An online clinical decision tool to screen for vertebral fragility fractures (Vfrac) in older women presenting with back pain in general practice: protocol for a feasibility study in preparation for a future cluster randomised controlled trial.

This feasibility study for a future definitive randomized trial assesses the use and acceptability of a new clinical decision tool to identify risk of a vertebral fracture and those who should be referred for spinal radiography in women aged 65 or over presenting to primary care with back pain. PURPOSE: Approximately 12% of older adults have vertebral fragility fractures, but currently fewer than one-third are diagnosed, potentially limiting access to bone protection treatment. Vfrac is a vertebral fracture screening tool which classifies individuals into high or low risk of having a vertebral fracture, allowing targeting of spinal radiographs to high-risk individuals. The objective of this study was to investigate the feasibility of conducting a cluster randomized controlled trial to evaluate the use of an online version of Vfrac in primary care. METHODS: The study will run in six general practices, with three given the Vfrac tool for use on older women (> 65 years) consulting with back pain and three using standard clinical processes for managing such back pain. Anonymised data covering a 12-month period will be collected from all sites on consultations by older women with back pain. Focus groups will be undertaken with healthcare professionals and patients on whom the tool was used to understand the acceptability of Vfrac and identify factors that impact its use. These patients will be sent a paper version of the Vfrac questionnaire to self-complete at home. Outputs of the self-completion Vfrac (high versus low risk) will be compared with the face-to-face Vfrac (high versus low risk), and agreement assessed using Cohen's kappa. RESULTS: This study will evaluate the use and acceptability of Vfrac within primary care and determine if data on resource use can be collected accurately and comprehensively. CONCLUSIONS: This article describes the protocol of the Vfrac feasibility study. TRIAL REGISTRATION: ISRCTN18000119 (registered 01/03/2022) and ISRCTN12150779 (registered 10/01/2022).

Imaging of Metabolic Bone Diseases: The Spine View, Part I.

Metabolic bone diseases comprise a wide spectrum. Of them, osteoporosis is the most frequent and the most commonly found in the spine, with a high impact on health care systems and on morbidity due to vertebral fractures (VFs).This article discusses state-of-the-art techniques on the imaging of metabolic bone diseases in the spine, from the well-established methods to the latest improvements, recent developments, and future perspectives.We review the classical features of involvement of metabolic conditions involving the spine. Then we analyze the different imaging techniques for the diagnosis, characterization, and monitoring of metabolic bone disease: dual-energy X-ray absorptiometry (DXA) and DXA-based fracture risk assessment applications or indexes, such as the geometric parameters, Bone Strain Index, and Trabecular Bone Score; quantitative computed tomography; and magnetic resonance and ultrasonography-based techniques, such as radiofrequency echographic multi spectrometry. We also describe the current possibilities of imaging to guide the treatment of VFs secondary to metabolic bone disease.

Imaging of Metabolic Bone Diseases: The Spine View, Part II.

Metabolic bone diseases comprise a wide spectrum. Osteoporosis, the most frequent, characteristically involves the spine, with a high impact on health care systems and on the morbidity of patients due to the occurrence of vertebral fractures (VFs).Part II of this review completes an overview of state-of-the-art techniques on the imaging of metabolic bone diseases of the spine, focusing on specific populations and future perspectives. We address the relevance of diagnosis and current status on VF assessment and quantification. We also analyze the diagnostic techniques in the pediatric population and then review the assessment of body composition around the spine and its potential application. We conclude with a discussion of the future of osteoporosis screening, through opportunistic diagnosis and the application of artificial intelligence.

Understanding current UK practice for the incidental identification of vertebral fragility fractures from CT scans: an expert elicitation study.

BACKGROUND: There is an emerging interest in using automated approaches to enable the incidental identification of vertebral fragility fractures (VFFs) on existing medical images visualising the spine. AIM: To quantify values, and the degree of uncertainty associated with them, for the incidental identification of VFFs from computed tomography (CT) scans in current practice. METHODS: An expert elicitation exercise was conducted to generate point estimates and measures of uncertainty for four values representing the probability of: VFF being correctly reported by the radiologist; the absence of VFF being correctly assessed by the radiologist; being referred for management when a VFF is identified; having a dual-energy X-ray absorptiometry (DXA) scan after general practitioner (GP) referral. Data from a sample of seven experts in the diagnosis and management of people with VFFs were pooled using mathematical aggregation. RESULTS: The estimated mean values for each probability parameter were: VFF being correctly reported by the radiologist = 0.25 (standard deviation (SD): 0.21); absence of VFF being correctly assessed by the radiologist = 0.89 (0.10); being referred for management when a VFF is identified by the radiologist = 0.15 (0.12); having a DXA scan after GP referral = 0.66 (0.28). DISCUSSION: These estimates could be used to facilitate the subsequent early economic evaluation of potential new approaches to improve the health outcomes of people with VFFs. CONCLUSION: In the absence of epidemiological studies, this study produced point estimates and measures of uncertainty for key parameters needed to describe current pathways for the incidental diagnosis of VFFs.

Digital health interventions for osteoporosis and post-fragility fracture care.

The growing burden from osteoporosis and fragility fractures highlights a need to improve osteoporosis management across healthcare systems. Sub-optimal management of osteoporosis is an area suitable for digital health interventions. While fracture liaison services (FLSs) are proven to greatly improve care for people with osteoporosis, such services might benefit from technologies that enhance automation. The term 'Digital Health' covers a variety of different tools including clinical decision support systems, electronic medical record tools, patient decision aids, patient apps, education tools, and novel artificial intelligence (AI) algorithms. Within the scope of this review are AI solutions that use algorithms within health system registries to target interventions. Clinician-targeted, patient-targeted, or system-targeted digital health interventions could be used to improve management and prevent fragility fractures. This review was commissioned by The Royal Osteoporosis Society and Bone Research Academy during the production of the 2020 Research Roadmap (https://theros.org.uk), with the intention of identifying gaps where targeted research funding could lead to improved patient health. We explore potential uses of digital technology in the general management of osteoporosis. Evidence suggests that digital technologies can support multidisciplinary teams to provide the best possible patient care based on current evidence and to support patients in self-management. However, robust randomised controlled studies are still needed to assess the effectiveness and cost-effectiveness of these technologies.

Opportunistic diagnosis of osteoporosis, fragile bone strength and vertebral fractures from routine CT scans; a review of approved technology systems and pathways to implementation.

Osteoporosis causes bones to become weak, porous and fracture more easily. While a vertebral fracture is the archetypal fracture of osteoporosis, it is also the most difficult to diagnose clinically. Patients often suffer further spine or other fractures, deformity, height loss and pain before diagnosis. There were an estimated 520,000 fragility fractures in the United Kingdom (UK) in 2017 (costing £4.5 billion), a figure set to increase 30% by 2030. One way to improve both vertebral fracture identification and the diagnosis of osteoporosis is to assess a patient's spine or hips during routine computed tomography (CT) scans. Patients attend routine CT for diagnosis and monitoring of various medical conditions, but the skeleton can be overlooked as radiologists concentrate on the primary reason for scanning. More than half a million CT scans done each year in the National Health Service (NHS) could potentially be screened for osteoporosis (increasing 5% annually). If CT-based screening became embedded in practice, then the technique could have a positive clinical impact in the identification of fragility fracture and/or low bone density. Several companies have developed software methods to diagnose osteoporosis/fragile bone strength and/or identify vertebral fractures in CT datasets, using various methods that include image processing, computational modelling, artificial intelligence and biomechanical engineering concepts. Technology to evaluate Hounsfield units is used to calculate bone density, but not necessarily bone strength. In this rapid evidence review, we summarise the current literature underpinning approved technologies for opportunistic screening of routine CT images to identify fractures, bone density or strength information. We highlight how other new software technologies have become embedded in NHS clinical practice (having overcome barriers to implementation) and highlight how the novel osteoporosis technologies could follow suit. We define the key unanswered questions where further research is needed to enable the adoption of these technologies for maximal patient benefit.

Increased prevalence of fractures in inadequately transfused and chelated Indian children and young adults with beta thalassemia major.

INTRODUCTION: In patients with beta thalassemia major, inadequate transfusion and chelation may compromise bone health and increase risk of fractures. The objective of this study was to describe the prevalence of fractures in Indian inadequately transfused and chelated children, adolescents and young adults with beta thalassemia major. METHODS: We studied 179 patients with beta thalassemia (3.6-28.3 years; 105 boys). Medical, transfusion, chelation and fracture history were recorded. Vertebral fracture assessment (VFA) was performed using lateral spine images acquired using the GE Lunar iDXA (Wisconsin, MD). Fractures were classified according to an adapted semi-quantitative method. RESULTS: History of non-traumatic long bone fractures was observed in 21% patients (n = 37); there were significantly greater (p < 0.05) number of males (n = 30) than females (n = 15). The 21% fracture prevalence in the present study is higher than the reported fractures of 9% in healthy Indian children and adolescents. The prevalence of vertebral fractures was 4.5% (n = 8) in the study group. Of those with fractures, four patients had both long bone and vertebral fractures, and (any, long bone or vertebral fractures) sixteen patients had more than 1 fracture; eleven patients had 2 fractures, four patients had 3 fractures and one patient had 5 fractures. Thus, in 179 patients, there were a total of 68 single fractures which translates to 307 fractures per 10,000 patient years. CONCLUSION: This study found increased prevalence of non-traumatic long bone and vertebral fractures in children and adolescents with thalassemia major.

The rare sprengel deformity: our experience with three cases.

Sprengel shoulder is a rare congenital deformity of one or both scapulae that is usually detected at birth. It occurs due to failure of the scapula to descend during intrauterine development and its cause is still unknown. Although the deformity appears randomly most of the time, familial cases have been reported. Sprengel shoulder is often associated with Klippel-Feil syndrome and other congenital skeletal deformities. Anteroposterior X-ray imaging can accurately diagnose Sprengel deformity. However, computed tomography and magnetic resonance scans with three-dimensional reconstruction are nowadays used in everyday practice in order to diagnose concomitant abnormalities, study in detail the anatomy of the affected shoulder(s), and plan appropriate management. We present here our imaging experience from three pediatric cases with Sprengel shoulder and take the opportunity to discuss this rare entity, which is, nevertheless, the commonest congenital defect of the scapula.

Eleven patients with testicular leydig cell tumors: clinical, imaging, and pathologic correlation.

We present the sonographic and magnetic resonance imaging findings of Leydig cell tumors in a series of patients, along with a brief review of the literature. We evaluated the sonographic features of 11 cases of Leydig cell tumors, including echogenicity, size, margins, and patterns of vascularity. The magnetic resonance imaging characteristics of 9 patients were also assessed, with special attention to the appearance of the tumors on T2-weighted imaging and postcontrast T1-weighted imaging. Seven tumors were hypoechoic, and 4 were almost isoechoic. Ten patients showed various patterns of hypervascularity in the tumors, combined in some cases with feeding vessels. One case presented with a single feeding vessel. The tumors showed homogeneous or heterogeneous low signal intensity on T2-weighted imaging and marked enhancement on postcontrast T1-weighted imaging. The small size of these tumors, the various patterns of vascularity on color and power Doppler sonography, and the marked enhancement on postcontrast T1-weighted imaging are considered valuable but generally nonspecific for identification of these tumors.

Adult type granulosa cell tumor of the testis: Radiological evaluation and review of the literature.

A testicular granulosa cell tumor of the adult type is very rare. Isolated case reports and small series have been published in the English literature. Here, we analyze an incidentally discovered testicular granulosa cell tumor in a 29-year-old man to discuss the radiological evaluation of this entity and review the literature.

Polymorphous low grade adenocarcinoma of the parotid gland. Cytological, histological and immunohistochemical features and review of the literature.

AIM: Polymorphous low grade adenocarcinoma of the salivary glands (PLGA) is a low grade neoplasm that predominantly occurs in the minor salivary glands. In this site is amenable to biopsy and histologic diagnosis. However, experience with cytological findings in these tumors is limited. We describe the cytology of this entity. EXPERIMENTAL DESIGN: Touch imprint cytology of a primary parotid PLGA is specified and correlated with histology. RESULTS: Smears were hypercellular showing branching papillae, sheets and clusters of uniform cells with bland nuclei, dispersed chromatin and no nucleoli. The cells had a scant to moderate amount of eosinophilic cytoplasm. They formed tubular structures containing hyaline globules. CONCLUSIONS: The cytologic differential diagnosis of PLGA includes adenoid cystic carcinoma, pleomorphic adenoma, and monomorphic adenoma. PLGA should be considered in the differential diagnosis of head and neck tumors, where the cytology suggests on of the above mentioned tumors, even when the clinical findings (involvement of a major salivary gland, lymph node metastasis) is not typical of PLGA.

Extramedullary hemopoiesis in a thyroid nodule with extensive bone metaplasia and mature bone formation.

Thyroid nodules may undergo a wide range of degenerative change such as infarction, hemorrhage, or fibrosis, which may be localized or extensive and associated with calcification or even ossification. However, the detection of true bone formation in a thyroid nodule is a very rare occurrence. Extramedullary hemopoiesis (EMH) has been described in almost every organ of the body, mainly in tissues active in hemopoiesis in embryonic life. It is extremely rare for EMH to occur in the thyroid gland especially in patients without known chronic anemia. We describe a case of a cold thyroid nodule with histologically proven extensive bone metaplasia and formation of mature bone with foci of hemopoietic tissue in a young woman without chronic anemia, which, to the best of our knowledge, is the first to be reported in the English language literature.