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      Polymyalgia rheumatica in der 18-Fluordesoxyglukose-Positronenemissionstomographie/Computertomographie : Verbesserung diagnostischer Genauigkeit und Abgrenzung von rheumatoider Arthritis Translated title: Polymyalgia rheumatica in 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography : Improvement in diagnostic accuracy and differentiation from rheumatoid arthritis

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          Abstract

          Hintergrund

          Die Diagnose von Patienten mit Polymyalgia rheumatica (PMR) beruht bislang auf der klinischen Symptomatik und laborchemischen Entzündungsparametern. Aktuell wird der Nutzen verschiedener bildgebender Verfahren evaluiert, hierunter die Sonographie, MRT und PET.

          Ziel der Arbeit/Fragestellung

          Ziel war die Evaluation der diagnostischen Wertigkeit der 18-Fluordesoxyglukose-Positronenemissionstomographie/Computertomographie (18F-FDG-PET/CT) bei PMR, um die Sensitivität und Spezifität in der diagnostischen Aufarbeitung zu verbessern, sowie die rheumatoide Arthritis (RA) differentialdiagnostisch verbessert abzugrenzen.

          Material und Methoden

          Es wurden 18F-FDG-PET/CT-Untersuchungen von 284 rheumatologischen Patienten – hierunter 97 Patienten mit PMR – aus einem 44-monatigen Zeitraum retrospektiv evaluiert. Weiter wurden 13 entzündlich veränderte Regionen via dreidimensionaler Region-of-interest(ROI)-Messung mit Bestimmung des maximalen Standardized-Uptake-Value (SUVmax) analysiert, gefolgt von statistischen Analysen.

          Ergebnisse und Diskussion

          Patienten mit PMR zeigten im Vergleich mit einer rheumatologisch behandelten Kontrollgruppe signifikant erhöhte Anreicherungen in allen gemessenen Regionen ( p < 0,001). Die Methode mit der stärksten diagnostischen Aussagekraft stellte die Kombination aus vier SUVmax-Messwerten – beider anterolateraler Hüftkapseln und beider Tubera ischiadica – dar, mit einer Sensitivität von 91,3 % und einer Spezifität von 97,6 % bei einem Cut-off von 11,0 SUV für die Erstdiagnose von PMR-Patienten, die noch keine immunsuppressive Therapie erhalten hatten. Patienten mit RA konnten bei Erstdiagnose an ebenjenen anatomischen Regionen signifikant von Patienten mit PMR unterschieden werden ( p < 0,001).

          Translated abstract

          Background

          The diagnosis of patients with polymyalgia rheumatica (PMR) has relied upon the clinical examination of symptoms and laboratory parameters of inflammation until now. Currently, the use of different imaging modalities is being explored, including ultrasound, MRI and PET.

          Objectives

          The aim was to evaluate the diagnostic value of 18-fluorodeoxyglucose-positron-emission-tomography/computed tomography (18F-FDG-PET/CT) for PMR, in order to improve the sensitivity and specificity of diagnosing PMR and to improve the differential diagnosis of rheumatoid arthritis (RA).

          Materials and Methods

          Examinations using 18F-FDG-PET/CT of 284 rheumatological patients, including 97 patients with PMR, were retrospectively evaluated over a 44-month period. Furthermore, 13 regions changed by inflammation were analysed via a three-dimensional region of interest (ROI) measurement with determination of maximum standardized uptake values (SUVmax), followed by statistical analyses.

          Results and Discussion

          Patients with PMR presented significantly elevated uptake in all regions examined ( p < 0.001), compared with a control group treated for rheumatological diseases. The method with the highest diagnostic relevance was represented by the combination of four SUVmax values of both anterolateral hip capsules and both ischial tuberosities, reaching a sensitivity of 91.3% and a specificity of 97.6% with a cut-off of 11.0 SUV at the initial diagnosis of PMR patients who had not yet received any immunosuppressive therapy. Patients with RA could be significantly distinguished from those with PMR at initial diagnosis in the same anatomical regions ( p < 0.001).

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          Most cited references30

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          Polymyalgia rheumatica and giant-cell arteritis.

          Polymyalgia rheumatica and giant-cell arteritis are closely related disorders that affect people of middle age and older. They frequently occur together. Both are syndromes of unknown cause, but genetic and environmental factors might have a role in their pathogenesis. The symptoms of polymyalgia rheumatica seem to be related to synovitis of proximal joints and extra-articular synovial structures. Giant-cell arteritis primarily affects the aorta and its extracranial branches. The clinical findings in giant-cell arteritis are broad, but commonly include visual loss, headache, scalp tenderness, jaw claudication, cerebrovascular accidents, aortic arch syndrome, thoracic aorta aneurysm, and dissection. Glucocorticosteroids are the cornerstone of treatment of both polymyalgia rheumatica and giant-cell arteritis. Some patients have a chronic course and might need glucocorticosteroids for several years. Adverse events of glucocorticosteroids affect more than 50% of patients. Trials of steroid-sparing drugs have yielded conflicting results. A greater understanding of the molecular mechanisms involved in the pathogenesis should provide new targets for therapy.
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            2012 provisional classification criteria for polymyalgia rheumatica: a European League Against Rheumatism/American College of Rheumatology collaborative initiative

            The objective of this study was to develop EULAR/ACR classification criteria for polymyalgia rheumatica (PMR). Candidate criteria were evaluated in a 6-month prospective cohort study of 125 patients with new onset PMR and 169 non-PMR comparison subjects with conditions mimicking PMR. A scoring algorithm was developed based on morning stiffness >45 minutes (2 points), hip pain/limited range of motion (1 point), absence of RF and/or ACPA (2 points), and absence of peripheral joint pain (1 point). A score ≥4 had 68% sensitivity and 78% specificity for discriminating all comparison subjects from PMR. The specificity was higher (88%) for discriminating shoulder conditions from PMR and lower (65%) for discriminating RA from PMR. Adding ultrasound, a score ≥5 had increased sensitivity to 66% and specificity to 81%. According to these provisional classification criteria, patients ≥50 years old presenting with bilateral shoulder pain, not better explained by an alternative pathology, can be classified as having PMR in the presence of morning stiffness>45 minutes, elevated CRP and/or ESR and new hip pain. These criteria are not meant for diagnostic purposes.
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              An evaluation of criteria for polymyalgia rheumatica.

              There has been little basis on which to standardise a diagnosis of polymyalgia rheumatica (PMR), and so 11 rheumatology units in the south and west of Great Britain have collaborated in a study to evaluate possible criteria. Symptoms and laboratory findings claimed to be of diagnostic value in PMR were included in an analysis of the features of 236 patients considered to have unequivocal PMR and 70 patients thought to have possible PMR. The results were compared with similar information from 253 patients with conditions that mimic PMR and from 201 consecutive new presentations to outpatients. The 7 most valuable criteria for differentiation were bilateral shoulder pain or stiffness, onset of illness of less than 2 weeks' duration, initial ESR greater than 40 mm/h, duration of morning stiffness exceeding 1 hour, age 65 years or more, depression and/or weight loss, and bilateral tenderness in the upper arms. We suggest that a patient might be regarded as having probable PMR if any 3 or more of these criteria are fulfilled, or if at least 1 criterion coexists with a clinical or pathological abnormality of the temporal artery. A standardised therapeutic test with prednisolone has value in making the diagnosis of PMR more certain.
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                Author and article information

                Contributors
                felix.witte@ukmuenster.de
                Journal
                Z Rheumatol
                Z Rheumatol
                Zeitschrift Fur Rheumatologie
                Springer Medizin (Heidelberg )
                0340-1855
                1435-1250
                1 December 2021
                1 December 2021
                2023
                : 82
                : 2
                : 91-101
                Affiliations
                [1 ]GRID grid.512807.9, ISNI 0000 0000 9874 2651, Johannes Wesling Klinikum Minden, , Universitätsklinikum der Ruhr-Universität Bochum, ; Minden, Deutschland
                [2 ]GRID grid.477456.3, ISNI 0000 0004 0557 3596, Universitätsklinik für Geriatrie, Mühlenkreiskliniken, , Johannes Wesling Klinikum Minden, ; Minden, Deutschland
                [3 ]GRID grid.477456.3, ISNI 0000 0004 0557 3596, Universitätsinstitut für Radiologie, Neuroradiologie und Nuklearmedizin, Mühlenkreiskliniken, , Johannes Wesling Klinikum Minden, ; Minden, Deutschland
                Author notes
                [Redaktion]

                Ulf Müller-Ladner, Bad Nauheim

                Uwe Lange, Bad Nauheim

                Author information
                http://orcid.org/0000-0003-4305-0713
                Article
                1133
                10.1007/s00393-021-01133-w
                9981502
                34851442
                b8b3da33-d1ac-49a8-a427-94ac37cb5048
                © The Author(s) 2021

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                History
                : 9 October 2021
                Funding
                Funded by: Mühlenkreiskliniken (8957)
                Categories
                Originalien
                Custom metadata
                © The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature 2023

                Rheumatology
                entzündung,glukokortikoide,diagnose,rheumatoide arthritis,riesenzellarteriitis,inflammation,glucocorticoids,diagnosis,rheumatoid arthritis,giant cell arteritis

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