Vertebral deformities and functional impairment in men and women.

The objective of this study was to assess the prevalence and health effects of vertebral deformities in men and women. The study was carried out as part of the cross-sectional baseline phase of The Rotterdam Study, a prospective population-based cohort study of residents aged 55 years or over of a district of Rotterdam, The Netherlands. The prevalence of vertebral deformities according to a modification of the Eastell method and concomitant functional impairment were assessed in a random sample of 750 men and 750 women. The prevalence of moderate (grade I) vertebral deformities was 8 and 7% in men and women, respectively. For severe deformities (grade II), these percentages were 4 and 8%. In men, the prevalence of both moderate and severe deformities increased with age. In women, however, the prevalence of moderate vertebral deformities remained constant, opposite to a marked increase in severe deformities. Moderate vertebral deformity was significantly associated with impaired rising in men only. Severe vertebral deformity was associated with a significantly increased risk of general disability and the use of a walking aid in both men and women, impaired bending in men, and impaired rising in women. It is concluded that (1) vertebral deformities are only slightly less common in men than in women from the general population and (2) severe progression with age occurs in women only and (3) severe vertebral deformity is, particularly in men, related to functional impairment.

Imaging of the anorectal region.

Imaging of anorectal region has drastically changed during the last decade. Transrectal ultrasound and transrectal MRI can be used for staging the rectal tumours. Endoanal sonography can be applied for the classification of perianal fistulae and identification of anal sphincter defects in patients with faecal incontinence. Due to the limitations of endoanal sonography, endoanal MRI was introduced to assess the pathology related to the anal sphincter complex. Endoanal MRI seems superior to endoanal sonography. This paper describes the new developments of the imaging techniques and presents new insights in anatomy and pathology of the anorectum.

Association of radiographically evident osteoarthritis with higher bone mineral density and increased bone loss with age. The Rotterdam Study.

OBJECTIVE: To investigate the relationship of osteoarthritis (OA) to bone mineral density (BMD) and rate of bone loss. METHODS: The study group consisted of 2,745 persons (1,624 women) from the general elderly population. Disability was assessed by the Health Assessment Questionnaire. Femoral neck BMD was measured at baseline and, in 1,723 subjects, after 2 years of followup. Knee and hip radiographic OA was assessed on anteroposterior radiographs. RESULTS: With the exception of knee radiographic OA in men, radiographic OA was associated with significantly increased BMD (3-8%). BMD increased significantly according to the number of affected sites and the Kellgren score. Radiographic OA was also associated with significantly elevated bone loss with age (in men, only for radiographic OA of the hip). A significant increase in relation to the number of affected sites and the Kellgren score (except with regard to knee OA in men) was found, independent of disability. CONCLUSION: Radiographic OA is associated with high BMD and increased rate of bone loss. This suggests a more pronounced difference in BMD earlier in life.

Accuracy and the influence of marrow fat on quantitative CT and dual-energy X-ray absorptiometry measurements of the femoral neck in vitro.

Bone mineral measurements with quantitative computed tomography (QCT) and dual-energy X-ray absorptiometry (DXA) were compared with chemical analysis (ChA) to determine (1) the accuracy and (2) the influence of bone marrow fat. Total bone mass of 19 human femoral necks in vitro was determined with QCT and DXA before and after defatting. ChA consisted of defatting and decalcification of the femoral neck samples for determination of bone mineral mass (BmM) and amount of fat. The mean BmM was 4.49 g. Mean fat percentage was 37.2% (23.3%-48.5%). QCT, DXA and ChA before and after defatting were all highly correlated (r > 0.96, p < 0.0001). Before defatting the QCT values were on average 0.35 g less than BmM and the DXA values were on average 0.65 g less than BmM. After defatting, all bone mass values increased; QCT values were on average 0.30 g more than BmM and DXA values were 0.29 g less than BmM. It is concluded that bone mineral measurements of the femoral neck with QCT and DXA are highly correlated with the chemically determined bone mineral mass and that both techniques are influenced by the femoral fat content.

[Vertebral deformities and bone density in the elderly; the ERGO Study (Erasmus Rotterdam Health and the Elderly). ERGO Study Group]. / Werveldeformaties en botdichtheid bij ouderen; het ERGO-onderzoek. ERGO-onderzoeksgroep.

OBJECTIVE: To assess the prevalence of vertebral deformities in men and women aged 55 years and over. DESIGN: Cross-sectional study. SETTING: A quarter in Rotterdam, The Netherlands. METHODS: As part of the 'Rotterdam elderly study', 750 responding men and 750 women underwent lateral radiography of the spine and subsequent morphometry of the vertebrae to detect presence of vertebral deformities. Grade 1 and grade 2 deformities were scored on the basis of the results of the morphometry. The entire vertebral column was classified as normal (no deformities), moderate spinal deformity (grade 1 deformities) or severe spinal deformity (grade 2 deformities). Dual Energy X-ray Absorptiometry (DXA) was used to assess the bone mineral density (BMD) at the femoral neck. RESULTS: The prevalence of moderate or severe spinal deformity was estimated to be 18% in men (12% moderate and 6% severe) and 22% in women (11% moderate and 11% severe) after adjustment for the present age distribution of the Dutch population. The prevalence of deformities increased with age, in particular for severe deformities in women aged 70 years and over. A decreasing BMD was observed with increasing severity of vertebral deformities. Men with severe spinal deformity had a 4% lower BMD whereas women with severe spinal deformity had a 6% lower BMD. CONCLUSION: Vertebral deformities are frequently present in the general population, mostly in the higher age groups. There was an association with decreased BMD. In view of the ongoing aging of the population, a future increase in the prevalence of vertebral deformities is to be expected.

Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones.

OBJECTIVES: In a prospective study, we analyzed 95 consecutive patients undergoing endoscopic papillotomy (EP) for cholangitis due to common bile duct (CBD) stones; our purpose was to evaluate the risk factors influencing the complication rate due to cholangitis, with special attention to the clinical history. METHODS: Patients with previous gastric surgery or EP were excluded. Complications subsequent to sphincterotomy were recorded over a 3-month period. RESULTS: In patients with persistent cholangitis before EP, the risk for complications due to cholangitis increased with increasing delay between the onset of cholangitis and biliary drainage. In patients with a good response to antibiotics before EP, the delay in biliary drainage did not influence the risk of complications. After complete CBD stone removal, the morbidity (42% vs. 4%, p = 0.001) and the mortality (8% vs. 0%, NS) due to cholangitis were much higher in 12 patients with progressive cholangitis for > 3 days before biliary drainage, compared with 73 cases who had experienced a good response to antibiotics before EP and/or early drainage (< 3 days) after the onset of cholangitis. Two patients with advanced cholangitis and septic shock at the time of EP died < 12 h after completed sphincterotomy with CBD stone removal. Three patients with retained CBD stones and failed biliary drainage after EP experienced disastrous morbidity (100% vs. 9%, p < 0.01) and mortality (67% vs. 1%, p < 0.01) due to cholangitis, compared with 85 patients without retained CBD stone(s). CONCLUSIONS: We recommend emergency biliary drainage in all patients presenting with calculous cholangitis who are severely ill with continuous fever for several days. Emergency nasobiliary drainage without EP or after a limited EP may be a safer treatment in patients with (impending) septic shock. We believe that a more conservative approach is justified in patients presenting with symptoms of mild cholangitis, restricting emergency biliary drainage for those who do not respond rapidly (< 24 h) to antibiotics. Further emergency surgical or percutaneous biliary drainage should be performed immediately on patients in whom CBD stones are retained, after EP and drainage fails, especially if a stone is left impacted distally.

Desmoplastic fibroma of bone: a report of 18 cases.

Desmoplastic fibroma is a rare benign primary bone tumor, histologically identical to the extra-abdominal desmoid tumor of soft tissues. The incidence in major series of bone tumors is 0.1%-0.3%. In the present study 18 cases from the files of the Netherlands Committee on Bone Tumors are reported, with an emphasis on the radiographic features. Eight female and ten male subjects were affected, with a fairly even age distribution from the second to the seventh decade of life. The most frequent sites of involvement were the femur and the pelvis. Radiographically the lesions nearly always demonstrated benign features with respect to pattern of destruction, margins, and reactive bone formation; however, soft tissue extension was sometimes present. Although desmoplastic fibroma usually presents with pain or swelling, in 5 of the 18 cases the existence of the lesion was an accidental finding, and in 2 cases the patient had long-standing, vague complaints of pain. Though overall benign radiographic features may support the final diagnosis, the main and often troublesome histological differential diagnosis is of a low-grade fibrosoma. En bloc resection is the treatment of choice in view of the high incidence of recurrence after curettage.

The association between age and bone mineral density in men and women aged 55 years and over: the Rotterdam Study.

In this cross-sectional study, bone mineral density (BMD) measurements were performed in 1762 ambulatory subjects (678 men and 1084 women) aged 55 years and over from the Rotterdam Study, a population based study of diseases in the elderly. BMD measurements of the proximal femur and lumbar spine were performed using dual energy X-ray absorptiometry. No age-related decline in BMD could be observed in the lumbar spine. Yearly percentage BMD reduction in women and men was -0.6% and -0.3% in the femoral neck, -0.8% and -0.5% in the Ward's triangle, and -0.4% and -0.3% in the trochanter, respectively. Late menopause was associated with high BMD in Ward's triangle and lumbar spine. We conclude that: (1) accurate assessment of age-related bone reduction in the spine is impossible from cross-sectional studies since BMD measurements in the elderly may be influenced by spinal osteoarthritis; and (2) the rate of age-related bone reduction in the femoral neck appears to be approximately two times higher in women than in men.

Endoscopic papillotomy for common bile duct stones: factors influencing the complication rate.

In a prospective study, the complications observed in 242 consecutive patients after endoscopic sphincterotomy for common bile duct stones were recorded over a period of up to three months. Patients with previous gastric surgery, papillotomy, or additional pancreato-biliary disease other than gallbladder stones were excluded. The overall complication rate was 14%, 74% of these complications being moderate or severe. The complication rate due to cholangitis was higher in (1) the group with retained stones following complete papillotomy and without biliary drainage, and (2) the group with failed precut papillotomy and drainage after cholangiography, both compared to patients with successful drainage (75% vs. 2.6%: p < 0.001 and 40% vs. 2.6%: p = 0.001 respectively). Both pancreatitis and retroperitoneal air leakage occurred in 1.7% of cases. They were more frequently observed in patients with a smaller diameter (< 10 mm) in the distal common bile duct (5.6% vs. 0%: p = 0.007 for pancreatitis, and 2.8% vs. 1.2%; n.s. for perforation) and especially following precut papillotomy (13.0% for pancreatitis and 8.7% for perforation), which had to be performed more often in these patients. Bleeding following sphincterotomy was relatively frequent when the papilla was located at the lower rim of or inside a diverticulum, compared to patients without a diverticulum (16.2% vs. 2.7%: p = 0.004 and 26.7% vs. 2.7%: p < 0.001 respectively). When the papilla was located inside diverticula, both the rate of perforation and bleeding increased following precut papillotomy, compared with standard papillotomy only (33% vs. 0%, n.s., and 33% vs. 22%, n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

[Revision of consensus statement on imaging diagnosis of the breast]. / Herziening consensus beeldvormende diagnostiek van de mamma.

Changes which have taken place since 1983, when the Dutch consensus meeting on mammography was held, made it necessary to review the consensus statement. In 1983 only radiologists participated in the working group, in 1993 representatives from all other relevant disciplines participated as well. Much attention was paid to the indication for mammography and supplementary diagnostic methods, especially ultrasound techniques and US-guided cytology. Along the lines given by the ACR guidelines on breast cancer reporting, attention was given to better communication with referring doctors.

CT assessment of resectability prior to transhiatal esophagectomy for esophageal/gastroesophageal junction carcinoma.

The ability of preoperative CT to assess resectability and to stage carcinoma of the esophagus and gastroesophageal junction was studied in 71 patients who underwent transhiatal esophagectomy. Patients with preoperatively proven distant metastases who did not have surgery were not included in the present study. At surgery the tumor invaded adjacent mediastinal or abdominal structures in 18 patients (prevalence 25%), but was nonresectable in only 7 of these 18 patients (39%). Invasions of the tracheobronchial tree, the aorta, and the diaphragm were correctly detected on CT in 5 of 6, 1 of 2, and 2 of 10 patients. There were four false-positive results on CT; tracheobronchial invasion and pericardial invasion were incorrectly predicted in one and three patients, respectively. Invasion of adjacent structures was correctly assessed on CT in 58 (82%) patients and the depth of tumor invasion was correctly determined in 49 (69%) patients. Computed tomography correctly staged 57% of patients according to the classification of the American Joint Committee on Cancer. Understaging (31%) occurred more often than overstaging (11%). In the present study, computed tomography was not effective in assessing non-resectability by diagnosing invasion because of the relatively low prevalence of invasion of adjacent structures and the fact that invasion was often not associated with nonresectability. In assessing invasion itself, CT was accurate in diagnosing tracheobronchial involvement, but was limited in diagnosing invasion of other adjacent structures. In assessing stage grouping, CT was limited in detecting either diaphragmatic invasion or lymph node involvement.

Determinants of lumbar bone mineral density in normal weight, non-smoking women soon after menopause. A study using clinical data and quantitative computed tomography.

OBJECTIVES: Is there an influence of oral contraceptive use, parity and lactation on early postmenopausal bone mass? Is assessment of reproductive history, body weight in combination with biochemical markers of bone metabolism suitable to predict lumbar bone mass soon after menopause? STUDY DESIGN: A cross-sectional study in 94 healthy, normal weight, non-smoking women, 1-3 years after spontaneous menopause. Bone mineral density (BMD) of the lumbar spine was measured with single energy quantitative computed tomography. RESULTS: Multiple regression analysis showed that only total duration of lactation and alkaline phosphatase (AP) levels are independently related to trabecular BMD (P = 0.001 and P = 0.002 respectively). AP was also associated with cortical BMD (P = 0.003). Assessment of reproductive history, body mass index and biochemical markers of bone metabolism could only account for 17% of the variation of trabecular BMD observed in the study population. CONCLUSION: This study suggests that total duration of lactation rather than parity is associated with trabecular BMD of the spine. Clinical assessment of risk factors unsuccessfully predicts lumbar BMD in healthy, early postmenopausal women.

Improved assessment of supraclavicular and abdominal metastases in oesophageal and gastro-oesophageal junction carcinoma with the combination of ultrasound and computed tomography.

The purpose of the study was to evaluate ultrasound and computed tomography in the assessment of distant metastases, supraclavicular and abdominal, in 113 patients with carcinoma of the oesophagus and gastrooesophageal junction. Ultrasound and computed tomographic findings were compared with the cytological data in 29 patients and with the surgical data in 84 patients. In assessing distant metastases, ultrasound and computed tomography had a sensitivity of 61% and 70%, and a specificity of 93% and 85%, respectively (p = 1.0). When ultrasound and computed tomography were combined the sensitivity increased to 83% and the specificity decreased to 81%. There was no significant difference in the assessment of supraclavicular metastases (p = 0.8), coeliac metastases (p = 1.0) or liver and other non-lymphatic abdominal metastases (p = 1.0) on ultrasound or computed tomography. The results show that both ultrasound and computed tomography should be used for assessment of distant metastases and abnormalities confirmed by image-guided biopsy.

The value of ultrasound in the follow-up of patients treated with biliary lithotripsy. Implications for monitoring patients after nonsurgical therapy of gallbladder stones.

To establish the value of ultrasound (US) in the follow-up of patients treated with extracorporeal shockwave lithotripsy (ESWL), the results of 484 US examinations of 87 patients were analyzed and related to the results of ESWL. Reliability of US in assessing efficacy was investigated by comparing consecutive US examinations. Unreliable US results were found in 36 patients (41%); in 7 patients US failed to demonstrate fragments. In nine patients (10%) unreliable US findings contributed to delayed retreatment with ESWL. To prevent errors in treatment regimen, verification of US findings is advised in case no fragments or fragments < 5 mm are found. In 22 patients (25%) US findings appeared indicative of hampered stone migration. Only 2 of these 22 patients (9.1%) became free of stones, compared with 32 of the remaining 65 patients (49.3%) (p < 0.01), even though both groups had similar initial stone characteristics and similar time of follow-up. US findings such as a contracted gallbladder or a common bile duct > 7 mm therefore indicate poor efficacy of ESWL.

Giant cell tumor in children and adolescents.

The radiological appearance of giant cell tumors (GCT) in the developing skeleton was retrospectively assessed in 49 (10.6%) of the 462 patients with GCTs seen in consultation by the Netherlands Committee on Bone Tumors. There were 31 female and 18 male patients, all below 19 years of age. Thirty-four tumors were located in short and long tubular bones, two in the tarsus, while the others were in the pelvis, vertebral spine, and a rib. Involvement of the epiphysis in tubular bones was closely related to the age of the patient: the average age of the 3 patients with a lesion in the metaphysis was 11 years, that in the 6 patients with metadiaphyseal lesions 13 years, average age in the 10 patients with epimetaphyseal lesions 17 years, and it was also 17 years in the 17 patients with epimetadiaphyseal lesions. In tubular bones with the epiphyseal growth plates still open, the epiphysis was never involved, with the exception of two epimetadiaphyseal lesions in which closure of the growth plate was difficult to establish. Assessing GCT characteristics in this study population demonstrated that epiphyseal involvement increased with age and showed; to some extent, a predominance of female patients.

Reactive mesenchymal proliferation.

One hundred and thirteen cases in the files of the Netherlands Committee on Bone Tumors were diagnosed as heterotopic soft tissue ossification. Myositis ossificans was diagnosed in 62, ossifying hematoma in 21, and pseudomalignant osseous tumor of soft tissues in 30 cases. Antecedent trauma was present in 37%, 46% and 7%, respectively. Myositis ossificans arose in the large muscle groups of the thighs and upper arms; when closely related to the shaft of a bone, periosteal reactions were more outspoken. Pseudomalignant osseous tumor of soft tissues was located in the hands, feet, and pelvis, some cases were not in muscle groups and some were almost periosteal. Ossifying hematoma was located in the upper and lower legs and usually in close relation to bone. The three entities belong to the same kind of reactive mesenchymal proliferative process. The radiologic and histologic patterns are reflections of whether the lesions are closely localized to bone shafts or in soft tissues, e.g. in muscles and therefore the term "reactive mesenchymal proliferation" is preferred to myositis ossificans, pseudomalignant osseous tumor of soft tissues and ossifying hematoma. Diagnostic problems are encountered in early phases when cellularity, mitotic activity, and infiltrative spread suggest malignancy. Recognition of these reactions in early phases is important to avoid mutilating surgery.