHODS

A prospective study enrolled twenty women with a diagnosis of major. All were not treated before for depression. Thirteen healthy age-matched women served as controls. All signed a consent form before recruitment to the study. Peripheral blood was drawn to build colonies of EPCs within 5 days. ELISA methods were used to measure levels of vascular cell adhesion molecule-1 (VCAM-1) and vascular endothelial growth factor (VEGF).

RESULTS

Twenty female patients with depression were recruited. The mean age was 43 ± 14 years (vs. controls 41 ± 11 years, P = 0.682), patients' average CFU-EPCs was 7 ± 8 colonies per well (controls 31 ± 11, P = 0.0001), VCAM-1 level was 121.7 ± 3.0 ng/ml (controls 119.3 ± 3.1 pg/ml, P = 0.037), VEGF level was 6.4 ± 0.2 pg/ml (controls 5.2 ± 0.5 pg/ml, P = 0.0001). An inverse correlation was found between VEGF level and EPCs' colonies (r  = -0.547, P < 0.001) and between age and CFU-EPCs (r = -0.576, P = 0.008).

CONCLUSIONS

We found that patients with major depression had high levels of VCAM-1 and VEGF. They also had a significant inhibition of EPCs' colonies. An inverse correlation was found between levels of VEGF and the ability to grow colonies of EPCs in culture.

Protocol optimization of sacroiliac joint MR Imaging at 3 Tesla: Impact of coil design and motion resistant sequences on image quality

PURPOSE

To evaluate the impact of coil design and motion-resistant sequences on the quality of sacroiliac magnetic resonance imaging (MRI) examination in patients with spondyloarthropathy.

PATIENTS AND METHODS

One hundred and twenty-one patients with suspected sacroiliitis and referred for MRI of the sacroiliac joints were retrospectively evaluated with MRI at 3-Tesla. There were 78 women and 43 men with a mean age of 36.7±11.5 (SD) years (range: 15.8-78.4 years). Conventional and motion-resistant fat-saturated fast-spin echo T2-weighted sequences were performed with two different coils. Image quality was subjectively evaluated by two independent readers (R1 and R2) using a four-point scale. Confidence in the identification of bone marrow edema pattern (BMEP) was also evaluated subjectively using a three-point scale.

RESULTS

Phased array body coil yielded improved image quality compared to surface coil (14.1 to 30.4% for R1 and 14.6 to 25.7% for R2; P<0.0001). The impact of the sequence type on quality was also statistically significant (P=0.0046). BMEP was identified in 40 patients and best inter-reader agreement was obtained using the combination of phased-array body coil with motion-resistant T2-weighted sequence (kappa 0.990). The smallest number of indeterminate BMEP zones was seen on MRI set acquired with the phased-array body coil and motion-resistant T2-weighted sequence.

CONCLUSION

Phased array body coil and motion-resistant T2-weighted sequences perform better than surface coil and conventional T2-weighted sequences for the evaluation of sacroiliac joints, increasing confidence in the identification of BMEP.

Vascular responsiveness in type 2 diabetes mellitus (T2DM)

BACKGROUND

Diabetic retinopathy is used for staging of progression of micro and macro-vascular complications of patients with DM. Our hypothesis was that diabetic patients at different stages of retinopathy would have different vascular responsiveness that will be used as a surrogate marker of macro-vascular disease for risk assessment of cardiovascular complications.

METHODS

A prospective study enrolled 96 patients. Twenty-three healthy volunteers (44 ± 11 years), 25 diabetic patients without retinopathy (63 ± 11 years), 25 patients with non-proliferative retinopathy [NPDR] (62 ± 9 years) and 23 patients with proliferative diabetic retinopathy [PDR] (59 ± 10 years). All patients underwent an ophthalmologic examination to diagnose retinopathy staging, and vascular responsiveness evaluation that included endothelial function evaluation (using the brachial artery method to measure flow mediated diameter change (FMD%)) and measuring the ankle-brachial blood pressure ratio, a measure of arterial stiffness.

RESULTS

Endothelial function was severely impaired in all diabetic patients. Patients with PDR had an FMD% of -3.1 ± 6.6%, patients with NPDR had -3.3 ± 9.2%, patients without retinopathy -1.9 ± 7.4% (P = NS between all groups of patients). Healthy controls had an FMD% of 16.5 ± 7.5% with a significant difference (P < 0.001) compared with each group of patients. No difference in FMD% was observed among patients (P = 0.93 between PDR and NPDR groups, P = 0.54 between NPDR and no retinopathy groups and P = 0.71 between patients without retinopathy and those with PDR).The ankle brachial (ABI) ratio was 1.03 ± 0.28 in the PDR group, 1.14 ± 0.24 in the NPDR group and 0.97 ± 0.18 in the no-retinopathy group. Healthy volunteers had an ABI of 1.07 ± 0.18. No difference was observed between ABI of PDR and NPDR patients (P = 0.17) and between patients without retinopathy and PDR patients (P = 0.91). However, a significant difference was observed between the NPDR and no-retinopathy groups (P = 0.008). No significant difference was found between ABI ratios when compared with the control group (P = 0.62 for PDR, P = 0.26 for NPDR and P = 0.07 for the no-retinopathy group). No difference was observed in age and BMI among all groups of patients (P = NS for all). Patients were older (P < 0.001) and had a higher BMI (P < 0.001). Interestingly there was no difference in height among groups of patients, but controls were significantly taller compared with each group of patients (P < 0.02).

CONCLUSIONS

All patients with T2DM had severe endothelial dysfunction with no difference among the different retinopathy groups. In our patients, all patients had a normal arterial stiffness but patients without retinopathy who had the highest arterial stiffness. We could not distinguish vascular traits that would define diabetic patients at the highest risk to develop cardiovascular complications.

Developments in imaging methods used in hip arthroplasty: A diagnostic algorithm

BACKGROUND

Several imaging modalities can be used to diagnose complications of hip prosthesis placement. Despite progress in these imaging techniques, there are, as yet, no guidelines as to their respective indications.

METHODS

We formed a panel of experts in fields related to prosthesis imaging (radiology, nuclear medicine, orthopedic surgery) and conducted a review of the literature to determine the value of each modality for diagnosing complications following hip replacement.

RESULTS

Few recent studies have investigated the benefits related to the use of the latest technical developments, and studies comparing different methods are extremely rare.

CONCLUSIONS

We have developed a diagnostic tree based on the characteristics of each imaging technique and recommend its use. Computed topography was found to be the most versatile and cost-effective imaging solution and therefore a key tool for diagnosing the complications of hip replacement surgery.

Subchondral linear hyperintensity of the femoral head: MR imaging findings and associations with femoro-acetabular joint pathology

PURPOSE

The goal of this study was to evaluate the associations between linear hyperintensity in the subchondral bone of the femoral head on T2-weighted MR imaging and structural bone lesions.

MATERIAL AND METHODS

The MR imaging examinations of 63 patients (66 hips) that showed a bone marrow edema pattern (BMEP) of the hip were retrospectively evaluated (study group). The study group comprised 43 men and 20 women, with a mean age of 55.3 years±16.9 (SD) (range: 19-84 years). A control group of 61 patients (77 hips) without BMEP of the hip on MR imaging was created. The control group comprised 30 men and 31 women, with a mean age of 53.1 years±15.6 (SD) (range: 25-83 years). The presence of linear abnormalities of the subchondral bone on T2-weighted fat-saturated sequences (TR/TE=4220-4340/42-45ms) was evaluated and MR imaging findings were correlated with structural femoro-acetabular pathology (advanced chondropathy, osteonecrosis, subchondral insufficiency fractures and macroscopic fractures) and with pain duration.

RESULTS

A linear hyperintensity in the subchondral bone on T2-weighted MR imaging was found in 43/66 hips with areas of BMEP (65.1%) and in 3/77 hips without BMEP (3.8%). Subchondral linear hyperintensity was seen in 15/16 (93.7%) hips with a subchondral insufficiency fracture. Among the 16 hips with an ARCO stage III osteonecrosis, 13 (76.9%) presented BMEP associated with a subchondral linear hyperintensity. BMEP was present in 6/8 hips with ARCO stage IV osteonecrosis; however, only two hips (25%) exhibited subchondral linear hyperintensities. Finally, 77.7% of patients with subchondral linear hyperintensities presented with acute or subacute hip pain (P<0.0001).

CONCLUSION

Femoral head subchondral linear hyperintensity on T2-weighted MR imaging is common and is associated with acute subchondral bone damage.

Imaging of benign complications of exostoses of the shoulder, pelvic girdles and appendicular skeleton

Exostoses are the most common benign bone tumors, accounting for 10 to 15% of all bone tumors. They develop at the bone surface by enchondral ossification and stop growing when skeletal maturity has been reached. At first, exostoses are covered by a smooth cartilage cap that progressively ossifies with skeleton maturity. Then they may regress, partly or even completely. Osteochondromas may be solitary or multiple, with the latter associated with hereditary multiple exostoses (HME). Exostoses develop during childhood and become symptomatic during the third decade of life in the case of solitary exostoses, or earlier, in case of HME. They stop growing after puberty, when the epiphyseal plates close. Most exostoses remain asymptomatic. Local complications, usually benign, may occur, such as fractures or mechanical impingements upon nearby structures. In rare cases, sarcomatous degeneration occurs. Most of these complications have been described in case reports. This article describes the imaging features of benign complications of exostoses of the shoulder, pelvic girdles and appendicular.