A little-known cause of painful shoulder: os acromiale.

The incidental discovery of an 'os acromiale' might explain some cases of 'painful shoulder': this is what we have observed in three patients. The purpose of our article is to underline the relevance of the axillary roentgenogram of the shoulder for the correct diagnosis of this anomaly. In all patients the radiographic examination was performed using a computed radiography system; moreover we performed a computed tomographic examination of the acromioclavicular portion of the shoulders with three-dimensional reconstructions.

Clinical trials in rheumatoid arthritis: methodological suggestions for assessing radiographs arising from the GRISAR Study. Gruppo Reumatologi Italiani Studio Artrite Reumatoide.

OBJECTIVES: The three x ray assessors of the GRISAR study (blinded to treatment) gave consensual erosion and damage scores to the baseline and 12 month radiographs of 284 rheumatoid arthritis (RA) patients using three different methods: single readings (blinded as to patient and chronological sequence of the x rays), paired readings (blinded as to sequence), and chronologically ordered paired readings. The aim was to evaluate which of these reading procedures is the most appropriate for clinical trials. METHODS: The progression of the scores obtained using each procedure was compared by means of descriptive statistics, principal components analysis, and intra-patient correlation coefficients of pairs of methods. Bootstrap estimates of the variance of the difference in the means of two equally sized random samples were calculated to evaluate the power of the statistical analysis performed to assess the possible treatment effect for both paired and chronological reading methods. RESULTS: (a) The standard deviations of the paired and chronological readings were similar, but that of the single readings was higher. (b) The knowledge that two x rays were of the same patient accounted for a sizeable proportion of the between method variability. (c) Agreement was satisfactory between the paired and chronological methods for both scores but, between them and the single readings, it was modest for erosions and poor for damage. (d) The bootstrap estimate of the variance of the difference was smaller for the paired than the chronological method, possibly giving it greater power to test treatment effect. CONCLUSIONS: These results suggested that paired readings were the most suitable for evaluating the progression of joint damage in the GRISAR study.

The radiological assessment of rheumatoid arthritis.

Antirheumatic therapy has changed from a rather conservative approach towards more aggressive early intervention. Objective measures of the course and outcome of rheumatoid arthritis are essential to understand the disease process and evaluate the therapeutic response. Radiological evaluation fulfils many of the criteria of objectivity: the films provide a permanent record and can be evaluated serially and repeatedly; the changes do not fluctuate with disease activity; and good technique and correct timing can keep the radiation load to a very acceptable level. Consequently, therapies can be evaluated on the basis of their efficacy on radiological progression. In clinical practice, a visual qualitative assessment is usually sufficient, but for therapeutic trials or studies of disease progression in certain patient groups, quantitative methods are needed. A number of different evaluation systems have been introduced, but none of these have gained universal acceptance. No ideal evaluation method (which should be rapid, easy to use and have a good level of reproducibility) has yet been found. Here we make provisional recommendations on the conduct of future therapeutic trials to maximise the likelihood that they will give conclusive results using radiographic outcome assessments.

Radiographic changes in the feet of patients with early rheumatoid arthritis. GRISAR (Gruppo Reumatologi Italiani Studio Artrite Reumatoide)

OBJECTIVE: To assess the value of radiographs of the feet of patients with early rheumatoid arthritis (RA) in the evaluation of RA classification and outcome. METHODS: Within a multicenter therapeutic trial, baseline and 12 month radiographs of the hands, wrists, and feet of 284 patients with early RA (< or = 4 years; mean 1.4; median 0.6) were scored according to a modified Larsen-Dale method by an independent radiological reading committee, blinded to the treatment, clinical, and laboratory data. RESULTS: Thirty-two patients (11%) had only foot erosions at baseline. Twelve month progression in the eroded joint count was more frequent in the patients with foot erosions than in those without (63% CI 55 divided by 71 vs 42% CI 35 divided by 50). CONCLUSION: Foot radiographs facilitate the identification of patients with early erosive RA. Foot involvement is indicative of more aggressive disease. Assessment of foot radiographs allows the most adequate therapeutic strategy to be adopted.

The pelvic digit: five new examples of an unusual anomaly.

Five new cases of a rare congenital anomaly known as the "pelvic digit", were each discovered incidentally on a radiographic examination of the pelvis. The features are described, using tomograms in some cases to show the most important and typical radiographic signs of this anomaly. We review the cases previously reported in the literature and discuss the features in the differential diagnosis between the pelvic digit, myositis ossificans, avulsion injury of the pelvis and the pelvic rib.

[Statistics of bone mineral density determined with a double-energy X-ray equipment]. / Statistica dei valori di densità minerale ossea determinati utilizzando una apparecchiatura a raggi X con doppia energia.

This study was aimed at analyzing the bone mineral density values measured in a non-selected sample of more than 2,500 Italian women from the Treviso province. The subjects were divided into nine 10-year age groups. The figures (%) in each age group are presumed to be constant over time, although arranged on a Gaussian curve because of high interperson variability. The tables with normal rates, made on the basis of the data obtained, represent the reference parameters to evaluate bone mineral content in all the women referred to our hospital for this particular reason. The tables mirror, with the highest possible accuracy, the typical figures of the female population in Treviso, inasmuch as those findings were obtained from a statistically homogeneous sample (that is, uniform in nature). On the other hand, slight differences were observed relative to the figures of population segments other than our study population. Since the risk of bone fractures is related to how quickly bone mass decreases over time, seriated measurements should be compared with the normal curve which is similar in women of every race. Thus, the tables indicate probable normality whenever the figure found for one woman falls within the normal age and race ranges the patient belongs to. If the patient belongs to a population with different lifestyle and environmental factors, the tables are but indicative; for more accurate evaluation, a late control should be made. On the contrary, if rates are markedly lower than normal, a control should be made much sooner. Moreover, the correlations between the bone density rates found in different bone segments indicate the very poor chance of predicting fracture risk at a different point from the examined one. This means that the body areas at greater risk must be studied separately. Finally, we stress the reason why it is impossible to obtain the very same information from bone mineral content measurements on the whole skeleton and how these data can be used.

[The physical aspects of traditional radiology and of computed radiology compared]. / Aspetti fisici della radiologia tradizionale e della radiologia computerizzata a confronto.

In the last decade a new radiographic technique has been establishing itself which makes the most of technological progress in the fields of laser optics, of materials and of computer science and integrates conventional techniques introducing the digital image also into radiographic diagnosis. The authors, who have gained a wide experience in both the theory and the applications of Computed Radiography (CR), carefully reviewed Italian literature and found no review article on technical theoretical principles, while many such papers are found in international literature. Therefore, they took the lead for a review paper on this subject. For easier reading, the paper was divided into three parts: the first one is the necessary introduction to the physical parameters to understand radiographic images, i.e., the signal-to-noise ratio, the modulation transfer function, the Wiener spectrum and the detective quantum efficiency. The second part deals with the physical features of the formation of conventional radiographic images: the latest notions about the conversion of X-ray energy into light photons by intensifying screen phosphors are here reported. Finally, radiographic image readability is related to the characteristics of the screen-film system. The third part of the paper deals with CR, in particular with the problems related to image acquisition through the screens called imaging plates, to the laser reading technique and to image reconstruction. Finally, the different physical phenomena leading to radiant image degradation are examined sequentially, bearing in mind that the diagnostic yield of CR images can be improved with image processing, to obtain images which can be compared to conventional ones.

[Bone mineral content measurement: reflections on the equipment]. / Misura della componente minerale dell'osso: riflessioni sulle apparecchiature.

Metabolic bone disorders are extremely interesting from an epidemiological, clinical and social point of view. In particular, some of them are important for they are typical of elderly people--i.e., the portion of population which is on the increase due to the lengthening of the average life. On the other hand, thanks to the current intervention techniques, the number of chronic nephropathics (in whom metabolic bone conditions may develop) has markedly increased. Therefore, sufficiently reliable methods are needed to allow the thorough evaluation of bone mineral components. Unfortunately, these methods are only of quantitative value because they are unable to discriminate the statuses of the two essential bone components--i.e., cortex and spongiosa--; we all know that bone mineral loss can currently be quantified only when amounting to < 20% of the total value, due to the addition of the mineral contents of the two components. In this paper the authors briefly report on the noninvasive techniques currently in use for the measurement of bone mineral components, especially relative to their physical bases, the knowledge of which is essential for a correct evaluation. The authors accurately reviewed the literature data relative to the various techniques and compared the results obtained by the different authors. Thus, no personal experience is reported, since this paper is aimed at being considered as a reference mark for the reader to be helped in the choice of the equipment suiting him most. However, as to preventing metabolic osteopathies, quantitative methods cannot yield absolute data, which addresses the current research to densitometry by means of the Compton method. The latter may finally lead to the development of operative equipment allowing not only the separate measurement of cortical and spongiose values, but also the qualitative evaluation of bone status--i.e., not limited to mineral loss but including also the determination of the protein, fat and water components.

[Extrarenal ultrasound and color Doppler: renal artery stenosis]. / Eco e color Doppler extrarenale: la stenosi dell'arteria renale.

There is a long term interest in noninvasive Doppler (Duplex Doppler, Color Doppler) methods to screen patients with reno-vascular hypertension resistant to medical therapy. Doppler criteria for the diagnosis of renal artery stenosis in native kidneys vary (peak systolic velocity exceeding 100 cm/sec; RAR (Renal Aortic Ratio) exceeding 3.5; Doppler shift frequency exceeding 6-8 KHz; dampened peripheral waveform; lack of signal in complete occlusion). When the vessels are adequately visualized (about 40% of cases) sensitivity and specificity are quite good (80-90%). In the transplanted kidney Doppler diagnosis of renal artery is easier (diagnostic accuracy about 90%). The diagnostic criteria have been well codified (Doppler shift of 7.5 KHz at an insonating frequency of 3 MHz).

[The hypothesis of a diagnostic-prognostic assessment of intestinal invagination with the aim of treatment by echo-guided pneumatic reduction]. / Ipotesi di valutazione diagnostico-prognostica della invaginazione intestinale finalizzata al trattamento con riduzione pneumatica ecoguidata.

The authors investigated the role of US in the diagnostic-prognostic evaluation of enteric intussusception, for the use of US-guided pneumatic reduction (RPEG). In the last 5 years, 59 young patients were examined; 44 of them had clinically suspected enteric intussusception which was confirmed by US. US allowed site and nature of the condition to be demonstrated (sensitivity and specificity: 100%), while supplying helpful predictive prognostic elements as to the extent of intussuscepted loop involvement (predictive prognostic value: 100%). On the contrary, its etiological screening capabilities were poor (11%) in the identification of secondary forms (5 ileal diverticula). A grading score was introduced to select the patients undergoing RPEG. Six clinical and US parameters were considered, with values increasing according to severity of the condition. The higher the score, the lower the chances of therapeutical success with RPEG. In 3 cases (2 loop necroses and 1 severe intestinal obstruction) with US score greater than 6 [9] and clinical score greater than 11 [15], RPEG, was replaced by surgery. Fourteen patients underwent RPEG: positive results were obtained in 12 cases (85%). In one case, a short-term relapse (within 6 hours) was observed.

[The echo-guided fine-needle biopsy of thoracic and abdominal masses]. / Agobiopsia ecoguidata con ago sottile su masse toraciche e addominali.

Five hundred and seventy-two US-guided fine-needle biopsies were performed on 561 patients (1.2 puncture/patient); in two cases only minor complications were observed. The patients were 12 to 86 years old--most of them ranging 40 to 75. In 5.42% of cases FNAB proved inadequate; 1.75% of the diagnoses was questionable, 28.89% was negative, and 63.98% positive. A comparison with histology was possible in 218 cases: 2 false positives and 5 false negatives were observed. The low rate of false-positive findings demonstrates US-guided FNAB to have high positive predictive value. The method had 95% sensitivity, 98.4% specificity and 84.3% accuracy. The high reliability of FNAB depends on the possibility of centering the lesion through the direct US visualization of the needle tip. This characteristic, together with the presence of the cytologist, who immediately evaluates the aspirated material, helps reduce the number of unnecessary biopsies and, consequently, complications.

[The intraoperative echography of malignant hepatic lesions]. / Ecografia intraoperatoria nelle lesioni maligne epatiche.

IOU (intraoperative ultrasound) is nowadays an indispensable technique for the surgeon to confirm the information collected from preoperative tests or to gain further information that may modify surgical strategy. A series of 350 patients were studied with IOU: in 67 cases the liver was involved, with 23 malignant lesions. In the latter group, 10 lesions were found which had been missed even at palpation; the size of 9 of them could be correctly assessed, which had been overestimated in 8 cases and underestimated in 1 before surgery. Moreover, in 39.1% of the cases, the information yielded by IOU determined a change in surgical strategy, favoring a more accurate dissection of the lesion. Surgery was modified depending on the recognition of: nonpalpable lesions (5 cases); portal thrombosis (1 case); lesions bigger (2 cases)--smaller (2 cases) than preoperatively diagnosed. Moreover, IOU was a useful tool to guide the surgeon during intervention, by yielding accurate anatomical information on the segment/segments hosting the lesion.

[Utility of the Doppler technique in the uro-nephrologic field]. / Utilità delle tecniche Doppler in campo uro-nefrologico.

Doppler techniques (echo Doppler, Color Doppler) may be useful in many urologic and nephrologic applications. Renal vein thrombosis can be determined by discovering a combination of a distended, thrombus-filled renal vein and the absence of detectable flow. The use of Doppler as screening technique for suspected renal artery hypertension remains controversial. Although patency of the renal artery can be assessed by Doppler, it is difficult to evaluate always the entire course of the vessel and it is impossible to detect multiple renal arteries. In the renal masses Doppler can investigate the vascularity: most malignant lesions gives rise to abnormal, high frequency, Doppler shifted signals that can aid the differential diagnosis of benign and malignant conditions. Doppler has recently been shown to help distinguish between the dilated renal pelvis and renal obstruction. A Resistive Index (RI) of 0.70 or greater is suspicious for obstruction, while a value of less than this virtually rules out the diagnosis in most cases. The use of Doppler techniques in renal transplants has become routine. Doppler assesses the presence of blood flow in the main renal arteries and veins, the presence of post-surgical abnormalities such as pseudo-aneurysms, stenoses, A-V fistulas and has proven useful in the evaluation of flow waveforms associated with variety of different abnormalities which can produce a decrease in renal function. Acute vascular rejection produces an increased resistance to flow with decreased, absent or reversed diastolic flow within the transplant kidney. Severe rejection produces abnormalities of the RI which are non-specific; severe acute tubular necrosis, infections, obstructions, peri-renal collections can also produce elevated RI.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ultrasonography of the borderline between normal and pathological state of the hip in newborn infants (borderline hip)]. / Reperti al confine fra normale e patologico nell'ecografia dell'anca neonatale (anca "borderline").

Infant hips are classified, according to Graf, in 4 US types on the basis of the morphologic changes in both the cartilaginous and the bony roofs (type I, II, III, IV). Out of 6,000 examined hips, 170 (2.8%) were considered, which could be classified neither as type I (mature) nor as type II (delayed/immature ossification). These hips were called borderline hips. They exhibited some characteristic US features: good bone modeling, rounded cotyle, and alpha angle 60 degrees +/- 2. They were always observed during the first month of the patients' life. Anamnestic data were not specific (27.5% breech delivery, and 13% oligohydramnios); clinics sometimes overestimated the actual anatomic development (64/170 cases with positivity of Ortolani's sign and/or restricted abduction; 25% of patients presented with no suspicious signs). Dynamic hip examination showed only physiological cranial deflection of the cartilaginous roof. Finally, borderline hips developed into type I hips in 99% of cases, within the third month of the patients' life.

[Diagnostic errors in the echography of the hip in newborns]. / Errori nell'ecografia dell'anca neonatale.

Neonatal hip sonography according to Graf employs a standardized image in a frontal section plane ("3-point system") and a good scanner adjustment (the femoral head must be anechoic, like the hyaline cartilage roof triangle). Pathologic conditions can change some of these parameters. The authors examined 6,000 neonatal hips in order to point out the commonest causes of diagnostic error. Two types of error were considered: method errors and interpretation errors. Method errors: they are due to the choice of transducer and frequency, to scanner adjustment and definition of the standard section plane. Their incidence was 2.25% and supported by an uncorrect definition of the standard section plane. Interpretation errors: they come from the wrong localization of some reference points--i.e., lower iliac margin, labrum--, uncorrect evaluation of increased echogenicity of the cartilaginous roof, infant age, application of radiographic criteria and uncorrect measurements of alpha and beta angles. Interpretation errors had 5.5% incidence; they were all due to the uncorrect measurement of alpha (3.18%) and beta (2.33%) angles, especially in pathological hips (68%). To reduce the number of errors, the authors suggest to strictly apply Graf's method, to make a diagnosis based on the morphological changes of the cartilaginous and osseous acetabular roof and, only later on, to measure alpha and beta angles to confirm the diagnosis or in the follow-up.

[Prostaglandin E2 liberation in the synovial fluid induced by organo-iodinated contrast media. Interrelations with the genesis of post-arthrographic pain]. / Liberazione di prostaglandina E2 nel liquido sinoviale indotta da mezzi di contrasto organoiodati. Interrelazione con la genesi del dolore postartrografico.

RCM have been observed to cause--during arthrography--the appearance of a slow onset painful symptomatology with the clinical characteristics of a slight and transient acute arthritis. These substances are supposed to set in a production of humoral mediators of inflammation with algogenic action--PGE2 in particular. During arthrography of the knee the release of synovial fluid PGE2 after RCM introduction was studied. Two RCM were compared: meglumine iothalamate and iopamidol. Twenty patients underwent arthrography of the knee: synovial fluid PGE2 concentration was measured both before and 15' after RCM introduction with 125I-RIA method. Results show a significant increase in PGE2 concentration after both iothalamate (p less than 0.0001) and iopamidol (p less than 0.01) --especially in iothalamate--treated patients (p less than 0.01). A physiopathologic mechanism about post-arthrographic pain and, more generally, about RCM toxicity is thus hypothesized.

[Accessory spleen: echographic images]. / La milza accessoria: quadri ecografici.

In a three-year period, 25 cases of accessory spleen were diagnosed by means of ultrasound. Accessory spleens were demonstrated to be eterotopic nodes of normal splenic tissue, situated usually near the main spleen, to which they may be bound by a pedicle. Their dimensions are usually less than 2 cm. Accessory spleen is usually present in a 10% of normal subjects and represents a TC or US occasional finding. When large, the accessory spleen causes problems about a differential diagnosis with neoplasms of the left upper quadrant. It must not be confused with polysplenia or with splenosis; TC, angiography and scintigraphy may be useful in these cases.

[Echotomography in the study of the pathology of Achilles tendon]. / L'ecotomografia nello studio della patologia del tendine di Achille.

Achilles tendon was evaluated by B scan ultrasound in 54 cases (20 normal and 34 symptomatic subjects). The ultrasonographic features of tendon's diseases were correlated with the anatomical patterns. On the basis on their experience, the authors concluded that ultrasonography is a simple and highly accurate method for the diagnosis of Achilles tendon diseases and that it should be the initial imaging procedure.