Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study.

OBJECTIVE: Accurate pre-operative evaluation of renal vascular anatomy is essential for successful renal harvest in live donor transplantation. Non-contrast renal MR angiographic (MRA) techniques are potentially well suited to the screening of donors; however, their restricted imaging field of view (FOV) has previously been an important limitation. We sought to assess whether the addition of a large FOV balanced fast field echo (BFFE) steady-state free precession (SSFP) sequence to non-contrast SSFP MRA could overcome this problem. Comparison with contrast-enhanced MRA (CE MRA) and findings at surgery were performed. METHODS: 22 potential renal donors each underwent SSFP and CE MRA. 11 out of 22 potential donors subsequently underwent a donor nephrectomy. RESULTS: All images were diagnostic. Both SSFP MRA and CE MRA identified an equal number of arteries. Surgery confirmed two accessory renal arteries, both demonstrated with both imaging techniques. A third accessory vessel was identified with both techniques on a kidney contralateral to the donated organ. 6 out of 11 procured kidneys demonstrated early branch arteries at surgery, 5 out of 6 of which had been depicted on both SSFP and CE MRA. The median grading of image quality for main renal arteries was slightly better for CE MRA (p=0.048), but for accessory vessels it was better for SSFP MRA. CONCLUSION: This pilot study indicates that by combining free-breathing SSFP MRA with large-FOV bFFE images, an accurate depiction of renal vascular anatomy without the need for intravenous contrast administration can be obtained, as compared with surgical findings and CE MRA.

Facing the future: the effects of the impending financial drought on NHS finances and how UK radiology services can contribute to expected efficiency savings.

The recent turmoil within the banking sector has led to the development of the most significant recession since the "great depression" of the 1930s. Although the coalition government has promised to "guarantee that health spending increases in real terms in each year of Parliament", this may still not be enough to meet future needs over the coming years due to increasing demand and cost pressures. The expected mismatch between actual National Health Service (NHS) funding post-2011 and that required to satisfy increasing demand has been estimated by the Department of Health to require efficiency savings representing up to one-fifth of the overall NHS budget. This paper explains the reasons behind the anticipated slowdown in the growth of real NHS funding, and how, as a discipline, radiology can increase the efficiency of the services it provides in anticipation of future financial austerity within the NHS.

Regional grey and white matter volumetric changes in myalgic encephalomyelitis (chronic fatigue syndrome): a voxel-based morphometry 3 T MRI study.

OBJECTIVE: It is not established whether myalgic encephalomyelitis/chronic fatigue syndrome (CFS) is associated with structural brain changes. The aim of this study was to investigate this by conducting the largest voxel-based morphometry study to date in CFS. METHODS: High-resolution structural 3 T cerebral MRI scanning was carried out in 26 patients with CFS and 26 age- and gender-matched healthy volunteers. Voxel-wise generalised linear modelling was applied to the processed MR data using permutation-based non-parametric testing, forming clusters at t>2.3 and testing clusters for significance at p<0.05, corrected for multiple comparisons across space. RESULTS: Significant voxels (p<0.05, corrected for multiple comparisons) depicting reduced grey matter volume in the CFS group were noted in the occipital lobes (right and left occipital poles; left lateral occipital cortex, superior division; and left supracalcrine cortex), the right angular gyrus and the posterior division of the left parahippocampal gyrus. Significant voxels (p<0.05, corrected for multiple comparisons) depicting reduced white matter volume in the CFS group were also noted in the left occipital lobe. CONCLUSION: These data support the hypothesis that significant neuroanatomical changes occur in CFS, and are consistent with the complaint of impaired memory that is common in this illness; they also suggest that subtle abnormalities in visual processing, and discrepancies between intended actions and consequent movements, may occur in CFS.

Immediate and sustained benefits of a "total" implementation of speech recognition reporting.

Speech recognition reporting was introduced in our institution to address the significant delay between report dictation and the appearance of a typed report on the Picture Archiving and Communication System (PACS). We report our experience of a "total" implementation of a speech recognition reporting (SRR) system, which became the sole means of radiology reporting from day 1 of introduction. Prospectively gathered Radiology Information System (RIS) data were examined to determine the monthly mean reporting times and completion times for all studies from January 2004 to February 2006 (11 months before introduction of SRR and 15 months after introduction). Studies were grouped for analysis according to referral source (casualty, general practice, inpatient or outpatient). A large, sustained reduction in time to completion was noted in all referral groups at both hospital sites within our institution (6.79 +/- 0.92 days pre-SRR and 2.20 +/- 0.78 days post-SRR, independent two-sample Student's t-test, p<10(-11)). Workflow was maintained following the introduction of SRR: numbers of reports per month and mean times to report were unchanged. SRR eliminated the delays associated with report transcription and subsequent authorisation, dramatically reducing report turnaround times. Resistance to change has perhaps led to suboptimal implementation of SRR in some other institutions, such that benefits have not been fully realised. Our experience demonstrates the dramatic impact that a well-planned, organisation-wide implementation of SRR can have on radiology service delivery.

Provision of a "same-day" ultrasound service in an inner-city NHS trust: report on experience and lessons learned after the first 2 years.

AIM: To assess the effect of changing from an "appointment" to a "same-day" ultrasound (US) service on referral pattern, departmental workload, and patient satisfaction. MATERIALS AND METHODS: To reduce US waiting time of 3 weeks for routine examinations, a "same-day" service was started for outpatients and general practitioner (GP) patients in September 2006. To examine the effect of this change a retrospective assessment was performed of workload during 1 week in June 2006 (appointments only) and the same week in 2008, 22 months after the implementation of the new service. Distance travelled by patients and waiting time was recorded. Patient satisfaction with the service was assessed by questionnaire in September 2008. RESULTS: Hospital referrals remained stable, but GP referrals increased from 99 to 367 (270%) and distance travelled by patients increased from a median of 3.1 km (range 0.1-12.1 km) in 2006 to 4.8 km (range 0.2-19.8 km) in 2008 (p<0.001). Non-local GP referrals increased from 20/99 in 2006 (20%) to 198/367 in 2008 (54%). The increased workload was managed by flexible working by radiologists and two additional sonographers. Departmental waiting time increased for all patients with same-day patients waiting a median of 35 min (interquartile range 19-60 min). Ninety-one percent (79/87) of same-day patients rated the service excellent or good, but many requested better information on the waiting time. CONCLUSION: There is a demand from GPs for same-day US, and it is feasible in a large hospital with flexible radiology working and increased sonographic staffing. Unless adjacent hospitals offer a similar service, continuing rise in demand could overwhelm the service.

Anatomic and functional imaging in the management of lymphoma.

Lymphoma has become one of the most successfully treated malignancies. The success of treatment and long-term prognosis depend on accurate staging in which imaging plays a pivotal role. In addition to staging, imaging assists in the evaluation of early and late response to therapy, detecting disease activity in a residual mass and locating sites of recurrence. The mainstay of imaging remains computed tomography (CT), which has replaced lymphangiography, and staging laparotomy. Magnetic resonance imaging (MRI) has additional value in detecting disease in bone marrow, the musculoskeletal and central nervous system. Recent technical developments in CT and MRI have improved acquisition times and resolution, but the main drawback of cross-sectional imaging techniques is their reliance on size criteria to define disease, with consequent failure to detect disease in small lymph nodes and exclude disease in large, but treated, masses. Diffuse visceral involvement is likewise difficult to detect by both modalities. Functional imaging with nuclear medicine techniques offers an answer to these problems. Imaging with the fluorinated glucose analogue, [18F]FDG positron emission tomography (PET), can detect metabolically active disease by its increased glycolysis that is proportional to mitotic activity. It can separate high from low-grade tumors and aid in prognostication. Recent publications suggest that imaging with [18F]FDG PET should be an important component in staging; assessment of response to therapy and restaging. Like other imaging modalities, it has its own drawbacks including inability to detect very small lesions (<5 mm) and reduced specificity due to increased uptake in metabolically active inflammatory and infective tissues. The new generation of hybrid PET-CT combines anatomical and functional imaging and is considered the state-of-the-art imaging technique for the assessment of lymphoma and other malignancies.

Endoanal magnetic resonance imaging of fistula-in-ano: a comparison of STIR with gadolinium-enhanced techniques.

PURPOSE: To compare a STIR sequence with gadolinium-enhanced techniques on endoanal magnetic resonance (MR) imaging of fistulas-in-ano by correlating the findings with those at surgery. MATERIAL AND METHODS: Twenty-two consecutive patients with clinical suspicion of perianal sepsis were studied using an endoanal coil followed immediately by a phased array coil. T1-weighted precontrast and postcontrast and STIR images in transverse and coronal planes were produced with each coil and analysed by noting the presence and site of a collection, primary track, the position of any internal opening, and subcutaneous or supralevator extension. An "expert" and also a "trainee" radiologist assessed the images. Operative findings were similarly recorded. The Fisher exact test was used to compare imaging with surgery. Interobserver variation was calculated using a kappa statistic. RESULTS: Of 22 patients with suspected fistulas, 8 were simple, 4 were complex, and 3 were superficial sinuses. Five had no anal pathology, 1 had anal excoriation, and 1 had a polyp. At surgery, 6 intersphincteric, 1 transsphincteric, 8 extrasphincteric, no supralevator collections, and 9 internal openings were noted. The overall sensitivity and specificity for detecting these were 75% and 64%, respectively, for STIR imaging, and 58.3% and 62.8% for gadolinium-enhanced imaging. There was good agreement between the "trainee" and the "expert" in the interpretation of images (kappa=0.7). CONCLUSION: A STIR sequence is more sensitive overall than gadolinium-enhanced techniques on endoanal magnetic resonance imaging of fistulas-in-ano because of increased sensitivity in detecting the internal opening. A combination of endoanal and phased array techniques using STIR imaging sequences is valuable preoperative assessment in both simple and complex cases.

Magnetic resonance imaging of the Achilles tendon using ultrashort TE (UTE) pulse sequences.

AIM: To assess the potential value of imaging the Achilles tendon with ultrashort echo time (UTE) pulse sequences. MATERIALS AND METHODS: Four normal controls and four patients with chronic Achilles tendinopathy were examined in the sagittal and transverse planes. Three of the patients were examined before and after intravenous gadodiamide. RESULTS: The fascicular pattern was clearly demonstrated within the tendon and detail of the three distinct fibrocartilaginous components of an "enthesis organ" was well seen. T2* measurements showed two short T2* components. Increase in long T2 components with reduction in short T2 components was seen in tendinopathy. Contrast enhancement was much more extensive than with conventional sequences in two cases of tendinopathy but in a third case, there was a region of reduced enhancement. CONCLUSION: UTE pulse sequences provide anatomical detail not apparent with conventional sequences, demonstrate differences in T2* and show patterns of both increased and decreased enhancement in tendinopathy.

A one-year, randomised, placebo (saline) controlled clinical trial of 500-730 kDa sodium hyaluronate (Hyalgan) on the radiological change in osteoarthritis of the knee.

The primary objective of this study was to investigate structural changes, as measured by joint space narrowing (JSN), within the knee joint during treatment with intra-articular sodium hyaluronate (HA) of molecular weight 500-730 kDa in patients with osteoarthritis (OA) of the knee. Patients received a weekly intra-articular injection of either 20 mg2/ml HA or a 2 ml vehicle placebo (saline) for three weeks. This course was repeated twice more at four-monthly intervals. Concomitant treatment with analgesics or NSAIDs was allowed. The primary efficacy measure was the reduction in mean joint space width (JSW) of the medial compartment at 52 weeks. A total of 408 patients were randomised and 319 completed the one-year study (HA: n=160, placebo: n=159); 273 of the 319 were included in the primary analysis. Analysis of variance on these 273 patients did not show a statistically significant difference between the two treatment groups. However, there was a significant difference in response to treatment in terms of the baseline JSW (p=0.01), indicating that outcome of treatment may depend on-baseline JSW. Therefore, a subgroup analysis by baseline JSW was conducted. This compared patients with a JSW >4.6 mm with those with a JSW <4.6 mm. In those with radiologically milder disease at baseline and receiving HA, the JSN was significantly reduced compared with placebo (p=0.02). In patients with radiologically more severe disease there was no difference in JSN between the two treatments. Although, in this one-year study, no overall treatment effect was seen, those with radiologically milder disease at baseline had less progression of joint space narrowing when treated with HA.

Percutaneous excision of a facet joint cyst under CT guidance.

We report a patient with a cyst of the posterior inter-articular joint that was decompressed using a bone biopsy Temno needle.

The strengthening effect of percutaneous vertebroplasty.

AIM: To examine whether single-needle vertebroplasty is effective in strengthening vertebrae. MATERIALS AND METHODS: Four adjacent intact lumbar vertebrae were removed from each of nine adult post-mortem subjects. One or two vertebra of each set was injected with low viscosity acrylic bone cement using a single-track posterolateral approach. Vertebral strength was measured during constant rate axial compression. RESULTS: Single-needle injection delivered different quantities of cement (1-8 ml) in an asymmetric distribution. Injected vertebrae were stronger than controls in 10 out of 12 cases (P < 0.01), suggesting that cement injection increases the load needed to cause initial vertebral fracture. Compression was continued past the point of initial failure, to simulate progressive vertebral collapse. Injected specimens were more resistant to deformation than control specimens (P < 0.05), most of which initially deformed with little increase in load. CONCLUSION: Single-track injection of bone cement appeared to strengthen vertebrae against both initial failure and subsequent collapse. The magnitude of strength increase from vertebroplasty was variable, and did not correlate with the volume of cement injected. Further investigation is needed to optimize the technique.Gishen, P. (2000). Clinical Radiology55, 471-476.

Radiologically guided bone biopsy: results of 502 biopsies.

PURPOSE: To analyze the results of 502 biopsies over a 19-year period for the purpose of highlighting the results that can be expected from such a large study, with emphasis on needle choice and anesthetic methods. METHODS: The histological, cytological, and microbiological results of 477 patients who had 502 bone biopsies carried out between July 1977 and March 1996 were studied. Less than 5% of patients required second biopsies. There were almost equal numbers of males and females in the group. The lesions were visible radiologically and most of the biopsies were carried out by a single operator. The lesions were classified on their histopathological, cytopathological, and microbiological findings. RESULTS: Tumors accounted for 40% of the biopsies, and infection for 16%. Biopsies which did not yield a "positive" diagnosis accounted for 31%; these included specimens reported as normal, or as showing reactive changes, repair, remodelling, non-specific features, inflammation (but not clearly infective), or no evidence of malignancy or inflammation. Less than 4% of biopsies were incorrect, and some of these were re-biopsied. CONCLUSION: Bone biopsy is a valuable technique for positive diagnosis of malignancy or infection, as it enables a definitive plan for treatment and management of patients to be established. Exclusion of serious pathology is almost equally important. In principle, any osseous site can be biopsied using fluoroscopic or computed tomographic guidance. Care in the biopsy technique and selection of the bone needle is required.

Effects of antiinflammatory drugs on the progression of osteoarthritis of the knee. LINK Study Group. Longitudinal Investigation of Nonsteroidal Antiinflammatory Drugs in Knee Osteoarthritis.

OBJECTIVE: To compare the rate of radiographic progression in knee osteoarthritis (OA) comparing indomethacin with placebo and tiaprofenic acid with placebo. METHODS: Rate of radiographic progression of OA of the knees was studied in 812 patients randomized double blind parallel group study at 20 rheumatology clinics in the United Kingdom and analyzed sequentially. Patients received either indomethacin 25 mg three times daily, tiaprofenic acid 300 mg twice daily, or matched placebo. All had access to paracetamol as a rescue analgesic. Joint space narrowing was measured by a 6 point grading scale, using radiographs taken with a standardized technique at recruitment and annually thereafter. RESULTS: Three hundred and seventy six patients completed at least one year of study medication and therefore contributed evaluable results. More than twice as many patients showed deterioration in the indomethacin group as in the placebo group; of 170 available patients at the 3rd interim analysis, 40 of 85 receiving indomethacin had deteriorated compared to 19 of 85 receiving placebo, a statistically significant difference (p = 0.009). No statistically significant difference (p = 0.308) was found between tiaprofenic acid and placebo at the 7th interim analysis, the conclusion of the study. CONCLUSION: Indomethacin increased the rate of radiological deterioration of joint space in patients with OA of the knee; tiaprofenic acid did not.

Technical note: a radiological education system--organization of an image library.

A successful radiological library and teaching system should be easy to compile, user-friendly, dynamic and flexible. Nowadays it must be amenable to incorporation into digitally-based communication systems such as personal computers (pc) and picture archiving and communication systems (PACS). This article describes the structural organization and capabilities of such a digital radiological education system, and demonstrates how it fulfils these aims.

Case report: a rare origin of the common iliac artery.

A rare origin of the common iliac artery is presented. The authors believe that the anomaly described has not been previously reported and suggest possible explanations.

The natural history of sciatica associated with disc pathology. A prospective study with clinical and independent radiologic follow-up.

The purpose of this study was to assess the natural history of sciatica due to lumbosacral nerve root compromise and to evaluate the pathomorphologic changes that accompany the natural resolution of the disease. One hundred sixty-five consecutive patients, 114 males and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. The cornerstone of treatment was the serial epidural administration of steroid and local anesthetic by the caudal route on an outpatient basis. Lumbar epidural injection or periradicular infiltration at the appropriate level, confirmed under image intensifier, was the next step before considering surgical decompression. An average of three injections (range, 0-8) was received by each patient. Patients underwent clinical examination and computed tomography. Twenty-three patients (14%) underwent surgical decompression. The remainder were clinically assessed at 1 year after presentation, and 111 were rescanned at the appropriate levels. All conservatively managed patients made a satisfactory clinical recovery: average reduction of pain on the visual analog scale was 94% (range, 45-100), and 64 (76%) of the 84 disc herniations and 7 (26%) of the 27 disc bulges showed partial or complete resolution (chi-square = 20.27, P = 0.0001). Thus a high proportion of patients with discogenic sciatica make a satisfactory recovery with aggressive conservative management, and this recovery is accompanied by resolution of disc herniations in a significant number. Only a small proportion of patients needed surgical decompression.

The natural history of sciatica: a prospective radiological study.

This prospective study was set up to record the changes in the intervertebral disc accompanying resolution of sciatica following conservative treatment. Patients presenting with sciatica (n = 165) were examined by computed tomography (CT) of the lumbar spine. Disc lesions were classified into the following groups: herniation, sequestration, generalized bulge and focal bulge. Follow-up CT of the pathological disc was performed in 106 of the 165 patients after 1 year and identical anatomical sections were compared. All patients were initially treated conservatively by the injection of steroid and local anaesthetic at the intervertebral disc/nerve root interface. Of 84 cases of disc herniation and sequestration 64 (76%) showed either complete or partial resolution on follow-up CT examination. Of 22 cases with either a generalized or focal bulge of the disc 18 (82%) were unchanged on follow up. The classical disc herniation in a young patient is the type of disc lesion most likely to show greatest improvement at follow-up CT.

'Sabre sheath' trachea with mediastinal lipomatosis mimicking a mediastinal tumour.

Two cases of 'sabre sheath' trachea in combination with mediastinal lipomatosis are reported. The initial chest radiographs in both cases were interpreted as showing a mediastinal tumour causing tracheal compression. The correct diagnosis was subsequently made using computed tomography (CT). It is important to be aware of these benign conditions when interpreting chest radiographs, particularly in cases of suspected mediastinal pathology.