The validity of the New York radiological grading criteria in diagnosing sacroiliitis by computed tomography.

BACKGROUND: Sacroiliitis in ankylosing spondylitis has frequently been graded radiographically using the New York (NY) criteria, which also have been applied in computed tomography (CT). PURPOSE: To validate the grading of the NY criteria in CT of the sacroiliac joints. MATERIAL AND METHODS: With the aid of the NY criteria, assessment of inflammatory and degenerative changes was made in 1304 CT studies. Assessment included erosions, the distribution, type, and width of sclerosis, and the involvement of the joints in sacroiliitis, as well as of normal anatomic variants such as joint space width and shape. RESULTS: There was definite radiological sacroiliitis in 420 joints in 251 patients. Among these, more than two-thirds of the joint was involved in 71.0% of the affected joints. Sclerosis of the ilium was much more prevalent than sacral sclerosis. With increasing NY grade, iliac sclerosis, width, and extent increased, transition from sclerosis to normal bone became indistinct, and the structure of sclerosis was more inhomogeneous. Erosions of the joint surfaces were localized predominantly on the iliac side. CONCLUSION: Only erosions seem to be a valid solitary diagnostic sign. Solitary erosions need supplemental evidence from other inflammatory signs. Inflammatory sclerosis may be distinguished from degenerative sclerosis, and can sometimes support early diagnosis. Joint space width, joint shape, bone mineral content, or enthesopathy have no place in sacroiliitis diagnosis on CT. The NY criteria are not ideal for use with CT. A practical classification of sacroiliitis on CT is proposed, with a grading of no disease, suspected disease, and definite disease.

Three-dimensional radiological classification of lumbar disc herniation in relation to surgical outcome.

Centrally located lumbar disc herniations have been reported to be of predictive value for poor post-operative clinical outcome. One hundred and fifty patients undergoing lumbar disc herniation surgery were prospectively included. Herniation-related parameters, including the grading of contours, were assessed from pre-operative computed tomography (CT) and magnetic resonance imaging (MRI) images using a new three-dimensional grading system. The radiological findings were compared with outcome parameters two years post-operatively (patient-assessed pain, function/health scores and evaluation by an independent observer). An intra- and inter-observer validation of the classification was performed in a subgroup of patients. High intra-observer and good inter-observer reliability for both CT and MRI was seen. In the study population, no relation between the distribution or size of the herniations and outcome at 2-year follow-up were found. The distribution and size of the lumbar disc herniations with the three-dimensional classification were not found to be of importance for the clinical outcome.

Observer variation in computed tomography of the sacroiliac joints: a retrospective analysis of 1383 cases.

BACKGROUND: Computed tomography (CT) for evaluation of sacroiliitis has a higher diagnostic accuracy than radiography. There is a high degree of interobserver variation in evaluating sacroiliitis on radiographs. PURPOSE: To evaluate interobserver variation in CT of the sacroiliac joints for evaluation of sacroiliitis in a large number of patients. MATERIAL AND METHODS: 1383 CT examinations of the sacroiliac joints were reviewed by two observers. The outcomes as originally reported and the findings from the reviews were classified as no sacroiliitis, equivocal, unilateral sacroiliitis, or bilateral sacroiliitis. The unweighted kappa statistic was used for assessment of observer agreement. RESULTS: The interobserver agreement between the two reviewers was good (kappa = 0.6724), with excellent agreement on cases of bilateral sacroiliitis and moderate agreement on cases of unilateral sacroiliitis. Excellent agreement was also reached in normal cases. Compared to the original reports, there were moderate interobserver agreements between both reviewers' findings and the original reports (kappa = 0.4651 and kappa = 0.4481, respectively). CONCLUSION: The interobserver variation for the diagnosis of sacroiliitis on CT between two reviewers in a study setting showed good agreement, with moderate agreement between each of the observers and the original clinical reports. CT is a reliable method for evaluating the sacroiliac joints for changes of sacroiliitis.

Clinical utility of chest roentgenograms.

Because chest roentgenograms are the most common radiological procedure, they represent a considerable use of resources. Because the usefulness of chest radiography is frequently disputed, it is mandatory to investigate whether or not this use of resources can be defended in terms of clinical utility. The current study was performed as an outcome analysis to assess the clinical utility of chest radiography for monitoring patients in general practice (GP). One year of chest radiography referrals from a municipality practice, comprising a total of 55 patients, were prospectively studied. Prior to the referrals, questionnaires were filled in with indications and expected results. After the examination, the radiological results were assessed regarding clinical utility. All 55 patients were carefully monitored by the same GP. The most frequent reason for referral was infectious disease. Only in 5 patients was the radiology report without value. In the 29 patients with a negative report, it was considered of value. In 7 of these 29 patients the ongoing treatment was altered. The subjective value of the radiology reports were considered to be high. The clinical utility was good, both when receiving positive and negative answers. Of special interest was the negative answers as 7 patients actually changed treatment. The clinical utility was considered high enough to justify the costs. Good access to radiology for GPs is both cost-saving and cost-effective.

The role of CT in the diagnosis of sacro-iliitis.

OBJECTIVE: Ankylosing spondylitis is a progressive, debilitating disease in which early diagnosis and early treatment can improve the prognosis. Radiographic confirmation is essential for diagnosis but conventional radiography has not proved useful, particularly in the early course of the disease. The aims of this study were to correlate the findings at conventional radiography with those at CT, and to correlate the duration of clinical symptoms with the radiological findings. MATERIAL AND METHODS: Forty patients with clinical sacro-iliitis and 13 controls were evaluated by means of conventional radiography and CT. RESULTS: Conventional radiography was positive in 10/40 patients and CT in 30/40 patients. Conventional radiography was positive in only 2/14 patients with a symptom duration of less than 2 years while CT was positive in 10/14 such patients. CONCLUSION: The study demonstrated a considerably higher sensitivity in CT than in conventional radiography in detecting the subtle changes necessary for the radiological diagnosis of sacro-iliitis, particularly in cases of short duration. CT allows an early start to be made in treatment with a consequently improved prognosis. The use of conventional radiography cannot be recommended because its low sensitivity delays diagnosis in many instances.

Cost-effectiveness of colour duplex sonography compared with angiography of the pelvis and lower limb.

The present investigation was performed to assess the clinical consequences, utility and efficacy of colour duplex sonography (CDS) compared with angiography as a preoperative examination in aorta, pelvis and lower limb, and thus to estimate the cost-effectiveness of CDS. CDS was additionally performed in 53 consecutive patients referred for preoperative angiography of the lower limb. The results for 49 patients were reviewed and compared to assess the technique's clinical utility. The costs of the two methods and the consequences of inappropriate treatment were assessed. In 15 patients inadequate diagnoses were obtained at CDS. If surgery had been performed solely on the basis of the ultrasonographic diagnosis, repeat surgery would have been necessary in 9 patients. In a further 3 patients necessary surgery would not have been performed. Two patients would have been overtreated (unnecessary surgery instead of percutaneous transluminal balloon angioplasty). To correct the initial incorrect diagnosis the estimated yearly cost would be approximately 1.3 million Swedish crowns. In addition, complications and discomfort could be anticipated for the patients. Because of its low sensitivity CDS ist not cost-effective as a preoperative investigation of arteries of the pelvis and lower limb.

Comparison of nephrectomy and/or doxorubicin treatment in rabbit renal VX-2 carcinoma.

To compare survival after local intra-arterial and intravenous administration of doxorubicin, VX-2 carcinoma was implanted in one kidney of 48 rabbits. Treatments were given 9-14 days after tumor implantation. Survival after doxorubicin was significantly longer than the controls, whereas no difference was established between intra-arterial or intravenous treatment. Overall only 9 of 32 doxorubicin-treated rabbits were cured at autopsy after 18 months. It was assumed that circulating tumor cells from tumor implantation resulted in "primary" lung metastases. To kill circulating tumor cells intravenous doxorubicin was given immediately before implantation in 40 rabbits, followed by combinations of nephrectomy and doxorubicin. Doxorubicin without nephrectomy cured 8 of 16 rabbits, whereas doxorubicin combined with nephrectomy cured 4 of 16. Doxorubicin improved survival in responders, but likelihood of response was limited. Nephrectomy did not improve survival, most likely due to metastatic seeding at implantation. Intravenous doxorubicin immediately before did not prevent metastatic spread in connection with tumor implantation.

Doxorubicin treatment of rabbit renal VX-2 carcinoma: nephrotoxicity, serum parameters and weight.

Serum electrolytes, creatinine, urea, protein, albumin, bilirubin and glucose were examined every 4 days until time of death in rabbits with VX-2 carcinoma implanted in one kidney. The rabbits were treated with doxorubicin, nephrectomy or combinations thereof and observed for up to 1 year. Rabbits treated with doxorubicin only showed a slight creatinine rise initially, but over time creatinine reached almost the same concentration as that in nephrectomized rabbits receiving equivalent doses of doxorubicin. Creatinine concentrations increased significantly above the normal range following nephrectomy combined with doxorubicin. Doxorubicin nephrotoxicity in rabbits occurs at lower doses than previously reported. In all rabbits the parameters except creatinine remained stable within the established normal ranges, except for the last 4 days before time of death in the animals with metastatic disease. Weight loss was the best parameter for making a prognosis for an individual rabbit, since peak weight was noted 16-20 days before death. In experimental work with VX-2 carcinoma, weight is thus the most important indicator of the time at which rabbits not responding to treatment can be put to death to avoid unnecessary suffering before the end of the experiment.

Angiography and colour flow duplex ultrasonography in the evaluation of peripheral ischaemic occlusive arterial disease.

Colour flow duplex ultrasonography (CFDUS) was performed in 50 patients with advanced peripheral ischaemic disease scheduled for conventional angiography. Atherosclerosis was diagnosed by the appearance of plaque and spectral broadening. Haemodynamically significant stenosis was represented as a doubling of peak systolic velocity expressed as peak velocity ratio. Occlusion was diagnosed by the lack of colour saturation and absence of Doppler wave form. In the pelvis and thigh/knee region the sensitivity and specificity exceeded 90% except for stenoses, where the sensitivity was lower. The run-off was evaluated by examination of the tibial and peroneal arteries to at least midcalf. If 2 open arteries were identified, or, if only the posterior tibial artery was patent, the run-off was considered good. Compared to angiography the sensitivity and specificity exceeded 90%. We conclude that CFDUS is an accurate non-invasive method for preoperative screening of patients with peripheral ischaemic disease.

Radiology of the continent ileostomy reservoir: I. Method of examination and normal findings.

The aim of the present study is to describe the radiologic methods used to study continent ileostomy reservoirs and to depict the normal radiologic features and variations identified by these procedures. During an 8-year period, 408 double-contrast studies were performed in 261 patients. The present study comprises 170 examinations in 99 patients with normal findings. A high-density barium contrast medium and air were used. Modes variation in the size and shape of the reservoirs was observed. The mucosal pattern of the reservoirs resembled that of the ileum but the folds were slightly wider. The continence-providing valves were 3-5 cm long and had a diameter of 2.5-4.0 cm. The diameter of the afferent ileal segments was usually slightly larger than that of more proximal ileal segments, with an upper limit of approximately 4 cm. The efferent ileal segments generally had a straight course without widening or out-pouches. Retrograde barium double-contrast examination is a satisfactory method for the evaluation of continent ileostomy reservoirs. Here we define the range of normal variations of such reservoirs as seen on retrograde double-contrast radiologic examinations.

Radiology of the continent ileostomy reservoir: II. Findings in patients with late complications.

During an 8-year period, 238 barium double-contrast studies performed in 162 patients with continent ileostomy reservoirs who had signs and symptoms of late complications (malfunction of the valve, nonspecific inflammation of the mucosa, stenoses, hernias, and fistulas) showed radiologic abnormalities. The aim of the present study is to depict the radiologic findings in patients with late complications of continent ileostomy reservoirs. With radiologic examination, the correct diagnosis of valve malfunction was made in 96% of patients with surgically proven valve defects. We were able to differentiate between various types of valve dysfunction and complications related to the fixation of the reservoir to the abdominal wall. Inflammatory mucosal changes and fistulas of the reservoir and the afferent ileal segment were depicted with a high degree of accuracy. Barium double-contrast radiologic examination proved to be very valuable in the work-up of patients with dysfunction of continent ileostomy reservoirs. The method was of particular value in assessing the cause of valve dysfunction and in the appraisal of the afferent ileal segment.

Relationship between renal capsular artery feeding and size of VX-2 carcinoma implant in the rabbit kidney.

When regional intraarterial infusion is applied in the treatment of malignant tumors it is essential to reach the tumor via all its major feeder vessels. In this study VX-2 carcinoma was implanted into the lower pole of the left kidney in 24 rabbits to investigate whether the renal capsular artery takes part in tumor feeding. The rabbits were divided into four groups that were followed for 8, 10, 12 or 14 days after tumor implantation. At that time the renal artery was ligated close to the kidney and subsequently silicone rubber on barium sulfate/gelatin suspension was injected into the capsular artery. The tissue was cleared, and the tumor carefully removed and examined microscopically for traces of silicone rubber. When barium sulfate had been injected, the kidney was examined radiographically in order to detect possible presence of contrast medium in the tumor. This study revealed no vascular supply to the implanted VX-2 carcinoma from the capsular artery when the tumor was confined intracapsularly, i.e., up to 12 days after tumor implantation in untreated rabbits.

Comparison between radiologic and endoscopic evaluation of the continent ileostomy reservoir.

The present study was performed to compare the results of radiologic examination and endoscopy in 156 patients with continent ileostomy reservoirs. Data from clinical follow-up and findings at revisional surgery were used for confirmation of diagnosis. One hundred and one patients had the clinical diagnosis nonspecific inflammation, 48 had symptoms of valve dysfunction, and 7 were studied because of suspected valve-shunting fistulas. For moderate and severe inflammation the findings on radiographs and at endoscopy were in accordance, whereas slight inflammation was more frequently reported by radiology than endoscopy. Radiology overdiagnosed slight inflammation. One disadvantage of endoscopy in patients with inflammation was that the afferent ileal segment could be reached in only 56%. By radiology 41 of 44 defective valves were identified (93%), whereas endoscopy disclosed only 24 defective valves (55%). The combined efforts of radiologic examination and endoscopy only managed to diagnose three of the seven patients with valve-shunting fistulas (two by radiologic and one by endoscopic examination). In conclusion, the retrograde double-contrast examination is a valuable complement in the assessment of patients with continent ileostomies and appears to be superior to endoscopy in the diagnosis of valve dysfunction and in depicting the afferent ileal segment.

Insufficient hemodialysis access fistulas: 18 months' experience in laser-supported dilation.

Patients with end-stage renal failure disease frequently develop venous stenoses or occlusions in their hemodialysis access fistulas caused by intimal fibrosis. A complete dilation with high pressure balloons up to 20 atm may be unsuccessful in those cases. We investigated two new pulsed dye laser devices for the ablation of obstructions, which were not adequately treatable with a previous balloon angioplasty. From November 1990 to April 1992 a total of 154 percutaneous transluminal angioplasties (PTAs) of hemodialysis access fistulas were performed. In 23 of them an additive laser angioplasty was necessary. Twenty patients with Cimino fistulas presented 28 stenoses and two occlusions, and three Goretex loops presented all occlusions. Two pulsed dye laser devices emitting at 504 nm and 595 nm wavelength were tested. Technical success was achieved in 22/23 cases, but clinical success was obtained in 20/23 patients because two early reocclusions caused by thrombosis appeared. Five restenoses occurred 2, 3, 10, and in two cases 14 months after angioplasty with a mean follow-up period of 13.5 (5-18) months. Pulsed dye laser ablation in hemodialysis access fistula lesions due to intimal fibrosis is a valuable enrichment of radiological recanalization techniques and an alternative to surgery if stand alone balloon PTA fails.

The frequency of technical errors in an automatic daylight system.

Considerable interest has been devoted to automatic daylight film processing systems (ADS) because of their potentials in saving money by decreasing the need for dark-room personnel. In 1982 a new centralized department of diagnostic radiology became operational at Haukeland University Hospital, and six ADS were installed 1983-1984. After 4 years in use the ADSs have been found reliable with few technical errors.