Denise Napoli

Esophageal distensibility was significantly limited in patients with eosinophilic esophagitis, compared with healthy controls, reported Monika A. Kwiatek, Ph.D., and colleagues in the January issue of Gastroenterology.

The finding, which represents "the first quantification of reduced esophageal distensibility in EoE," could make distensibility "a useful objective measure to characterize disease severity ... [given that] solid food dysphagia and food impaction are likely dependent on the opening aperture of the esophagus," wrote the researchers (Gastroenterology 2011 January [doi:10.1053/j.gastro.2010.09.037]).

Dr. Kwiatek of the division of gastroenterology at Northwestern University, Chicago, looked at 33 patients with EoE, including 22 males and 11 females (age range, 19-67 years). Patients were from the gastroenterology clinic at Northwestern Memorial Faculty Foundation, and had current endoscopic biopsies with histopathology confirming EoE (that is, 15 or more eosinophils per high-powered field).

These patients were compared with a volunteer group of 15 healthy controls (6 males and 9 females, aged 21-68 years) who had no gastrointestinal symptoms and were not currently using gastrointestinal medications.

Esophageal volume was measured with a functional luminal imaging probe, known as the EndoFLIP, which uses impedance planimetry to determine multiple, adjacent, cross-sectional areas (CSAs) in the esophagus, according to the authors. The compliant, cylindrical bag is filled with a "specially formulated conductive solution" once it is inside the esophagus, which allows communication between electrodes inside the bag. The device is also capable of measuring intrabag pressure during distension, they added.

All subjects underwent esophagogastroduodenoscopy to evaluate for EoE and to help place the EndoFLIP across the esophagogastric junction (EGJ).

Dr. Kwiatek found that when the EndoFLIP bag was placed at the EGJ and inflated to 20 mL, controls had a median CSA of 15 mm2. That was significantly greater than EoE patients’ median CSA of 13 mm2 (P less than 0.05).

The difference was even greater when the EndoFLIP was further inflated to 30 mL. In this stage, controls had a median CSA of 22 mm2, whereas EoE patients registered a median of just 14 mm2 (P less than 0.05).

A similar – although not statistically significant – trend was seen when the EndoFLIP was used to measure pressure. With the bag inflated to 20 mL, control subjects had a median pressure of 19 mm Hg, compared with 21 mm Hg among EoE patients.

With the bag inflated to 30 mL, the pressure difference was once again even greater, although not significant (24 mm Hg among controls vs. 29 mm Hg among EoE patients).

The measures amounted to a "distensibility index" that was significantly lower among EoE patients, compared with controls, at both the 20-mL level (controls, 0.9 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .03) and the 30-mL threshold (controls, 0.8 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .01).

The authors also sought to determine whether esophageal distensibility was correlated with the degree of eosinophilic infiltration, or any other patient factors.

They found that none of the following factors were significantly related: mucosal eosinophil count, patient age and sex, and current gastrointestinal treatment at the time of the study.

The process of testing distensibility was well tolerated, according to the researchers. There were no cases of bleeding or mucosal tearing related to the subsequent esophageal biopsy.

"We hypothesize that measuring esophageal distensibility may be an important adjunct to the clinical management of EoE that potentially provides a more objective measure from which to guide medical and dilation therapy," concluded the authors.

"However, future studies done before and after therapy are required to determine whether reduced distensibility is responsive to treatment focused on reducing inflammation and fibrosis, and whether these changes are associated with improvement in patient reported symptom severity reported outcomes," they added.

The authors disclosed that the EndoFLIP equipment used in this study was provided by Crospon Ltd., maker of the device. One of the authors also disclosed serving on the advisory board for Crospon.

Esophageal distensibility was significantly limited in patients with eosinophilic esophagitis, compared with healthy controls, reported Monika A. Kwiatek, Ph.D., and colleagues in the January issue of Gastroenterology.

The finding, which represents "the first quantification of reduced esophageal distensibility in EoE," could make distensibility "a useful objective measure to characterize disease severity ... [given that] solid food dysphagia and food impaction are likely dependent on the opening aperture of the esophagus," wrote the researchers (Gastroenterology 2011 January [doi:10.1053/j.gastro.2010.09.037]).

Dr. Kwiatek of the division of gastroenterology at Northwestern University, Chicago, looked at 33 patients with EoE, including 22 males and 11 females (age range, 19-67 years). Patients were from the gastroenterology clinic at Northwestern Memorial Faculty Foundation, and had current endoscopic biopsies with histopathology confirming EoE (that is, 15 or more eosinophils per high-powered field).

These patients were compared with a volunteer group of 15 healthy controls (6 males and 9 females, aged 21-68 years) who had no gastrointestinal symptoms and were not currently using gastrointestinal medications.

Esophageal volume was measured with a functional luminal imaging probe, known as the EndoFLIP, which uses impedance planimetry to determine multiple, adjacent, cross-sectional areas (CSAs) in the esophagus, according to the authors. The compliant, cylindrical bag is filled with a "specially formulated conductive solution" once it is inside the esophagus, which allows communication between electrodes inside the bag. The device is also capable of measuring intrabag pressure during distension, they added.

All subjects underwent esophagogastroduodenoscopy to evaluate for EoE and to help place the EndoFLIP across the esophagogastric junction (EGJ).

Dr. Kwiatek found that when the EndoFLIP bag was placed at the EGJ and inflated to 20 mL, controls had a median CSA of 15 mm2. That was significantly greater than EoE patients’ median CSA of 13 mm2 (P less than 0.05).

The difference was even greater when the EndoFLIP was further inflated to 30 mL. In this stage, controls had a median CSA of 22 mm2, whereas EoE patients registered a median of just 14 mm2 (P less than 0.05).

A similar – although not statistically significant – trend was seen when the EndoFLIP was used to measure pressure. With the bag inflated to 20 mL, control subjects had a median pressure of 19 mm Hg, compared with 21 mm Hg among EoE patients.

With the bag inflated to 30 mL, the pressure difference was once again even greater, although not significant (24 mm Hg among controls vs. 29 mm Hg among EoE patients).

The measures amounted to a "distensibility index" that was significantly lower among EoE patients, compared with controls, at both the 20-mL level (controls, 0.9 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .03) and the 30-mL threshold (controls, 0.8 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .01).

The authors also sought to determine whether esophageal distensibility was correlated with the degree of eosinophilic infiltration, or any other patient factors.

They found that none of the following factors were significantly related: mucosal eosinophil count, patient age and sex, and current gastrointestinal treatment at the time of the study.

The process of testing distensibility was well tolerated, according to the researchers. There were no cases of bleeding or mucosal tearing related to the subsequent esophageal biopsy.

"We hypothesize that measuring esophageal distensibility may be an important adjunct to the clinical management of EoE that potentially provides a more objective measure from which to guide medical and dilation therapy," concluded the authors.

"However, future studies done before and after therapy are required to determine whether reduced distensibility is responsive to treatment focused on reducing inflammation and fibrosis, and whether these changes are associated with improvement in patient reported symptom severity reported outcomes," they added.

The authors disclosed that the EndoFLIP equipment used in this study was provided by Crospon Ltd., maker of the device. One of the authors also disclosed serving on the advisory board for Crospon.

Esophageal distensibility was significantly limited in patients with eosinophilic esophagitis, compared with healthy controls, reported Monika A. Kwiatek, Ph.D., and colleagues in the January issue of Gastroenterology.

The finding, which represents "the first quantification of reduced esophageal distensibility in EoE," could make distensibility "a useful objective measure to characterize disease severity ... [given that] solid food dysphagia and food impaction are likely dependent on the opening aperture of the esophagus," wrote the researchers (Gastroenterology 2011 January [doi:10.1053/j.gastro.2010.09.037]).

Dr. Kwiatek of the division of gastroenterology at Northwestern University, Chicago, looked at 33 patients with EoE, including 22 males and 11 females (age range, 19-67 years). Patients were from the gastroenterology clinic at Northwestern Memorial Faculty Foundation, and had current endoscopic biopsies with histopathology confirming EoE (that is, 15 or more eosinophils per high-powered field).

These patients were compared with a volunteer group of 15 healthy controls (6 males and 9 females, aged 21-68 years) who had no gastrointestinal symptoms and were not currently using gastrointestinal medications.

Esophageal volume was measured with a functional luminal imaging probe, known as the EndoFLIP, which uses impedance planimetry to determine multiple, adjacent, cross-sectional areas (CSAs) in the esophagus, according to the authors. The compliant, cylindrical bag is filled with a "specially formulated conductive solution" once it is inside the esophagus, which allows communication between electrodes inside the bag. The device is also capable of measuring intrabag pressure during distension, they added.

All subjects underwent esophagogastroduodenoscopy to evaluate for EoE and to help place the EndoFLIP across the esophagogastric junction (EGJ).

Dr. Kwiatek found that when the EndoFLIP bag was placed at the EGJ and inflated to 20 mL, controls had a median CSA of 15 mm2. That was significantly greater than EoE patients’ median CSA of 13 mm2 (P less than 0.05).

The difference was even greater when the EndoFLIP was further inflated to 30 mL. In this stage, controls had a median CSA of 22 mm2, whereas EoE patients registered a median of just 14 mm2 (P less than 0.05).

A similar – although not statistically significant – trend was seen when the EndoFLIP was used to measure pressure. With the bag inflated to 20 mL, control subjects had a median pressure of 19 mm Hg, compared with 21 mm Hg among EoE patients.

With the bag inflated to 30 mL, the pressure difference was once again even greater, although not significant (24 mm Hg among controls vs. 29 mm Hg among EoE patients).

The measures amounted to a "distensibility index" that was significantly lower among EoE patients, compared with controls, at both the 20-mL level (controls, 0.9 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .03) and the 30-mL threshold (controls, 0.8 mm2/Hg vs. EoE patients, 0.5 mm2/Hg; P = .01).

The authors also sought to determine whether esophageal distensibility was correlated with the degree of eosinophilic infiltration, or any other patient factors.

They found that none of the following factors were significantly related: mucosal eosinophil count, patient age and sex, and current gastrointestinal treatment at the time of the study.

The process of testing distensibility was well tolerated, according to the researchers. There were no cases of bleeding or mucosal tearing related to the subsequent esophageal biopsy.

"We hypothesize that measuring esophageal distensibility may be an important adjunct to the clinical management of EoE that potentially provides a more objective measure from which to guide medical and dilation therapy," concluded the authors.

"However, future studies done before and after therapy are required to determine whether reduced distensibility is responsive to treatment focused on reducing inflammation and fibrosis, and whether these changes are associated with improvement in patient reported symptom severity reported outcomes," they added.

The authors disclosed that the EndoFLIP equipment used in this study was provided by Crospon Ltd., maker of the device. One of the authors also disclosed serving on the advisory board for Crospon.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Patients whose colonoscopies were performed by endoscopists with high completion rates were less likely to receive a diagnosis of colorectal cancer 6-36 months later, compared with patients whose colonoscopies were done by endoscopists with lower completion rates, reported Dr. Nancy N. Baxter and colleagues in the January issue of Gastroenterology.

The study drew on five databases comprising virtually all residents of Ontario, wrote Dr. Baxter of the department of surgery at the University of Toronto. Patients were included in the analysis if they had colorectal cancer (CRC) diagnosed in 2000-2005 and had had a colonoscopy 6-36 months prior to diagnosis (Gastroenterology 2011; 140:65-72).

[Bowel Prep Affects Interval To Next Colonoscopy]

Cancers for which a primary site could not be determined were excluded. Additionally, all patients had to be older than 20 years, have no previous CRC history, and have no history of Crohn’s disease or ulcerative colitis.

Endoscopist specialty was ascertained through the Ontario Physicians Human Resources Data Centre, and endoscopist volume was determined by taking the yearly average of all coded colonoscopies performed in the 2 years prior to the date of the colonoscopy in question.

Polypectomy rate was the proportion of colonoscopies associated with a code indicating removal of a polyp larger than 3 mm over the same 2-year period, and completion rate was the proportion of colonoscopies performed by the relevant endoscopist that were complete to the cecum.

Overall, more than 34,000 patients were diagnosed with CRC during the study period, and 14,064 met the study criteria.

Of these, 1,260 (9.0%) were considered to have a postcolonoscopy colorectal cancer (PCCRC), defined as a "CRC within 3 years following a colonoscopy in which the cancer was not detected," wrote the authors.

"After controlling for patient and endoscopy factors, patients undergoing colonoscopy performed by an endoscopist with a completion rate of 95% or greater were less likely to have a PCCRC than if performed by an endoscopist with a less than 80% completion rate for proximal [odds ratio, 0.72; 95% confidence interval, 0.53-0.97] and distal [OR, 0.73; 95% CI, 0.54-0.97] cancers," wrote Dr. Baxter.

Polypectomy rate was also associated with PCCRCs, at least in the proximal colon. Endoscopists with polypectomy rates greater than 30% had an OR of 0.61 for proximal PCCRC, compared with endoscopists whose polypectomy rates were less than 10% (95% CI, 0.42-0.89), they wrote.

Endoscopist specialty played a role as well. Compared with gastroenterologists, endoscopists who were identified as "other" specialties (excluding surgeons) had an OR of 1.87 for proximal PCCRCs (95% CI, 1.34-2.60), and 1.67 for distal cancers (95% CI, 1.13-2.46).

Setting was important too: Colonoscopies performed in a nonhospital setting had an OR of 1.88 for proximal PCCRCs (95% CI, 1.2-2.92), and an OR of 1.67 for distal PCCRCs (95% CI, 1.13-2.46).

The authors did not find any significant relationship between polypectomy rate and the diagnosis of distal PCCRCs, or between procedure volume and any PCCRCs.

The authors conceded several limitations to their study, including the possibility of errors in coding (from which their data were derived).

"Additionally, we could not assess a number of other aspects of care that are likely to have an impact on colonoscopy performance and effectiveness, including factors such as quality of preparation and sedation," they wrote.

Moreover, although the study does show that endoscopist completion rates, polypectomy rates, and specialty are "meaningful quality indicators," the authors wrote, "it is less clear ... [that] use of these indicators in performance management would lead to an improvement in the quality of colonoscopy or a reduction in the number of PCCRC."

The authors stated that they have no conflicts of interest relative to this study, which was funded by an American College of Gastroenterology Cancer Prevention Action Plan Grant, as well as the Ontario Institute for Cancer Research, and Cancer Care Ontario.

Since the launch of the new “blue button” on the Medicare and Veterans Affairs patient Web sites this summer, tens of thousands of patients have downloaded their personal health records to computers, flash drives, and disks – including claims data, test results, and more.

Now, physicians' groups and patients are calling for this practice to be commonplace for all.

“If the patient has access to his or her [personal health] information, they become part of the decision-making process, they are more engaged in their care, and they're empowered to make better decisions,” said Dr. Steven Waldren, director of the American Academy of Family Physicians' Center for Health Information Technology. “The blue button initiative is saying, 'Let's get started.'”

The blue button, developed jointly by Veterans Affairs, the Centers for Medicare and Medicaid Services, and the Defense Department, is “a Web-based feature through which patients may easily download their health information and share it with health care providers, caregivers, and others they trust,” according to Todd Park, chief technology officer at the Health and Human Services department, writing in a post on the White House's Office of Science and Technology blog.

The blue button went live in August on www.mymedicare.govwww.myhealth.va.gov

“This new option will help veterans and Medicare beneficiaries save their information on individual computers and portable storage devices or print that information in hard copy,” Mr. Park wrote. “Having ready access to personal health information from Medicare claims can help beneficiaries understand their medical history and partner more effectively with providers.”

Now, many physicians and physician groups want to see the concept of downloadable personal health records extended to all of their patients.

A policy paper on the topic published by the nonprofit Markle Foundation aims to promote the use of the blue button by calling on “organizations that display personal health information electronically to individuals in Web browsers to include an option for individuals to download the information.”

Additionally, the paper recommended making the download capability a “core procurement requirement for federal- and state-sponsored health [information technology] grants and projects” that come about as a result of the American Recovery and Reinvestment Act of 2009, which allocated billions of dollars for the development of health care technology.

Dr. Waldren was a member of the work group that reviewed the policy paper; he and more than a dozen physicians and other stakeholders endorsed it, including Dr. Jack Lewin, CEO of the American College of Cardiology and Dr. Allan Korn, chief medical officer for the Blue Cross and Blue Shield Association.

Patients, too, seem to embrace the concept of downloadable personal health records. In an online survey commissioned by Markle, 70% of almost 1,600 adult respondents agreed that they should be able to download and keep copies of their personal health information.

The real benefit, however, lies in the potential of Internet- and mobile phone–based applications, which can access the data and increase its usefulness for patients and physicians alike.

For example, said Dr. Waldren, imagine a tool that parses through all of a patient's downloaded health data, highlighting all potential and actual medical problems, making lists of all prescribed medications and doses, assessing them for drug-drug interactions, and communicating that information to the physician at every visit.

He went on to say that such a smart “app” also could scan resource Web sites to find new scientific data and government findings that affect patient care. “Those are the things that can start to happen,” with blue button technology.

But despite the myriad possible benefits of downloadable records, privacy remains a concern, for patients and physicians.

According to the Markle Foundation paper, “Any online download capability for personal health information must be provided via secure access. That means the identity of each individual given credentials to access their own data must be proofed to an acceptable level of accuracy, and the individual must present those credentials or some acceptable token of those credentials upon login in order to get access to the data for download.”

Dr. Waldren agreed. “There's no question that privacy and security are real issues,” he said. And that means not only keeping the site secure, but educating patients, too. “Every time the patient clicks on that blue button, they need to be reminded, 'You're doing something that puts your information at risk,'” he said.

But he added that privacy concerns should not be something that keeps technology like the blue button moving forward. “I personally view privacy as a balance between benefit and risk. We could put your records in an encrypted format … that no one could get to. It would be highly secure and I would bet it would never be released inappropriately,” he said. “But it's never available to actually help make sure you get good care.”

The Markle Foundation's paper, “The Download Capability,” is available at www.markle.org/downloadable_assets/20100831_dlcapability.pdf

Patients who can access their records “are more engaged in their care.”

Source ©crystal kirk/Fotolia.com

Since the launch of the new “blue button” on the Medicare and Veterans Affairs patient Web sites this summer, tens of thousands of patients have downloaded their personal health records to computers, flash drives, and disks – including claims data, test results, and more.

Now, physicians' groups and patients are calling for this practice to be commonplace for all.

“If the patient has access to his or her [personal health] information, they become part of the decision-making process, they are more engaged in their care, and they're empowered to make better decisions,” said Dr. Steven Waldren, director of the American Academy of Family Physicians' Center for Health Information Technology. “The blue button initiative is saying, 'Let's get started.'”

The blue button, developed jointly by Veterans Affairs, the Centers for Medicare and Medicaid Services, and the Defense Department, is “a Web-based feature through which patients may easily download their health information and share it with health care providers, caregivers, and others they trust,” according to Todd Park, chief technology officer at the Health and Human Services department, writing in a post on the White House's Office of Science and Technology blog.

The blue button went live in August on www.mymedicare.govwww.myhealth.va.gov

“This new option will help veterans and Medicare beneficiaries save their information on individual computers and portable storage devices or print that information in hard copy,” Mr. Park wrote. “Having ready access to personal health information from Medicare claims can help beneficiaries understand their medical history and partner more effectively with providers.”

Now, many physicians and physician groups want to see the concept of downloadable personal health records extended to all of their patients.

A policy paper on the topic published by the nonprofit Markle Foundation aims to promote the use of the blue button by calling on “organizations that display personal health information electronically to individuals in Web browsers to include an option for individuals to download the information.”

Additionally, the paper recommended making the download capability a “core procurement requirement for federal- and state-sponsored health [information technology] grants and projects” that come about as a result of the American Recovery and Reinvestment Act of 2009, which allocated billions of dollars for the development of health care technology.

Dr. Waldren was a member of the work group that reviewed the policy paper; he and more than a dozen physicians and other stakeholders endorsed it, including Dr. Jack Lewin, CEO of the American College of Cardiology and Dr. Allan Korn, chief medical officer for the Blue Cross and Blue Shield Association.

Patients, too, seem to embrace the concept of downloadable personal health records. In an online survey commissioned by Markle, 70% of almost 1,600 adult respondents agreed that they should be able to download and keep copies of their personal health information.

The real benefit, however, lies in the potential of Internet- and mobile phone–based applications, which can access the data and increase its usefulness for patients and physicians alike.

For example, said Dr. Waldren, imagine a tool that parses through all of a patient's downloaded health data, highlighting all potential and actual medical problems, making lists of all prescribed medications and doses, assessing them for drug-drug interactions, and communicating that information to the physician at every visit.

He went on to say that such a smart “app” also could scan resource Web sites to find new scientific data and government findings that affect patient care. “Those are the things that can start to happen,” with blue button technology.

But despite the myriad possible benefits of downloadable records, privacy remains a concern, for patients and physicians.

According to the Markle Foundation paper, “Any online download capability for personal health information must be provided via secure access. That means the identity of each individual given credentials to access their own data must be proofed to an acceptable level of accuracy, and the individual must present those credentials or some acceptable token of those credentials upon login in order to get access to the data for download.”

Dr. Waldren agreed. “There's no question that privacy and security are real issues,” he said. And that means not only keeping the site secure, but educating patients, too. “Every time the patient clicks on that blue button, they need to be reminded, 'You're doing something that puts your information at risk,'” he said.

But he added that privacy concerns should not be something that keeps technology like the blue button moving forward. “I personally view privacy as a balance between benefit and risk. We could put your records in an encrypted format … that no one could get to. It would be highly secure and I would bet it would never be released inappropriately,” he said. “But it's never available to actually help make sure you get good care.”

The Markle Foundation's paper, “The Download Capability,” is available at www.markle.org/downloadable_assets/20100831_dlcapability.pdf

Patients who can access their records “are more engaged in their care.”

Source ©crystal kirk/Fotolia.com

Since the launch of the new “blue button” on the Medicare and Veterans Affairs patient Web sites this summer, tens of thousands of patients have downloaded their personal health records to computers, flash drives, and disks – including claims data, test results, and more.

Now, physicians' groups and patients are calling for this practice to be commonplace for all.

“If the patient has access to his or her [personal health] information, they become part of the decision-making process, they are more engaged in their care, and they're empowered to make better decisions,” said Dr. Steven Waldren, director of the American Academy of Family Physicians' Center for Health Information Technology. “The blue button initiative is saying, 'Let's get started.'”

The blue button, developed jointly by Veterans Affairs, the Centers for Medicare and Medicaid Services, and the Defense Department, is “a Web-based feature through which patients may easily download their health information and share it with health care providers, caregivers, and others they trust,” according to Todd Park, chief technology officer at the Health and Human Services department, writing in a post on the White House's Office of Science and Technology blog.

The blue button went live in August on www.mymedicare.govwww.myhealth.va.gov

“This new option will help veterans and Medicare beneficiaries save their information on individual computers and portable storage devices or print that information in hard copy,” Mr. Park wrote. “Having ready access to personal health information from Medicare claims can help beneficiaries understand their medical history and partner more effectively with providers.”

Now, many physicians and physician groups want to see the concept of downloadable personal health records extended to all of their patients.

A policy paper on the topic published by the nonprofit Markle Foundation aims to promote the use of the blue button by calling on “organizations that display personal health information electronically to individuals in Web browsers to include an option for individuals to download the information.”

Additionally, the paper recommended making the download capability a “core procurement requirement for federal- and state-sponsored health [information technology] grants and projects” that come about as a result of the American Recovery and Reinvestment Act of 2009, which allocated billions of dollars for the development of health care technology.

Dr. Waldren was a member of the work group that reviewed the policy paper; he and more than a dozen physicians and other stakeholders endorsed it, including Dr. Jack Lewin, CEO of the American College of Cardiology and Dr. Allan Korn, chief medical officer for the Blue Cross and Blue Shield Association.

Patients, too, seem to embrace the concept of downloadable personal health records. In an online survey commissioned by Markle, 70% of almost 1,600 adult respondents agreed that they should be able to download and keep copies of their personal health information.

The real benefit, however, lies in the potential of Internet- and mobile phone–based applications, which can access the data and increase its usefulness for patients and physicians alike.

For example, said Dr. Waldren, imagine a tool that parses through all of a patient's downloaded health data, highlighting all potential and actual medical problems, making lists of all prescribed medications and doses, assessing them for drug-drug interactions, and communicating that information to the physician at every visit.

He went on to say that such a smart “app” also could scan resource Web sites to find new scientific data and government findings that affect patient care. “Those are the things that can start to happen,” with blue button technology.

But despite the myriad possible benefits of downloadable records, privacy remains a concern, for patients and physicians.

According to the Markle Foundation paper, “Any online download capability for personal health information must be provided via secure access. That means the identity of each individual given credentials to access their own data must be proofed to an acceptable level of accuracy, and the individual must present those credentials or some acceptable token of those credentials upon login in order to get access to the data for download.”

Dr. Waldren agreed. “There's no question that privacy and security are real issues,” he said. And that means not only keeping the site secure, but educating patients, too. “Every time the patient clicks on that blue button, they need to be reminded, 'You're doing something that puts your information at risk,'” he said.

But he added that privacy concerns should not be something that keeps technology like the blue button moving forward. “I personally view privacy as a balance between benefit and risk. We could put your records in an encrypted format … that no one could get to. It would be highly secure and I would bet it would never be released inappropriately,” he said. “But it's never available to actually help make sure you get good care.”

The Markle Foundation's paper, “The Download Capability,” is available at www.markle.org/downloadable_assets/20100831_dlcapability.pdf

Patients who can access their records “are more engaged in their care.”

Source ©crystal kirk/Fotolia.com

Major Finding: Digital x-ray radiogrammetry detected small but significant bone loss in a group of postmenopausal women, compared with women receiving hormone therapy.

Data Source: A 2-year, single-blind, randomized controlled trial of 88 postmenopausal women with rheumatoid arthritis.

Disclosures: Dr. Forsblad-d'Elia and Dr. Carlsten said this study was supported by several grants from rheumatology and other foundations; they added that they had no competing interests to disclose.

Hormone therapy stabilized bone loss over a 2-year period in rheumatoid arthritis patients, as measured on digital x-ray radiogrammetry, a study has shown.

The study is important not only for finding that hormone therapy (HT) was effective, but because it depended on readings that detected losses of as little as 0.36%.

In contrast, plain radiographs, “the standard method for detection and quantification of joint destruction in RA,” cannot detect bone loss of less than 30%, wrote Dr. Helena Forsblad-d'Elia and Dr. Hans Carlsten (Ann. Rheum. Dis. 2010 Nov. 3 [doi: 10.1136/ard.2010.137133]).

Dr. Forsblad-d'Elia and Dr. Carlsten, both of the center for bone and arthritis research at the University of Gothenburg (Sweden), looked at 88 postmenopausal women with radiographic joint destruction due to rheumatoid arthritis. Findings from earlier research by Dr. Forsblad-d'Elia has shown that RA is strongly associated with generalized osteoporosis (Ann. Rheum. Dis. 2003;62:617-23).

Patients were randomized to one of two groups. The first received HT, which consisted of estradiol and norethisterone acetate, plus a daily dose of 500 mg calcium and 400 IU vitamin D. Controls received only the calcium and vitamin D.

Patients had digital x-ray radiogrammetry–bone mineral density (DXR-BMD) readings at baseline and at 2 years. A total of 50 women (23 HT patients, 27 controls) were ultimately included in the study analysis. The mean age of both groups was roughly 58 years, and both groups had a mean disease duration of greater than 10 years.

According to the researchers, at baseline, HT patients and controls had an identical mean DXR-BMD reading of 0.45 g/cm

Two years later, HT patients' mean reading was identical except for a tiny increase in the standard deviation, to 0.097, whereas control patients' mean DXR-BMD was 0.44, with a standard deviation of 0.084. The minute difference was insignificant for the HT group, but significant for controls, both in terms of change from baseline and difference from the HT group. Put another way, the decrease among HT patients from baseline was 0.36%, while the decrease from baseline for controls was 3.74% – more than 10 times greater.

“DXR-BMD has been proposed to be an outcome measure in monitoring treatments in early RA, and can predict future radiographic joint damage,” concluded the authors. Based on the current data, however, “we suggest that DXR-BMD could serve as an outcome measure in [randomized controlled trials] in long-standing RA,” they wrote.

Major Finding: Digital x-ray radiogrammetry detected small but significant bone loss in a group of postmenopausal women, compared with women receiving hormone therapy.

Data Source: A 2-year, single-blind, randomized controlled trial of 88 postmenopausal women with rheumatoid arthritis.

Disclosures: Dr. Forsblad-d'Elia and Dr. Carlsten said this study was supported by several grants from rheumatology and other foundations; they added that they had no competing interests to disclose.

Hormone therapy stabilized bone loss over a 2-year period in rheumatoid arthritis patients, as measured on digital x-ray radiogrammetry, a study has shown.

The study is important not only for finding that hormone therapy (HT) was effective, but because it depended on readings that detected losses of as little as 0.36%.

In contrast, plain radiographs, “the standard method for detection and quantification of joint destruction in RA,” cannot detect bone loss of less than 30%, wrote Dr. Helena Forsblad-d'Elia and Dr. Hans Carlsten (Ann. Rheum. Dis. 2010 Nov. 3 [doi: 10.1136/ard.2010.137133]).

Dr. Forsblad-d'Elia and Dr. Carlsten, both of the center for bone and arthritis research at the University of Gothenburg (Sweden), looked at 88 postmenopausal women with radiographic joint destruction due to rheumatoid arthritis. Findings from earlier research by Dr. Forsblad-d'Elia has shown that RA is strongly associated with generalized osteoporosis (Ann. Rheum. Dis. 2003;62:617-23).

Patients were randomized to one of two groups. The first received HT, which consisted of estradiol and norethisterone acetate, plus a daily dose of 500 mg calcium and 400 IU vitamin D. Controls received only the calcium and vitamin D.

Patients had digital x-ray radiogrammetry–bone mineral density (DXR-BMD) readings at baseline and at 2 years. A total of 50 women (23 HT patients, 27 controls) were ultimately included in the study analysis. The mean age of both groups was roughly 58 years, and both groups had a mean disease duration of greater than 10 years.

According to the researchers, at baseline, HT patients and controls had an identical mean DXR-BMD reading of 0.45 g/cm

Two years later, HT patients' mean reading was identical except for a tiny increase in the standard deviation, to 0.097, whereas control patients' mean DXR-BMD was 0.44, with a standard deviation of 0.084. The minute difference was insignificant for the HT group, but significant for controls, both in terms of change from baseline and difference from the HT group. Put another way, the decrease among HT patients from baseline was 0.36%, while the decrease from baseline for controls was 3.74% – more than 10 times greater.

“DXR-BMD has been proposed to be an outcome measure in monitoring treatments in early RA, and can predict future radiographic joint damage,” concluded the authors. Based on the current data, however, “we suggest that DXR-BMD could serve as an outcome measure in [randomized controlled trials] in long-standing RA,” they wrote.

Major Finding: Digital x-ray radiogrammetry detected small but significant bone loss in a group of postmenopausal women, compared with women receiving hormone therapy.

Data Source: A 2-year, single-blind, randomized controlled trial of 88 postmenopausal women with rheumatoid arthritis.

Disclosures: Dr. Forsblad-d'Elia and Dr. Carlsten said this study was supported by several grants from rheumatology and other foundations; they added that they had no competing interests to disclose.

Hormone therapy stabilized bone loss over a 2-year period in rheumatoid arthritis patients, as measured on digital x-ray radiogrammetry, a study has shown.

The study is important not only for finding that hormone therapy (HT) was effective, but because it depended on readings that detected losses of as little as 0.36%.

In contrast, plain radiographs, “the standard method for detection and quantification of joint destruction in RA,” cannot detect bone loss of less than 30%, wrote Dr. Helena Forsblad-d'Elia and Dr. Hans Carlsten (Ann. Rheum. Dis. 2010 Nov. 3 [doi: 10.1136/ard.2010.137133]).

Dr. Forsblad-d'Elia and Dr. Carlsten, both of the center for bone and arthritis research at the University of Gothenburg (Sweden), looked at 88 postmenopausal women with radiographic joint destruction due to rheumatoid arthritis. Findings from earlier research by Dr. Forsblad-d'Elia has shown that RA is strongly associated with generalized osteoporosis (Ann. Rheum. Dis. 2003;62:617-23).

Patients were randomized to one of two groups. The first received HT, which consisted of estradiol and norethisterone acetate, plus a daily dose of 500 mg calcium and 400 IU vitamin D. Controls received only the calcium and vitamin D.

Patients had digital x-ray radiogrammetry–bone mineral density (DXR-BMD) readings at baseline and at 2 years. A total of 50 women (23 HT patients, 27 controls) were ultimately included in the study analysis. The mean age of both groups was roughly 58 years, and both groups had a mean disease duration of greater than 10 years.

According to the researchers, at baseline, HT patients and controls had an identical mean DXR-BMD reading of 0.45 g/cm

Two years later, HT patients' mean reading was identical except for a tiny increase in the standard deviation, to 0.097, whereas control patients' mean DXR-BMD was 0.44, with a standard deviation of 0.084. The minute difference was insignificant for the HT group, but significant for controls, both in terms of change from baseline and difference from the HT group. Put another way, the decrease among HT patients from baseline was 0.36%, while the decrease from baseline for controls was 3.74% – more than 10 times greater.

“DXR-BMD has been proposed to be an outcome measure in monitoring treatments in early RA, and can predict future radiographic joint damage,” concluded the authors. Based on the current data, however, “we suggest that DXR-BMD could serve as an outcome measure in [randomized controlled trials] in long-standing RA,” they wrote.

When it comes to heart disease in rheumatoid arthritis, the classic risk factors like body mass index and abnormal lipid profiles play a role, but a very different one than among the general population, according to Dr. George D. Kitas and Dr. Sherine E. Gabriel.

Moreover, systemic inflammation is likely just as important for the development of cardiovascular disease in this cohort. Therefore, “effective, even optimal control of traditional risk factors is imperative, but may be insufficient to reduce CV risk for people with RA,” the investigators wrote (Ann. Rheum. Dis. 2010 Nov. 24 [doi:10.1136/ard.2010.142133]). Rather, “tight control of systemic inflammation is likely to be required for optimal results.”

According to Dr. Kitas of the Arthritis Research U.K. Epidemiology Unit at Manchester (England) University, and Dr. Gabriel of the division of rheumatology at the Mayo Clinic, Rochester, Minn., one of the commonest and simplest risk factors for heart disease among the general population – increased body mass index – may, paradoxically, be associated with increased survival among RA patients.

They point to one study showing that even after the presence of diabetes mellitus, cardiac history, smoking, and hypertension were controlled for, lower BMI carried a threefold risk of death, compared with patients without RA (Arthritis Rheum. 2004;50:3450-7).

“RA appears to be associated with profound alterations in body composition, which are not reflected in the BMI thresholds used in the general population,” the authors wrote.

These alterations include what the authors call “rheumatoid cachexia,” characterized by low muscle mass combined with a high fat mass, which may represent “from the CV perspective, the 'worst of both worlds.'”

A similar paradoxical relationship appears to exist concerning lipids in RA. “Serum levels of total cholesterol and LDL cholesterol decline precipitously during the 3- to 5-year period before RA incidence,” they wrote, citing a study by other investigators (Ann. Rheum. Dis. 2009;68[suppl. 3]:78).

On the other hand, dyslipidemia has been documented to affect “up to half” of hospitalized RA patients (Ann. Rheum. Dis. 2010;69:683-8).

Meanwhile, the landmark JUPITER study (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) excluded RA patients, because of C-reactive protein levels in excess of the “arbitrarily chosen threshold of 2 mg/L used in that trial, as well as a significant classical CV risk factor load, unlike the participants in JUPITER, who had no other risk factors.” They reported that a trial of statins specifically in RA, enrolling 4,000 patients, is underway in the United Kingdom, but will not report results until 2016 (www.dgoh.nhs.uk/tracera

Another area where research is lacking is concerning the effects of inflammation on CV risk. The authors pointed, for example, to the theory of “accelerated atherosclerosis,” first postulated in the 1990s.

“The cell types, cytokine signaling, adhesion interactions, and tissue-damaging processes involved in the generation, progression, instability, and rupture of atheromatous plaques are reminiscent of those seen in chronic rheumatoid synovitis,” they wrote.

Moreover, “effective RA treatment appears to be associated with some, often transient, improvements in vascular function,” they added, although “there are no clear, consistent relationships between this and contemporary disease activity.”

Another theory, that “high-grade systemic inflammation in RA does not necessarily imply accelerated atherosclerosis but rather an increased propensity to plaque instability and rupture,” was confirmed in an autopsy analysis in one study (J. Rheumatol. 2007;34:937-42).

The work was funded by Arthritis Research U.K., the British Heart Foundation, the Medical Research Council, and the U.S. National Institute of Arthritis and Musculoskeletal Diseases. Dr. Kitas and Dr. Gabriel said they had no relevant financial disclosures.

When it comes to heart disease in rheumatoid arthritis, the classic risk factors like body mass index and abnormal lipid profiles play a role, but a very different one than among the general population, according to Dr. George D. Kitas and Dr. Sherine E. Gabriel.

Moreover, systemic inflammation is likely just as important for the development of cardiovascular disease in this cohort. Therefore, “effective, even optimal control of traditional risk factors is imperative, but may be insufficient to reduce CV risk for people with RA,” the investigators wrote (Ann. Rheum. Dis. 2010 Nov. 24 [doi:10.1136/ard.2010.142133]). Rather, “tight control of systemic inflammation is likely to be required for optimal results.”

According to Dr. Kitas of the Arthritis Research U.K. Epidemiology Unit at Manchester (England) University, and Dr. Gabriel of the division of rheumatology at the Mayo Clinic, Rochester, Minn., one of the commonest and simplest risk factors for heart disease among the general population – increased body mass index – may, paradoxically, be associated with increased survival among RA patients.

They point to one study showing that even after the presence of diabetes mellitus, cardiac history, smoking, and hypertension were controlled for, lower BMI carried a threefold risk of death, compared with patients without RA (Arthritis Rheum. 2004;50:3450-7).

“RA appears to be associated with profound alterations in body composition, which are not reflected in the BMI thresholds used in the general population,” the authors wrote.

These alterations include what the authors call “rheumatoid cachexia,” characterized by low muscle mass combined with a high fat mass, which may represent “from the CV perspective, the 'worst of both worlds.'”

A similar paradoxical relationship appears to exist concerning lipids in RA. “Serum levels of total cholesterol and LDL cholesterol decline precipitously during the 3- to 5-year period before RA incidence,” they wrote, citing a study by other investigators (Ann. Rheum. Dis. 2009;68[suppl. 3]:78).

On the other hand, dyslipidemia has been documented to affect “up to half” of hospitalized RA patients (Ann. Rheum. Dis. 2010;69:683-8).

Meanwhile, the landmark JUPITER study (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) excluded RA patients, because of C-reactive protein levels in excess of the “arbitrarily chosen threshold of 2 mg/L used in that trial, as well as a significant classical CV risk factor load, unlike the participants in JUPITER, who had no other risk factors.” They reported that a trial of statins specifically in RA, enrolling 4,000 patients, is underway in the United Kingdom, but will not report results until 2016 (www.dgoh.nhs.uk/tracera

Another area where research is lacking is concerning the effects of inflammation on CV risk. The authors pointed, for example, to the theory of “accelerated atherosclerosis,” first postulated in the 1990s.

“The cell types, cytokine signaling, adhesion interactions, and tissue-damaging processes involved in the generation, progression, instability, and rupture of atheromatous plaques are reminiscent of those seen in chronic rheumatoid synovitis,” they wrote.

Moreover, “effective RA treatment appears to be associated with some, often transient, improvements in vascular function,” they added, although “there are no clear, consistent relationships between this and contemporary disease activity.”

Another theory, that “high-grade systemic inflammation in RA does not necessarily imply accelerated atherosclerosis but rather an increased propensity to plaque instability and rupture,” was confirmed in an autopsy analysis in one study (J. Rheumatol. 2007;34:937-42).

The work was funded by Arthritis Research U.K., the British Heart Foundation, the Medical Research Council, and the U.S. National Institute of Arthritis and Musculoskeletal Diseases. Dr. Kitas and Dr. Gabriel said they had no relevant financial disclosures.

When it comes to heart disease in rheumatoid arthritis, the classic risk factors like body mass index and abnormal lipid profiles play a role, but a very different one than among the general population, according to Dr. George D. Kitas and Dr. Sherine E. Gabriel.

Moreover, systemic inflammation is likely just as important for the development of cardiovascular disease in this cohort. Therefore, “effective, even optimal control of traditional risk factors is imperative, but may be insufficient to reduce CV risk for people with RA,” the investigators wrote (Ann. Rheum. Dis. 2010 Nov. 24 [doi:10.1136/ard.2010.142133]). Rather, “tight control of systemic inflammation is likely to be required for optimal results.”

According to Dr. Kitas of the Arthritis Research U.K. Epidemiology Unit at Manchester (England) University, and Dr. Gabriel of the division of rheumatology at the Mayo Clinic, Rochester, Minn., one of the commonest and simplest risk factors for heart disease among the general population – increased body mass index – may, paradoxically, be associated with increased survival among RA patients.

They point to one study showing that even after the presence of diabetes mellitus, cardiac history, smoking, and hypertension were controlled for, lower BMI carried a threefold risk of death, compared with patients without RA (Arthritis Rheum. 2004;50:3450-7).

“RA appears to be associated with profound alterations in body composition, which are not reflected in the BMI thresholds used in the general population,” the authors wrote.

These alterations include what the authors call “rheumatoid cachexia,” characterized by low muscle mass combined with a high fat mass, which may represent “from the CV perspective, the 'worst of both worlds.'”

A similar paradoxical relationship appears to exist concerning lipids in RA. “Serum levels of total cholesterol and LDL cholesterol decline precipitously during the 3- to 5-year period before RA incidence,” they wrote, citing a study by other investigators (Ann. Rheum. Dis. 2009;68[suppl. 3]:78).

On the other hand, dyslipidemia has been documented to affect “up to half” of hospitalized RA patients (Ann. Rheum. Dis. 2010;69:683-8).

Meanwhile, the landmark JUPITER study (Justification for the Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin) excluded RA patients, because of C-reactive protein levels in excess of the “arbitrarily chosen threshold of 2 mg/L used in that trial, as well as a significant classical CV risk factor load, unlike the participants in JUPITER, who had no other risk factors.” They reported that a trial of statins specifically in RA, enrolling 4,000 patients, is underway in the United Kingdom, but will not report results until 2016 (www.dgoh.nhs.uk/tracera

Another area where research is lacking is concerning the effects of inflammation on CV risk. The authors pointed, for example, to the theory of “accelerated atherosclerosis,” first postulated in the 1990s.

“The cell types, cytokine signaling, adhesion interactions, and tissue-damaging processes involved in the generation, progression, instability, and rupture of atheromatous plaques are reminiscent of those seen in chronic rheumatoid synovitis,” they wrote.

Moreover, “effective RA treatment appears to be associated with some, often transient, improvements in vascular function,” they added, although “there are no clear, consistent relationships between this and contemporary disease activity.”

Another theory, that “high-grade systemic inflammation in RA does not necessarily imply accelerated atherosclerosis but rather an increased propensity to plaque instability and rupture,” was confirmed in an autopsy analysis in one study (J. Rheumatol. 2007;34:937-42).

The work was funded by Arthritis Research U.K., the British Heart Foundation, the Medical Research Council, and the U.S. National Institute of Arthritis and Musculoskeletal Diseases. Dr. Kitas and Dr. Gabriel said they had no relevant financial disclosures.

Major Finding: A novel system for scoring MRIs in children with juvenile idiopathic arthritis showed significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

Data Source: A total of 66 consecutively recruited patients with JIA from a single center in Italy.

Disclosures: The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

The adult-targeted Rheumatoid Arthritis MRI Score, previously considered unusable in children because of the “peculiarities of the growing skeleton,” was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues.

Dr. Malattia, of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis involving the wrist.

The patient's clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale.

Bone marrow edema was evaluated using a 0-2 scale. Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001). The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician's global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints.

Assessment of 39 follow-up MRIs completed a median of 1.2 years after the index scan showed that of the 22 who had improved according to the ACR Pediatric 30 criteria, there was a significant decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Major Finding: A novel system for scoring MRIs in children with juvenile idiopathic arthritis showed significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

Data Source: A total of 66 consecutively recruited patients with JIA from a single center in Italy.

Disclosures: The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

The adult-targeted Rheumatoid Arthritis MRI Score, previously considered unusable in children because of the “peculiarities of the growing skeleton,” was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues.

Dr. Malattia, of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis involving the wrist.

The patient's clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale.

Bone marrow edema was evaluated using a 0-2 scale. Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001). The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician's global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints.

Assessment of 39 follow-up MRIs completed a median of 1.2 years after the index scan showed that of the 22 who had improved according to the ACR Pediatric 30 criteria, there was a significant decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Major Finding: A novel system for scoring MRIs in children with juvenile idiopathic arthritis showed significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

Data Source: A total of 66 consecutively recruited patients with JIA from a single center in Italy.

Disclosures: The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

The adult-targeted Rheumatoid Arthritis MRI Score, previously considered unusable in children because of the “peculiarities of the growing skeleton,” was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues.

Dr. Malattia, of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis involving the wrist.

The patient's clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale.

Bone marrow edema was evaluated using a 0-2 scale. Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001). The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician's global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints.

Assessment of 39 follow-up MRIs completed a median of 1.2 years after the index scan showed that of the 22 who had improved according to the ACR Pediatric 30 criteria, there was a significant decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Roughly 18% of children exhibit renal scarring 5-24 months after their first urinary tract infection, although only 2.5% have severe grade IV or grade V vesicoureteral reflux – long considered the main risk factor for scarring in this population.

The finding means that while “the identification of VUR may be important, VUR is neither necessary nor sufficient for the development of renal scarring,” wrote Dr. Nader Shaikh and colleagues (Pediatrics 2010;126:1084-91). Moreover, “a sole focus on VUR, as has been the dominant strategy for decades, is unlikely to result in large reductions in rates of renal scarring,” they added.

Dr. Shaikh and associates at the University of Pittsburgh looked at 1,533 articles found in Medline (between 1950 and January 2009) and Embase (between 1974 and January 2009) that included the terms “technetium Tc 99m dimercaptosuccinic acid (DMSA),” “pyelonephritis,” or “urinary tract infection.”

Studies were included only if all patients were 18 years of age or younger, and had DMSA scans – “the current gold standard for the detection of renal parenchymal involvement.” A total of 328 studies were retrieved for full-text review. Thirty-three of these, comprising 4,891 children, were assessed.

Overall, the authors found the pooled prevalence of any VUR to be 24%. However, only 2.5% of the children had severe VUR, rated as grade IV or V. Nevertheless, in 14 studies that included data from follow-up DMSA scans, 18% of children exhibited renal scarring 5-24 months after the UTI. That was despite a 0.6% incidence of pre-existing renal scarring, according to the four studies that had that data available.

The authors did find that children with VUR had a 2.6 times higher prevalence of renal scarring, compared with children without VUR (41% vs. 17%; P = .001), and that prevalence was 2.1 times higher among children with VUR grades III-V at 53%, versus 25% in children with grades I and II (P = .001), reported Dr. Shaikh and associates.

However, the results show that “VUR is not the only risk factor for renal scarring,” wrote the authors.

They also sought to characterize the link between VUR and acute pyelonephritis (APN). They found that VUR patients were 1.5 times more likely to exhibit findings consistent with APN on the acute DMSA scan, compared with children without VUR (67% vs. 49%, respectively; P = .004).

The authors conceded that “identification of VUR can be a practical method of identifying children who are at risk for renal scarring.” However, a top-down approach of scanning every UTI patient is likely not feasible, because scans are “expensive, invasive, and expose children to radiation.”

“Furthermore, it is unclear how to best manage the large numbers of children with a positive acute phase DMSA scan … most of whom (85%) will not scar,” they wrote. So, “additional research is warranted to help determine management strategies for children with UTIs.”

Dr. Shaikh and associates reported having no relevant financial disclosures.

Roughly 18% of children exhibit renal scarring 5-24 months after their first urinary tract infection, although only 2.5% have severe grade IV or grade V vesicoureteral reflux – long considered the main risk factor for scarring in this population.

The finding means that while “the identification of VUR may be important, VUR is neither necessary nor sufficient for the development of renal scarring,” wrote Dr. Nader Shaikh and colleagues (Pediatrics 2010;126:1084-91). Moreover, “a sole focus on VUR, as has been the dominant strategy for decades, is unlikely to result in large reductions in rates of renal scarring,” they added.

Dr. Shaikh and associates at the University of Pittsburgh looked at 1,533 articles found in Medline (between 1950 and January 2009) and Embase (between 1974 and January 2009) that included the terms “technetium Tc 99m dimercaptosuccinic acid (DMSA),” “pyelonephritis,” or “urinary tract infection.”

Studies were included only if all patients were 18 years of age or younger, and had DMSA scans – “the current gold standard for the detection of renal parenchymal involvement.” A total of 328 studies were retrieved for full-text review. Thirty-three of these, comprising 4,891 children, were assessed.

Overall, the authors found the pooled prevalence of any VUR to be 24%. However, only 2.5% of the children had severe VUR, rated as grade IV or V. Nevertheless, in 14 studies that included data from follow-up DMSA scans, 18% of children exhibited renal scarring 5-24 months after the UTI. That was despite a 0.6% incidence of pre-existing renal scarring, according to the four studies that had that data available.

The authors did find that children with VUR had a 2.6 times higher prevalence of renal scarring, compared with children without VUR (41% vs. 17%; P = .001), and that prevalence was 2.1 times higher among children with VUR grades III-V at 53%, versus 25% in children with grades I and II (P = .001), reported Dr. Shaikh and associates.

However, the results show that “VUR is not the only risk factor for renal scarring,” wrote the authors.

They also sought to characterize the link between VUR and acute pyelonephritis (APN). They found that VUR patients were 1.5 times more likely to exhibit findings consistent with APN on the acute DMSA scan, compared with children without VUR (67% vs. 49%, respectively; P = .004).

The authors conceded that “identification of VUR can be a practical method of identifying children who are at risk for renal scarring.” However, a top-down approach of scanning every UTI patient is likely not feasible, because scans are “expensive, invasive, and expose children to radiation.”

“Furthermore, it is unclear how to best manage the large numbers of children with a positive acute phase DMSA scan … most of whom (85%) will not scar,” they wrote. So, “additional research is warranted to help determine management strategies for children with UTIs.”

Dr. Shaikh and associates reported having no relevant financial disclosures.

Roughly 18% of children exhibit renal scarring 5-24 months after their first urinary tract infection, although only 2.5% have severe grade IV or grade V vesicoureteral reflux – long considered the main risk factor for scarring in this population.

The finding means that while “the identification of VUR may be important, VUR is neither necessary nor sufficient for the development of renal scarring,” wrote Dr. Nader Shaikh and colleagues (Pediatrics 2010;126:1084-91). Moreover, “a sole focus on VUR, as has been the dominant strategy for decades, is unlikely to result in large reductions in rates of renal scarring,” they added.

Dr. Shaikh and associates at the University of Pittsburgh looked at 1,533 articles found in Medline (between 1950 and January 2009) and Embase (between 1974 and January 2009) that included the terms “technetium Tc 99m dimercaptosuccinic acid (DMSA),” “pyelonephritis,” or “urinary tract infection.”

Studies were included only if all patients were 18 years of age or younger, and had DMSA scans – “the current gold standard for the detection of renal parenchymal involvement.” A total of 328 studies were retrieved for full-text review. Thirty-three of these, comprising 4,891 children, were assessed.

Overall, the authors found the pooled prevalence of any VUR to be 24%. However, only 2.5% of the children had severe VUR, rated as grade IV or V. Nevertheless, in 14 studies that included data from follow-up DMSA scans, 18% of children exhibited renal scarring 5-24 months after the UTI. That was despite a 0.6% incidence of pre-existing renal scarring, according to the four studies that had that data available.

The authors did find that children with VUR had a 2.6 times higher prevalence of renal scarring, compared with children without VUR (41% vs. 17%; P = .001), and that prevalence was 2.1 times higher among children with VUR grades III-V at 53%, versus 25% in children with grades I and II (P = .001), reported Dr. Shaikh and associates.

However, the results show that “VUR is not the only risk factor for renal scarring,” wrote the authors.

They also sought to characterize the link between VUR and acute pyelonephritis (APN). They found that VUR patients were 1.5 times more likely to exhibit findings consistent with APN on the acute DMSA scan, compared with children without VUR (67% vs. 49%, respectively; P = .004).

The authors conceded that “identification of VUR can be a practical method of identifying children who are at risk for renal scarring.” However, a top-down approach of scanning every UTI patient is likely not feasible, because scans are “expensive, invasive, and expose children to radiation.”

“Furthermore, it is unclear how to best manage the large numbers of children with a positive acute phase DMSA scan … most of whom (85%) will not scar,” they wrote. So, “additional research is warranted to help determine management strategies for children with UTIs.”

Dr. Shaikh and associates reported having no relevant financial disclosures.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.

A new magnetic resonance imaging scoring system is a reliable method for assessing joint damage in patients with juvenile idiopathic arthritis.

Moreover, the adult-targeted Rheumatoid Arthritis MRI Score (RAMRIS), previously considered unusable in pediatric image studies because of the "peculiarities of the growing skeleton," was also moderately well correlated with clinical indicators of disease, wrote Dr. Clara Malattia and her colleagues in the Annals of Rheumatic Diseases.

Dr. Malattia of the Istituto G Gaslini in Genoa, Italy, and her colleagues looked at 66 patients, of whom 51 were females, who had juvenile idiopathic arthritis (JIA) involving the wrist. Study participants were recruited consecutively from the researchers’ institution between June 2006 and June 2008.

The patient’s clinically more affected wrist was assessed with MRI, radiography, and clinical assessment (Ann Rheum Dis. 2010 [doi:10.1136/ard.2009.126862]).

Two readers, who were blinded to which patient’s MRIs they were evaluating, then applied the new, pediatric scoring system. Bone erosions were scored at 15 sites within the carpus according to a 0-4 scale, with 0 being equivalent to no erosion; 1 signifying between erosion of 1%-25% of the wrist; 2 signifying erosion of 26%-50%, 3 signifying between 51%-75% erosion, and 4 meaning 76%-100% erosion.

Bone marrow edema was evaluated using a 0-2 scale (with 0 signifying no edema; 1 signifying edema of less than 50% of the bone; and 2 meaning edema of 50% or more of the bone).

Finally, synovitis was assessed using the standard Rheumatoid Arthritis MRI Scoring System.

"As the inter-reader agreement was excellent, the independent scores of the two observers for each MRI were averaged, and this average was used for the analyses of the construct validity," wrote the researchers.

The existing, entire adult RAMRIS system also was completed for all patients.

At baseline, 55 out of the total 66 patients (83.3%) patients had erosions detected by MRI (only 23 of which were detected on radiography). Bone marrow edema was also seen in 55 of the 66 patients (83.3%), and synovitis was detected in 60 of the 66 patients (90.9%).

The authors then calculated the Spearman’s rank correlation between each pediatric MRI score and several clinical indicators. A correlation between 0.40-0.59 was considered moderate, correlations of 0.60-0.79 were considered high, and correlations 0.80 and greater were considered very high.

The pediatric MRI erosion score registered significant, moderate correlation (0.47) with the Juvenile Arthritis Damage Index Articular (JADI-A) score (P less than .0001), as well as a moderate (0.55) significant correlation with the Sharp/van der Heijde score for reading radiographs (P less than .0001).

The pediatric MRI bone edema score correlated highly (0.66) with the Sharp/van der Heijde score (P less than 0.0001), and registered moderate correlation (0.40) with the JADI-A (P = .001).

On the other hand, there was also high correlation (0.66) between the RAMRIS bone marrow edema score and the Sharp/van der Heijde score (P less than .0001), as well as between the RAMRIS bone erosion score and the Sharp/van der Heijde score (0.60, P less than .0001).

The synovitis score correlated moderately but significantly with the physician’s global assessment, the swollen joint count, and the Juvenile Arthritis Disease Activity Score for 71 joints (JADAS-71).

The authors then assessed the scale’s sensitivity to change by assessing 39 follow-up MRIs completed a median of 1.2 years after the index scan.

They found that among the 22 patients who had improved according to the American College of Rheumatology Pediatric 30 criteria, there was a significant but small decrease on the pediatric bone marrow edema score, a non-significant decrease in the RAMRIS bone marrow edema score, and a significant, small decrease on the synovitis score.

Meanwhile, the 17 patients who did not improve according to clinical assessment were scored as having a significant increase on the pediatric erosion scale, as well as on the RAMRIS erosion scores.

"MRI bone erosions progressed significantly at 1-year follow-up scans, but the responsiveness to change of the pediatric erosion score was poor," wrote the authors.

They postulated that this might be because the images were read without reference to the baseline scans.

Nevertheless, "a major limitation of the proposed scale is the lack of grading of erosive changes affecting less than 25% of the bone, which may hamper responsiveness to change over time," they added.

"The proposed pediatric-targeted MRI scoring system is a reliable and valid method for assessing disease activity and damage in JIA, and therefore could represent a useful framework for further development of MRI assessment of JIA," wrote the authors.

"Further work, especially in a longitudinal setting, is required," they added.

The authors stated that they had no competing interests in relation to this study.