National survey of imaging practice for suspected or confirmed plasma cell malignancies.

OBJECTIVE:: Cross-sectional imaging is now recommended by the National Institute for Health and Care Excellence (NICE) for patients with suspected and newly diagnosed myeloma instead of skeletal survey. The objectives of this study were: (1) To evaluate compliance of current UK imaging practice with reference to National Institute for Health and Care Excellence best-practice clinical guidelines for plasma cell malignancies. (2) To identify factors which may influence diagnostic imaging choices. METHODS:: We conducted a national online survey to assess compliance with guidelines and to identify challenges to implementation (endorsed by Myeloma UK, UK Myeloma Forum and the British Society of Skeletal Radiologists). RESULTS:: Responses were received from 31 district general and 28 teaching hospitals. For suspected and confirmed myeloma, skeletal survey remained the most frequent first-line imaging test (suspected myeloma 44.3%, confirmed myeloma 37.7%). Only 9.8 % of responders offered first-line whole body MRI. CONCLUSION:: Significant challenges remain to standardisation of imaging practice in accordance with national best-practice guidelines. ADVANCES IN KNOWLEDGE:: This is the first publication to date evaluating current UK imaging practice for assessing myeloma since the publication of new guidelines recommending use of advanced cross-sectional imaging techniques. Skeletal survey remains the most commonly performed first-line imaging test in patients with suspected or confirmed myeloma and this is largely due to resource limitations within radiology departments.

Can we improve the outcome of hydrodilatation for adhesive capsulitis?

BACKGROUND: Hydrodilatation (HD) has been shown to improve pain and function in patients with adhesive capsulitis (AC). There is no consensus concerning how HD should be performed or what volume should be injected. It has distinct advantages compared to surgery; however, it is a painful procedure and is often poorly tolerated. METHODS: We retrospectively reviewed all patients referred for HD over a 2.5-year period aiming to assess whether volume injected influences outcome. RESULTS: There were 107 patients treated with HD; of these, 76 (43 female, 32 male) had full data for analysis. The majority were classified as primary AC (n = 57) with an average age of 55.5 years. The mean improvement in Oxford Shoulder Score (OSS) was 12.1, with females (13.9) and post-traumatic cases of AC (14.1) demonstrating the best outcome. No complications were observed during the HD process. There was a negative correlation observed between volume injected and OSS improvement. Only two patients experienced a poor outcome and required further treatment with manipulation +/- arthroscopic arthrolysis. CONCLUSIONS: The present study supports the use of HD as a first line treatment for AC regardless of the underlying cause, and also demonstrates that the volume injected does appear to influence the outcome.

Magnetic resonance arthrography for labral tears and chondral wear in femoroacetabular impingement.

Magnetic resonance arthrography (MRA) is a useful pre-operative investigation for patients with clinical signs and symptoms of femoroacetabular impingement. Our aim was to assess the diagnostic accuracy of MRA in detecting labral tears and chondral wear in this context. Sixty nine hips were included in the study after exclusions. All patients underwent pre-operative MRA and then subsequent hip arthroscopy. The findings at MRA were compared to those found intraoperatively. For labral tears, sensitivity, specificity and accuracy were 81%, 51% and 58% respectively. For chondral wear these figures were 17%, 100%, and 55% respectively. In our institution, MRA was therefore not as accurate as previously published work suggests.

Patterns of pain in Paget's disease of bone and their outcomes on treatment with pamidronate.

Two-thirds of patients with Paget's disease seeking medical attention present with pain. We studied patterns of pagetic pain in relation to physical activity, and the effect of coexistent osteoarthritis (OA)/pagetic arthropathy on pain and physical activity before and after treatment with pamidronate. Patients with lower-segment Paget's disease (lumbar spine, pelvis or lower limbs), raised alkaline phosphatase (ALP), and pain as a symptom were included. Two subgroups were identified based on the absence (P group), or presence (POA group) of radiological OA in the lower segment. They received 2-4 fortnightly infusions of pamidronate 30-60 mg and were followed up at 6 weeks, 3 months and 6 months. Outcome measures were visual analog scales for pain at rest, on standing, on walking and at night; standing time, walking distance, 50-yard walking time, and ALP. Twenty-five patients (12 men, 13 women, mean age 70.1+/-1.9 years), received a mean of 142+/-9.7 mg of pamidronate. The P group had higher mean ALP (p=0.003) and higher scores for pain (not significant) at baseline than the POA group. Compared to baseline, P group had significant improvements (p<0.01) at 6 months in rest pain, standing pain and walking pain. The POA group had non-significant changes in pain at 6 months. ALP improved significantly at 6 months in both subgroups (p<0.01). The whole group also improved at 6 months in standing time (55.7%, not significant), walking distance (33.9%, not significant), and 50-yard walking time (24.2%, p<0.05). Paget's patients with coexistent joint disease had less severe pain and bone disease at baseline than those without coexistent joint disease, and responded less well to pamidronate, although they did have significant improvement in ALP levels. Radiographic assessment for coexisting joint disease prior to treatment might improve prognostication from the patient's point of view, and improve treatment compliance.