Incidence of hip osteonecrosis among renal transplantation recipients: a prospective study.

AIM: To investigate whether a lessened glucocorticoid cumulative dose would lead to a decreased incidence of femoral head osteonecrosis. METHODS: Newly transplanted in-patients (n = 49) underwent hip radiographs and magnetic resonance imaging (MRI) a mean of 17.0+/-4.3 (range 8-29) days after renal transplantation. For the 48 patients without evidence of prevalent osteonecrosis, imaging at a mean of 5.9+/-0.8 (range 4.8-8.7) months after renal transplantation was graded for presence/absence of femoral head osteonecrosis by two blinded radiologists. Sociodemographic and disease characteristics of patients were compared to identify potential associations with incident osteonecrosis. RESULTS: At 6-month follow-up, only two patients (4%) had osteonecrosis of the femoral head (three hips). The two primary radiologists had excellent agreement between osteonecrosis diagnosis (kappa coefficient=0.78). Both cases of a definite MRI diagnosis of osteonecrosis occurred in patients who were in the highest tertile of glucocorticoid dosage. CONCLUSION: Osteonecrosis was uncommon among a prospective cohort of renal transplant recipients within 6 months after engraftment.

MTX affects inflammation and tissue destruction differently in the rat AA model.

OBJECTIVE: To investigate the dose response relationships of methotrexate (MTX) therapy in rat adjuvant arthritis (AA), an animal model of rheumatoid arthritis (RA). METHODS: Female Lewis rats were fed a defined diet and were treated with 0, 0.3, 1, 2, 3, 5, and 10 mg MTX per week beginning 3 days after adjuvant injection and lasting 6 weeks. The presence or absence of arthritis, and its degree were measured by hindpaw edema scores, ankle widths, and radiographic and histopathologic scores. RESULTS: The 2, 3, 5, and 10 mg MTX per week doses resulted in deaths before the end of the protocol and suppressed normal body weight gain. Tissue destruction, measured by radiographic and histopathologic scores, was reduced in a dose dependent manner with increasing MTX dose. Suppression of inflammation, measured by ankle widths and radiographic and histopathologic scores, reached a maximum at the 1 mg MTX dose and declined at higher doses. CONCLUSIONS: Suppression of tissue destruction and inflammation in rat AA does not occur in a concerted fashion as the dose of MTX increases. The implications of these findings to human disease remain to be determined.

Reducing the cost of diagnosis of breast carcinoma: impact of ultrasound and imaging-guided biopsies on a clinical breast practice.

BACKGROUND: The objective of this study was to determine whether the use of ultrasound and percutaneous breast biopsies in patients with screen-detected nonpalpable abnormalities can reduce benign open surgical biopsies of the breast without increasing cost or sacrificing detection of potentially curable breast carcinomas. METHOD: Using a computerized mammography database and consecutive logs of needle localization procedures and fine- and large core needle biopsies of a single university-based breast imaging practice, the authors determined the breast carcinoma yield and cost of diagnosis over a 14-year period and the changes that occurred over time with the sequential introduction of ultrasound, ultrasound-guided biopsies, and stereotactic biopsies. RESULTS: The overall breast carcinoma yield for needle localization biopsies of nonpalpable lesions increased from 21% in 1984 to 68% in 1998 (P < 0.0001). The yield for nonpalpable masses increased from 21% to 87% (P < 0.0001) over the same period. The selective use of ultrasound alone and percutaneous fine- and large core needle biopsy resulted in a substantial reduction in benign open surgical biopsies. A cost analysis showed a 50% reduction in the average expense of discovering breast carcinoma. The breast carcinomas detected after introduction of these methods were prognostically favorable with 88% measuring 1.5 cm or less in size and 66% measuring less than 1 cm. CONCLUSIONS: Selective use of ultrasound and imaging-guided percutaneous biopsies can significantly reduce the number of benign open surgical biopsies generated by mammographic screening. This can result in substantial cost savings without decreasing the sensitivity for detecting small potentially curable lesions.

Three-dimensional reconstruction system for imaging of the temporomandibular joint using magnetic resonance imaging.

This study was undertaken to develop a three-dimensional reconstruction system using magnetic resonance (MR) images in order to visualize three-dimensional images of the temporomandibular joint (TMJ) including the disk. The computerized reconstruction program (written using Visual Basic for Windows, Microsoft Corp.) could reliably generate three-dimensional images of the TMJ. Image processing techniques made the tracing of images unnecessary, reduced complex human manipulation and associated measurement errors. This system, capable of treating fifty thousand pixels or more, generates smooth three-dimensional images of the TMJ.

PACS and CR implementation in a level I trauma center emergency department.

Implementation of a picture archive and communication system (PACS) at a large teaching hospital is an expensive and daunting endeavor. The approach taken at the University of Alabama Hospitals has been to assemble an institution-wide system through focused integration of smaller mini-PACS. Recently a mini-PACS using Computed Radiography (CR) has been placed in the Emergency Department (ED) of a Level I Trauma Center completely replacing conventional screen-film radiography. This area of the hospital produces approximately 250 images per day and provided many challenging requirements: the need for rapid radiography; providing good image quality for difficult examinations with potentially uncooperative patients; reproduction of lost films to maintain availability of images to multiple consulting teams; and frequently unknown patient demographics. The PACS includes both vendor-supplied and in-house developed devices for image storage, distribution, and display. Digital images are produced using two photo-stimulable phosphor CR systems. Currently, all radiographic examinations are acquired digitally with production of a hard copy film as well as electronic distribution via the PACS. Interpretation of images is done primarily via hard copy with a goal of transition to soft copy interpretation. This paper discusses the functional requirements of the PACS and solutions to workflow issues arising in the ED.

Mammography of breasts in which catheter cuffs have been retained: normal, infected, and postoperative appearances.

OBJECTIVE: The purpose of this report is to show that Dacron (DuPont, Wilmington, DE) cuffs retained in breasts after the removal of Hickman catheters may result in complications requiring radiographic evaluation for subsequent management. We also describe potential complications, including infection, associated with a retained cuff and changes after the removal of a retained cuff. CONCLUSION: Because of the increased use of Hickman catheters for central vein access, Dacron cuffs more frequently are retained in breasts and are likely to be seen on mammograms. Radiologists need to be aware of the mammographic findings of a normal cuff, infected cuff, and the site of a surgically excised cuff.

Cartilage imaging in osteoarthritis.

Osteoarthritis (OA) is the most common articular disorder encountered worldwide. Its successful evaluation (and eventual treatment) depends on establishing a set of criteria for measuring disease progression. An ideal measurement would evaluate changes in articular cartilage, where the primary pathology of the disease takes place. Plain radiographs are the simplest and most readily employable means of joint evaluation, and now microfocal radiographs have been developed, which magnify the radiograph and help portray the joint space more accurately. However, radiography, along with nuclear medicine scans, arthrography, and computed tomography (CT) scans, are limited in their use because they are unable to detect early cartilage abnormalities. Magnetic resonance imaging (MRI) has the advantages of multiplanar imaging, soft tissue contrast, and noninvasiveness. Like radiography, MRI can underestimate the extent of cartilage abnormality. The most sensitive technique for measuring superficial articular abnormalities is arthroscopy, and small-bore arthroscopes are being used to assess knee damage in conscious, nonsedated patients. However, it is not yet clear if arthroscopy can detect subtle changes over time, and vision can be blocked by cloudy synovial fluid. Finally, although it is usually well tolerated, arthroscopy is an invasive technique.

Needle-localization biopsy of the breast: impact of a selective core needle biopsy program on yield.

PURPOSE: To determine the effect of a selective core biopsy program on the yield at needle-localization biopsy (NLB) of nonpalpable lesions. MATERIALS AND METHODS: Two hundred consecutive core biopsy samples of the breast were evaluated in an ongoing consecutive series of 1,172 NLB samples. RESULTS: Before implementation of the core biopsy program, the yield at NLB improved from 21% at 100 cases to 35% just before the introduction of core biopsy. After implementation, the yield increased gradually to 55% at 200 cases. The yield in masses increased from 21% at 100 cases to 43% just before the initiation of the core biopsy program and then increased dramatically to 72% at 200 cases. The percentage of small lesions detected did not change with implementation: 88% of invasive cancers measured less than 1.5 cm and 60% measured less than 1 cm in the last 100 cases. CONCLUSION: Appropriate selection of cases for core biopsy can more than double the yield of cancer in NLB samples without a decrease in the percentage of small cancers detected.

Successful delivery of mature twins after a ruptured interstitial heterotopic pregnancy. A case report.

A 31-year-old primigravida had a combined pregnancy consisting of intrauterine twins and an interstitial ectopic after in vitro fertilization/embryo transfer. The patient underwent repair of the ectopic pregnancy at 15 weeks of gestation, with subsequent delivery of mature twins close to term.

Arthroscopic evaluation of knee articular cartilage: a comparison with plain radiographs and magnetic resonance imaging.

OBJECTIVE: To compare radiographic, magnetic resonance imaging (MRI), and outpatient direct arthroscopic evaluation of cartilage in patients with osteoarthritis (OA) of the knee. METHODS: Thirty-three patients with OA of the knee were evaluated by plain weight bearing radiographs and arthroscopy using a 1.9 mm arthroscope under local anesthesia. Sixteen of these patients also had MRI of the knee performed. Knee compartments were evaluated using AP weight bearing and lateral radiographs of the knee. MRI and outpatient arthroscopic grading of cartilage were performed within 2 weeks of the plain radiographs. The MRI and arthroscopic evaluations were performed independently and were graded without knowledge of the other. RESULTS: In patients in whom plain radiographs, MRI, and arthroscopy were compared, the plain radiographs and MRI significantly underestimated the extent of cartilage abnormalities. There was a moderate correlation between imaged cartilage scores and the arthroscopy scores (Pearson correlation coefficient = 0.40). The arthroscopic scores were reproducible with good intra and inter-observer reliability. The arthroscopic procedure was well tolerated and actually preferred over the MRI by the majority of patients. No significant complications were noted as a result of arthroscopy. CONCLUSIONS: Our results indicate that outpatient arthroscopic evaluation is a useful method in evaluating surface cartilage abnormalities and is more sensitive in detecting these abnormalities than either plain radiographs or MRI. Outpatient arthroscopic evaluation of cartilage appears to be a safe, sensitive, and a well tolerated tool for evaluating patients with OA of the knee and may prove to be particularly useful in evaluating response to therapeutic interventions.

MR imaging of anatomy and tears of wrist ligaments.

Numerous intrinsic and extrinsic wrist ligaments are visible at magnetic resonance (MR) imaging. Because the previously published descriptions of these ligaments were often conflicting, the authors derived a classification system based on a functional perspective and their experience with MR imaging, arthroscopy, and surgical dissection. This system was used to evaluate MR images of 23 cadaveric wrists for the presence and integrity of 16 wrist ligaments. MR images were prospectively analyzed by two observers, and all findings were correlated with the results of arthroscopy. The best detection rates and diagnostic confidence rates were achieved for the triangular fibrocartilage (100% and 100%, respectively) and the scapholunate ligament (91% and 87%, respectively). Other ligaments were less well seen, partly because of their size and course. Eighty-two percent of the triangular fibrocartilage tears, 50% of the scapholunate tears, and 40% of the lunotriquetral tears seen at arthroscopy were detectable on MR images. Identification of these three types of tears on MR images is important because they are functionally significant and because there are accepted methods of treating them in orthopedic practice.

Functional magnetic resonance imaging should be included in the evaluation the cervical spine in patients with rheumatoid arthritis.

OBJECTIVE: To determine the value of functional (flexion) magnetic resonance imaging (MRI) studies in patients with rheumatoid arthritis (RA) suspected of having cervical (C)-spine involvement. METHODS: Four patients with RA suspected of having C spine involvement, with neurological symptoms and/or signs, and who had normal MRI in neutral position, underwent functional MRI. RESULTS: In all 4 patients functional MRI provided additional information. Cord compression (3 patients) and angulation of the cord (1 patient) were evident only in this view. CONCLUSION: Functional MRI provided additional information in these patients and may be indicated in patients with RA suspected of having C spine involvement who have a normal MRI study in a neutral position.

MR imaging of the hands in early rheumatoid arthritis: preliminary results.

Several magnetic resonance (MR) imaging pulse sequences (unenhanced T1 weighted spin echo, with and without fat suppression; unenhanced T2 weighted with fat suppression; and spoiled gradient-recalled acquisition in the steady state [GRASS], with fat suppression, before and after gadolinium enhancement) were analyzed in 30 patients with early rheumatoid arthritis to determine which sequences were best for imaging various aspects of the disease as manifested in the hands and wrists. A single hand was imaged in all patients. Inflammation and erosions were best seen on spoiled GRASS images with fat suppression and gadolinium enhancement, with the latter also being well seen on T1-weighted images. Articular cartilage was best seen on unenhanced spoiled GRASS or T1-weighted images with fat suppression. For the latter application, increased resolution is needed before the results will be meaningful. MR imaging has potential as an objective method for evaluating rheumatoid arthritis. However, change in MR imaging findings in a single hand must be carefully monitored and compared with the overall disease course for a long period in a large number of patients to establish the clinical value of MR imaging.

Gadolinium-enhanced MR imaging of renal masses.

Preliminary reports indicate that gadolinium-enhanced magnetic resonance (MR) imaging is highly accurate for diagnosis of renal masses. The authors demonstrate the clinical utility of MR imaging for evaluating renal masses in 26 patients for whom contrast material-enhanced computed tomography (CT) was contraindicated or inadequate for diagnosis or staging. Nine patients had complex cysts, one had a perinephric hematoma, and 16 had a solid mass (three of which were benign). All patients underwent MR imaging before and after administration of gadopentetate dimeglumine. Multiple imaging techniques and sequences were used. All tumors and no cysts enhanced with gadolinium. Even though the three benign tumors enhanced, two were differentiated from renal carcinoma on the basis of other imaging features. Unenhanced MR imaging was accurate in staging of renal carcinomas, and use of gadolinium did not improve staging accuracy. Gadolinium-enhanced MR imaging is indicated when results of CT and sonography are indeterminate for malignancy and when contrast-enhanced CT is contraindicated because of renal failure or adverse reaction to iodinated contrast material. In this latter instance, MR imaging is useful for both diagnosis and staging.

Temporomandibular joint sounds and condyle/disk relations on magnetic resonance images.

This study compared the condyle/disk relationships on magnetic resonance images (MRIs) in a group of subjects with completely silent temporomandibular joints (TMJ) when tested clinically with those in subjects with readily discernible TMJ sounds. The sounds were recorded with an accelerometer as the transducer. Selected degrees of jaw separation were electronically determined and recorded with interocclusal wafers for use with the imaging process. Of the "silent joints" 89% were found to have sounds when tested with the accelerometer. These "subclinical" sounds tended to be of shorter duration and occurred at a greater degree of vertical opening than the clinically discernable sounds. The MRIs of the group with clinically discernable sounds tended to show a change in the relationship between the head of the condyle and the intermediate zone of the disk, at the degree of jaw separation of the sound occurrence, whereas no condyle/disk change occurred in the group with "clinically silent joints." It is likely that all joints create sound during function. The different characteristics of the subclinical sounds versus the clinical sounds may indicate differing sound origins.

Leiomyosarcoma of bone. A clinicopathologic, immunohistochemical, and ultrastructural study of five cases.

The authors identified five leiomyosarcomas (LMS) in a review of 13 nonmatrix-producing spindle cell sarcomas of bone. Only two were initially recognized as LMS; the others had been diagnosed as malignant fibrous histiocytoma (two) and fibrosarcoma (one). The patients, four of whom were women, ranged in age from 32 to 70 years. Sites included proximal humerus (two), distal femur (two), and rib (one). All tumors presented with clinical and radiographic features consistent with a diagnosis of primary bone neoplasms, although one probably represented a solitary metastasis from a primary uterine LMS. Radiographs showed lytic bone destruction with a moth-eaten appearance, and three cases had soft tissue extension. Histologically, all tumors showed broad, interlacing fascicles of spindle cells with pleomorphic nuclei, frequent mitoses, and necrosis. Two cases had a focal storiform pattern and bizarre multinucleated cells, and two other cases had focally prominent osteoclast-like giant cells. Extensive immunoreactivity for muscle actin was seen in all cases and for desmin in three. In each case, electron microscopy showed definite smooth muscle differentiation including cytoplasmic filaments with densities. At this writing, two patients are free of disease (including the patient with a presumed metastasis), one is alive with locally recurrent disease, and two are dead of disease. Experience suggests that LMS of bone is a distinct clinicopathologic entity that may be more common than previously recognized. Application of immunohistochemistry and electron microscopy to nonmatrix-producing bone sarcomas should facilitate diagnosis of additional cases.

Melanotic schwannoma. Clinicopathologic, immunohistochemical, and ultrastructural features of a rare primary bone tumor.

The authors report a 35-year-old woman who presented with a lytic and blastic tumor of the ilium with soft tissue extension. The resected tumor showed light microscopic and ultrastructural features characteristic of a melanotic schwannoma. An unusual histologic finding was the presence of laminated concretions resembling psammoma bodies. Immunohistochemical stains for S-100, HMB-45, and vimentin were strongly positive. The patient is free of disease 18 months after complete surgical excision.

Patient-initiated mobile mammography: analysis of the patients and the problems.

Patient initiation of mammographic screening is one method of increasing compliance with screening mammography guidelines. A low-cost screening project using a mobile van was developed at the University of Alabama at Birmingham. Analysis of the first 2,099 patients revealed that the participants were generally white (92%), more likely to have had a previous mammogram than the norm (33% in this study vs 19% in a 1986 Gallup survey), and relatively high-risk (30% having a breast cancer risk factor). The cancer detection rate was 6.2 per 1,000 women screened, with a biopsy rate of 1.3% and a positive predictive value of 48%. More than half the cancers detected were in situ lesions or invasive carcinomas smaller than 1 cm. Our results suggest that low-cost mobile mammographic screening can operate at appropriate levels of sensitivity and specificity and is well accepted by participants. Such projects require considerable preliminary planning, significant financial and time commitment by the physicians involved, and meticulous follow-up. A mammography management software system was developed to facilitate tracking of patients for routine and diagnostic follow-up studies and rapid communication of results. Although most follow-up studies and biopsies were done in the community, resistance in the medical community was significant and is perhaps the greatest impediment to such screening endeavors.