Reliability of high-resolution ultrasound and magnetic resonance arthrography of the shoulder in patients with sports-related shoulder injuries.

INTRODUCTION: The shoulder, a very complex joint, offers a wide range of pathologies. Intraarticular abnormalities and rotator cuff injuries are mainly assessed and diagnosed by magnetic resonance arthrography (MRA). In contrast to this well-established gold standard, high-resolution ultrasound (US) offers an additional easy and excellent modality to assess the shoulder joint. Therefore, the purpose of this study was to evaluate in which anatomic structures and pathologies comparable results of US and MRA could be achieved. MATERIALS AND METHODS: In this IRB-approved prospective study 67 patients with clinically suspected labral lesions, rotator cuff rupture, or injury of the long head of the biceps (LHB) tendon were enrolled. Each participant was examined with high resolution US, and directly followed by MRA at 3 Tesla with a standard sequence protocol. To evaluate the agreement of the diagnostic performance between US and MRA a weighted kappa statistic was used. RESULTS: Both of the investigated modalities yielded a moderate to almost perfect agreement in assessing a wide range of shoulder joint pathologies. For the rotator cuff, consistency was found in 71.64% for the supraspinatus tendon, in 95.52% for the infraspinatus tendon, in 83.58% for the subscapularis tendon, and in 98.51% for the teres minor tendon. The diagnostic accuracy between both modalities was 80.60% for the LHB tendon, 77.61% for the posterior labroligamentous complex, 83.58% for the acromioclavicular joint, and 91.04% for the assessment of osseous irregularities and impaction fractures. CONCLUSIONS: High resolution US is a reliable imaging modality for the rotator cuff, the LHB tendon, and the acromioclavicular joint, so for these structures we recommend a preference for US over MRA based on its diagnostic accuracy, comfortability, cost effectiveness, and availability. If the diagnosis remains elusive, for all other intraarticular structures we recommend MRA for further diagnostic assessment.

Magnetic Resonance Imaging of Rheumatoid Arthritis: Peripheral Joints and Spine.

Both the fields of rheumatology and radiology are changing rapidly. Effective medication has become available for rheumatoid arthritis (RA) and transformed it from a progressive disabling disease into a chronic disease. Indications for magnetic resonance imaging (MRI) have changed accordingly, shifting toward early detection. There is also an overall increased clinical demand for high-end imaging. Together with improvement of MRI units and sequences, MRI protocols are adapted based on clinical indications. This article addresses (1) the clinical background and present role of MRI in early disease detection, (2) RA involvement of peripheral joints, (3) RA involvement of the spine, and (4) state-of-the-art RA MRI protocols. The key toward cost-effective MRI examination in RA is communication between radiologist and rheumatologist as well as awareness and knowledge of the basics and advancements in both fields.

Anterior Chest Wall in Axial Spondyloarthritis: Imaging, Interpretation, and Differential Diagnosis.

Anterior chest wall (ACW) inflammation is not an uncommon finding in patients with axial spondyloarthritis (ax-SpA) and reportedly occurs in 26% of these patients. Radiologists may only be familiar with spinal and peripheral joint imaging, possibly due to the inherent challenges of ACW imaging on some cross-sectional imaging modalities. Knowledge of relevant joint anatomy and the location of sites of inflammation allows the interpreting radiologist to better plan appropriate imaging tests and imaging planes. Accurate assessment of disease burden, sometimes in the absence of clinical findings, may alert the treating rheumatologist, allowing a better estimation of disease burden, increased accuracy of potential imaging scoring systems, and optimize assessment and response to treatment. This article reviews salient anatomy and various imaging modalities to optimize diagnosis, important differential diagnoses, and the interpretation of ACW imaging findings in ax-SpA.

Ultrasound in Arthritis.

Ultrasound is currently performed in everyday rheumatologic practice. It is used for early diagnosis, to monitor treatment results, and to diagnose remission. The spectrum of pathologies seen in arthritis with ultrasound includes early inflammatory features and associated complications. This article discusses the spectrum of ultrasound features of arthritides seen in rheumatoid arthritis and other connective tissue diseases in adults, such as Sjögren syndrome, lupus erythematosus, dermatomyositis, polymyositis, and juvenile idiopathic arthritis. Ultrasound findings in spondyloarthritis, osteoarthritis, and crystal-induced diseases are presented. Ultrasound-guided interventions in patients with arthritis are listed, and the advantages and disadvantages of ultrasound are discussed.

Which MR sequences should we use for the reliable detection and localization of bone marrow edema in spondyloarthritis?

OBJECTIVES: To assess the diagnostic confidence in detecting and localizing areas of bone marrow edema in the sacroiliac joint of patients with suspected spondyloarthritis using a single-plane method and comparing it with multiplanar unenhanced and enhanced methods. MATERIALS AND METHODS: Patients with clinical suspicion of spondyloarthritis undergoing an MRI of the sacroiliac joint were included in this retrospective study. To assess sacroiliitis, three methods were applied: single-plane (i.e., para-coronal STIR alone), multiplanar unenhanced (i.e., para-coronal STIR and para-axial PD-fs), and multiplanar enhanced method (i.e., para-coronal and para-axial post-contrast T1-fs). Two 4-point scales were used to evaluate, respectively, the diagnostic confidence in detection and localization of bone marrow edema. The distribution of certain and uncertain rating according to signal intensity and size of the lesions was also calculated. RESULTS: Seventy-four patients met the inclusion criteria. Both multiplanar methods increased the diagnostic confidence in detection (p < 0.001) and localization (p < 0.001) of sacroiliitis; no significant difference occurred between the multiplanar unenhanced and enhanced methods (p = 0.405 and p = 1.00, respectively, for detection and localization). A statistically significant difference between the distributions of certain and uncertain rating for detection based on the size and signal intensity of each lesion emerged (p = 0.006 and p < 0.001, respectively), whereas no statistically significant difference occurred for the confidence of localization (p = 0.452 and p = 0.694, respectively). CONCLUSIONS: The multiplanar methods increased the diagnostic confidence in detection and localization of sacroiliitis. The absence of a significant difference between the proposed unenhanced and enhanced methods suggests that contrast medium is not mandatory for the detection of sacroiliitis.

Recommendations of the ESSR Arthritis Subcommittee on Ultrasonography in Inflammatory Joint Disease.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee on the use of ultrasonography (US) in rheumatic disease, focused on the examination of joints in the adult population. The recommended examination technique and protocols used in a radiologic work-up are discussed. The main US features that can lead to a final diagnosis in the most common rheumatic diseases are addressed. The differential diagnosis that should be considered at image interpretation is presented. The role of US in interventional procedures and clinically important recent developments is also discussed.

Optimizing the MRI protocol of the sacroiliac joints in Spondyloarthritis: which para-axial sequence should be used?

INTRODUCTION: To assess the diagnostic value of para-axial T2w-TSE (paT2) and fat-suppressed proton density (paPD-FS) MRI sequences for the evaluation of the sacroiliac joint (SIJ) of patients with axial Spondylarthritis (SpA). MATERIALS AND METHODS: One hundred and six patients with clinical findings suggestive of SpA underwent an MR protocol of the SIJ with additional paPD-FS (41 patients) and paT2 (105 patients). Acute (bone marrow oedema [BME], enthesitis, capsulitis, synovitis) and chronic findings (erosions, ankylosis) were assessed by paPD-FS and compared with the gold standard post-contrast sequences, whereas chronic features (because of the lack of fat suppression) were evaluated on paT2 and compared with pcT1. RESULTS: paPD-FS demonstrated high sensitivity (98.9 %) and specificity (99.1 %) for BME; sensitivity and specificity for synovitis and enthesitis were 100 %; 85.7 % and 100 %, respectively, for capsulitis. paPD-FS and paT2 showed 100 % sensitivity and specificity for ankylosis; for erosions, paT2 demonstrated 85.3 % sensitivity and 100 % specificity, whereas paPD-FS, respectively, 98 % and 100 %. DISCUSSION: PaT2 and paPD-FS provided precious information enabling an accurate interpretation of the heterogeneous findings of SpA. paPD-FS showed good results in detecting acute and chronic lesions and its inclusion in a routine MR examination of the SIJ could increase the diagnostic performance of a pre-contrast protocol. KEY POINTS: Para-axial sequence should be included in a routine MRI protocol for SpA. Acute and chronic findings can be evaluated on para-axial PD-FS. Para-axial PD-FS is superior to para-axial T2-W in SpA.

The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology.

Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.

High-resolution peripheral quantitative CT imaging: Cortical porosity, poor trabecular bone microarchitecture, and low bone strength in lung transplant recipients.

PURPOSE: To characterize bone microarchitecture and quantify bone strength in lung transplant (LT) recipients by using high-resolution (HR) peripheral quantitative computed tomographic (CT) imaging of the ultradistal radius. MATERIALS AND METHODS: After study approval by the local ethics committee, all participants provided written informed consent. Included were 118 participants (58 LT recipients [mean age, 46.8 years ± 1.9; 30 women, 28 men] and 60 control participants [mean age, 39.9 years ± 1.9; 41 women, 19 men]) between April 2010 and May 2012. HR peripheral quantitative CT of the ultradistal radius was performed and evaluated for bone mineral density and trabecular and cortical bone microarchitecture. Mechanical competence was quantified by microfinite element analysis. Differences between LT recipients and control participants were determined by using two-way factorial analysis of covariance with age adjustment. RESULTS: Total and trabecular bone mineral density were significantly lower (-13.4% and -16.4%, respectively; P = .001) in LT recipients than in healthy control participants. LT recipients had lower trabecular number (-9.7%; P = .004) and lower trabecular thickness (-8.1%; P = .025). Trabecular separation and trabecular network heterogeneity were higher (+24.3% and +63.9%, respectively; P = .007 and P = .012, respectively) in LT recipients. Moreover, there was pronounced cortical porosity (+31.3%; P = .035) and lower cortical thickness (-10.2%, P = .005) after LT. In addition, mechanical competence was impaired, which was reflected by low stiffness (-15.0%; P < .001), low failure force (-14.8%; P < .001), and low bone strength (-14.6%; P < .001). CONCLUSION: Men and women with recent LT showed severe deficits in cortical and trabecular bone microarchitecture. Poor bone microarchitecture and low bone strength are likely to contribute to high fracture susceptibility observed in LT recipients.

The traumatized vertebral spine reloaded: injury mechanisms and their radiologic patterns.

The ideal classification of spinal trauma does not yet exist, primarily because the implementation of morphological, biomechanical, and clinical parameters in a single nomenclature is a difficult task. For radiologists and surgeons, who are partners in trauma teams, only a few classifications of injury patterns have been shown to be useful enough to provide rapid and stable therapy decisions in daily practice. From a didactic point of view, however, simplifications of injury mechanisms are of help to become aware of the most important radiologic injury patterns of vertebral trauma. The members of trauma teams should be aware of the strengths and limitations of existing descriptions of imaging features when reporting trauma to the spine. These are discussed in this article.

Imaging and interpretation of axial spondylarthritis: the radiologist's perspective--consensus of the Arthritis Subcommittee of the ESSR.

This article reflects the radiologist's perspective on the imaging and interpretation of axial spondylarthritis (SpA). The arthritis subcommittee of the European Society of Skeletal Radiology provides a consensus for the following questions: When and how should we image? How should we analyze the images? How should we interpret the imaging findings? To answer these questions, we address the indications in imaging axial SpA and the different imaging techniques, with a special focus on magnetic resonance imaging protocols. The value of different imaging modalities is discussed. For adequate image analysis, knowledge of the anatomy and the pathologic changes in chronic and acute inflammation of the sacroiliac joints and the spine is mandatory. Differential diagnoses of inflammatory lesions of the sacroiliac joints and the spine are addressed due to their importance in image interpretation.

Dual-energy computed tomography compared with ultrasound in the diagnosis of gout.

OBJECTIVES: The aim of our study was to compare dual-energy CT (DECT) with US for the diagnosis of gouty arthritis and to correlate the imaging findings with results from synovial fluid aspiration whenever possible. METHODS: We recruited 21 patients (17 male and 4 female) who presented with a clinical suspicion of acute or chronic gout in 37 joints. DECT scans of the hands, wrists, feet, ankles, knees and elbows were performed. For post-processing, a colour-coding gout software protocol was used. US examinations of the same joints were performed. In addition, joint fluid aspiration was performed in a total of 14 joints. RESULTS: DECT images were positive for urate crystal deposits in 25 of 37 joints. US findings were positive in 24 of 37 examined joints. In 12 of 14 joints the synovial fluid aspiration was positive. CT and US findings correlated in 32 of 37 joints (86.5%; κ = 0.698, P < 0.001). CT and synovial fluid results correlated in 12 of 14 joints (85.7%; κ = 0.417, P = 0.119). US and cytology findings correlated in 14 of 14 joints (100%; κ = 1, P < 0.001). CONCLUSION: DECT and US have comparable sensitivity for the detection of gouty arthritis in a clinical setting. However, DECT results should be interpreted carefully, as there could be some false-negative findings.

Contrast-enhanced MR imaging of hand and finger joints in patients with early rheumatoid arthritis: do we really need a full dose of gadobenate dimeglumine for assessing synovial enhancement at 3 T?

PURPOSE: To investigate the diagnostic value of a half dose compared with a full dose of gadobenate dimeglumine in the assessment of synovitis or tenosynovitis in the wrist and finger joints in patients with early rheumatoid arthritis (RA) and a disease activity score greater than 3.2. MATERIALS AND METHODS: With institutional review board approval and informed consent, 57 patients with early RA underwent 3-T magnetic resonance (MR) imaging with two different doses of contrast media. The contrast enhancement was measured in inflamed synovial tissue at half dose (0.05 mmol per kilogram of body weight) and at full dose (0.1 mmol/kg) by using T1-weighted sequences with fat saturation. The differences and the correlation of signal intensities (SIs) at half- and full-dose sequences were compared by using the paired t test and Pearson correlations. Image quality, Rheumatoid Arthritis MRI Score (RAMRIS), and tenosynovitis score on half- and full-dose images were compared by two observers using the Wilcoxon test. Interrater agreement was assessed by using κ statistics. RESULTS: A significant difference in SI was found between half-dose and full-dose gadobenate dimeglumine-enhanced synovial tissue (mean: 914.35 ± 251.1 vs 1022 ± 244.5, P < .001). Because the SI showed high correlation between the ratio at half dose and full dose (r = 0.875), the formula, ratio of synovial enhancement to saline syringe at full dose = 0.337 + 1.070 × ratio of synovial enhancement to saline syringe at half dose, can be used to convert the normalized value of half dose to full dose. However, no difference in RAMRIS (score 0 in 490 of 1026 joints; score 1 in 344; score 2 in 158; and score 3 in 34) or tenosynovitis scores in grading synovitis or tenosynovitis in image quality and in assessment of synovial enhancement was detected between half-dose and full-dose images (P = 1). CONCLUSION: Postcontrast synovial SIs showed high correlation between half dose and full dose, and image quality was rated identically. Therefore, half-dose gadobenate dimeglumine at 3-T MR imaging may be sufficient for assessing synovitis or tenosynovitis in early RA.

Radiological aspects of osteoarthritis.

Osteoarthritis (OA) is one of the most frequent indications in musculoskeletal imaging because OA is the most prevalent musculoskeletal disease in developed countries. As the population becomes older and older, the need for adequate imaging techniques also increases. The various forms of osteoarthritis are associated with a high degree of illness-induced physical disability and reduced life quality. In some forms, the pathogenesis is complex and can require the discrimination of a variety of predisposing diseases. The specific forms of osteoarthritis will be highlighted in this article. In addition, the value of each imaging modality will be assessed, with special regard to the most common sites: hand, hip, and knee.

Computational identification and quantification of trabecular microarchitecture classes by 3-D texture analysis-based clustering.

High resolution peripheral quantitative computed tomography (HR-pQCT) permits the non-invasive assessment of cortical and trabecular bone density, geometry, and microarchitecture. Although researchers have developed various post-processing algorithms to quantify HR-pQCT image properties, few of these techniques capture image features beyond global structure-based metrics. While 3D-texture analysis is a key approach in computer vision, it has been utilized only infrequently in HR-pQCT research. Motivated by high isotropic spatial resolution and the information density provided by HR-pQCT scans, we have developed and evaluated a post-processing algorithm that quantifies microarchitecture characteristics via texture features in HR-pQCT scans. During a training phase in which clustering was applied to texture features extracted from each voxel of trabecular bone, three distinct clusters, or trabecular microarchitecture classes (TMACs) were identified. These TMACs represent trabecular bone regions with common texture characteristics. The TMACs were then used to automatically segment the voxels of new data into three regions corresponding to the trained cluster features. Regional trabecular bone texture was described by the histogram of relative trabecular bone volume covered by each cluster. We evaluated the intra-scanner and inter-scanner reproducibility by assessing the precision errors (PE), intra class correlation coefficients (ICC) and Dice coefficients (DC) of the method on 14 ultradistal radius samples scanned on two HR-pQCT systems. DC showed good reproducibility in intra-scanner set-up with a mean of 0.870±0.027 (no unit). Even in the inter-scanner set-up the ICC showed high reproducibility, ranging from 0.814 to 0.964. In a preliminary clinical test application, the TMAC histograms appear to be a good indicator, when differentiating between postmenopausal women with (n=18) and without (n=18) prevalent fragility fractures. In conclusion, we could demonstrate that 3D-texture analysis and feature clustering seems to be a promising new HR-pQCT post-processing tool with good reproducibility, even between two different scanners.

Automated threshold-independent cortex segmentation by 3D-texture analysis of HR-pQCT scans.

The quantitative assessment of metabolic bone diseases relies on tissue properties such as bone mineral density (BMD) and bone microarchitecture. In spite of an increasing number of publications using high-resolution peripheral quantitative computed-tomography (HR-pQCT), the accurate and reproducible separation of cortical and trabecular bone remains challenging. In this paper, we present a novel, fully automated, threshold-independent technique for the segmentation of cortical and trabecular bone in HR-pQCT scans. This novel post-processing method is based on modeling appearance characteristics from manually annotated cases. In our experiments the algorithm automatically selected texture features with high differentiating power and trained a classifier to separate cortical and trabecular bone. From this mask, cortical thickness and tissue volume could be calculated with high accuracy. The overlap between the proposed threshold-independent segmentation tool (TIST) and manual contouring was 0.904±0.045 (Dice coefficient). In our experiments, TIST obtained higher overall accuracy in our measurements than other techniques.

Challenges of work-life balance for women physicians/mothers working in leadership positions.

BACKGROUND: Female leadership in medicine is still disproportionately small, which might be due to the barriers of combining work and family. OBJECTIVES: The aim of this study was, first, to perform a strengths, weakness, opportunities, and threats (SWOT) analysis and, second, to create a strategic concept for career development. METHODS: In this study, all women in leadership positions in the health care system in Vienna, Austria, with at least 1 child (n = 8), were interviewed about the advantages and disadvantages of gender with regard to career development, the strengths and weaknesses of female leadership, and their work-life balance. Different factors that influenced the work-life balance were specified, and career strategies to realize adequate solutions were developed. RESULTS: The sporadic focus on career advancement, time-consuming child care, responsibility for family life, and a woman's tendency toward understatement were barriers to career development. Work-family enrichment has a positive spillover effect that spreads positive energy and helps to balance the work-life relationship. For each individual, the allocation and interaction of different resources such as time, money, scope of decision making, and physical, emotional, and social resources, were essential to maintain the individual work-life balance. CONCLUSIONS: In addition to the existing "glass ceiling," the predominant responsibility for child care is still borne by the woman. However, mentoring programs, coaching, networking, and support of the partner or of other people help to strengthen female "soft" skills and achieve a work-life balance.

Bone microarchitecture in hemodialysis patients assessed by HR-pQCT.

BACKGROUND AND OBJECTIVES: Dialysis patients are at high risk for low-trauma bone fracture. Bone density measurements using dual-energy x-ray absorptiometry (DXA) do not reliably differentiate between patients with and without fractures. The aim of this study was to identify differences in bone microarchitecture between patients with and without a history of fracture using high-resolution peripheral quantitative computed tomography (HR-pQCT). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Seventy-four prevalent hemodialysis patients were recruited for measurements of areal bone mineral density (aBMD) by DXA and bone microarchitecture by HR-pQCT. Patients with a history of trauma-related fracture were excluded. Forty healthy volunteers served as controls. Blood levels of parathyroid hormone, vitamin D, and markers of bone turnover were determined. RESULTS: Dialysis patients, particularly women, had markedly impaired bone microarchitecture. Patients with fractures had significantly reduced cortical and trabecular microarchitecture compared with patients without fractures. aBMD tended to be lower in patients with fractures, but differences were statistically not significant. The strongest determinant of fracture was the HR-pQCT-measured trabecular density of the tibia, which also had the highest discriminatory power to differentiate patients according to fracture status. Radial DXA had a lower discriminatory power than trabecular density. CONCLUSIONS: Bone microarchitecture is severely impaired in dialysis patients and even more so in patients with a history of fracture. HR-pQCT can identify dialysis patients with a history of low-trauma fracture.

Comparison of 5-megapixel cathode ray tube monitors and 5-megapixel liquid crystal monitors for soft-copy reading in full-field digital mammography.

PURPOSE: To retrospectively compare the image quality, lesion detection, and the diagnostic efficacy of 5-megapixel (MP) cathode ray tube monitors (CRTs) and 5-MP liquid crystal display monitors (LCDs) for soft-copy reading in full-field digital mammography (FFDM). MATERIALS AND METHODS: Informed consent was waived by the Institutional Review Board for the data analysis. A total of 220 cases were compared with two 5-MP (2048×2560 pixels) CRTs and two 5-MP (2048×2560 pixels) LCDs. Nine aspects of image quality (brightness, contrast, sharpness, noise, skin, fat, retromamillary space, glandular tissue, and detection of calcifications) were evaluated. In addition, the detection of breast lesions (mass, calcifications) and diagnostic efficacy, based on the BI-RADS classification, were correlated with histologic results (n=70) and follow-up (n=150). RESULTS: Each aspect of the image quality was rated significantly better for 5-MP LCDs (p<0.05) compared to the 5-MP CRTs. With 5-MP CRTs, 31 masses and 119 calcifications were detected, compared to 30 and 121 with 5-MP LCDs. The differences in diagnostic efficacy between 5-MP CRTs and 5-MP LCDs were not significant (p=0.157) although 5-MP CRTs yielded two false-negative results. Both lesions were rated BI-RADS 3 with 5-MP CRTs. Both were invasive carcinomas at histology. The sensitivity, specificity, positive and negative predictive values, and accuracy were 0.966, 0.975, 0.933, 0.988, and 0.973 for 5-MP CRTs, compared to 1.0, 0.963, 0.903, 1.0, 0.973 for 5-MP LCDs. CONCLUSION: The image quality of 5-MP LCDs is significantly better than that of 5-MP CRTs for soft-copy reading in FFDM, based on histologic and follow-up correlation. However, lesion detection and diagnostic efficacy are comparable to 5-MP CRTs. The interpretation of the false-negative results suggests that the characterization of breast lesions with FFDM is not defined solely by the monitors, but is strongly influenced by the radiologist.