Assessment of clinically significant urolithiasis positivity rate using CT KUB for suspected renal colic.

BACKGROUND: Unenhanced low-dose computed tomography of the kidneys, ureter and bladder (CT KUB) is the gold standard diagnostic imaging modality in the assessment of suspected renal colic. As the radiation dose is not negligible, it is important to monitor the diagnostic yield of CT KUBs. The aim of this study is to evaluate the diagnostic yield of CT KUB studies performed for suspected renal colic in patients presenting to the emergency department. METHODS: A retrospective review was performed of 500 patients who underwent CT KUB for suspected renal colic over a seven month period from June 2019 to January 2020. Clinical information and imaging was reviewed for each patient. Statistical analysis was performed using GraphPad Prism 8 (GraphPad Software, San Diego, CA, USA). RESULTS: Forty-nine percent of patients in the series were female (248/500) and the mean age was 45. The positivity rate for obstructing ureteral calculus was 34% (169/500). Concerningly, there was a significantly lower positivity rate in females compared to males (19% versus 48%; p < 0.0001) which raises the issue of unnecessary radiation exposure to this cohort. In the 200 female patients who were negative for obstructing urolithiasis, the mean age was 43. Females also had a significantly higher rate of negative CT KUB (62% versus 37%; p < 0.0001) where no underlying alternative pathology was diagnosed. CONCLUSIONS: Women are less likely than men to have obstructing urolithiasis on CT KUB for suspected renal colic. This difference is not accounted for by a higher rate of alternative diagnoses among female patients. The findings of this study should prompt clinicians to exercise caution when considering this imaging modality in this patient cohort.

A multi-site review of second hip fractures across 6 Dublin teaching hospitals.

INTRODUCTION: Fragility hip fractures are common and costly. Secondary fracture prevention is a treatment goal following hip fracture; however, the number of those that proceed to fracture their contralateral hip in Ireland is unknown. There are plans to introduce a Fracture Liaison Service Database in Ireland which will aim to prevent secondary fractures. To establish a baseline figure for secondary hip fractures, the injury radiographs of 1284 patients from 6 teaching hospitals over a 1-year period were reviewed. METHODS: Irish Hip Fracture Datasheets and corresponding injury radiographs were reviewed locally for all hip fractures within each respective teaching hospital for a 1-year period (2019). RESULTS: A total of 8.7% of all fragility hip fractures across the 6 hospitals were secondary hip fractures (range 4.9-11.5%). 46% occurred within years 1 to 3 following index hip fracture. Forty-eight per cent of patients were started on bone protection medications following their second hip fracture. DISCUSSION/CONCLUSION: Approximately 1 in 11 hip fractures treated across the 6 teaching hospitals assessed in 2019 was a patient's second hip fracture. We advocate for the widespread availability of Fracture Liaison Services to patients throughout Ireland to assist secondary fracture prevention.

Can saline injection protect phrenic nerve? - A randomised controlled study.

BACKGROUND AND AIMS: Various methods were attempted to reduce the incidence of phrenic nerve palsy during interscalene brachial plexus nerve block. Mechanism of phrenic palsy was presumed to be due to the spread of local anaesthetic anterior to the anterior scalene muscle. We hypothesised that by injecting saline in this anatomical location prior to performing an interscalene block might reduce the incidence of phrenic palsy. METHODS: This was a double-blinded randomised controlled study performed in a single-centre, university-teaching hospital. A total of 36 patients were randomised to either group C (conventional group) or group S (saline group). Ultrasound-guided interscalene block was administered with 20 ml of 0.25% levo-bupivacaine in both groups. Ten ml of normal saline was injected anterior to anterior scalene muscle in group S prior to performing interscalene block. A blinded radiologist performed diaphragmatic ultrasound pre- and post-operatively to document phrenic palsy. Bedside spirometry was used to perform baseline and post-operative pulmonary function test. The primary outcome was to look at the incidence of phrenic palsy as measured by diaphragmatic palsy on ultrasound performed by radiologist. Statistical Package for the Social Sciences (SPSS) version 25 was used for statistical analysis. RESULTS: Significantly less patients in the saline group developed diaphragmatic paresis when compared to conventional group (44% vs. 94%, Chi-squared = 10.01, P = 0.002). There was no difference in post-operative pain, subjective sensation of dyspnoea or patient satisfaction between the groups. CONCLUSION: Injecting saline anterior to anterior scalene muscle reduces the incidence of diaphragmatic palsy when performing interscalene block.

Hepatocellular carcinoma likelihood on MRI exams: evaluation of a standardized categorization system.

PURPOSE: Evaluate the reliability and validity of a standardized reporting system designed to improve communication between the clinician and radiologist regarding likelihood of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: The system assigns liver lesions into 1 of 5 categories of estimated likelihood of HCC: 1, <5%; 2, 5%-20%; 3, 21%-70%; 4, 71%-95%; 5, >95%. Six American Board of Radiology-certified radiologists reviewed 100 abdominal MRI studies (performed between September 2009 and June 2010 for HCC surveillance) blinded to the official reports and clinical information. Each reader recorded the highest category (1-5) assigned to any lesion per study. Reliability between readers was calculated by the Shrout-Fliess random sets intraclass correlation (ICC). To examine validity, original pretransplant reports from January 2009 to December 2010 were compared to pathology reports on liver explants. Sensitivities, specificities, predictive values, and receiver operating characteristic (ROC) curves were then produced. RESULTS: The ICC for retrospective readings was 0.80, indicating very good reliability. Of 45 pathologically proven cases, 16 category 1 or 2 cases were all free of HCC (negative predictive value 100%). Five of nine category 3 cases contained HCC. Six of eight category 4 cases contained HCC (PPV 75%). All 12 category 5 cases contained HCC (positive predictive value 100%). The area underneath the ROC curve was 0.949. If categories 1 and 2 are considered negative and categories 3-5 considered positive, this achieves 100% sensitivity with 73% specificity. CONCLUSION: This standardized system for reporting likelihood of HCC, which is a forerunner of the recently introduced Liver Imaging Reporting and Data System, produces strong reliability and validity, while aiming to improve the clarity of clinical magnetic resonance imaging reports.

Magnetic resonance imaging of the midfoot and forefoot: normal variants and pitfalls.

Magnetic resonance imaging of the midfoot and forefoot are increasingly requested examinations for a variety of symptoms. This region has its own particular anatomic variants, which the interpreting radiologist needs to be aware of, including accessory ossicles, sesamoid variants, and tarsal coalitions. In addition, certain pulse sequences used in this region are predisposed to artifact, which may lead to false-positive findings. These topics are discussed in this content in addition to the inclusion of pointers to help avoid pitfalls in interpretation of common diseases.

The role of whole-body imaging in the diagnosis, staging, and follow-up of multiple myeloma.

Multiple myeloma is one of the most common hematological malignancies and accounts for significant morbidity and mortality. In the past, detection of myelomatous deposits by radiography was the main method of radiological assessment in this disease. However, in recent years the introduction of whole-body imaging techniques, specifically low-dose whole-body computed tomography, whole-body magnetic resonance imaging, and positron emission tomography, has facilitated a more comprehensive assessment of this heterogeneous and often diffuse disease. Each of these whole-body imaging techniques has specific applications and limitations in the assessment of multiple myeloma that the interpreting radiologist and referring clinician need to be aware of. As these techniques gain further acceptance in the radiology and hematology communities, their use in the assessment of multiple myeloma is likely to increase further.

Whole-body imaging modalities in oncology.

This article outlines the expanding approaches to whole-body imaging in oncology focusing on whole-body MRI and comparing it to emerging applications of whole-body CT, scintigraphy, and above all PET CT imaging. Whole-body MRI is widely available, non-ionizing and rapidly acquired, and inexpensive relative to PET CT. While it has many advantages, WBMRI is non-specific and, when compared to PET CT, is less sensitive. This article expands each of these issues comparing individual modalities as they refer to specific cancers.

The influence of reduced hamstring length on patellofemoral joint stress during squatting in healthy male adults.

Increased patellofemoral joint (PFJ) stress has been implicated in the development of PFJ pathologies. Previous studies have identified a relationship between reduced hamstring length and patellofemoral pain syndrome. Hamstring stretching is also recommended in the management thereof. However, the relationship between reduced hamstring length and PFJ stress has not been explored in vivo during activities that load the PFJ, such as squatting. The objective of this study was to determine if persons with reduced hamstring length demonstrate increased PFJ stress during squatting compared with individuals without reduced hamstring length. Eight participants with, and eight participants without, reduced hamstring length were assessed to determine their PFJ contact area using magnetic resonance imaging, and their PFJ reaction force during squatting using motion analysis. Data collected were entered into a biomechanical model to calculate medial, lateral and total PFJ stress. It was found that participants with reduced hamstring length had significantly greater total (393.39 Pa/kg vs. 213.01 Pa/kg) and lateral (311.23 Pa/kg vs. 142.55 Pa/kg) PFJ stress at 60 degrees knee flexion during squat descent and ascent (427.75 Pa/kg vs. 255.64 Pa/kg and 337.75 Pa/kg vs. 170.63 Pa/kg, respectively). This was due to significantly increased PFJ reaction force at 60 degrees knee flexion during squat descent (12.18 N/kg vs. 7.21 N/kg) and ascent (13.03 N/kg vs. 8.72 N/kg), and lower medial PFJ contact area at 60 degrees knee flexion (88 mm(2) vs. 160 mm(2)). The results of this study demonstrate a relationship between reduced hamstring length and increased PFJ stress during squatting due to increased PFJ reaction force and reduced medial PFJ contact area.

Association of glenoid morphology and anterosuperior labral variation.

OBJECTIVE: The objective of this study was to determine whether glenoid morphology correlates with anterosuperior labral variation. METHODS: Eighty-eight direct shoulder magnetic resonance arthrograms were retrospectively reviewed. Sagittal oblique images were assessed for the presence or absence of anterosuperior glenoid concavity. Evaluation of axial images was performed, separately classifying the anterosuperior labrum into 1 of 4 categories: no variation, diminutive labrum, sublabral foramen, or Buford complex. RESULTS: In 88 shoulders, there were 13 notched glenoids (15%). In this group, 3 (23%) had a Buford complex, 2 (15%) had a sublabral foramen, and 4 (31%) had a diminutive labrum. There were 75 ovoid glenoids (85%). In this group, 3 (4%) had a Buford complex, 8 (11%) had a sublabral foramen, and 7 (9%) had a diminutive labrum. There was a significant association (P = 0.001) between notched glenoid morphology and developmental variation of the anterosuperior labrum. CONCLUSIONS: The presence of anterior glenoid concavity is significantly associated with overlying labral variation, which may be of use in discriminating labral pathology from developmental variation.

Whole-Body MRI versus PET in assessment of multiple myeloma disease activity.

OBJECTIVE: The purpose of this study was to compare FDG PET; whole-body MRI; and the reference standard, bone marrow aspiration and biopsy, to determine the best imaging technique for assessment of disease activity in multiple myeloma. SUBJECTS AND METHODS: Twenty-four patients (13 women, 11 men; mean age, 67.1 years; range, 44-83 years) with bone marrow biopsy-proven multiple myeloma were included in the study. All patients underwent PET/CT and whole-body MRI within 10 days of each other. Eight patients underwent more than one follow-up PET/CT and whole-body MRI examination, for a total of 34 pairs of images. Activity was defined as lesions with a maximum standardized uptake value greater than 2.5 at PET and as evidence of marrow packing at whole-body MRI. PET and whole-body MRI results were correlated with findings at bone marrow aspiration biopsy. RESULTS: PET had a sensitivity of 59%, specificity of 75%, positive predictive value of 81%, and negative predictive value of 50% (p = 0.08). Whole-body MRI had a sensitivity of 68%, specificity of 83%, positive predictive value of 88%, and negative predictive value of 59% (p = 0.01). In 62% of cases, PET and whole-body MRI findings were concordant. When PET and whole-body MRI findings were concordant and positive, no false-positive results were found, yielding a specificity and a positive predictive value of 100% (p = 0.04). CONCLUSION: Whole-body MRI performed better than PET in the assessment of disease activity, having a higher sensitivity and specificity. The positive predictive value of whole-body MRI in the assessment of active disease was high at 88%. When used in combination and with concordant findings, PET and whole-body MRI were found to have a specificity and positive predictive value of 100%, which may be of value to clinicians assessing the effectiveness of aggressive and expensive treatment regimens.

Shoulder, hip, and knee arthrography needle placement using fluoroscopic guidance: practice patterns of musculoskeletal radiologists in North America.

OBJECTIVE: The aim of this study was to evaluate the range of techniques used by radiologists performing shoulder, hip, and knee arthrography using fluoroscopic guidance. MATERIALS AND METHODS: Questionnaires on shoulder, hip, and knee arthrography were distributed to radiologists at a national radiology meeting. We enquired regarding years of experience, preferred approaches, needle gauge, gadolinium dilution, and volume injected. For each approach, the radiologist was asked their starting and end needle position based on a numbered and lettered grid superimposed on a radiograph. RESULTS: Sixty-eight questionnaires were returned. Sixty-eight radiologists performed shoulder and hip arthrography, and 65 performed knee arthrograms. Mean experience was 13.5 and 12.8 years, respectively. For magnetic resonance arthrography, a gadolinium dilution of 1/200 was used by 69-71%. For shoulder arthrography, an anterior approach was preferred by 65/68 (96%). The most common site of needle end position, for anterior and posterior approaches, was immediately lateral to the humeral cortex. A 22-gauge needle was used by 46/66 (70%). Mean injected volume was 12.7 ml (5-30). For hip arthrography, an anterior approach was preferred by 51/68 (75%). The most common site of needle end position, for anterior and lateral approaches, was along the lateral femoral head/neck junction. A 22-gauge needle was used by 53/68 (78%). Mean injected volume was 11.5 ml (5-20). For knee arthrography, a lateral approach was preferred by 41/64 (64%). The most common site of needle end position, for lateral and medial approaches, was mid-patellofemoral joint level. A 22-gauge needle was used by 36/65 (56%). Mean injected volume was 28.2 ml (5-60). CONCLUSION: Arthrographic approaches for the shoulder, hip, and knee vary among radiologists over a wide range of experience levels.

Anatomy, pathology, and MRI findings in the sports hernia.

"Sports hernia" is a frequently used term on athletic injury reports and in the sportscasting media, but its true definition remains elusive in the medical literature. Magnetic resonance imaging (MRI) is a useful tool in the evaluation of clinical athletic pubalgia, yet specific pathologies associated with this commonly encountered syndrome are poorly described in the imaging literature. In this article we review the musculoskeletal anatomy of the pubic region as well as several reproducible patterns of pathology on MRI we have encountered in patients with a clinical diagnosis of sports hernia.

Bone marrow edema: patterns and clinical implications.

This article outlines the causes of bone marrow edema and classifies them by mechanism into congestive, vasogenic, traumatic, and tumorigenic forms. In particular, the article focuses on traumatic edema, emphasizing the differing patterns on the basis of mechanism of injury, impaction, distraction, and shear-type injuries. Finally the article reviews the impact of understanding mechanisms in image interpretation and in patient management.

Muscle edema: classification, mechanisms, and interpretation.

Muscle edema is commonly encountered in patients following extremity trauma. This article presents an overview of differential considerations in patients presenting with muscle edema, and while focusing on trauma outlines causes on the basis of mechanism, vasogenic, congestive, traumatic, and tumorigenic edema.