Vertebral Fractures in Type 2 Diabetes Patients: Utility of Trabecular Bone Score and Relationship With Serum Bone Turnover Biomarkers.

BACKGROUND: Patients with type 2 diabetes (T2D) have an increased risk for vertebral fracture (VF). The aim of this study is to determine the utility of trabecular bone score (TBS) in T2D patients with VF and the relationship of TBS with serum bone turnover biomarkers (SBTBs). METHODOLOGY: Postmenopausal T2D female patients were prospectively enrolled. All patients received: (1) dual-energy X-ray absorptiometry exam for bone mineral density (BMD), T-score, and TBS values; (2) lateral lumbar spine radiographs for VF assessment; and (3) SBTBs: bone specific alkaline phosphatase and Beta-C-Terminal telopeptides. BMD, T-score, TBS, and SBTBs were tested for association with VF. RESULTS: The study included 285 T2D patients (mean age = 61.1 years) and 32 patients had VF (11.2%). TBS had the strongest association with VF in T2D patients (area under curve 0.775). The TBS cutoff values for VF are 1.279 in T-score ≥1 and 1.236 in T-score <-1. In patients without VF, all sites of BMD and TBS are significantly associated with SBTBs, but in patients with VF, no associations are found between SBTBs and all sites of BMD and TBS. CONCLUSIONS: TBS can assess bone quality in the spine. The low TBS cutoff values for T2D patients with VF imply T2D does impair bone quality. Thus, TBS should be incorporated in VF risk assessment in T2D patients. In addition, a dissociated relationship between BMD and TBS with SBTBs represents imbalanced bone turnover rate and results in bone fragility and VF.

The skinny on skin: MRI features of cutaneous and subcutaneous lesions detected on body MRI studies.

The skin and subcutaneous tissues are inevitably imaged as part of most body MRI studies. Incidental or even symptomatic skin lesions may, therefore, be detected and present a diagnostic challenge for the radiologist. We aim to provide a comprehensive review, with illustrative examples, of the skin abnormalities encountered on body MRI studies in our busy academic radiology department.

Safety of omitting routine bleeding tests prior to image-guided musculoskeletal core needle biopsy.

PURPOSE: To evaluate the safety of withholding preprocedure international normalized ratio (INR) and platelet testing in patients undergoing musculoskeletal (MSK) core needle biopsy (CNB). MATERIAL AND METHODS: Initially, a retrospective review of 1,162 consecutive patients undergoing MSK CNB with preprocedural INR and platelet testing was performed. Clinical (age, gender, bleeding disorder, liver disease, anticoagulation use, INR > 2, platelet count <50,000/ul) and biopsy factors (imaging modality, lesion type, biopsy needle gauge, number biopsy samples) were tested for association with bleeding complications. During the second phase, an additional 188 biopsies performed without preprocedural coagulation testing were studied. Categorical variables were compared using Chi-squared or Fisher's exact tests, continuous variables with a student t-test. Multivariate analysis was performed using logistic regression. RESULTS: In the first phase, there was a complication rate of 2.6%, 30/1162. Of the 11 clinical and biopsy factors, soft tissue lesions (p = 0.029) and lesions biopsied under ultrasound (p = 0.048) had a higher rate of bleeding than bone lesions or lesions biopsied under CT, respectively. Only three patients had an INR >2, 0.3% (3/1162) and only four patients had platelet count <50,000/ul, 0.3% (4/1162). No patient with a bleeding complication had an abnormal preprocedure bleeding test. In the second phase, there was a bleeding complication rate of 1.1% (2/188). CONCLUSION: Bleeding complications from MSK biopsy are low, even when preprocedure coagulation testing is omitted.

Effect of sarcopenia on clinical and surgical outcome in elderly patients with proximal femur fractures.

PURPOSE: To investigate the relationship between sarcopenia with short-term surgical outcome in elderly patients with proximal femur fractures. METHODS AND MATERIALS: Following Institutional Review Board approval, a database of patients receiving a pelvis CT scan for acute trauma between January 2000-August 2016 was screened for an isolated proximal femur fracture. Patients were excluded if they were: < 50 years old, had conditions predisposing to sarcopenia (renal failure, congestive heart failure, muscular dystrophies), had undergone no surgical treatment, had other major traumatic injuries, or had a pathologic femur fracture. The paraspinal muscle density (PSD) at the L4 level was measured in Hounsfield units. The skeletal muscle index (SMI) was measured as the total skeletal muscle area at L4 divided by patient height.2 PSD and SMI were tested for association with surgical outcome measures: length of hospital stay, perioperative mortality, medical complications, in-hospital blood transfusion volume, and 90-day readmission rate, using multiple variable regression analysis. Pearson correlation of PSD and SMI was performed. RESULTS: Controlling for age, gender, body mass index (BMI), and fracture type, low PSD and SMI were both independently associated with longer length of hospitalization (p = 0.008 and p = 0.032, respectively). Low PSD was associated with a higher amount of blood transfusion volume during the perioperative period (p = 0.004). Pearson correlation revealed moderate positive correlation between the SMI and PSD (r = 0.579, p < 0.001). CONCLUSION: In proximal femur fractures, elderly patients with sarcopenia are more likely to have prolonged hospitalization following surgery and require more blood transfusion volume during the perioperative period.

MR Imaging of the Female Perineum: Clitoris, Labia, and Introitus.

The female perineum has a complex anatomy and can be involved by a wide range of pathologies. In this article, we specifically focus on the clitoris, labia, and introitus. We discuss the normal anatomy of these structures, the MR imaging techniques to optimize their evaluation, and several common and uncommon entities that may affect them, including benign and malignant tumors, as well as infectious and inflammatory, vascular, iatrogenic, and developmental entities.

Imaging of adult flatfoot: correlation of radiographic measurements with MRI.

OBJECTIVE. The purpose of this study is to determine whether radiographic foot measurements can predict injury of the posterior tibial tendon (PTT) and the supporting structures of the medial longitudinal arch as diagnosed on MRI. MATERIALS AND METHODS. After institutional review board approval, 100 consecutive patients with radiographic and MRI examinations performed within a 2-month period were enrolled. Thirty-one patients had PTT dysfunction clinically, and 69 patients had other causes of ankle pain. Talonavicular uncoverage angle, incongruency angle, calcaneal pitch angle, Meary angle, cuneiform-to-fifth metatarsal height, and talar tilt were calculated on standing foot or ankle radiographs. MRI was used to assess for abnormalities of the PTT (tenosynovitis, tendinosis, and tear) and supporting structures of the medial longitudinal arch (spring ligament, deltoid ligament, and sinus tarsi). Statistical analysis was performed using the chi-square and Fisher exact tests for categoric variables; the Student t test was used for continuous variables. RESULTS. There was a statistically significant association of PTT tear with abnormal talonavicular uncoverage angle, calcaneal pitch angle, Meary angle, and cuneiform-to-fifth metatarsal height. PTT tendinosis and isolated tenosynovitis had a poor association with most radiologic measurements. If both calcaneal pitch and Meary angles were normal, no PTT tear was present. An abnormal calcaneal pitch angle had the best association with injury to the supporting medial longitudinal arch structures. CONCLUSION. Radiographic measurements, especially calcaneal pitch and Meary angles, can be useful in detecting PTT tears. Calcaneal pitch angle provides the best assessment of injury to the supporting structures of the medial longitudinal arch.

Bone tumor mimickers: A pictorial essay.

Focal lesions in bone are very common and many of these lesions are not bone tumors. These bone tumor mimickers can include numerous normal anatomic variants and non-neoplastic processes. Many of these tumor mimickers can be left alone, while others can be due to a significant disease process. It is important for the radiologist and clinician to be aware of these bone tumor mimickers and understand the characteristic features which allow discrimination between them and true neoplasms in order to avoid unnecessary additional workup. Knowing which lesions to leave alone or which ones require workup can prevent misdiagnosis and reduce patient anxiety.

Complication rate of ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy.

OBJECTIVE: The purpose of this article is to compare the complication rate for ultrasound-guided percutaneous cholecystostomy in patients with coagulopathy to the rate in patients with normal coagulation. MATERIALS AND METHODS: We performed a database search for patients who underwent ultrasound-guided percutaneous cholecystostomy from January 2000 through December 2010. Patients were divided into those with normal coagulation and those with coagulopathy, as documented by abnormal laboratory values (international normalized ratio ≥ 1.5 and platelet count ≤ 50 × 10(9)/L) or history of anticoagulant medication in the preceding 5 days. Medical records were reviewed, and complication rates and subsequent treatment was recorded. Statistical analysis was performed using the Fisher exact and chi-square tests. RESULTS: Two hundred forty-two patients underwent ultrasound-guided percutaneous cholecystostomy (132 men and 110 women; mean [± SD] age, 73.9 ± 15.9 years; range, 22-104 years). One hundred thirty-two patients were coagulopathic and 110 had normal coagulation. Major complications related to ultrasound-guided percutaneous cholecystostomy were rare (4/242 cases [1.7%]) and included hemorrhage requiring transfusion (n = 1), death directly related to the procedure (n = 1), sepsis related to the procedure (n = 1), and abscess or biloma formation (n = 1). All of these occurred in the group with normal coagulation. Fourteen additional deaths (5.8%) that occurred within 30 days of the procedure were related to comorbidities. Minor catheter-related complications (15/242 [6.2%]) were due to catheter dislodgement (n = 11 [4.5%]), failure of placement (n = 1 [0.4%]), and hemorrhage not requiring transfusion (n = 3 [1.2%]). Two of the minor hemorrhagic complications were seen in the coagulopathic group and one in the normal coagulation group (p = 0.599). CONCLUSION: There is no difference in the complication rate for ultrasound-guided percutaneous cholecystostomy in patients who are coagulopathic compared with those who have normal coagulation.

Isolated pharmacomechanical thrombolysis plus primary stenting in a single procedure to treat acute thrombotic superior vena cava syndrome.

PURPOSE: To report a combined procedure that opens the acutely thrombosed superior vena cava (SVC) to rapidly alleviate symptoms in seriously ill patients with SVC syndrome. CASE REPORTS: Four patients aged 54 to 63 years old with underlying malignancies were referred for treatment of SVC syndrome. All received isolated pharmacomechanical thrombolysis (IPMT) with tissue plasminogen activator delivered in a Trellis Peripheral Infusion System that removed obstructive clot in minutes versus the 24 to 48 hours required for traditional catheter-directed thrombolysis. In each case, stents were inserted immediately following IPMT in a combined procedure lasting <1 hour. Patients exhibited near-immediate relief of debilitating symptoms; completion venography demonstrated patent vessels with excellent blood flow. CONCLUSION: Combining IPMT with immediate stenting during the same session is an effective method for managing acute thrombotic SVC syndrome and limiting the exposure time and number of interventions performed on seriously ill patients.

Bone biopsy of new suspicious bone lesions in patients with primary carcinoma: prevalence and probability of an alternative diagnosis.

OBJECTIVE: We sought to assess the probability that a new suspicious bone lesion is an alternative diagnosis, that is, a benign lesion or a second malignant tumor as opposed to metastatic disease from the malignant tumor, in a person with known primary malignant disease. MATERIALS AND METHODS: We reviewed the radiologic and pathologic records of bone biopsies scheduled at our institution between 2002 and 2007. The following parameters were recorded: indication, type of primary cancer, date of diagnosis, complications of biopsy, whether the sample was of diagnostic quality, pathologic finding, and thus whether the primary malignant tumor was concordant with the lesion sampled. RESULTS: Fifty-four of 55 patients (17 men, 37 women; mean age, 67 years) with known primary cancer and suspicious bone lesions underwent biopsy. One of the 55 patients did not undergo biopsy because a sacral insufficiency fracture was confidently diagnosed at CT. The primary malignant disease had been diagnosed up to 16 years before the new bone lesion was suspected and bone biopsy performed. Cancer types included those of genitourinary tract, breast, thyroid, gastrointestinal tract, and lung and lymphoma and myeloma. Diagnostic material was obtained in 43 of 54 cases (80%), and nondiagnostic material was obtained in 11 of 54 cases (20%). Forty-two of 43 positive biopsy findings (98%) were consistent with the primary malignant tumor. The other positive finding was a new malignant tumor. This new tumor was myelofibrosis in a man with chronic myelocytic leukemia. The primary diagnosis correlated highly with that of the new bone lesion (Spearman's test, R = 0.842; p < 0.001). No complications, including hemorrhage, infection, sinus track formation, fracture, and pneumothorax, were encountered. CONCLUSION: In a patient with known primary malignant disease, the probability is low (2%) that biopsy of a new suspicious bone lesion will show the lesion is other than metastasis from the primary tumor.

Hypotonic MR duodenography with water ingestion alone: feasibility and technique.

To date, cross-sectional imaging of the duodenum has a number of inadequacies, most likely a reflection of its tortuous and complex anatomical course, resulting in somewhat suboptimal imaging. The purpose of this study was to describe and assess the feasibility of performing a 'tubeless', per-oral, single contrast, hypotonic magnetic resonance (MR) duodenography technique. Secondly, to assess the efficacy of intravenous Buscopan in facilitating duodenal distension at cross-sectional MR imaging. Ten healthy volunteers prospectively underwent MR imaging of the duodenum pre- and post-Buscopan immediately after consuming 1,000 ml of water. Images were qualitatively (using a visual assessment grading scale of 1-3) and quantitatively evaluated with regard to degree of small bowel distension by two observers. The contrast medium was successfully ingested and MR examination was completed in all participants. Quantitatively and qualitatively, the per-oral, hypotonic duodenography technique yielded superior distension scores and was significantly greater in diameter in comparison with the per-oral non-hypotonic duodenography technique (p < 0.003, p < 0.002). Per-oral, single-contrast, hypotonic MR duodenography is a feasible, simple, fast mode of investigation of the duodenum, which does not involve radiation and represents a useful technique in the armamentarium of the radiologist.

MRI small-bowel follow-through: prone versus supine patient positioning for best small-bowel distention and lesion detection.

OBJECTIVE: The purpose of this study was to assess whether prone or supine imaging provides superior small-bowel loop distention during MRI small-bowel follow-through examinations and whether either position is better with regard to lesion detection and evaluation. SUBJECTS AND METHODS: Forty consecutively enrolled clinically referred patients with known or suspected small-bowel abnormalities prospectively underwent 62 MRI small-bowel follow-through examinations in both the prone and the supine positions. Images were blindly and independently reviewed by two observers. Each small-bowel segment was assessed with a 3-point scoring system, and differences in bowel distention in the prone and supine positions were evaluated with a paired Wilcoxon's test. Differences between rates of lesion detection and characterization (e.g., ulceration, stricturing) were analyzed with a paired Student's t test. Interobserver agreement was estimated with the kappa coefficient. RESULTS: In both normal and diseased small bowel, the prone position had statistically significantly higher distention scores than did the supine position (p < 0.05) with a high level of interobserver agreement. This finding, however, did not translate into improved lesion detection or characterization (p > 0.05). CONCLUSION: Although use of the prone position results in superior small-bowel distention during MRI small-bowel follow-through, both the prone and supine positions are equal in terms of lesion detection and feature visualization.