Machine learning and magnetic resonance imaging: Differentiating benign from malignant osseous tumors.

Radiomics and machine learning applied to the isolated cartilaginous bone lesion on magnetic resonance imaging (MRI) is increasingly useful to distinguish malignant versus benign bone lesions, to determine whether repetitive imaging over time, to determine dynamic expansion, or immediate excisional biopsy are indicated.

Sonoelastography: A powerful technique in musculoskeletal imaging.

Sonoelastography is a powerful method available to observe the musculoskeletal system, and appears particularly valuable in detecting early tendinopathies, pursuing complaints of localized musculoskeletal pain, analyzing soft tissue masses, and research applications in musculoskeletal medicine.

Intralesional Injection of Triamcinolone Acetonide for Subcutaneous Lipoma causing Musculoskeletal and Neurologic Symptoms.

Objective: Benign subcutaneous lipomas can cause musculoskeletal pain and nerve impingement. We hypothesized that the potent lipolytic and atrophic effect of 40mg/mL triamcinolone acetonide would atrophy symptomatic lipomas so surgical excision could be avoided. Design: This was a cohort study. Setting: This study took place in an ultrasound injection clinic. Participants: Eight subjects with painful symptomatic lipoma were included. Measurements: Preprocedurally, the margins of the lipomas were palpated and marked with ink, then measured in centimeters (cm). Small lipomas (1-3cm) were injected with 40mg triamcinolone acetonide, while large lipomas (4-6cm) were injected with 80mg of triamcinolone acetonide. The subjects were reassessed at a four-month follow-up appointment and then again at one year and two years after the procedure. Results: Pre-injection, all eight subjects had symptoms related to impingement or pain with compression of the lipoma. At four months post-injection, none of the patients had symptoms attributable to the lipoma (p<0.001). The mean lipoma palpable dimension was 5.0±1.2cm prior to the injection and was 2.0±1.1cm at four months after the injection, with a significant mean 3.0±0.3cm (60%) reduction in lipoma dimensions (p<0.001). Two subjects demonstrated some mild hypopigmentation of the skin at four months post-injection. Within two years, three lipomas had symptomatically recurred, one of which was removed surgically and the two of which were reinjected. There were no infections or other serious adverse reactions that occurred. Conclusions: For individuals with painful subcutaneous lipoma, intralesional injection of 40mg/mL of triamcinolone acetonide is an effective and safe alternative to surgical excision or injection of sclerosing agents and should be considered as a reasonable therapeutic alternative in select patients.

Outcomes and cost-effectiveness of ultrasound-guided injection of the trochanteric bursa.

We hypothesized that ultrasound (US) guidance improves outcomes of corticosteroid injection of trochanteric bursitis. 40 patients with greater trochanteric pain syndrome defined by pain to palpation over the trochanteric bursa were randomized to injection with 5 ml of 1% lidocaine and 80 mg of methylprednisolone using (1) conventional anatomic landmark palpation guidance or (2) US guidance. Procedural pain (Visual Analogue Pain Scale), pain at outcome (2 weeks and 6 months), therapeutic duration, time-to-next intervention, and costs were determined. There were no complications in either group. Ultrasonography demonstrated that at least a 2-in (50.8 mm) needle was required to consistently reach the trochanteric bursa. Pain scores were similar at 2 weeks: US: 1.3 ± 1.9 cm; landmark: 2.2 ± 2.5 cm, 95% CI of difference: - 0.7 < 0.9 < 2.5, p = 0.14. At 6 months, US was superior: US: 3.9 ± 2.0 cm; landmark: 5.5 ± 2.6 cm, 95% CI of difference: 0.8 < 1.6 < 2.4, p = 0.036. However, therapeutic duration (US 4.7 ± 1.4 months; landmark 4.1 ± 2.9 months, 95% CI of difference - 2.2 < - 0.6 < 1.0, p = 0.48), and time-to-next intervention (US 8.7 ± 2.9 months; landmark 8.3 ± 3.8 months, 95% CI of difference - 2.8 < - 0.4 < 2.0, p = 0.62) were similar. Costs/patient/year was 43% greater with US (US $297 ± 99, landmark $207 ± 95; p = 0.017). US-guided and anatomic landmark injection of the trochanteric bursa have similar 2-week and 6-month outcomes; however, US guidance is considerably more expensive and less cost-effective. Anatomic landmark-guided injection remains the method of choice, but should be routinely performed using a sufficiently long needle [at least a 2 in (50.8 mm)]. US guidance should be reserved for extreme obesity or injection failure.

Image-directed fine-needle aspiration biopsy of the thyroid with safety-engineered devices.

PURPOSE: The purpose of the present study was to integrate safety-engineered devices into outpatient fine-needle aspiration (FNA) biopsy of the thyroid in an interventional radiology practice. MATERIALS AND METHODS: The practice center is a tertiary referral center for image-directed FNA thyroid biopsies in difficult patients referred by the primary care physician, endocrinologist, or otolaryngologist. As a departmental quality of care and safety improvement program, we instituted integration of safety devices into our thyroid biopsy procedures and determined the effect on outcome (procedural pain, diagnostic biopsies, inadequate samples, complications, needlesticks to operator, and physician satisfaction) before institution of safety devices (54 patients) and after institution of safety device implementation (56 patients). Safety devices included a patient safety technology-the mechanical aspirating syringe (reciprocating procedure device), and a health care worker safety technology (antineedlestick safety needle). RESULTS: FNA of thyroid could be readily performed with the safety devices. Safety-engineered devices resulted in a 49% reduction in procedural pain scores (P < 0.0001), a 56% reduction in significant pain (P < 0.002), a 21% increase in operator satisfaction (P < 0.0001), and a 5% increase in diagnostic specimens (P = 0.5). No needlesticks to health care workers or patient injuries occurred during the study. CONCLUSIONS: Safety-engineered devices to improve both patient and health care worker safety can be successfully integrated into diagnostic FNA of the thyroid while maintaining outcomes and improving safety.

Syringe and needle size, syringe type, vacuum generation, and needle control in aspiration procedures.

PURPOSE: Syringes are used for diagnostic fluid aspiration and fine-needle aspiration biopsy in interventional procedures. We determined the benefits, disadvantages, and patient safety implications of syringe and needle size on vacuum generation, hand force requirements, biopsy/fluid yield, and needle control during aspiration procedures. MATERIALS AND METHODS: Different sizes (1, 3, 5, 10, and 20 ml) of the conventional syringe and aspirating mechanical safety syringe, the reciprocating procedure device, were studied. Twenty operators performed aspiration procedures with the following outcomes measured: (1) vacuum (torr), (2) time to vacuum (s), (3) hand force to generate vacuum (torr-cm2), (4) operator difficulty during aspiration, (5) biopsy yield (mg), and (6) operator control of the needle tip position (mm). RESULTS: Vacuum increased tissue biopsy yield at all needle diameters (P<0.002). Twenty-milliliter syringes achieved a vacuum of -517 torr but required far more strength to aspirate, and resulted in significant loss of needle control (P<0.002). The 10-ml syringe generated only 15% less vacuum (-435 torr) than the 20-ml device and required much less hand strength. The mechanical syringe generated identical vacuum at all syringe sizes with less hand force (P<0.002) and provided significantly enhanced needle control (P<0.002). CONCLUSIONS: To optimize patient safety and control of the needle, and to maximize fluid and tissue yield during aspiration procedures, a two-handed technique and the smallest syringe size adequate for the procedure should be used. If precise needle control or one-handed operation is required, a mechanical safety syringe should be considered.

Does sonographic needle guidance affect the clinical outcome of intraarticular injections?

OBJECTIVE: This randomized controlled study addressed whether sonographic needle guidance affected clinical outcomes of intraarticular (IA) joint injections. METHODS: In total, 148 painful joints were randomized to IA triamcinolone acetonide injection by conventional palpation-guided anatomic injection or sonographic image-guided injection enhanced with a one-handed control syringe (the reciprocating device). A one-needle, 2-syringe technique was used, where the first syringe was used to introduce the needle, aspirate any effusion, and anesthetize and dilate the IA space with lidocaine. After IA placement and synovial space dilation were confirmed, a syringe exchange was performed, and corticosteroid was injected with the second syringe through the indwelling IA needle. Baseline pain, procedural pain, pain at outcome (2 weeks), and changes in pain scores were measured with a 0-10 cm visual analog pain scale (VAS). RESULTS: Relative to conventional palpation-guided methods, sonographic guidance resulted in 43.0% reduction in procedural pain (p < 0.001), 58.5% reduction in absolute pain scores at the 2 week outcome (p < 0.001), 75% reduction in significant pain (VAS pain score > or = 5 cm; p < 0.001), 25.6% increase in the responder rate (reduction in VAS score > or = 50% from baseline; p < 0.01), and 62.0% reduction in the nonresponder rate (reduction in VAS score < 50% from baseline; p < 0.01). Sonography also increased detection of effusion by 200% and volume of aspirated fluid by 337%. CONCLUSION: Sonographic needle guidance significantly improves the performance and outcomes of outpatient IA injections in a clinically significant manner.

Introduction of new safety technologies into central venous access.

The American Society of Anesthesiologists, the Anesthesia Patient Safety Foundation, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), and the Patient Safety and Quality Improvement Act of 2005 encourage anesthesiology departments to institute systematic improvements in patient safety, including but not limited to integration of new safety technologies. The evaluation and method of use of the reciprocating procedure device in central venous access is presented.

Integration of new safety technologies for needle aspiration of breast cysts.

INTRODUCTION: National and international regulatory agencies and professional societies mandate systematic improvements in both the safety of patients and heath care workers (HCW), including the integration of safety technologies into the procedures of obstetrics and gynecology (Ob-Gyn). MATERIALS AND METHODS: Using national resources for patient safety and literature review, these safety technologies were identified: (1) a safety needle to reduce needle sticks to HCW, and (2) the reciprocating procedure device (RPD) to reduce injuries to patients. These technologies were introduced in a trial fashion into routine breast cyst aspiration, and physician responses were determined. RESULTS: The safety needle presented a number of difficulties associated with the safety sheath, but could be used efficiently for breast cyst aspiration. The RPD safety device functioned well for breast aspiration procedures and was well accepted by physicians. CONCLUSIONS: New safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during outpatient breast procedures. Since these technologies have been demonstrated to decrease injuries to patients and HCW by 60-70%, serious efforts should be undertaken to systematically integrate safety technologies into the routine practice, including aspiration of breast cysts.

Integration of patient safety technologies into sclerotherapy for varicose veins.

The American College of Surgeons, the Joint Commission, the Needlestick Safety and Prevention Act, and the Occupational Safety and Health Administration all direct surgical departments, including vascular surgeons who supply sclerotherapy services, to develop formal mechanisms to improve the safety of the patient and health care worker (HCW), including integration of new safety technologies. The purpose of the present study was to identify and evaluate new safety technologies for outpatient sclerotherapy for chronic venous disease. Using national resources for patient safety and literature review, the following safety technologies were identified: (1) a safety needle to reduce inadvertent needlesticks to workers, and (2) the reciprocating procedure device (RPD) to reduce iatrogenic injuries to patients. Both devices were evaluated in the clinic, and physician responses were determined. Although the safety sheath of the needle was somewhat bulky and could interfere with the ultrasound transducer, sclerotherapy could be performed with it. The RPD safety device required instruction to show how the RPD functioned ("push-push" to aspirate-inject with the RPD rather than the usual "push-pull" with the conventional syringe), but the RPD permitted better needle control and more precise injections. The RPD was well accepted by physicians who found it to be convenient, safer, and less painful. Subsequently, the involved services successfully integrated these safety technologies into their routine clinical practices. As recommended by the Joint Commission, safety technologies can be successfully evaluated and introduced into the clinic to improve patient and HCW safety during physician-performed syringe and needle procedures, including sclerotherapy.

Control and performance characteristics of eight different suction biopsy devices.

PURPOSE: To determine the control and performance characteristics of eight different suction biopsy devices. MATERIALS AND METHODS: Physician control of the syringe and needle was measured precisely with the validated linear displacement method during the aspiration phase and during five biopsy passes. The visual analog scale was used to measure operator difficulty in the following domains: (i) attachment to the needle, (ii) generation of vacuum, (iii) detection of loss of vacuum, (iv) release of the vacuum, and (v) clearing of the sample from the needle. RESULTS: Performance in various phases of the biopsy procedure varied widely among the biopsy devices tested. Unintended forward penetration (ie, loss of control in the forward direction) was significant with the reverse aspiration syringe (31.5 +/- 1.7 mm), three-ringed control syringe (25.4 +/- 4.1 mm), BioSuc-C7 syringe (28.3 +/- 1.9 mm), conventional syringe with a plunger lock (6.1 +/- 1.5 mm), syringe pistol (9.2 +/- 2.4 mm), and conventional syringe (3.8 +/- 2.9 mm) but was significantly less for the reciprocating procedure device (RPD; 0.7 +/- 0.7 mm; P

Physician control of needle and syringe during aspiration-injection procedures with the new reciprocating syringe.

OBJECTIVE: To evaluate physician control of needle and syringe during aspiration-injection syringe procedures by comparing the new reciprocating procedure syringe to a traditional conventional syringe. METHODS: Twenty-six physicians were tested for their individual ability to control the reciprocating and conventional syringes in typical aspiration-injection procedures using a novel quantitative needle-based displacement procedure model. Subsequently, the physicians performed 48 clinical aspiration-injection (arthrocentesis) procedures on 32 subjects randomized to the reciprocating or conventional syringes. Clinical outcomes included procedure time, patient pain, and operator satisfaction. Multivariate modeling methods were used to determine the experimental variables in the syringe control model most predictive of clinical outcome measures. RESULTS: In the model system, the reciprocating syringe significantly improved physician control of the syringe and needle, with a 66% reduction in unintended forward penetration (p < 0.001) and a 68% reduction in unintended retraction (p < 0.001). In clinical arthrocentesis, improvements were also noted: 30% reduction in procedure time (p < 0.03), 57% reduction in patient pain (p < 0.001), and a 79% increase in physician satisfaction (p < 0.001). The variables in the experimental system--unintended forward penetration, unintended retraction, and operator satisfaction--independently predicted the outcomes of procedure time, patient pain, and physician satisfaction in the clinical study (p < or = 0.001). CONCLUSION: The reciprocating syringe reduces procedure time and patient pain and improves operator satisfaction with the procedure syringe. The reciprocating syringe improves physician performance in both the validated quantitative needle-based displacement model and in real aspiration-injection syringe procedures, including arthrocentesis.