Reduction of unnecessary repeat knee radiographs during osteoarthrosis follow-up visits in a large teaching medical center.

BACKGROUND: Professional organizations recommend against repeat radiographs for routine follow-up of osteoarthrosis. However, clinics frequently obtain radiographs during or before the clinical visit. The purpose of our project was to determine the baseline frequency of unnecessary knee radiographs and whether educational interventions can reduce this frequency. METHODS: This QI project was exempt from IRB review. Radiology reports of knee radiographs were searched in our database filtered by presence of the words "severe", "degenerative", "osteoarthritis", and similar variants. We reviewed 500 consecutive corresponding medical records to confirm the presence of severe osteoarthritis, and presence of a repeat radiograph within 6 months. Indications for repeat radiographs were determined. Repeat radiographs were counted as "non-indicated" when medical records revealed no new symptoms. A focused educational intervention was provided to the orthopedic and family practice departments. An additional 500 radiology reports were evaluated 9 months after intervention in the same manner and the rate of non-indicated radiographs was calculated. Follow-up review of additional 500 radiology reports at 1-year time point was performed. RESULTS: Our initial search returned 1517 reports. Upon evaluation of 500 studies, there were 112/500 repeat radiographs (22%); 77/500 (15%) of knee radiographs were not indicated. Upon initial follow-up evaluation of 500 studies, there were 52/500 repeat radiographs (10%) and 40/500 (8%) radiographs were not indicated. The reduction of unnecessary repeat knee radiographs rate was sustained at 1 year. CONCLUSIONS: Focused educational intervention results in a substantial (50%) reduction of the number of unnecessary repeat knee radiographs in patients with known severe OA.

Evaluation of giant cell tumors by diffusion weighted imaging-fractional ADC analysis.

BACKGROUND: A single ADC value is used in clinical practice on multi b-value acquisitions. Low b-value acquisitions are affected by intravoxel incoherent motion, which is dependent on perfusion. Giant cell tumors (GCTs) are known to exhibit early arterial enhancement and low ADC values. Mean, minimum and fractional ADC characteristics of osseous and tenosynovial GCTs are systematically evaluated. METHODS: Tenosynovial and osseous GCTs were included. Each lesion was evaluated on conventional MRI and DWI by two musculoskeletal radiologists. ADC was measured by placing an ROI on the most confluent enhancing portion of the lesion. Fractional and best fit ADC calculations were performed using MATLAB software. RESULTS: No statistically significant difference was found between tenosynovial and osseous lesions' ADC values. Mean ADC for all lesions was 1.0 × 10-3 mm2/s (SD = 0.2 × 10-3 mm2/s) and minimum ADC was 0.5 × 10-3 mm2/s (SD = 0.3 × 10-3 mm2/s). Average mean ADC value obtained from B50-B400 slope was 1.1 × 10-3 mm2/s (SD = 0.2 × 10-3 mm2/s), and the average mean ADC value obtained from B400-B800 slope was 0.8 × 10-3 mm2/s (SD = 0.1 × 10-3 mm2/s) [p-value <0.01]. CONCLUSION: Tenosynovial and osseous GCTs demonstrate similar and low ADC values, which become even lower when using high b-value pairs. Our study also supports the theory of intravoxel incoherent motion that becomes apparent at low b values as related to giant cell tumors, which are known to be hyperperfused.

Seasonal variation of serum 25 hydroxy D3 in residents of Tehran.

BACKGROUND AND AIM: vitamin D is essential for bone health. It has been shown that in many communities serum levels of vitamin D can be subject to seasonal variations but so far no study has been conducted on this variable in natives of Tehran. SUBJECTS AND METHODS: 1172 natives of Tehran, 682 women and 490 men, aged 3-69 yr entered the study. Sampling was performed monthly except during Ramadhan, the holy month of Islamic fasting. Serum 25-hydroxyvitamin D (25-OHD) was measured using protein binding assay and levels below 20 ng/ml were determined as vitamin D deficient. RESULTS: serum 25-OHD concentrations showed monthly variations in both sexes but the magnitude of variations was more pronounced in men. The nadir of serum levels in both sexes were seen in December and February, 12 +/- 13 and 14 +/- 14 ng/ml in women, and 28 +/- 16 and 24 +/- 18 mg/ml in men, respectively with the highest values being seen in October; 29 +/- 29 ng/ml in women and 55 +/- 27 ng/ml in men. During the whole period of study the maximum values for women were either equal or less than the minimum values for men. The values for men during summer and winter (31 +/- 17 and 28 +/- 22 ng/ ml, respectively) were significantly lower than the values for spring and fall (38 +/- 27 and 43 +/- 29 ng/ml respectively). In women there was no significant difference in the values of the first three seasons and only the values pertaining to winter were significantly different from the values of fall. CONCLUSIONS: the absence of expected seasonal variations in women coupled with obvious deficiency of vitamin D can be attributed to patterns of life style and also to the traditional clothing of the women of Tehran. Nationwide strategies to improve the vitamin D status of the community, specially for women and children, are highly recommended.