A critical appraisal of the quality of low back pain practice guidelines using the AGREE II tool and comparison with previous evaluations: a EuroAIM initiative.

PURPOSE: To assess the methodologic quality of guidelines for the management of low back pain (LBP) and compare their recommendations. METHODS: No ethics committee approval was needed for this systematic review. In March 2017, a systematic search was performed using MEDLINE, EMBASE, National Guideline Clearinghouse, and National Institute for Health and Clinical Excellence to find practice guidelines of assessment and management of LBP. The evaluation of guidelines quality was performed independently by four authors using the AGREE II tool, and the results were compared with previous appraisals performed in 2004 and 2009. RESULTS: Of 114 retrieved guidelines, eight were appraised. All except one reached the level of "acceptable" in overall result, with two of them reaching the highest scores. Only two guidelines reached a level of "acceptable" in every domain; the others had at least one domain with low scores. The guidelines had the higher scores (range = 63-94%) on "Scope and purpose" and "Clarity of presentation" (47-89%). "Stakeholder Involvement" has the highest variability between the guidelines results (40-96%). "Rigor of Development" reached an intermediate mean result (34-90%), "Applicability" (42-70%), and "Editorial Independence" (38-85%). Only three guidelines had a radiologist among authors and reached higher scores compared to guidelines without a radiologist among the authors. Compared to previous assessments, low-level guidelines were 53% in 2004, 36% in 2009, and 13% in 2017. CONCLUSIONS: Considering all guidelines, only one had a "low" overall score, while half of them were rated as of "high" quality. Future guidelines might take this into account to improve clinical applicability.

Does Tetralogy of Fallot affect brain aging? A proof-of-concept study.

The impact of congenital heart disease on brain aging has not been extensively investigated. We evaluated cerebral microbleeds and white matter hyperintensities on brain magnetic resonance imaging in adult patients with tetralogy of Fallot (ToF). Ten ToF patients (6 women, 4 men; aged 21-58 years; New York Heart Association [NYHA] class 1-2) were prospectively enrolled and underwent a T1-weighted, a T2-weighted dark fluid, and a T2*-weighted scans. Ten age- and sex-matched controls were prospectively recruited and subjected to the same acquisition protocol. Cerebral microbleeds (CMBs) were manually counted while white matter hyperintensities (WMHs) were segmented using ITK-Snap. Wilcoxon signed-rank test, Spearman correlation, and Bland-Altman statistics were used. The median (interquartile range [IQR]) age was 45.0 (30.5-49.5) years in ToF patients and 46.0 (30.5-49.8) years in controls. The median (IQR) of the number of CMBs was 6.0 (4.0-7.8) in ToF patients and 0 (0.0-0.0) in controls (p = 0.002). The WMHs burden was 2,506 (1,557-2,900) mm3 for ToF patients and 2,212 (1,860-2,586) mm3 for controls (p = 0.160). Moreover, a positive significant correlation was found between the WMHs burden and the NYHA class (ρ = 0.80, p = 0.005). Inter-operator concordance rate for the presence/absence of CMBs was 90%; the reproducibility for the WMHs burden was 77%. In conclusion, we found more cerebral microbleeds and a higher WMHs burden in adult ToF patients than in controls. This preliminary comparison supports the hypothesis of an early brain aging in ToF patients. Larger studies are warranted.

Measurement of jugular foramen diameter using MRI in multiple sclerosis patients compared to control subjects.

BACKGROUND: Multiple sclerosis (MS) is a chronic disease of the central nervous system. As an association between MS and reduced cerebral venous blood drainage was hypothesised, our aim was to compare the size of the jugular foramina in patients with MS and in control subjects. METHODS: Ethics committee approval was received for this retrospective case-control study. We collected imaging and clinical data of 53 patients with MS (23 men, mean age 45 ± 9 years) and an age/gender-matched control group of 53 patients without MS (23 men, mean age 46 ± 10 years). The minimal diameter of both jugular foramina was measured on T1-weighted contrast-enhanced axial magnetic resonance images; the two diameters were summed. Student t test and Spearman correlation coefficient were used for analysis. Reproducibility was estimated using the Bland-Altman method. RESULTS: The mean diameter of the right foramen in patients with MS (6.3 ± 1.6 mm) was 10% smaller than that of the controls (7.0 ± 1.4 mm) (p = 0.020); the mean diameter of the left foramen in patients with MS (5.6 ± 1.3 mm) was 7% smaller than that of the controls (6.0 ± 1.3 mm) (p = 0.089). The sum of the diameters of both jugular foramina in patients with MS (mean 11.9 ± 2.3 mm) was 8% smaller (p = 0.009) than that of the controls (mean 13.0 ± 2.1 mm). The differences in diameters between patients with relapsing-remitting MS and patients with secondary progressive MS were not significant (p ≥ 0.332). There was no significant correlation between foramen diameters and the expanded disability status scale (p ≥ 0.079). Intra-reader and inter-reader reproducibility were 91% and 88%, respectively. CONCLUSIONS: Jugular foramen diameter in patients with MS was 7-10% smaller than that in controls, regardless of the MS disease course.

Is Carotid Plaque Contrast Enhancement on MRI Predictive for Cerebral or Cardiovascular Events? A Prospective Cohort Study.

OBJECTIVE: The aim of this study was to correlate carotid plaque contrast enhancement (CPCE) to onset of cerebral/cardiovascular events (CCVE) in patients with atherosclerotic carotid disease. METHODS: The ethics committee approved this prospective study. Patients with carotid artery stenosis underwent magnetic resonance angiography before/after injection of 0.1 mmol/kg of gadobenate dimeglumine. Carotid plaque contrast enhancement was graded as follows: 0, no CPCE; 1, 1 single enhancement focus; 2, 2 or more foci. RESULTS: Seventy-seven patients (71 ± 9 years) had a stenosis degree: 34 mild, 16 moderate, 27 severe at the right side, and 36, 15, and 25 at the left side. Carotid plaque contrast enhancement was 0 in 30 patients, 1 in 26, 2 in 11 at the right, and 37, 19, and 13 at the left. Forty-seven CCVE occurred after magnetic resonance imaging, correlated to both stenosis degree (P = 0.006) and CPCE (P = 0.032). Excluding surgery/stenting, the correlation held only for CPCE (P = 0.017). Of 49 patients showing CPCE, 5 (10%) reported CCVE; of 21 patients without CPCE, none reported CCVE (P = 0.129). CONCLUSIONS: The absence of CPCE seems to be a negative predictor for CCVE.

A new diagnostic score to detect osteoporosis in patients undergoing lumbar spine MRI.

OBJECTIVES: Signal intensity of lumbar-spine at magnetic resonance imaging (MRI) correlates to bone mineral density (BMD). Our aim was to define a quantitative MRI-based score to detect osteoporosis on lumbar-spine MRI. METHODS: After Ethics Committee approval, we selected female patients who underwent both lumbar-spine MRI and dual-energy X-ray absorptiometry (DXA) and a reference group of 131 healthy females (20-29 years) who underwent lumbar-spine MRI. We measured the intra-vertebral signal-to-noise ratio in L1-L4. We introduced an MRI-based score (M-score), on the model of T-score. M-score diagnostic performance in diagnosing osteoporosis was estimated against DXA using receiver operator characteristic (ROC) analysis. RESULTS: We included 226 patients (median age 65 years), 70 (31%) being osteoporotic at DXA. MRI signal-to-noise ratio correlated to BMD (r = -0.677, P < 0.001). M-score negatively correlated to T-score (r = -0.682, P < 0.001). Setting a 90%-specificity, an M-score threshold of 5.5 was found, distinguishing osteoporosis from non-osteoporosis (sensitivity 54%; ROC AUC 0.844). Thirty-one (14%) patients had a fragility fracture, with osteoporosis detected in 15 (48%) according to M-score and eight (26%) according to T-score (P = 0.016). CONCLUSIONS: M-score obtained on lumbar spine MRI is a quantitative method correlating with osteoporosis. Its diagnostic value remains to be demonstrated on a large prospective cohort of patients. KEY POINTS: • M-score is a quantitative score potentially screening osteoporosis on lumbar-spine MRI; • This method showed good intra- and inter-reader reproducibility; • M-score may be used for identifying patients who should undergo DXA.

Short-term precision assessment of trabecular bone score and bone mineral density using dual-energy X-ray absorptiometry with different scan modes: an in vivo study.

OBJECTIVES: We estimated the in vivo reproducibility of trabecular bone score (TBS) from dual-energy X-ray absorptiometry (DXA) using different imaging modes to be compared to that of bone mineral density (BMD). METHODS: We enrolled 30 patients for each imaging mode: fast-array, array, high definition. Each patient underwent two DXA examinations with in-between repositioning. BMD and TBS were obtained according to the International Society for Clinical Densitometry guidelines. The coefficient of variation (CoV) was calculated as the ratio between root mean square standard deviation and mean, percent least significant change (LSC) as 2.77 × CoV, reproducibility as the complement to 100% LSC. RESULTS: Fast-array imaging mode resulted in 0.8% CoV and 2.1% LSC for BMD, 1.9% and 5.3% for TBS, respectively; array imaging mode resulted in 0.7% and 2.0% for BMD, 1.9% and 5.2%, for TBS; high-definition imaging mode resulted in 0.7% and 2.0%, for BMD; 2.0% and 5.4% for TBS, respectively. Reproducibility of TBS (95%) was significantly lower than that of BMD (98%) (p < 0.012). Difference in reproducibility among the imaging modes was not significant for either BMD or TBS (p = 0.942). CONCLUSION: While TBS reproducibility was significantly lower than that of BMD, differences among imaging modes were not significant for both TBS and BMD. KEY POINTS: • TBS is an emerging tool for assessing BMD. • TBS reproducibility is lower than that of BMD. • Differences between imaging modes are not significant for either TBS or BMD.

Prevalence and type of errors in dual-energy x-ray absorptiometry.

OBJECTIVES: Pitfalls in dual-energy x-ray absorptiometry (DXA) are common. Our aim was to assess rate and type of errors in DXA examinations/reports, evaluating a consecutive series of DXA images of patients examined elsewhere and later presenting to our institution for a follow-up DXA. METHODS: After ethics committee approval, a radiologist retrospectively reviewed all DXA images provided by patients presenting at our institution for a new DXA. Errors were categorized as patient positioning (PP), data analysis (DA), artefacts and/or demographics. RESULTS: Of 2,476 patients, 1,198 had no previous DXA, while 793 had a previous DXA performed in our institution. The remaining 485 (20 %) patients entered the study (38 men and 447 women; mean age ± standard deviation, 68 ± 9 years). Previous DXA examinations were performed at a total of 37 centres. Of 485 reports, 451 (93 %) had at least one error out of a total of 558 errors distributed as follows: 441 (79 %) were DA, 66 (12 %) PP, 39 (7 %) artefacts and 12 (2 %) demographics. CONCLUSIONS: About 20 % of patients did not undergo DXA at the same institution as previously. More than 90 % of DXA presented at least one error, mainly of DA. International Society for Clinical Densitometry guidelines are very poorly adopted. KEY POINTS: • More than 90 % of DXA examinations/reports presented one or more errors. • About 80 % of errors are related to image data analysis. • Errors in DXA examinations may have potential implications for patients' management.