Prevalence of vertebral fractures among patients with chronic obstructive pulmonary disease in Canada.

PURPOSE: Patients with chronic obstructive pulmonary disease (COPD) may be at higher risk for osteoporosis. The primary objective of this case-control study was to determine the prevalence of vertebral fractures among patients with COPD admitted to acute care compared with a gender- and age-matched control group. SUBJECTS AND METHODS: Subjects were identified by chart reviews from an acute care hospital in Hamilton, Ontario, in 1999, including patients who were over 50 years old. In total, 127 patients with ICD-9 codes specifying COPD were randomly selected and compared with 127 gender- and age-matched controls. Chest radiographs were interpreted by two radiologists who defined and graded vertebral fractures using Genant's method. Medications taken, or prescribed at discharge, were recorded from charts. RESULTS: The overall prevalence of at least one vertebral fracture was found to be 34/127 (26.8%) in the COPD patients compared with 30/127 (23.6%) in the controls ( p=0.556). A significantly greater proportion of COPD patients had at least one severe vertebral fracture (OR=3.75, 95% CI 1.24 to 11.3). Review of hospital chest X-ray reports indicated that only 12 of 64 (18.8%) patients with vertebral fractures identified by the study radiologists actually had a vertebral fracture noted in the report. The proportion of COPD patients with vertebral fractures who were discharged on osteoporosis therapy was 5/27 (18.5%). There was a suggestion of lower lung function, as measured by forced vital capacity (FVC%), in patients with severe vertebral fractures ( p=0.067). CONCLUSIONS: These data indicate that: (1) There is an increased proportion of COPD patients with severe vertebral fracture, and (2) Documentation and treatment of osteoporosis in acute care COPD patients is low. Therefore, there is a need to target this high-risk group for osteoporosis screening and potential clinical management.

Ultrasound of the knee.

Ultrasound is emerging as a viable imaging modality in the diagnosis and assessment of the musculoskeletal system. Advantages of ultrasound include its easy availability and multiplanar capability, as well as economic advantages. Unlike magnetic resonance imaging, ultrasound demonstrates the fibrillar microanatomy of tendons, ligaments and muscles, enhancing its diagnostic capability. The ability to compress. dynamically assess structures and compare easily with the contralateral side is advantageous. The patient's exact point of clinical tenderness can be correlated with underlying anatomical structures and associated pathology. The main strength of knee ultrasound is the assessment of para-articular disease. The specific structures best suited for ultrasound assessment include tendons, muscles and ligaments, as well as periarticular soft tissue masses. Joint effusions, synovial thickening, bursal fluid collections, intra-articular loose bodies, ganglion cysts, ligament and tendons tears, tendonitis and occult fractures can be diagnosed. With experience, ultrasound is a time-efficient, economical imaging tool for assessment of the knee.

Imaging of chronic recurrent multifocal osteomyelitis.

The disease of CRMO is a "great clinical and radiologic mimic. There are no specific clinical or laboratory findings and no pathognomonic imaging or pathologic features have been described. Because the disease is not well known by clinician, radiologist, and pathologist alike, it is likely to be more common than the literature implies. It has been suggested that the diagnosis of CRMO requires an interdisciplinary team approach dependent on the cooperation of the pediatrician, orthopedic surgeon, pathologist, and microbiologist. We strongly advocate the addition of the radiologist to this list. We believe that it is the informed radiologist who frequently suggests the correct diagnosis.

Antenatal and postnatal findings in encephalocraniocutaneous lipomatosis.

Encephalocraniocutaneous lipomatosis (ECCL) is a congenital neurocutaneous syndrome that comprises unilateral porencephalic cysts with cortical atrophy; ipsilateral hamartomas of scalp, eyelid, and outer part of the eye; lipomas of the central nervous system (CNS); cranial asymmetry; and characteristic cutaneous lesions. We report on the antenatal and postnatal sonographic and radiologic, and on the postnatal pathologic findings of an infant diagnosed with ECCL at birth. The antenatal sonogram at 28 weeks of gestation showed normal intracranial structures; the sonogram at 38 weeks of gestation showed asymmetry of the cerebral hemispheres and ventriculomegaly. Magnetic resonance imaging at age 6 weeks demonstrated a porencephalic cyst on the left, hemiatrophy of the left cerebrum with cortical dystrophy, and a lipoma in the middle cranial fossa. Histologic findings of the resected cutaneous lesion confirmed the presence of fibrolipoma hamartoma. This case offers a unique insight into the antenatal and postnatal development of the hamartoneoplastic lesions of ECCL, and it highlights the difficulties inherent in the antenatal sonographic diagnosis of hamartoneoplastic syndromes.

Magnetic resonance imaging. Application to family practice.

OBJECTIVE: To review indications, contraindications, and risks of using magnetic resonance imaging (MRI) in order to help primary care physicians refer patients appropriately for MRI, screen for contraindications to using MRI, and educate patients about MRI. QUALITY OF EVIDENCE: Recommendations are based on classic textbooks, the policies of our MRI group, and a literature search using MEDLINE with the MeSH headings magnetic resonance imaging, brain, musculoskeletal, and spine. The search was limited to human, English-language, and review articles. Evidence in favour of using MRI for imaging the head, spine, and joints is well established. For cardiac, abdominal, and pelvic conditions, MRI has been shown useful for certain indications, usually to complement other modalities. MAIN MESSAGE: For demonstrating soft tissue conditions, MRI is better than computed tomography (CT), but CT shows bone and acute bleeding better. Therefore, patients with trauma or suspected intracranial bleeding should have CT. Tumours, congenital abnormalities, vascular structures, and the cervical or thoracic spine show better on MRI. Either modality can be used for lower back pain. Cardiac, abdominal, and pelvic abnormalities should be imaged with ultrasound or CT before MRI. Contraindications for MRI are mainly metallic implants or shrapnel, severe claustrophobia, or obesity. CONCLUSIONS: With the increasing availability of MRI scanners in Canada, better understanding of the indications, contraindications, and risks will be helpful for family physicians and their patients.

Chronic sputum production: correlations between clinical features and findings on high resolution computed tomographic scanning of the chest.

BACKGROUND: There are few published data on the correlation between the clinical findings in subjects with chronic sputum production and the appearances on high resolution computed tomographic (HRCT) scans of the chest. METHODS: HRCT scanning of the chest was performed on 40 subjects with chronic sputum production. Three readers independently reported the scans for the presence or absence of bronchiectasis and the extent of bronchiectasis on the basis of the percentage of involved bronchi in each lobe. Relationships were sought between these findings and the clinical history, physical examination, and laboratory investigations. RESULTS: HRCT scanning showed that 27 subjects had bronchiectasis. Of the clinical features only the continual production of purulent sputum and childhood pertussis were associated with bronchiectasis. There was a positive correlation between the extent of bronchiectasis and dyspnoea, and a negative correlation with forced expiratory volume in one second but not with forced vital capacity. CONCLUSIONS: These results indicate that, in subjects with chronic sputum production, only a few clinical features show any correlation with the presence or extent of bronchiectasis as visualised on HRCT scans.

Interobserver variation in the diagnosis of bronchiectasis on high-resolution computed tomography.

The purpose of our study was to determine interobserver variation in the analysis of high-resolution computed tomography (HRCT) in the lungs of patients with clinically suspected bronchiectasis. HRCT scans of 88 patients were analysed independently by three radiologists with variable experience in thoracic radiology using a subjective scoring system to record bronchi as normal, mildly abnormal or severely abnormal. The presence, severity and distribution of bronchial dilatation and bronchial wall thickening were recorded. Kappa values were calculated for assessment of interobserver agreement. Agreement between the three readers was good for the detection of bronchiectasis (kappa 0.78) and assessment of its severity (0.68), detection of bronchial wall thickening (0.64) and moderately good for the assessment of its severity (0.58) on a per-patient basis. When individual lobes were analysed, agreement was moderately good for the detection of abnormal bronchi (0.59). Agreement on the extent of abnormal bronchi using five categories was only fair (0.39), but was good when differences of one category were ignored (0.63). Interobserver variation with HRCT in suspected bronchiectasis appears satisfactory for comparative studies.

Endosonographic monitoring of transurethral cryoprostatectomy.

Cryoprostatectomy, the use of subzero temperatures to ablate prostate tissue gained favour in the 1960s because of its speed and lack of haemodynamic effects. It fell from use because the freezing process could not be monitored and this led to a high incidence of local complications. We have performed transrectal real time ultrasound in 12 patients undergoing cryoprostatectomy. In all the freezing process was easily visualized as an advancing hyperechoic 'iceball' with distal acoustic shadowing. Monitoring allowed maximum prostate ablation without breaching the prostatic capsule. There were no significant complications and all but one patient gained symptomatic relief. Ultrasound at 1 month showed a heterogeneous echo pattern with very little cavity formation but by 3 months a significant cavity was seen. This study demonstrates that it is possible to monitor the freezing process during transurethral cryoprostatectomy. This, theoretically, should significantly reduce the local complications encountered in previous studies.

Bolus chasing: a new technique in peripheral arteriography.

Recent advances in digital angiographic equipment design have enabled a new technique of peripheral arteriography involving digital bolus chasing to be developed. This technique permits real-time visualization of the contrast bolus so that it can be followed peripherally with digital images being acquired at a suitable frame rate. We give the first description of this technique using the Philips Integris C2000 and compare it to conventional stepped arteriography. Sixty-one patients undergoing peripheral arteriography using the conventional stepped technique were compared with 55 patients using bolus chasing. The parameters assessed were the procedure time, the number of runs and screening time per investigation, the consumables used, the patient and radiologist radiation dose and the image quality. A reduction in the procedure time and the patient and radiologist radiation dose, and improvement in image quality are demonstrated with the bolus chasing technique. Bolus chasing represents an important advance in peripheral arteriography.

Renal transplantation: the normal morphological and Doppler ultrasound examination.

If ultrasound imaging and image-directed Doppler examination of the renal allograft is to provide information with respect to graft complications and graft failure, then a clear understanding of normal characteristics is required. Criteria for abnormality of a graft will include change in size, in parenchymal pattern, and in blood flow characteristics in the main and branch renal arteries and within the renal vein. Normal measurements for the renal allograft are presented as well as morphological and numerical data relating to cortico medullary differentiation. A wide range of values for indices quantifying Doppler data is recorded in the literature. Mean values and standard deviations from the mean are presented. The importance of different parameters as potential indicators of disease are stressed, but the limitations, usually as a result of normal variation and lack of specificity, are presented. The normal features of color-coded Doppler vascular supply, perfusion, and drainage are described.

The current status of embolization in renal cell carcinoma--a survey of local and national practice.

The current role of renal embolization in carcinoma of the kidney is uncertain. In order to assess surgeons' opinion of its usefulness a questionnaire was circulated to all general urologists practising in Britain and Ireland. Also, a series of cases in which the technique was employed (n = 35) was reviewed and compared with a similar group who were not embolized (n = 40). There was a 71% response to the survey. The principal findings were that all but five urologists believe that embolization should not be used routinely in the management of renal cell carcinoma. Thirty-five per cent stated that they felt it has a role in management of symptoms in metastatic or inoperable tumours. The review of both series of patients in our unit shows that embolization (using 95% ethanol infused via a balloon occlusion catheter) did not reduce peroperative blood loss and did significantly increase hospital stay. There were no deaths in this series, and morbidity was confined to 'post-embolization syndrome' in 16 cases. We believe that in those cases where embolization is indicated, alcohol infusion via a balloon occlusion catheter is a safe and efficient method.