Leah Lawrence

It may only be a matter of time before experts add salivary gland ultrasound score (SGUS) to the diagnostic criteria for SjÃ¶gren’s syndrome (SS), as studies continue to produce data showing that the diagnostic performance of classification criteria for the disorder is improved by the addition.

Flaws exist in both classification systems currently used to diagnose SS, the classification criteria from the American-European Consensus Group (AECG)  and the American College of Rheumatology (ACR). SGUS lends itself well to evaluating the production and composition of saliva from the salivary glands primarily involved in SS and, relatively inexpensive and noninvasive, is an attractive alternative to the labial gland biopsy recommended by current ACR criteria, especially for patients with only early signs of the disease.

, Takashi Makamura DDS PhD of Nagasaki University School of Dentistry and colleagues pointed out that the current ACR system lacks morphological markers for SS, and that the addition of ultrasound would allow physicians to grade the severity of gland damage and predict treatment outcomes.

 They felt that, although ultrasound did not improve the diagnostic accuracy of the ACR criteria, the imaging modality would be a useful alternative to any of the three ACR diagnostic items (positive serum anti-SSA and/or antiSSB antibodies, ocular staining score test, or lymphocytic infiltrations in lip biopsy specimens) without modified concordance with AECG criteria.

However, another study authored by ValÃ©rie Devauchelle-Pensec MD PhD  of Brest University Medical School Hospital in France and colleagues reached quite the opposite conclusion.

“In a prospective cohort of recently suspected SjÃ¶gren’s syndrome, adding the SGUS score to the ACR criteria increased sensitivity from 64.4% to 84.4% and only slightly decreased specificity, from 91.1% to 89.3%,” Devauchelle-Pensec told 

. “So, the diagnostic performance of the ACR classification criteria for SS is notably improved by adding the SGUS score.”

Devauchelle-Pensec also published research in 2013 demonstrating that SGUS improves the diagnostic sensitivity of the AECG criteria from 77.9% to 87.0%; however, there was no improvement in specificity.

Based on their research, Devauchelle-Pensec said she could envision that in the future, salivary gland biopsy might be used only when a patient suspected of SS has negative SGUS.

“If this approach were used, the inconveniences associated with salivary gland biopsy could be avoided in a substantial number of patients,” she said.

Inclusion of SGUS into diagnostic criteria for SS may be inevitable, but more work must be done to standardize and validate the method first.

 Many studies to date have included scores for a variety of items beyond the main feature related to diagnosis-parenchyma heterogeneity-such as gland size, parenchyma inflammation, precision of borders and more.

Once a scoring system is established, rheumatologists must conduct research to ensure reproducibility of the ultrasound procedures, which can sometimes be examiner-dependent.  

Ultrasonography as an additional item in the American College of Rheumatology classification of SjÃ¶gren’s syndrome. 

2014;53:1977-1983. doi:10.1093/rheumatology/keu238.

2. Cornec D, Jousse-Joulin S, Marhadour T, et al. 

Salivary gland ultrasonography improves the diagnostic performance of the 2012 American College of Rheumatology classification criteria for SjÃ¶gren’s syndrome.

 2014;53:1604-1407. doi:10.1093/rheumatology/keu037.

3. Cornec D, Jousse-Joulin S, Pers JO, et al. 

Contribution of salivary gland ultrasonography to the diagnosis of SjÃ¶gren’s syndrome. Toward new diagnostic criteria?

4. Cornec D, Jousse-Joulin S, Saraux A, Devauchelle-Pensec V. Sal

ivary gland ultrasound to diagnose SjÃ¶gren's syndrome: a claim to standardize the procedure.

Articles

Evidence Growing for Value of Salivary Ultrasound in Sjögren’s 

MRI assessment of suppression of structural damage in patients with rheumatoid arthritis receiving rituximab: results from the randomized, placebo-controlled, double-blind RA-SCORE study

 2014: doi:10.1136/annrheumdis-2014-206015.

MRI may finally be coming into its own for the evaluation of cartilage loss in rheumatoid arthritis (RA). 

The modality shows rituximab's success in significantly reducing erosion and cartilage loss in RA patients who don't do well on methotrextrate

the first to demonstrate MRI's ability to reveal cartilage loss

, and may give the modality an edge over x-ray in clinical trials for RA treatment response assessment, the authors explain.

MRI allows for direct evaluation of cartilage loss, 

whereas radiography evaluates cartilage loss indirectly by looking at joint space narrowing, they explain.

They randomized patients to two infusions with rituximab (500 mg or 1,000 mg) or placebo. The patient's affected hand and wrist underwent MRI evaluation at multiple time points.

The authors report that patients assigned to either the 1,000-mg or 500-mg dose have significantly better RAMRIS (Outcome Measures in Rheumatology Clinical Trials RA MRI Scoring) erosion scores versus placebo patients.

MRI proves itself as a valuable tool “for assessing inflammatory and structural damage in patients with established rheumatoid arthritis receiving rituximab,

Their conclusion jibes with recommendations from rheumatology societies that support the use of MRI for detecting joint inflammation and assessing treatment response.

MRI proves itself as a valuable tool for pinpointing inflammatory and structural damage in select rheumatoid arthritis patients.

MRI Successfully Gauges RA Treatment Response

Riecke BF, Christensen R, Torp-Pedersen S, 

An ultrasound score for knee osteoarthritis: a cross-sectional validation study.

2014 22:1675-1691. doi: 10.1016/j.joca.2014.06.020.

Observer or operator dependence limits the value of ultrasound for diagnosing osteoarthritis (OA), but a proposed standardized diagnostic scoring method could correct that.

An ultrasound scoring system proves reliable and reproducible, according to its Danish developers. The system ranks five areas in knee OA:

Medial compartment morphological changes,

Lateral compartment morphological changes,

Inflammation in the lateral compartment, and

These researchers from Copenhagen University's Parker Institute, who are engaged in long-term studies of the effects of weight loss on knee OA, compared their scoring system with x-ray and the Knee Injury and Osteoarthritis Outcome Score (KOOS) for ability to discern degrees of knee OA. For the five domains, the ultrasound scores showed "substantial" reproducibility, they say.

"The score detected all aspects of knee OA with relevant precision” superior to radiography, the authors say, while noting that ultrasound cannot identify early cartilage damage.

A proposed five-point system for diagnostic scoring of knee osteoarthritis by ultrasound could resolve problems of operator inconsistency. 

New Scoring System Proposed for Knee Ultrasound

What was the mummy's real curse? Researchers using computed tomography (CT) for late-day diagnosis report that, in the case of several mummified human remains in Egypt, it was not (as previously thought) ankylosing spondylitis – disputing, in the process, the claimed antiquity of that condition.

“Ankylosing spondylitis was long believed to be a disease that occurred in antiquity, mostly based on its diagnosis in the Ancient Egyptian subjects, specifically diagnosis using x-rays of the mummies dated to 18th-19th dynasties,” says author Sahar N. Saleem MD, a radiology professor at the Kasr Al Ainy Faculty of Medicine in Cairo, whose team used CT to dispute earlier claims that several ancient Egyptian mummies had ankylosing spondylitis.

 In 13 royal mummies, they discovered diffuse idiopathic skeletal hypertosis (DISH), a degenerative disorder.



“This study proved that 13 of the studied mummies dated to 18th-early 20th dynasties did not have ankylosing spondylitis disease,” Saleem told 

.

The majority of ancient remains are discovered as skeletons that are amenable to physical exam, so imaging plays a lesser role. But “mummies are a unique form of remains with preserved soft tissue covering the skeleton,” Saleem points out, making them suitable for imaging exams.

Over the past decade, imaging-based studies have revealed new information about musculoskeletal diseases in other ancient remains.

With x-ray, mammography, and whole-body CT, investigators uncovered rheumatoid arthritis (RA) in a 16th century mummy known as the “Braids Lady” of Arezzo.



They report several features of RA, including large erosions of the metacarpophalangeal joints, volar metacarpophalangeal subluxation of the third and fourth fingers, and lateral deviation of all fingers.

Other researchers identified chondrocalcinosis on x-rays done in the mummified remains of the 190-year-old “Soap Lady.”



In 2012, CT studies of mummies from the Capuchin Catacombs of Palermo, Sicily revealed that 37.5% of the adult male mummies had herniation pits that match currently accepted imaging characteristics of early osteoarathritis (OA), validating the antiquity of a common modern "curse".



Benign herniation pits of the femoral neck are seen on CT as “round to oval subcortical/subchondral lesions at the anterior femoral neck, which is clearly demarcated by an encircling sclerotic margin,” the investigators explain.
They suggest that other researchers keep an eye out for this potential precursor to OA.

“OA of the hip joint is a very common observation in paleopathology and the discussed clinical relevance of [herniation pits] should also be addressed in paleoradiology,” they explain.


 


1. Feldtkeller E, Lemmel EM, Russell AS.

 Ankylosing spondylitis in the pharaohs on ancient Egypt

 Ankylosing spondylitis or diffuse idiopathic skeletal hypertosis (DISH) in Royal Egyptian mummies of 18th-20th Dynasties? CT and archaeology studies

 (2014) doi:10.1002/art.38864.
3. Ciranni R, Garbini F, Meri E, 

The “Braids Lady” of Arezzo: a case of rheumatoid arthritis in a 16th century mummy. 

Chondrocalcinosis in a 180-year-old cadaver. 

 (2005) 11:172-174.
5. Panzer S, Piombino-Mascali D, Zink AR. 

Herniation pits in human mummies: A CT investigation in the Capuchin Catacombs of Palermo, Sicily.

 (2012) doi: 10.1371/journal.pone.0036537

"Paleoradiology" has now disputed claims that ankylosing spondylitis plagued some royal Egyptians in antiquity. This is the latest of several revelations about the provenance of some rheumatic conditions, based on imaging of ancient remains.

Author | Leah Lawrence

Articles

Evidence Growing for Value of Salivary Ultrasound in Sjögren’s

MRI Successfully Gauges RA Treatment Response

New Scoring System Proposed for Knee Ultrasound

Imaging Beams Into Rheumatic Diseases of the Ancient Past