[An infant with a bowed lower leg]. / Een zuigeling met een gebogen onderbeen.

The parents of a 5-month-old boy noticed bowing of his left leg. Radiographic survey showed an anterolateral bowing of the left tibia and fibula with intramedullary sclerosis, typical for neurofibromatosis type 1. As the mother had neurofibromatosis, this boy was diagnosed with neurofibromatosis type 1.

Computed tomography for the detection of thumb base osteoarthritis: comparison with digital radiography.

OBJECTIVE: To compare computed tomography (CT) with digital radiography for the detection of osteoarthritis (OA) of the first carpometacarpal (CMC1) and scaphotrapeziotrapezoid (STT) joint. MATERIALS AND METHODS: We retrospectively identified patients who were assessed for CMC1 OA or STT OA at our hand surgery outpatient clinic between January 2008 and March 2011, and who had both a digital radiograph and a CT scan of the hand within a 3-month period. CT and radiographic images were scored independently by two musculoskeletal radiologists for joint space narrowing (JSN), osteophytes, subchondral sclerosis, bone cysts, and erosions in the CMC1 and STT joints. RESULTS: Thirty patients were identified. The inter-reader reliability of CT for the detection of CMC1 OA (ICC 1.00) and STT OA (ICC 0.80) was higher than radiography (ICC's 0.15 and 0.45). In comparison with their own radiographical scoring, both readers detected with CT 3 more patients with CMC1 OA, and 13 and 5 more patients with STT OA. CONCLUSION: Computed tomography had a higher inter-reader reliability and detection rate for both CMC1 and STT OA, compared with radiography. As surgical treatment selection of thumb base OA depends on the presence of pathology in the CMC1 and STT joints, CT may improve treatment selection and surgical planning.

Multicenter randomized controlled trial of the costs and effects of noninvasive diagnostic imaging in patients with peripheral arterial disease: the DIPAD trial.

OBJECTIVE: The purpose of our study was to compare the costs and effects of three noninvasive imaging tests as the initial imaging test in the diagnostic workup of patients with peripheral arterial disease. MATERIALS AND METHODS: Of 984 patients assessed for eligibility, 514 patients with peripheral arterial disease were randomized to MR angiography (MRA) or duplex sonography in three hospitals and to MRA or CT angiography (CTA) in one hospital. The outcome measures included the clinical utility, functional patient outcomes, quality of life, and actual diagnostic and therapeutic costs related to the initial imaging test during 6 months of follow-up. RESULTS: With adjustment for potentially predictive baseline variables, the learning curve, and hospital setting, a significantly higher confidence and less additional imaging were found for MRA and CTA compared with duplex sonography. No statistically significant differences were found in improvement in functional patient outcomes and quality of life among the groups. The total costs were significantly higher for MRA and duplex sonography than for CTA. CONCLUSION: The results suggest that both CTA and MRA are clinically more useful than duplex sonography and that CTA leads to cost savings compared with both MRA and duplex sonography in the initial imaging evaluation of peripheral arterial disease.

Vessel wall calcifications at multi-detector row CT angiography in patients with peripheral arterial disease: effect on clinical utility and clinical predictors.

PURPOSE: To evaluate retrospectively the effect of vessel wall calcifications on the clinical utility of multi-detector row computed tomographic (CT) angiography performed in patients with peripheral arterial disease and to identify clinical predictors for the presence of vessel wall calcifications. MATERIALS AND METHODS: The study was approved by the hospital institutional review board, and informed consent was obtained from all patients. For this study the authors included patients from two randomized controlled trials that measured the costs and effects of diagnostic imaging in patients with peripheral arterial disease. All patients underwent CT angiography and were followed up for 6 months. Clinical utility was measured on the basis of therapeutic confidence (rated on a 10-point scale) in the results of initial CT angiography and the need for additional vascular imaging. Univariable and multivariable logistic and linear regression analysis and the area under the receiver operating characteristic curve were used to evaluate the effect of vessel wall calcifications on the clinical utility of CT angiography and the use of patient characteristics to predict the number of calcified segments at CT angiography. RESULTS: A total of 145 patients were included (mean age, 64 years; 70% men). The authors found that the number of calcified segments was a significant predictor of the need for additional imaging (P = .001) and of the confidence scores (P < .001). The number of calcified segments discriminated between patients who required additional imaging after CT angiography and those who did not (area under the receiver operating characteristic curve, 0.66; 95% confidence interval: 0.54, 0.77). Age, diabetes mellitus, and cardiac disease were significant predictors of the number of calcified segments in both the univariable and multivariable analyses (P < .05). CONCLUSION: Vessel wall calcifications decrease the clinical utility of CT angiography in patients with peripheral arterial disease. Diabetes mellitus, cardiac disease, and elderly age (older than 84 years) are independently predictive for the presence of vessel wall calcifications.

Peripheral arterial disease: clinical and cost comparisons between duplex US and contrast-enhanced MR angiography--a multicenter randomized trial.

PURPOSE: To prospectively determine the clinical and economic consequences of replacing duplex ultrasonography (US) with contrast material-enhanced magnetic resonance (MR) angiography for the initial imaging work-up of patients with peripheral arterial disease (PAD). MATERIALS AND METHODS: This randomized multicenter study was approved by the institutional review board of each hospital, and all patients signed written informed consent prior to randomization. Patients with PAD who needed to undergo imaging work-up and who had an ankle-brachial pressure index (ABPI) of less than 0.90 were recruited by vascular surgeons between January 2002 and September 2003. Patients were randomly assigned to undergo contrast-enhanced MR angiography or duplex US. The primary outcome measure was cost. Secondary outcome measures included therapeutic confidence, changes in disease severity, and changes in quality of life (QOL) assessed during 6 months of follow-up. Indicators for disease severity were based on the Rutherford classification, treadmill walking distance, ABPI at rest, and ABPI after exercise. QOL was assessed with the Rating Scale, Short Form 36, EuroQol-5D, and VascuQol questionnaires. The cost of (additional) imaging procedures, therapeutic interventions, and outpatient visits were calculated from a hospital perspective (ie, all costs incurred inside the hospital were estimated, including physician costs). Data were evaluated by using the Student t test and a multivariable linear regression analysis. RESULTS: At 6 months, 352 patients (239 [68%] men, 113 [32%] women; mean age, 65 years) were analyzed. The use of contrast-enhanced MR angiography versus duplex US reduced the number of additional vascular imaging procedures by 42%; contrast-enhanced MR angiography was also associated with higher therapeutic confidence. Diagnostic costs for contrast-enhanced MR angiography were 167 euros (186 dollars) higher than those for duplex US (P < .001). No statistically significant differences were found for total cost, changes in disease severity, or changes in QOL between patients examined with duplex US and those examined with contrast-enhanced MR angiography (P > .05). CONCLUSION: Replacing duplex US with contrast-enhanced MR angiography for the initial imaging work-up of patients with PAD reduces the need for additional imaging, although diagnostic costs are higher.

Interobserver agreement for the interpretation of contrast-enhanced 3D MR angiography and MDCT angiography in peripheral arterial disease.

OBJECTIVE: The objective of our study was to compare interobserver agreement for interpretations of contrast-enhanced 3D MR angiography and MDCT angiography in patients with peripheral arterial disease. SUBJECTS AND METHODS: Of 226 eligible patients, 69 were excluded. The remaining 157 consecutive patients were prospectively randomized to either MR angiography (n = 78) or MDCT angiography (n = 79). Two observers independently evaluated for arterial stenosis or occlusion on MR angiography (2,157 segments) and MDCT angiography (2,419 segments) using a 5-point ordinal scale. Vessel wall calcifications were noted. Interobserver agreement for each technique was evaluated with a weighted kappa (kappa(w)) statistic. RESULTS: Although interobserver agreement for both was excellent, the interobserver agreement for MR angiography (kappa(w) = 0.90; 95% confidence interval [CI], 0.89-0.92) was higher than that for MDCT angiography (kappa(w) = 0.85; 95% CI, 0.83-0.86) for reporting the degree of arterial stenosis or occlusion in all segments. For the different anatomic locations, the interobserver agreement for MR angiography versus MDCT angiography was as follows: aortoiliac (kappa(w) =0.91 vs 0.84, respectively), femoropopliteal (kappa(w) = 0.91 vs 0.87), and crural (kappa(w) = 0.90 vs 0.83) segments. The interobserver agreement of MDCT angiography significantly decreased in the presence of calcifications but was still good for all anatomic locations. The lowest agreement was found for crural segments in the presence of calcifications (kappa(w) = 0.67). With MR angiography, there were 12 times more nondiagnostic segments than with MDCT angiography (81 vs 7, respectively). CONCLUSION: Interpretations of MR angiography and MDCT angiography for peripheral arterial disease have an excellent interobserver agreement. MR angiography has a higher interobserver agreement than MDCT angiography, and the presence of calcified segments significantly decreases interobserver agreement for MDCT angiography.

Imaging peripheral arterial disease: a randomized controlled trial comparing contrast-enhanced MR angiography and multi-detector row CT angiography.

PURPOSE: To prospectively evaluate clinical utility, patient outcomes, and costs of contrast material-enhanced magnetic resonance (MR) angiography compared with multi-detector row computed tomographic (CT) angiography for initial imaging in the diagnostic work-up of patients with peripheral arterial disease. MATERIALS AND METHODS: Institutional review board approval and informed consent were obtained. Patients referred for diagnostic imaging work-up to evaluate the feasibility of a revascularization procedure were randomly assigned to undergo either MR angiography or CT angiography. Clinical utility was assessed with therapeutic confidence (scale of 0-10) at initial imaging and with the need for additional imaging. Patient outcomes included ankle-brachial index, maximum walking distance, change in clinical status, and health-related quality of life. Actual diagnostic and therapeutic costs were calculated from the hospital perspective. Differences between group means were calculated with unpaired t tests and 95% confidence intervals. RESULTS: A total of 157 consecutive patients with peripheral arterial disease were prospectively randomized to undergo MR angiography (51 men, 27 women; mean age, 63 years) or CT angiography (50 men, 29 women; mean age, 64 years). For one of the 78 patients in the MR group, no data were available. Mean confidence for MR angiography (7.7) was slightly lower than that for CT angiography (8.0, P = .8). During 6 months of follow-up, 13 patients in the MR group compared with 10 patients in the CT group underwent additional vascular imaging (P = .5). Although not statistically significant, there was a consistent trend of less improvement in the MR group across all patient outcomes. The average cost for diagnostic imaging was 359 ($438) higher in the MR group than in the CT group (95% confidence interval: 209, 511 [$255, $623]; P < .001). Therapeutic costs were higher in the MR group, but the difference was not significant. CONCLUSION: The results suggest that CT angiography has some advantages over MR angiography in the initial evaluation of peripheral arterial disease.

Comparison of generic and disease-specific questionnaires for the assessment of quality of life in patients with peripheral arterial disease.

OBJECTIVE: This study compared the ability of generic and disease-specific questionnaires to assess quality of life (QOL) at baseline and to detect change in QOL after treatment in patients with peripheral arterial disease (PAD). METHODS: This prospective multicenter trial recruited 514 patients with PAD who needed an imaging workup and had an ankle brachial pressure index of less than 0.90. Patients with severe comorbidity were excluded, leaving a study population of 450 patients. Patients completed two generic questionnaires, the Short Form 36 (SF-36) and the European Quality of Life 5D (EuroQol-5D), and one disease-specific questionnaire, the Vascular Quality of Life (VascuQol) at baseline and after 6 months of follow-up. Rutherford classification and treadmill walking distance were determined at baseline and after 6 months of follow-up and were considered indicators of disease severity. Receiver operating characteristic (ROC) curves and areas under the curves (AUCs) were used to evaluate each of the three questionnaires for its ability to discriminate between severe and mild disease at baseline and to discriminate between a large and small change in disease severity after follow-up. The underlying assumption was that disease severity is a major determinant of QOL. This implies that the validity of a QOL questionnaire is reflected by its ability to discriminate between mildly and severely diseased patients. RESULTS: At baseline, 443 patients and after follow-up, 386 patients completed questionnaires. At baseline, no significant ( P >.05) differences were observed among AUCs for the total scores of the three questionnaires, indicating that all three questionnaires assessed the disease severity equally well. After follow-up, the AUCs for the VascuQol were significantly higher than the AUCs for the SF-36 and EuroQol-5D with respect to detection of improvement in Rutherford classification ( P < .05), indicating that change in disease severity after follow-up was best detected by the VascuQol. CONCLUSION: The VascuQol is the preferred questionnaire as outcome measure for QOL in future trials and clinical follow-up of patients with PAD.