Cerebrospinal fluid flow artifact reduction with deep learning to optimize the evaluation of spinal canal stenosis on spine MRI.

PURPOSE: The aim of study was to employ the Cycle Generative Adversarial Network (CycleGAN) deep learning model to diminish the cerebrospinal fluid (CSF) flow artifacts in cervical spine MRI. We also evaluate the agreement in quantifying spinal canal stenosis. METHODS: For training model, we collected 9633 axial MR image pairs from 399 subjects. Then, additional 104 image pairs from 19 subjects were gathered for the test set. The deep learning model was developed using CycleGAN to reduce CSF flow artifacts, where T2 TSE images served as input, and T2 FFE images, known for fewer CSF flow artifacts. Post training, CycleGAN-generated images were subjected to both quantitative and qualitative evaluations for CSF artifacts. For assessing the agreement of spinal canal stenosis, four raters utilized an additional 104 pairs of original and CycleGAN-generated images, with inter-rater agreement evaluated using a weighted kappa value. RESULTS: CSF flow artifacts were reduced in the CycleGAN-generated images compared to the T2 TSE and FFE images in both quantitative and qualitative analysis. All raters concordantly displayed satisfactory estimation results when assessing spinal canal stenosis using the CycleGAN-generated images with T2 TSE images (kappa = 0.61-0.75) compared to the original FFE with T2 TSE images (kappa = 0.48-0.71). CONCLUSIONS: CycleGAN demonstrated the capability to produce images with diminished CSF flow artifacts. When paired with T2 TSE images, the CycleGAN-generated images allowed for more consistent assessment of spinal canal stenosis and exhibited agreement levels that were comparable to the combination of T2 TSE and FFE images.

Assessing visibility and bone changes of spinal metastases in CT scans: a comprehensive analysis across diverse cancer types.

OBJECTIVES: To analyze the characteristics of spinal metastasis in CT scans across diverse cancers for effective diagnosis and treatment, using MRI as the gold standard. METHODS: A retrospective study of 309 patients from four centers, who underwent concurrent CT and spinal MRI, revealing spinal metastasis, was conducted. Data on metastasis including total number, volume, visibility on CT (visible, indeterminate, or invisible), and type of bone change were collected. Through chi-square and Mann-Whitney U tests, we characterized the metastasis across diverse cancers and investigated the variation in the intra-individual ratio representing the percentage of lesions within each category for each patient. RESULTS: Out of 3333 spinal metastases from 309 patients, 55% were visible, 21% indeterminate, and 24% invisible. Sclerotic and lytic lesions made up 47% and 43% of the visible and indeterminate categories, respectively. Renal cell carcinoma (RCC), prostate cancer, and hepatocellular carcinoma (HCC) had the highest visibility at 86%, 73%, and 67% (p < 0.0001, p < 0.0001, and p = 0.003), while pancreatic cancer was lowest at 29% (p < 0.0001). RCC and HCC had significantly high lytic metastasis ratios (interquartile range (IQR) 0.96-1.0 and 0.31-1.0, p < 0.001 and p = 0.005). Prostate cancer exhibited a high sclerotic lesion ratio (IQR 0.52-0.97, p < 0.001). About 39% of individuals had invisible or indeterminate lesions, even with a single visible lesion on CT. The intra-individual ratio for indeterminate and invisible metastases surpassed 18%, regardless of the maximal size of the visible metastasis. CONCLUSIONS: This study highlights the variability in characteristics of spinal metastasis based on the primary cancer type through unique lesion-centric analysis.

Skeletal effects of combined bisphosphonates treatment and parathyroidectomy in osteoporotic patients with primary hyperparathyroidism.

INTRODUCTION: Bone loss caused by primary hyperparathyroidism (PHPT) is an indication for parathyroidectomy (PTX). However, whether adding bisphosphonates would be superior to PTX alone to increase bone mass remains unclear. We thus aimed to compare the skeletal effects of the combination treatment of bisphosphonates and PTX with PTX alone. MATERIALS AND METHODS: In this retrospective analysis, bone mineral density (BMD) changes after 1 year of combination treatment and PTX alone were compared. We also analyzed the correlation between changes in serum biochemical parameters and BMD after 1 year of treatment in both groups. RESULTS: The baseline characteristics of patients treated with PTX alone (n = 24) and combination treatment (n = 26) were comparable. BMD significantly increased after 1 year of treatment in both groups (all p < 0.001), and the increase in BMD at the femur neck was higher in the PTX alone group than in the combination group (p = 0.011). There was a decreasing trend in serum alkaline phosphatase (ALP) levels in PTX alone compared to the combination treatment group (p = 0.053). In the study cohort, lower BMD and higher ALP levels at baseline were associated with higher 1-year BMD changes at all sites. Interestingly, a significant association was found between changes in ALP and BMD at the femur neck in the PTX alone group (p = 0.003), but abolished in the combination group (p = 0.946). CONCLUSIONS: There is no additional benefit of BMD in combination treatment with bisphosphonates and PTX over PTX alone in osteoporotic patients with PHPT. Combined bisphosphonate treatment might interfere with the increase in bone mass caused by PTX.

Ensemble deep learning model for predicting anterior cruciate ligament tear from lateral knee radiograph.

OBJECTIVE: To develop an ensemble deep learning model (DLM) predicting anterior cruciate ligament (ACL) tears from lateral knee radiographs and to evaluate its diagnostic performance. MATERIALS AND METHODS: In this study, 1433 lateral knee radiographs (661 with ACL tear confirmed on MRI, 772 normal) from two medical centers were split into training (n = 1146) and test sets (n = 287). Three single DLMs respectively classifying radiographs with ACL tears, abnormal lateral femoral notches, and joint effusion were developed. An ensemble DLM predicting ACL tears was developed by combining the three DLMs via stacking method. The sensitivities, specificities, and area under the receiver operating characteristic curves (AUCs) of the DLMs and three radiologists were compared using McNemar test and Delong test. Subgroup analysis was performed to identify the radiologic features associated with the sensitivity. RESULTS: The sensitivity, specificity, and AUC of the ensemble DLM were 86.8% (95% confidence interval [CI], 79.9-92.0%), 89.4% (95% CI, 83.4-93.8%), and 0.927 (95% CI, 0.891-0.954), achieving diagnostic performance comparable with that of a musculoskeletal radiologist (P = 0.193, McNemar test; P = 0.131, Delong test). The AUC of the ensemble DLM was significantly higher than those of non-musculoskeletal radiologists (P = 0.043, P < 0.001). The sensitivity of the DLM was higher than that of the radiologists in the absence of an abnormal lateral femoral notch or joint effusion. CONCLUSION: The diagnostic performance of the ensemble DLM in predicting lateral knee radiographs with ACL tears was comparable to that of a musculoskeletal radiologist.

Spinal nerve signal intensity on Dixon T2-weighted water-only sequence: an important outcome predictor after lumbar transforaminal epidural injection.

OBJECTIVES: To evaluate the role of Dixon T2-weighted water-fat separation technique in predicting the outcome of lumbar transforaminal epidural injections (TFESIs). METHODS: Patients who underwent TFESI of a single spinal nerve within 3 months after magnetic resonance imaging (MRI) exam between August 2018 and April 2020 were identified. The patients were classified into positive or negative outcome groups based on the response to the TFESI procedure. Two musculoskeletal radiologists measured the signal intensity of the injected side spinal nerves, contralateral side spinal nerves, and subcutaneous fat on axial Dixon T2-weighted water-only images, and the diameter of spinal nerve on axial Dixon T2-weighted in-phase images of the pre-procedural MRI. The measured values of the injected side spinal nerves were compared between the two groups and with the contralateral side spinal nerve. RESULTS: A total of 94 patients were included, 76 in the positive outcome group and 18 in the negative outcome group. The mean signal intensity and the nerve-to-fat signal ratio of the injected side spinal nerve were significantly higher in the positive outcome group than in the negative outcome group (793.78 vs. 679.19, p = 0.016; 4.21 vs. 3.28, p = 0.003). In the positive outcome group, the diameter of the spinal nerve was significantly higher on the injected side than on the contralateral side (6.91 mm vs. 6.37 mm, p = 0.016). CONCLUSIONS: The mean signal intensity and the nerve-to-fat signal ratio of the spinal nerve on axial Dixon T2-weighted water-only images can help predict patient response to the TFESI. KEY POINTS: • Applying the Dixon technique to lumbar spine MRI can help predict patient response to the TFESI procedure. • An increased nerve-to-fat signal ratio and mean spinal nerve signal intensity on axial Dixon T2-weighted water-only images predicted favorable TFESI outcomes.

Bone Mineral Density Around the Knee Joint: Correlation With Central Bone Mineral Density and Associated Factors.

INTRODUCTION: The aims of this study were to (1) assess the bone mineral density (BMD) around the knee joint, (2) determine the correlation between central and knee BMDs, and (3) investigate the factors associated with BMD around the knee joint in patients with knee osteoarthritis (OA). METHODOLOGY: This cross-sectional study included 122 patients who underwent total knee arthroplasty. Central and knee dual-energy X-ray absorptiometry was performed preoperatively. BMD at 6 regions of interest (ROIs) around the knee joint were measured, and their correlations with central BMD were determined using Spearman's correlation analysis. Lower limb alignment, severity of OA, body mass index (BMI), preoperative functional and pain scores were assessed to elucidate the factors associated with knee BMD using linear regression analysis. RESULTS: Around the knee joint, BMD was the lowest at the distal femoral metaphysis and lateral tibial condyle. Knee BMD was significantly correlated with central BMD. However, the correlation coefficients varied by the ROI. Additionally, multivariate analysis revealed different associations with respect to the regions around the knee joint. Varus alignment of the lower limb was associated with increased BMD of the medial condyles and decreased BMD of lateral condyles. High grade OA was a protective factor; it was associated with increased BMD at the lateral condyles of the femur and tibia. Higher BMI was an independent protective factor in all ROIs around the knee joint except the lateral femoral condyles. Lower functional level was not associated with decreased BMD, whereas a higher pain score was significantly associated with lower BMD at the proximal tibial metaphysis. CONCLUSIONS: Knee BMD was significantly correlated with central BMD. However, the correlations varied with the regions around the knee joint probably due to their independent association with the alignment of the lower limb, severity of OA, BMI, and preoperative pain level.

Ultrasound Microflow Imaging Technology for Diagnosis of Adhesive Capsulitis of the Shoulder.

OBJECTIVES: To assess the diagnostic accuracy of Superb Microvascular Imaging (SMI; Canon Medical Systems, Otawara, Japan) at the subcoracoid triangle for adhesive capsulitis of the shoulder, to compare the diagnostic value of SMI with that of conventional ultrasound (US) and power Doppler ultrasound (PDUS) findings, and to investigate the correlation between vascular flow on SMI with clinical features. METHODS: Our study included 39 patients with a diagnosis of adhesive capsulitis and 35 healthy patients as a control group. The echogenicity in the rotator interval and coracohumeral ligament thickness were assessed with conventional US. Vascular flow in the subcoracoid fat triangle was evaluated with SMI and PDUS (SMI and PDUS areas). A receiver operating characteristic curve analysis was performed to evaluate diagnostic accuracy. The correlation between US findings and the range of motion, pain intensity, and duration of symptoms was also evaluated. RESULTS: The SMI area was higher in the adhesive capsulitis group than in the control group (2.95 versus 0 mm2 ; P < .01). The visualization of vascular flow at the subcoracoid fat triangle was superior with SMI compared with PDUS (P < .01). In the receiver operating characteristic analysis, the SMI area showed higher diagnostic performance, with an area under the curve of 0.90 compared with other US findings. The area of SMI vascular flow was also negatively correlated with external rotation and forward flexion (P < .05) in the adhesive capsulitis group. CONCLUSIONS: Measurement of vascular flow at the subcoracoid fat triangle using SMI facilitated the diagnosis of adhesive capsulitis. Superb Microvascular Imaging was superior to PDUS in diagnostic performance. Vascular flow was negatively correlated with the range of motion of external rotation and forward flexion.

Intratendinous Injection of Mesenchymal Stem Cells for the Treatment of Rotator Cuff Disease: A 2-Year Follow-Up Study.

PURPOSE: To assess the mid-term safety and efficacy of an intratendinous injection of autologous adipose tissue-derived mesenchymal stem cells (AD MSCs) for rotator cuff disease at 2-year follow-up. METHODS: The first part of the study consisted of 3 dose-escalation groups, with 3 patients each, for the evaluation of safety: low-dose (1.0 × 107 cells), mid-dose (5.0 × 107), and high-dose (1.0 × 108) groups. For the second part, we planned to include 9 patients receiving the high dose for the evaluation of exploratory efficacy. Clinical outcomes were assessed according to pain, range of motion, muscle strength, functional scores, overall satisfaction and function, and presence of failure. Structural outcomes included changes in volume of tendon defects measured using magnetic resonance imaging. RESULTS: This study enrolled 19 patients (9 for the first part and 10 for the second part) with partial-thickness rotator cuff tears. There were no treatment-related adverse events at minimum 2-year follow-up. Intratendinous injection of AD MSCs reduced shoulder pain by approximately 90% at 1 and 2 years in the mid- and high-dose groups. The strength of the supraspinatus, infraspinatus, and teres minor significantly increased by greater than 50% at 2 years in the high-dose group. Shoulder function measured with 6 commonly used scores improved for up to 2 years in all dose groups. Structural outcomes evaluated with magnetic resonance imaging showed that the volume of bursal-sided defects in the high-dose group nearly disappeared at 1 year and did not recur at up to 2 years. No failures-defined as the performance of any kind of shoulder surgery or return of the Shoulder Pain and Disability Index score to the preinjection level-occurred during follow-up. CONCLUSIONS: This study showed continued safety and efficacy of an intratendinous injection of AD MSCs for the treatment of partial-thickness rotator cuff tears over a 2-year period through regeneration of tendon defects. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Intratendinous Injection of Autologous Adipose Tissue-Derived Mesenchymal Stem Cells for the Treatment of Rotator Cuff Disease: A First-In-Human Trial.

Despite relatively good results of current symptomatic treatments for rotator cuff disease, there has been an unmet need for fundamental treatments to halt or reverse the progress of disease. The purpose of this study was to assess the safety and efficacy of intratendinous injection of autologous adipose tissue-derived mesenchymal stem cells (AD MSCs) in patients with rotator cuff disease. The first part of the study consists of three dose-escalation cohorts; the low- (1.0 × 107 cells), mid- (5.0 × 107 ), and high-dose (1.0 × 108 ) groups with three patients each for the evaluation of the safety and tolerability. The second part included nine patients receiving the high-dose for the evaluation of the exploratory efficacy. The primary outcomes were the safety and the shoulder pain and disability index (SPADI). Secondary outcomes included clinical, radiological, and arthroscopic evaluations. Twenty patients were enrolled in the study, and two patients were excluded. Intratendinous injection of AD MSCs was not associated with adverse events. It significantly decreased the SPADI scores by 80% and 77% in the mid- and high-dose groups, respectively. Shoulder pain was significantly alleviated by 71% in the high-dose group. Magnetic resonance imaging examination showed that volume of the bursal-side defect significantly decreased by 90% in the high-dose group. Arthroscopic examination demonstrated that volume of the articular- and bursal-side defects decreased by 83% and 90% in the mid- and high-dose groups, respectively. Intratendinous injection of autologous AD MSCs in patient with a partial-thickness rotator cuff tear did not cause adverse events, but improved shoulder function, and relieved pain through regeneration of rotator cuff tendon. Stem Cells 2018;36:1441-1450.

Anterior capsular abnormality: another important MRI finding for the diagnosis of adhesive capsulitis of the shoulder.

OBJECTIVE: To evaluate the usefulness of anterior capsular abnormality, thickening, and abnormal signal intensity on MRI for the diagnosis of adhesive capsulitis of the shoulder. MATERIALS AND METHODS: This retrospective study included 29 patients with adhesive capsulitis and 20 controls. Clinical criteria with significant restricted passive motion was used for the diagnosis of adhesive capsulitis. The anterior capsular thickness and signal intensity were evaluated on the thickest portion of anterior glenohumeral joint capsule, located deep to the subscapularis muscle. In addition, the previously known MR findings of adhesive capsulitis, such as humeral and glenoid capsular thickness in axillary recess, maximal axillary capsular thickness, and coracohumeral ligament thickness, were measured. The presence of humeral and glenoid capsular abnormal hyperintensity in axillary recess, abnormal hyperintensity, and obliteration of the subcoracoid fat triangle were also evaluated. RESULTS: All MRI findings significantly differed between adhesive capsulitis and controls. Among MR findings, multivariable analysis showed that anterior capsular thickness, maximal axillary capsular thickness, and anterior capsular abnormal hyperintensity were variables that could differentiate adhesive capsulitis from the control group, with odds ratios of 7.97, 17.75, and 12.41, respectively (p < 0.05). In ROC analysis, the anterior capsular thickness showed high diagnostic performances with an AUC of 0.897. The cut-off value of anterior capsular thickness at 3.5 mm showed excellent diagnostic accuracy, with sensitivity of 68.97% and specificity of 100%. CONCLUSIONS: Anterior capsular abnormality, thickening, and abnormal hyperintensity can be used for the diagnosis of adhesive capsulitis of shoulder, in addition to previously known abnormal MRI findings.

Radial head button holing: a cause of irreducible anterior radial head dislocation.

"Buttonholing" of the radial head through the anterior joint capsule is a known cause of irreducible anterior radial head dislocation associated with Monteggia injuries in pediatric patients. To the best of our knowledge, no report has described an injury consisting of buttonholing of the radial head through the annular ligament and a simultaneous radial head fracture in an adolescent. In the present case, the radiographic findings were a radial head fracture with anterior dislocation and lack of the anterior fat pad sign. Magnetic resonance imaging (MRI) clearly demonstrated anterior dislocation of the fractured radial head through the torn annular ligament. The anterior joint capsule and proximal portion of the annular ligament were interposed between the radial head and capitellum, preventing closed reduction of the radial head. Familiarity with this condition and imaging findings will aid clinicians to make a proper diagnosis and fast decision to perform an open reduction.

Intra-articular injection of mesenchymal stem cells for the treatment of osteoarthritis of the knee: a proof-of-concept clinical trial.

Mesenchymal stem cells (MSCs) are known to have a potential for articular cartilage regeneration. However, most studies focused on focal cartilage defect through surgical implantation. For the treatment of generalized cartilage loss in osteoarthritis, an alternative delivery strategy would be more appropriate. The purpose of this study was to assess the safety and efficacy of intra-articular injection of autologous adipose tissue derived MSCs (AD-MSCs) for knee osteoarthritis. We enrolled 18 patients with osteoarthritis of the knee and injected AD MSCs into the knee. The phase I study consists of three dose-escalation cohorts; the low-dose (1.0 × 10(7) cells), mid-dose (5.0 × 10(7)), and high-dose (1.0 × 10(8)) group with three patients each. The phase II included nine patients receiving the high-dose. The primary outcomes were the safety and the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at 6 months. Secondary outcomes included clinical, radiological, arthroscopic, and histological evaluations. There was no treatment-related adverse event. The WOMAC score improved at 6 months after injection in the high-dose group. The size of cartilage defect decreased while the volume of cartilage increased in the medial femoral and tibial condyles of the high-dose group. Arthroscopy showed that the size of cartilage defect decreased in the medial femoral and medial tibial condyles of the high-dose group. Histology demonstrated thick, hyaline-like cartilage regeneration. These results showed that intra-articular injection of 1.0 × 10(8) AD MSCs into the osteoarthritic knee improved function and pain of the knee joint without causing adverse events, and reduced cartilage defects by regeneration of hyaline-like articular cartilage.

Visualization of joint and bone using dual-energy CT arthrography with contrast subtraction: in vitro feasibility study using porcine joints.

OBJECTIVE: To assess the feasibility of subtracting various concentrations of iodinated contrast material on dual-energy computed tomographic (DECT) arthrography to provide both CT arthrography and virtual unenhanced CT (VUCT) in a single CT acquisition. MATERIALS AND METHODS: This was an in vitro study for which institutional review board approval was not required. CT arthrographies of 12 joints of pig cadavers were obtained using dual-energy CT. Various concentrations of iodinated contrast material, 25% (75 mg/ml), 50% (150 mg/ml), 75% (225 mg/ml), and 100% (300 mg/ml) were used for the DECT arthrography. The paired regions of interest (ROI) were drawn over the same location on two paired CT scans at different tube voltages (80 kVp and 140 kVp). The average Hounsfield units (HU) ratio of the contrast media(HU on CT at 80 kVp/HU on CT at 140 kVp) was calculated for each joint. Subtraction of contrast material was carried out using VUCT application RESULTS: The 25% iodinated contrast mixture was successfully subtracted from DECT arthrography of four joints, in which the average HU ratio ranged from 1.95 to 2.0. The subtraction of the 50%,75%, and 100% iodine contrast mixtures was not successful, because of the upper demonstrable HU limit in dual-energy CT. CONCLUSIONS: DECT arthrography with 25% iodinated contrast medium injection can provide both CT arthrography and virtual unenhanced images in a single CT acquisition.

[Imaging Evaluation of Early and Long-Term Complications Associated with the Postoperative Spine]. / 척추 ìˆ˜ìˆ í›„ 영상 평가: 초기 및 중장기 합병증.

As the number of spinal surgeries being performed expands, the number of medical imaging procedures such as radiography, CT, and MRI is also increasing, and the importance of their interpretation is becoming more significant. Herein, we present the radiological findings of a variety of complications that can occur after spinal surgery and discuss how effectively and accurately they can be diagnosed through imaging. In particular, this study details the characteristic imaging findings specific to the early and long-term postoperative periods. Early complications of spinal surgery include improper placement of surgical instruments (instrument malpositioning), seromas, hematomas, pseudomeningoceles, and infections in the region surrounding the surgical site. Conversely, long-term complications may include osteolysis around surgical instruments, failure of fusion, adjacent segment disease, and the formation of epidural fibrosis or scar tissue. A precise understanding of the imaging assessments related to complications arising after spinal surgery is crucial to ensure timely and accurate diagnosis, which is necessary to achieve effective treatment.

Automated Detection and Segmentation of Bone Metastases on Spine MRI Using U-Net: A Multicenter Study.

OBJECTIVE: To develop and evaluate a deep learning model for automated segmentation and detection of bone metastasis on spinal MRI. MATERIALS AND METHODS: We included whole spine MRI scans of adult patients with bone metastasis: 662 MRI series from 302 patients (63.5 ± 11.5 years; male:female, 151:151) from three study centers obtained between January 2015 and August 2021 for training and internal testing (random split into 536 and 126 series, respectively) and 49 MRI series from 20 patients (65.9 ± 11.5 years; male:female, 11:9) from another center obtained between January 2018 and August 2020 for external testing. Three sagittal MRI sequences, including non-contrast T1-weighted image (T1), contrast-enhanced T1-weighted Dixon fat-only image (FO), and contrast-enhanced fat-suppressed T1-weighted image (CE), were used. Seven models trained using the 2D and 3D U-Nets were developed with different combinations (T1, FO, CE, T1 + FO, T1 + CE, FO + CE, and T1 + FO + CE). The segmentation performance was evaluated using Dice coefficient, pixel-wise recall, and pixel-wise precision. The detection performance was analyzed using per-lesion sensitivity and a free-response receiver operating characteristic curve. The performance of the model was compared with that of five radiologists using the external test set. RESULTS: The 2D U-Net T1 + CE model exhibited superior segmentation performance in the external test compared to the other models, with a Dice coefficient of 0.699 and pixel-wise recall of 0.653. The T1 + CE model achieved per-lesion sensitivities of 0.828 (497/600) and 0.857 (150/175) for metastases in the internal and external tests, respectively. The radiologists demonstrated a mean per-lesion sensitivity of 0.746 and a mean per-lesion positive predictive value of 0.701 in the external test. CONCLUSION: The deep learning models proposed for automated segmentation and detection of bone metastases on spinal MRI demonstrated high diagnostic performance.

Fatty degeneration of the rotator cuff muscles on pre- and postoperative CT arthrography (CTA): is the Goutallier grading system reliable?

OBJECTIVES: To retrospectively evaluate fatty degeneration (FD) of rotator cuff muscles on CTA using Goutallier's grading system and quantitative measurements with comparison between pre- and postoperative states. MATERIALS AND METHODS: IRB approval was obtained for this study. Two radiologists independently reviewed pre- and postoperative CTAs of 43 patients (24 males and 19 females, mean age, 58.1 years) with 46 shoulders confirmed as full-thickness tears with random distribution. FD of supraspinatus, infraspinatus/teres minor, and subscapularis was assessed using Goutallier's system and by quantitative measurements of Hounsfield units (HUs) on sagittal images. Changes in FD grades and HUs were compared between pre- and postoperative CTAs and analyzed with respect to preoperative tear size and postoperative cuff integrity. The correlations between qualitative grades and quantitative measurements and their inter-observer reliabilities were also assessed. RESULTS: There was statistically significant correlation between FD grades and HU measurements of all muscles on pre- and postoperative CTA (p < 0.05). Inter-observer reliability of fatty degeneration grades were excellent to substantial on both pre- and postoperative CTA in supraspinatus (0.8685 and 0.8535) and subscapularis muscles (0.7777 and 0.7972), but fair in infraspinatus/teres minor muscles (0.5791 and 0.5740); however, quantitative Hounsfield units measurements showed excellent reliability for all muscles (ICC: 0.7950 and 0.9346 for SST, 0.7922 and 0.8492 for SSC, and 0.9254 and 0.9052 for IST/TM). No muscle showed improvement of fatty degeneration after surgical repair on qualitative and quantitative assessments; there was no difference in changes of fatty degeneration after surgical repair according to preoperative tear size and post-operative cuff integrity (p > 0.05). The average dose-length product (DLP, mGy · cm) was 365.2 mGy · cm (range, 323.8-417.2 mGy · cm) and estimated average effective dose was 5.1 mSv. CONCLUSIONS: Goutallier grades correlated well with HUs of rotator cuff muscles. Reliability was excellent for both systems, except for FD grade of IST/TM muscles, which may be more reliably assessed using quantitative measurements.

Isospora belli Infection with Chronic Diarrhea in an Alcoholic Patient.

Chronic diarrhea with a 35 kg weight loss (75 kg to 40 kg) occurred during 2 years in an alcoholic patient was diagnosed with Isospora belli infection in the Republic of Korea. The patient, a 70-year old Korean male, had been a heavy drinker for more than 30 years. He was admitted to the Seoul National University Hospital because of long-standing diarrhea and severe weight loss. He had an increased white blood cell (WBC) count with high peripheral blood eosinophilia (36.8-39.9%) and lowered protein and albumin levels but without any evidence of immunosuppression. A parasitic infection was suspected and fecal examination was repeated 3 times with negative results. Peroral endoscopy with mural biopsy was performed in the upper jejunum. The biopsy specimens revealed villous atrophy with loss of villi together with various life cycle stages of I. belli, including trophozoites, schizonts, merozoites, macrogamonts, and microgamonts. The patient was treated successfully with oral doses of trimethoprim 160-320 mg and sulfamethoxazole 800-1,600 mg daily for 4 weeks. A follow-up evaluation at 2.5 years later revealed marked improvement of body weight (68 kg), increased protein and albumin levels, and normal WBC count with low eosinophils (3.1%). This is the first clinical case of isoporiasis with demonstration of various parasitic stages in the Republic of Korea.

Effect of Patient's Positioning on the Grade of Tendinosis and Visible Range of Infraspinatus Tendon on Ultrasound.

Purpose: To investigate the effect of patient positioning on tendinosis grade, visible range, and infraspinatus tendon (IST) thickness, and to determine the feasibility of internal rotation (IR) position to assess IST on ultrasound (US). Materials and Methods: This study included 52 shoulders of 48 subjects who were evaluated for IST in three different positions: neutral position (N), IR, and position with the ipsilateral hand on the contralateral shoulder (HC). Two radiologists retrospectively graded IST tendinosis from grade 0 to grade 3 and the visible range from grade 1 to grade 4. The thickness of the IST was measured by another radiologist with a short-axis view. A generalized estimating equation was used for statistical analysis. Results: The tendinosis grades were higher in the HC position than in the IR position, with a cumulative odds ratio of 2.087 (0.004, 95% confidence interval [CI]: 1.268-3.433). The tendinosis grades in the HC position (p = 0.370) and IR position (p = 0.146) were not significantly different from those in the N position. The overall difference in IST thickness was significant (p < 0.001), but the visible range (p = 0.530) was not significantly different according to position. Conclusion: Patient positioning significantly affected the grade of tendinosis and thickness but not the visible range of the IST. The IR position is a feasible position for assessing the IST on US.

Low-quality muscle mass rather than normal-quality muscle mass determines fibrosis progression in biopsy-proven NAFLD.

BACKGROUND AND AIMS: Sarcopaenia is associated with advanced nonalcoholic fatty liver disease (NAFLD). However, the impact of the muscle mass categorised by muscle quality on fibrosis progression remains unclear. METHODS: A total of 292 patients with biopsy-proven NAFLD who underwent serial vibration-controlled transient elastography assessments at least 1 year from baseline were selected. The skeletal muscle area (SMA) was determined on abdominal computed tomography (CT) at the third lumbar vertebra level and categorised to normal-attenuation muscle area (NAMA), low-attenuation muscle area (LAMA) and intermuscular adipose tissue (IMAT) using a muscle quality map. These SMAs were normalised by the height squared to obtain the skeletal muscle index (SMI). RESULTS: At baseline, as the histological fibrosis stage increased, SMINAMA decreased and SMILAMA increased (p for trend = 0.014 and p for trend <0.001, respectively), which was not significant after adjustment for age, sex and obesity. During a median follow-up of 41 months, fibrosis progression was detected in 48 out of 292 patients, and higher SMILAMA quartiles independently increased the risk of fibrosis progression in a dose-dependent manner (hazard ratio [HR] per quartile: 1.41; 95% confidence interval [CI], 1.04-1.91). The highest quartile of SMILAMA increased the risk of fibrosis progression by 3.25 times compared to the lowest quartile of SMILAMA (95% CI, 1.18-8.90). SMINAMA quartiles were not associated with the risk of fibrosis progression. CONCLUSION: Increased low-quality muscle mass, but not decreased normal-quality muscle mass, as assessed by a muscle quality map in CT, predicts fibrosis progression in patients with NAFLD.

A problem-based approach in musculoskeletal ultrasonography: heel pain in adults.

Musculoskeletal ultrasonography (US) has unique advantages, such as excellent spatial resolution for superficial structures, the capability for dynamic imaging, and the ability for direct correlation and provocation of symptoms. For these reasons, US is increasingly used to evaluate problems in small joints, such as the foot and ankle. However, it is almost impossible to evaluate every anatomic structure within a limited time. Therefore, US examinations can be faster and more efficient if radiologists know where to look and image patients with typical symptoms. In this review, common etiologies of heel pain are discussed in a problem-based manner. Knowing the common pain sources and being familiar with their US findings will help radiologists to perform accurate and effective US examinations.