ObjectivesEarly identification of interstitial lung disease (ILD) among patients with rheumatoid arthritis (RA) is a challenge for clinicians. The aim of this study was to evaluate screening algorithms for ILD by comparing the proportion of patients assigned a high-risk profile by three recently proposed models.MethodWe used the four-factor risk score, categorizing patients into high and low risk; the ILD screening criteria, categorizing patients into high, intermediate, and low risk; and the risk score for detection of subclinical RA-ILD, with four different risk categories, on patients with RA followed for 5 years after the RA diagnosis with pulmonary function tests, dyspnoea score, and pulmonary imaging.ResultsThe four-factor risk score identified 22% of the cohort (25/115) as eligible for further ILD investigations, while the ILD screening criteria identified 37% as high risk (43/115) and 34% as intermediate risk (39/115). The risk score for detection of subclinical RA-ILD identified 44% of the cohort as being at increased risk, with 7% in the highest risk group. The agreement between high-risk groups in the two clinical ILD screening models was moderate (kappa 0.43). Three patients in the cohort had clinical or subclinical ILD, and they were identified as high risk in the two clinical models.ConclusionThe three algorithms identified approximately one-third of the cohort as being at increased risk of ILD. Further development and validation of these algorithms are needed to reduce false positives and balance the potential benefit of earlier ILD diagnosis and healthcare resources used for respiratory assessment.

Introduction: The combined use of 18 F-FDG-PET and computed tomography (CT) scans is an integrated part of diagnosing and staging patients with suspected malignancy or other pathologies. Magnetic resonance imaging (MRI) has proven its use as a non-ionizing imaging alternative for identifying potential malignancy in specific organs. Objective: To investigate the clinical value of whole-body MRI in detection of suspicious lesions, we compared 1.5T MRI findings to those obtained from a whole-body 18 F-FDG-PET/CT scan, the latter serving as the reference standard. Finally, the findings were compared with histology if available. Materials and methods: Twenty-five patients (9 women and 16 men, mean age ± SD: 64.5 ± 11.8 years; range: 34±85 years) with suspected malignancy or other pathologies were enrolled. All patients were scanned using both modalities. Imaging included the head, torso and extremities. Images were scored blinded by experienced readers: two radiologists and two nuclear medicine physicians. Statistical tests included weighted kappa for measuring interobserver reliability and Wilcoxon signed-rank test for detection differences between paired observations. Results and discussion: Interobserver reliability between each pair of specialists was fair-to-strong (Weighted kappa). Statistically significant differences between the findings of the two modalities were found in the colon (p=0.016), soft tissues of the extremities (p=0.002) and skeleton of the extremities (p=0.008). Twelve patients had histology available. WB-MRI and whole-body 18 F-FDG-PET/CT found 10 of these cases (sensitivity: 83.3%, 95% CI: 55.2%-95.3%). Conclusion: The diagnostic value of WB-MRI equaled whole-body 18 F-FDG-PET/CT. The MRI approach could therefore be considered in patients unsuitable for 18 F-FDG-imaging e.g. younger patients, during pregnancy or dysregulated diabetics.

We aimed to identify factors influencing the sensitivity of perfusion imaging after an initial positive coronary computed tomography angiography (CCTA) using invasive coronary angiography (ICA) with conditional fractional flow reserve (FFR) as reference. Secondly we aimed to identify factors associated with revascularisation and to evaluate treatment outcome after ICA. We analysed 292 consecutive patients with suspected significant coronary artery disease (CAD) at CCTA, who underwent perfusion imaging with either cardiac magnetic resonance (CMR) or myocardial perfusion scintigraphy (MPS) followed by ICA with conditional FFR. Stratified analysis and uni- and multiple logistic regression analyses were performed to identify predictors of diagnostic agreement between perfusion scans and ICA and predictors of revascularisation. Myocardial ischemia evaluated with perfusion scans was present in 65/292 (22%) while 117/292 (40%) had obstructive CAD evaluated by ICA. Revascularisation rate was 90/292 (31%). The overall sensitivity for perfusion scans was 39% (30–48), specificity 89% (83–93), PPV 69% (57–80) and NPV 68% (62–74). Stratified analysis showed higher sensitivities in patients with multi-vessel disease at CCTA 49% (37–60) and typical chest pain 50% (37–60). Predictors of revascularisation were multi-vessel disease by CCTA (OR 3.51 [1.91–6.48]) and a positive perfusion scan (OR 4.69 [2.49–8.83]). The sensitivity for perfusion scans after CCTA was highest in patients with typical angina and multiple lesions at CCTA and predicted diagnostic agreement between perfusion scans and ICA. Abnormal perfusion and multi vessel disease at CCTA predicted revascularisation.

We report a rare case of miliary tuberculosis (TB) in an adopted woman that developed following delayed diagnosis of presumed urogenital TB.The patient had a two year history of urological symptoms, diagnosed as interstitial cystitis and treated with cyclosporine.At admission, she presented with symptoms of pyelonephritis.Neck stiffness led to lumbar puncture that showed pleocytosis with lymphocytic predominance, high protein and low glucose levels, suggestive of TB meningitis.Computed tomography and magnetic resonance imaging scans showed nodular lung changes, lumbar spine destructive lesions, a unilateral kidney abscess and a parietal lobe tuberculoma.Urine and cerebrospinal fluids were positive for TB by polymerase chain reaction (PCR) and culture.The patient developed complications in the form of hydrocephalus.She was treated with a ventriculoperitoneal shunt and four drug anti-tuberculosis therapy.She was discharged to neurorehabilitation on continued anti-tuberculosis treatment, developing longer term sequelae in the form of severe cognitive disabilities.This case emphasizes the importance of continuing to include TB in the differential diagnosis of a variety of diseases, particularly in patients at possible increased risk of infection, and highlights the potentially serious consequences of delayed or missed TB diagnosis.

Aims Perfusion scans after coronary computed tomography angiography (CCTA) in patients with suspected coronary artery disease (CAD) may reduce unnecessary invasive coronary angiographies (ICAs). However, the diagnostic accuracy of perfusion scans after primary CCTA is unknown. The aim of this study was to determine the diagnostic accuracy of cardiac magnetic resonance (CMR) and myocardial perfusion scintigraphy (MPS) against ICA with fractional flow reserve (FFR) in patients suspected of CAD by CCTA. Methods and results Included were consecutive patients (1675) referred to CCTA with symptoms of CAD and low/intermediate risk profile. Patients with suspected CAD based on CCTA were randomized 1:1 to CMR or MPS followed by ICA with FFR. Obstructive CAD was defined as FFR ≤ 0.80 or > 90% diameter stenosis by visual assessment. After initial CCTA, 392 patients (23%) were randomized; 197 to CMR and 195 to MPS. Perfusion scans and ICA were completed in 292 patients (CMR 148, MPS 144). Based on the ICA, 117/292 (40%) patients were classified with CAD. Sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) for CMR were 41%, 95% CI [28-54], 84% [75-91], 62% [45-78], and 68% [58-76], respectively. For the MPS group 36% [24-50], 94% [87-98], 81% [61-93], and 68% [59-76], respectively. Conclusion Patients with low/intermediate CAD risk and a positive CCTA scan represent a challenge to perfusion techniques indicated by the low sensitivity of both CMR and MPS with FFR as a reference. The mechanisms underlying this discrepancy need further investigation.

Two unusual cases of third degree skin burns are reported using MRI approved electrocardiographic leads. This is very uncommon as it is most often the electrodes which are the source of heat related issues. Both patients were sedated due to pain related issues of their lower spine. The burns were caused by a combination of using a 3 Tesla MRI scanner and the inability to cry out during scanning. We would like to bring forward a message that even when using MRI conditional equipment, clinical staff must be extremely careful in order to secure safe image acquisition using MRI.