Reinjury Following Return to Play.

Radiologists are frequently called on for guidance regarding return to play (RTP) for athletes and active individuals after sustaining a musculoskeletal injury. Avoidance of reinjury is of particular importance throughout the rehabilitative process and following resumption of competitive activity. Understanding reinjury risk estimation, imaging patterns, and correlation of clinical and surgical findings will help prepare the radiologist to identify reinjuries correctly on diagnostic imaging studies and optimize management for a safe RTP.

Phosphaturic mesenchymal tumor: two cases highlighting differences in clinical and radiologic presentation.

Phosphaturic mesenchymal tumors are rare, usually benign neoplasms that occur in the soft tissue or bone and are the cause of nearly all cases of tumor-induced osteomalacia. Tumor-induced osteomalacia due to phosphaturic mesenchymal tumor is a challenging diagnosis to make-patients present with variable clinical and radiologic findings and the culprit neoplasm is often small and can occur anywhere head to toe. We present two cases of phosphaturic mesenchymal tumor in the scapular body and plantar foot. In both cases, the patient endured years of debilitating symptoms before a tissue diagnosis was eventually reached. Descriptions of clinical presentation, laboratory workup, surgical resection, and imaging characteristics, with a focus on CT, MRI, and functional imaging, are provided to assist with the diagnosis and management of this rare entity. A brief review of current literature and discussion of the differential diagnoses of phosphaturic mesenchymal tumor is also provided.

Hydroxyapatite deposition disease, an overlooked differential diagnosis in the emergency department: a case series and review of literature.

Hydroxyapatite crystal deposition disease (HADD) poses diagnostic challenges in the emergency department (ED) as it may clinically present similarly to infection and other musculoskeletal conditions. Misdiagnosis often leads to unnecessary treatments and resource over-utilization. This review article provides an overview of HADD in seven patients who presented to the ED secondary to an acute presentation of this disease process. HADD is a prevalent pathology, which commonly involves the shoulder, followed by the hip, elbow, wrist, and knee. Predisposing risk factors, such as diabetes and certain genetic factors, have also been identified. Clinical history and imaging, particularly radiographs, play a vital role in diagnosing HADD, with characteristic calcification patterns observed in different stages of the disease. Conservative nonsurgical therapy is the mainstay of treatment, providing effective symptom relief in over 90% of cases. By recognizing HADD as a crucial differential diagnosis for patients with acute or chronic pain, healthcare resource utilization can be optimized, leading to improved patient care in the ED.

Multifocal emphysematous osteomyelitis, a do not miss diagnosis for the emergency radiologist: a case report with literature review.

Emphysematous osteomyelitis (EO) is an uncommon fatal condition with high morbidity and mortality. Simultaneous involvement of the axial and appendicular skeleton with multifocal disease is even rarer, with only a few cases being reported in the literature. We present a case of multifocal emphysematous osteomyelitis in a 56-year-old woman with concurrent emphysematous pyelonephritis complicated by psoas and epidural abscesses. The causative organism in our patient was Escherichia coli. Emergency radiologists should be aware of this condition and differentiate it from other benign entities that can present with intraosseous gas. Prompt diagnosis is important given the high morbidity and mortality with this condition. This case report emphasizes the specific pattern of intraosseous gas seen with EO, which can help diagnose EO with confidence.

The Use of Artificial Intelligence in the Evaluation of Knee Pathology.

Artificial intelligence (AI) holds the potential to revolutionize the field of radiology by increasing the efficiency and accuracy of both interpretive and noninterpretive tasks. We have only just begun to explore AI applications in the diagnostic evaluation of knee pathology. Experimental algorithms have already been developed that can assess the severity of knee osteoarthritis from radiographs, detect and classify cartilage lesions, meniscal tears, and ligament tears on magnetic resonance imaging, provide automatic quantitative assessment of tendon healing, detect fractures on radiographs, and predict those at highest risk for recurrent bone tumors. This article reviews and summarizes the most current literature.

Tibial bone stress injury: diagnostic performance and inter-reader agreement of an abbreviated 5-min magnetic resonance protocol.

OBJECTIVE: To compare the diagnostic performance and inter-reader agreement of an abbreviated (5 min) MR protocol compared to a complete (25 min) protocol, for evaluation of suspected tibial bone stress injury. MATERIALS AND METHODS: This IRB-approved retrospective study consisted of 95 consecutive MR examinations in 88 patients with suspected tibial bone stress injury. Three musculoskeletal radiologists independently classified all examinations utilizing both an abbreviated protocol consisting only of axial T2-weighted images with fat suppression, and after a washout period again classified the complete examinations. Accuracy was calculated as proportion of cases classified exactly, within 1 grade, within 2 grades, and also utilizing a simplified "clinically relevant" classification combining grades 2, 3, and 4A into a single group. Significance testing was performed with the chi-test, and a post-hoc power analysis was performed. Inter-reader agreement was calculated with Kendall's coefficient of concordance, with significance testing performed utilizing the z-test after bootstrapping to obtain the standard error. RESULTS AND CONCLUSIONS: There was no significant difference in accuracy of grading tibial bone stress injuries between complete and abbreviated examinations. For complete exams, pooled exact accuracy was 47.8%; accuracy within 1 grade was 82.8%; and accuracy within 2 grades was 96.1%. For the abbreviated protocol, corresponding accuracies were 50.2, 82.0, and 93.9%. With the "clinically relevant" simplified classification, accuracy was 58.6% for complete exams and 64.2% for abbreviated exams. There was no significant difference in inter-reader agreement, with substantial agreement demonstrated for both complete (Kendall coefficient of concordance 0.805) and abbreviated examinations (coefficient of 0.767).

The association of the medial joint vacuum phenomenon with ulnar collateral ligament injury in symptomatic elbows of younger athletes.

OBJECTIVE: To determine the prevalence of intra-articular gas (IAG) on elbow radiography and evaluate variables, including IAG, as predictors of UCL injury. MATERIALS AND METHODS: This IRB-approved retrospective study consisted of 241 consecutive elbow radiographic studies containing AP radiographs with valgus stress of both symptomatic and asymptomatic sides in 234 patients. The IAG, medial joint space (MJS), and MJS difference between the symptomatic and asymptomatic elbow (MJSD) were evaluated by two readers, as well as patient age, gender, sport played, and handedness. Primary outcomes included IAG on valgus stress radiographs and UCL injury, which was determined by intraoperative findings as the reference standard or MRI if surgery was not performed. Univariate analysis with Student's t, Fisher's exact, and chi-square tests were performed. RESULTS: IAG only manifested with valgus stress and was demonstrated in 30/482 (6.2%) valgus stress radiographs in 27/234 (11.5%) patients. Overall, 21/241 (8.7%) valgus stress radiographs of the symptomatic elbow demonstrated IAG in 21 patients. A total of 128/241 (53.1%) elbow studies had evidence of UCL injury. MJS IAG (p = 0.0147) and increased MJSD (p = 0.0088) were significantly associated with UCL injury. Patient gender, age, handedness, laterality, sport played, and absolute MJS were not associated with UCL injury. MJS IAG with valgus stress demonstrates a sensitivity of 11.7% and specificity of 98.3% in detecting UCL injury for the symptomatic elbow. CONCLUSIONS: MJS IAG infrequently manifests on valgus stress radiographs, but is specific for UCL injury in the symptomatic elbow of overhead throwing athletes. MJS IAG and increased MJSD are significantly associated with UCL injury.

Frequency and Severity of Pulmonary Hemorrhage in Patients Undergoing Percutaneous CT-guided Transthoracic Lung Biopsy: Single-Institution Experience of 1175 Cases.

PURPOSE: To evaluate the frequency and severity of pulmonary hemorrhage after transthoracic needle lung biopsy (TTLB) and assess possible factors associated with pulmonary hemorrhage. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board. The requirement to obtain informed consent was waived. Records from 1113 patients who underwent 1175 TTLBs between January 2008 and April 2013 were retrospectively reviewed. Primary outcomes were pulmonary hemorrhage, documented hemoptysis, and bleeding complications necessitating intervention. Pulmonary hemorrhage was graded as follows: 0, none; 1, less than or equal to 2 cm around the needle; 2, more than 2 cm and sublobar; 3, at least lobar; and 4, hemothorax. Patient, technique, and lesion-related variables were evaluated as predictors of pulmonary hemorrhage. Patient-related variables included main pulmonary artery diameter (mPAD) at computed tomography (CT), pulmonary artery pressures at echocardiography and right-sided heart catheterization, medications, chronic lung disease, bleeding diathesis, and immunodeficiency. Technique- and lesion-related variables included needle gauge, number of passes, pleura-needle angle, lesion size and morphologic characteristics, and distance to pleura. Univariate analysis was performed with χ(2), Fisher exact, and Student t tests. RESULTS: Pulmonary hemorrhage occurred in 483 of the 1175 TTLBs (41.1%); hemoptysis was documented in 21 of the 1175 TTLBs (1.8%). Higher-grade hemorrhage (grade 2 or higher) occurred in 201 of the 1175 TTLBs (17.1%); five of the 1175 TTLBs (0.4%) necessitated hemorrhage-related admission. Higher-grade hemorrhage was more likely to occur with female sex (P = .001), older age (P = .003), emphysema (P = .004), coaxial technique (P = .025), nonsubpleural location (P < .001), lesion size of 3 cm or smaller (P < .001), and subsolid lesions (P = .028). Enlarged mPAD at CT (≥2.95 cm) was not significantly associated with higher-grade hemorrhage (P = .430). CONCLUSION: Pulmonary hemorrhage after TTLB is common but rarely requires intervention. An enlarged mPAD at CT may not be a risk factor for higher-grade hemorrhage.

Crossmodal reorganization in the early deaf switches sensory, but not behavioral roles of auditory cortex.

It is well known that early disruption of sensory input from one modality can induce crossmodal reorganization of a deprived cortical area, resulting in compensatory abilities in the remaining senses. Compensatory effects, however, occur in selected cortical regions and it is not known whether such compensatory phenomena have any relation to the original function of the reorganized area. In the cortex of hearing cats, the auditory field of the anterior ectosylvian sulcus (FAES) is largely responsive to acoustic stimulation and its unilateral deactivation results in profound contralateral acoustic orienting deficits. Given these functional and behavioral roles, the FAES was studied in early-deafened cats to examine its crossmodal sensory properties as well as to assess the behavioral role of that reorganization. Recordings in the FAES of early-deafened adults revealed robust responses to visual stimulation as well as receptive fields that collectively represented the contralateral visual field. A second group of early-deafened cats was trained to localize visual targets in a perimetry array. In these animals, cooling loops were surgically placed on the FAES to reversibly deactivate the region, which resulted in substantial contralateral visual orienting deficits. These results demonstrate that crossmodal plasticity can substitute one sensory modality for another while maintaining the functional repertoire of the reorganized region.

Vascular leiomyoma of the thigh: Classic presentation of a rare tumor with imaging and pathology correlation.

We report a case of a vascular leiomyoma arising from the superficial femoral artery presenting as a non-painful thigh mass in a 55-year-old woman. Leiomyomas typically arise from the uterus and gastrointestinal tract, and rarely arise from vessels. We present this case to emphasize that although extremity leiomyomas are rare, they should be considered if there is a soft tissue mass abutting a vessel. Radiologists should be familiar with the imaging features associated with vascular leiomyomas.

Atypical Chondroid Syringoma of the Toe.

Although chondroid syringoma rarely occurs outside the head and neck, the majority of malignant chondroid syringomas are identified in the extremities. Here, we present a case of atypical chondroid syringoma in the fifth toe. Diagnosis of chondroid syringoma with atypical cells was made following initial excisional biopsy and histology, necessitating repeated surgery for positive margins. In this case report, we examine the radiopathologic correlation of this diagnosis, detail the imaging findings of benign and malignant chondroid syringomas, and highlight how magnetic resonance imaging can be used to guide surgical planning and treatment course of this potentially malignant tumor.

Growth of carotid artery duplex ultrasound among Medicare beneficiaries (2000-2007).

OBJECTIVE: Although intervention in asymptomatic carotid artery stenosis remains controversial, most carotid interventions are performed in asymptomatic individuals. Carotid duplex ultrasound is the diagnostic test that precedes more than 90% of carotid interventions. In terms of economic incentives, providers who perform carotid artery revascularization may experience synergy if they also provide carotid duplex ultrasound, because the diagnostic service is reimbursed and also can lead to referrals for revascularization procedures. To test the hypothesis that providers of revascularization services are incentivized to increase utilization of carotid duplex ultrasound, we compared the utilization of carotid duplex ultrasound among Medicare beneficiaries by three specialties that perform revascularization for carotid stenosis (interventional radiology, vascular surgery, and cardiology) with one that usually does not (diagnostic radiology). MATERIALS AND METHODS: We analyzed 100% of procedure-specific claims submitted to Medicare by the four specialties during 2000, 2002, 2004, 2005, 2006, and 2007. Only professional and global components of services approved by Medicare were included. Compounded annual growth rates were used to compare utilization by different specialties. RESULTS: Utilization by diagnostic radiology increased at a compound annual growth rate of 1% during 2000-2007. Interventional radiology and vascular surgery experienced higher compound annual growth rates of 3% and 6%, respectively. Utilization by cardiology increased at a rate 11 times that of diagnostic radiology, translating into an additional 960 procedures per 100,000 Medicare beneficiaries by cardiology in 2007 than in 2000. CONCLUSION: Medicare beneficiaries are increasingly being tested for carotid artery stenosis, especially by specialties that perform revascularization for carotid stenosis. The health benefits of this practice are uncertain.

Teaching cancer imaging in the era of precision medicine: Looking at the big picture.

The role of imaging in cancer diagnosis and treatment has evolved at the same rapid pace as cancer management. Over the last twenty years, with the advancement of technology, oncology has become a multidisciplinary field that allows for researchers and clinicians not only to create individualized treatment options for cancer patients, but also to evaluate patients' response to therapy with increasing precision. Familiarity with these concepts is a requisite for current and future radiologists, as cancer imaging studies represent a significant and growing component of any radiology practice, from tertiary cancer centers to community hospitals. In this review we provide the framework to teach cancer imaging in the era of genomic oncology. After reading this article, readers should be able to illustrate the basics cancer genomics, modern cancer genomics, to summarize the types of systemic oncologic therapies available, their patterns of response and their adverse events, to discuss the role of imaging in oncologic clinical trials and the role of tumor response criteria and to display the future directions of oncologic imaging.

Absence of Posttraumatic Bone Marrow Edema in the Setting of Preeclampsia.

Magnetic resonance imaging is a powerful tool in the diagnosis of missed or occult fractures on radiographic and computed tomographic (CT) imaging, through the detection of bone marrow edema. Although radiologists often rely on bone marrow edema as a guide for diagnosing subtle underlying fractures, it is important to recognize its limitations as a diagnostic metric. We present a rare case demonstrating the absence of bone marrow edema after acute trauma and confirmed Lisfranc fracture in a patient with preeclampsia and propose an interesting physiologic mechanism to explain this manifestation.

Tales of Mentoring in Radiology: The Experience of Residents and Mentors at a Single Academic Program.

PURPOSE: To investigate the utility of mentoring groups in radiology residency. METHODS: Five assistant professors of Radiology and 20 radiology residents were divided into 5 groups. One resident from each academic year was randomly paired with a mentor group. Three 1-hour group mentoring sessions took place over the year. Upon completion of the project an anonymous Quality Improvement survey of 20 questions were sent out to participants to assess the utility of these mentoring sessions. RESULTS: Four mentors out of 5 responded. All 4 had prior neutral and positive experiences as mentees involving career advice and subspecialty choice. During this experience all mentors had a positive experience. The majority found it helpful to have residents of different levels in their group to allow for peer to peer mentoring and all thought the mentoring program should continue. The most common topics they covered during the sessions were career advice and specialty choice. Sixteen residents out of 20 responded. The majority had had a previous mentor experience which was mostly positive or very positive and predominantly career and/or research related. Almost all of them had a positive or very positive mentoring experience this year. The high majority found that having residents of different levels was beneficial. Topics that mentoring sessions helped mostly with were career advice, work life balance and study skills. All of the mentees thought the mentoring program should continue. CONCLUSIONS: Mentoring groups can be a valuable addition to residency training, especially in helping with career advice and work life balance.

Availability, affordability, and accessibility of a healthful diet in a low-income community, Central Falls, Rhode Island, 2007-2008.

BACKGROUND: Many Americans have diets that do not meet the dietary guidelines set by the US Department of Agriculture (USDA). Additionally, low-income people have the highest rates of obesity and have difficulty accessing the necessary foods for maintaining a healthful diet. CONTEXT: In December 2007 and January 2008, 21 retail food stores in Central Falls, Rhode Island, where residents were predominantly low-income Hispanics, were evaluated for the availability and costs of foods that fulfill the USDA's Thrifty Food Plan (TFP) guidelines. METHODS: Each surveyed store was evaluated for variety and weekly cost of 3 different types of market baskets (2 families and an elder). Each store's proximity to public transportation was estimated by using geographic information systems mapping. OUTCOME: Only 2 stores in Central Falls and the discount supermarket in an adjacent city, Pawtucket, carried enough variety of foods to fill the TFP basket. At the 2 stores, costs were up to 40% higher, and at the discount store, costs were up to 18% cheaper, than the national average. Each of the stores was accessible by public transportation. INTERPRETATION: Meeting the USDA TFP guidelines is difficult in this low-income, predominantly Hispanic city. Although the components of the TFP are available, high prices may make a nutritious diet unaffordable.

Sarcopenia is associated with longer hospital stay and multiorgan dysfunction in alcoholic hepatitis.

INTRODUCTION: Excessive alcohol consumption has steadily risen to become the third leading cause of preventable death in the USA. One consequence of heavy alcohol use recently under considerable investigation is alcoholic hepatitis. Although many risk factors for developing alcoholic hepatitis have been documented, our aim in this study was to examine the potential association between sarcopenia and severity, mortality, 30 days readmission rate, complication, infections and length of hospital stay in alcoholic hepatitis patients. METHODS: A retrospective analysis was performed at a large, academic hospital in 194 alcoholic hepatitis patients aged 18-60 who had cross-sectional computed tomography imaging and met our clinical definition of alcoholic hepatitis. The fifth percentile of the psoas muscle index was used as a cutoff for sarcopenia. RESULTS: One hundred ninety-four patients met the criteria for alcoholic hepatitis and had cross-sectional imaging. Higher Model for End-Stage Liver disease score was found in the sarcopenia group when compared to the non-sarcopenia group (mean Model for End-Stage Liver disease 21.5 and 24.2, respectively, P = 0.03). Sarcopenia also correlated with significantly longer hospital stay; the average length of stay in the sarcopenia group was 17.2 days while the non-sarcopenia patients had an average of 12.4 days. We found higher risk of developing pneumonia, sepsis and hepatic encephalopathy in sarcopenic patients. CONCLUSION: Alcoholic hepatitis patients with sarcopenia have significantly worse outcomes when compared with the patients without sarcopenia, including a severe form of alcoholic hepatitis, longer hospital stays, higher risk of developing pneumonia, sepsis and hepatic encephalopathy.

Prevalence and Predictive Value of BI-RADS 3, 4, and 5 Lesions Detected on Breast MRI: Correlation with Study Indication.

RATIONALE AND OBJECTIVES: This study aims to determine the prevalence and predictive value of Breast Imaging Reporting and Data System (BI-RADS) 3, 4, and 5 findings on breast magnetic resonance imaging (MRI) and to evaluate the impact of study indication on the predictive value of BI-RADS categories. MATERIALS AND METHODS: This institutional review board approved, Health Insurance Portability and Accountability Act (HIPAA) compliant retrospective review of our breast MRI database from 2009 to 2011, of 5778 contrast-enhanced studies in 3360 patients was performed. At our institution, each breast receives an individual BI-RADS assessment. Breast MRI reports and electronic medical records were reviewed to obtain BI-RADS assessment, patient demographics, and outcomes. Univariate analysis was performed with Fisher exact and chi-square tests. RESULTS: A total of 9216 BI-RADS assessments were assigned during the study period: 7879 (85.5%) BI-RADS 1 and 2, 567 (6.2%) BI-RADS 3, 715 (7.8%) BI-RADS 4, and 55 (0.6%) BI-RADS 5 assessments. The frequency of BI-RADS 3, 4, and 5 assessments was higher in studies performed for diagnostic (7.8%, 14.6%, 1.6%, respectively) than screening (5.2%, 4.0%, 0.1%) indications (P < 0.01). A total of 663 BI-RADS 4 and 5 lesions were biopsied with 209 (31.5%) malignant and 454 (68.5%) benign outcomes. The overall cancer rate for BI-RADS 3 findings was 1.9% (11 of 567) with no difference observed by study indication (diagnostic, 1.6%; screening, 2.3%; P = 0.76). The positive predictive value (PPV2) of BI-RADS 4 and 5 was higher for diagnostic (29.1%, 154 of 530) than for screening (22.9%, 55 of 240) indications. CONCLUSIONS: Abnormal interpretation rates and PPV2 for MRIs performed for diagnostic indications are higher than for screening indications. Similar to mammography, breast MRI audits should be separated by study indication.