Does gadolinium improve magnetic resonance arthrography of the hip beyond fluid distension alone?

AIM: To determine if there is a difference in the detection of labral tears and cartilage lesions using the T2-weighted sequences of magnetic resonance arthrography (MRA) only, which simulate MRA with saline alone, compared with the full examination including T1-weighted sequences. MATERIALS AND METHODS: One hundred hip MRA examinations performed at 3 T were identified retrospectively. Each study was reviewed by a musculoskeletal radiologist using either the T2-weighted sequences only (without gadolinium-based contrast agent [GBCA] effect) or the entire examination, including T1-weighted sequences (with GBCA effect). Receiver operating characteristic (ROC) curves were calculated for both groups and compared within a non-inferiority framework, using - 0.10 as the limit of non-inferiority. RESULTS: For labral tears, the difference area under the curve (AUC) was -0.004 (95% confidence interval [CI]: -0.064-0.056, p=0.90). For acetabular cartilage lesions, the difference AUC was 0.011 (95% CI: -0.073-0.096, p=0.79). For femoral cartilage lesions, the difference AUC was -0.059 (95% CI: -0.206-0.087, p=0.43). CONCLUSION: T2-weighted sequences alone were not inferior in diagnostic accuracy compared with the full examination (including T1-weighted sequences with intra-articular GBCA) in detecting acetabular cartilage lesions and labral tears. Further study with prospective comparison of saline injectate to GBCA-containing injectate may help clarify the necessity of continued GBCA use in MRA of the hip.

Prevalence of Asymptomatic Middle Cranial Fossa Floor Pits and Encephaloceles on MR Imaging.

BACKGROUND AND PURPOSE: Temporal lobe encephaloceles are increasingly identified and treated as epileptogenic foci. However, there is relatively scant research on the prevalence of asymptomatic encephaloceles. This study set out to describe the frequency of incidental temporal lobe encephaloceles and middle cranial fossa pits. MATERIALS AND METHODS: A retrospective review was completed of high-resolution (≤0.5-mm section thickness) axial T2WI for internal auditory canal protocol imaging. The presence and laterality of middle cranial fossa pits (small bony defects containing CSF) and encephaloceles (brain parenchyma protrusion through osseous defects with or without bony remodeling) were recorded. Electronic medical records of patients with encephaloceles were searched for a history of seizure. RESULTS: A total of 203 patients were included in the final cohort; 106 (52.2%) women. Forty-five (22.2%) patients had middle cranial fossa pits: 14 (31.1%) unilateral on the right, 17 (37.8%) unilateral on the left, and 14 (31.1%) bilateral. Ten (5.0%) patients had ≥1 encephalocele, none of whom had a documented history of seizure in the electronic medical record. No significant difference was noted in the frequency of pits or encephaloceles based on sex (P = .332 and P = .383, respectively) or age (P = .497 and P = .914, respectively). CONCLUSIONS: Incidental middle cranial fossa pits are common findings, and their prevalence is not related to age or sex. Temporal lobe encephaloceles, though rarer, also exist occasionally among asymptomatic patients. Such findings have diagnostic implications for encephaloceles identified during imaging work-up for epilepsy.

Prevalence of Spontaneous Asymptomatic Facial Nerve Canal Meningoceles: A Retrospective Review.

BACKGROUND AND PURPOSE: The prevalence of patent facial nerve canals and meningoceles along the facial nerve course is unknown. This study aimed to assess the frequency of such findings in asymptomatic patients. MATERIALS AND METHODS: A retrospective review was completed of patients with high-resolution MR imaging of the temporal bone whose clinical presentations were unrelated to facial nerve pathology. Facial nerve canals were assessed for the presence of fluid along each segment and meningoceles within either the labyrinthine segment (fluid-filled distention, ≥1.0-mm diameter) or geniculate ganglion fossa (fluid-filled distention, ≥2.0-mm diameter). If a meningocele was noted, images were assessed for signs of CSF leak. RESULTS: Of 204 patients, 36 (17.6%) had fluid in the labyrinthine segment of the facial nerve canal and 40 (19.6%) had fluid in the geniculate ganglion fossa. Five (2.5%) had meningoceles of the geniculate ganglion fossa; no meningoceles of the labyrinthine segment of the canal were observed. No significant difference was observed in the ages of patients with fluid in the labyrinthine segment of the canal or geniculate ganglion compared with those without fluid (P = .177 and P = .896, respectively). Of the patients with a meningocele, one had a partially empty sella and none had imaging evidence of CSF leak or intracranial hypotension. CONCLUSIONS: Fluid within the labyrinthine and geniculate segments of the facial nerve canal is relatively common. Geniculate ganglion meningoceles are also observed, though less frequently. Such findings should be considered of little clinical importance without radiologic evidence of CSF otorrhea, meningitis, or facial nerve palsy.

Association of the serotonin transporter-linked polymorphic region genotype with lower bone mineral density.

The serotonin transporter-linked polymorphic region (5-HTTLPR) of the serotonin transporter gene (SLC6A4) S allele is linked to pathogenesis of depression and slower response to selective serotonin reuptake inhibitors (SSRIs); depression and SSRIs are independently associated with bone loss. We aimed to determine whether 5-HTTLPR was associated with bone loss. This cross-sectional study included psychiatric patients with both 5-HTTLPR analysis and bone mineral density (BMD) assessment (hip and spine Z-scores if age <50 years and T-scores if ⩾50 years). BMD association with 5-HTTLPR was evaluated under models with additive allele effects and dominant S allele effects using linear regression models. Patients were stratified by age (<50 and ⩾50 years) and sex. Of 3016 patients with 5-HTTLPR genotyping, 239 had BMD assessments. Among the younger patients, the S allele was associated with lower Z-scores at the hip (P=0.002, dominant S allele effects; P=0.004, additive allele effects) and spine (P=0.0006, dominant S allele effects; P=0.01, additive allele effects). In sex-stratified analyses, the association of the S allele with lower BMD in the younger patients was also significant in the subset of women (P⩽0.003 for both hip and spine BMD under the additive allele effect model). In the small group of men younger than 50 years, the S allele was marginally associated with higher spine BMD (P=0.05). BMD T-scores were not associated with 5-HTTLPR genotypes in patients 50 years or older. The 5-HTTLPR variants may modify serotonin effects on bone with sex-specific effects.

Fluoroscopically guided transforaminal epidural steroid injections at a quaternary-care teaching institution: effect of trainee involvement and patient body mass index on fluoroscopy time and patient dose.

AIM: To investigate whether there are differences in fluoroscopy time and patient dose for fluoroscopically guided lumbar transforaminal epidural steroid injections (TFESIs) performed by staff radiologists versus with trainees and to evaluate the effect of patient body mass index (BMI) on fluoroscopy time and patient dose, including their interactions with other variables. MATERIALS AND METHODS: Single-level lumbar TFESIs (n=1844) between 1 January 2011 and 31 December 2013 were reviewed. Fluoroscopy time, reference point air kerma (Ka,r), and kerma area product (KAP) were recorded. BMI and trainee involvement were examined as predictors of fluoroscopy time, Ka,r, and KAP in models adjusted for age and gender in multivariable linear models. Stratified models of BMI groups by trainee presence were performed. RESULTS: Increased age was the only significant predictor of increased fluoroscopy time (p<0.0001). Ka,r and KAP were significantly higher in patients with a higher BMI (p<0.0001 and p=0.0009). When stratified by BMI, longer fluoroscopy time predicted increased Ka,r and KAP in all groups (p<0.0001). Trainee involvement was not a statistically significant predictor of fluoroscopy time or Ka,r in any BMI category. KAP was lower with trainees in the overweight group (p=0.0009) and higher in male patients for all BMI categories (p<0.02). CONCLUSION: Trainee involvement did not result in increased fluoroscopy time or patient dose. BMI did not affect fluoroscopy time; however, overweight and obese patients received significantly higher Ka,r and KAP. Male patients received a higher KAP in all BMI categories. Limiting fluoroscopy time and good collimation practices should be reinforced in these patients.

Elevated baseline serum glutamate as a pharmacometabolomic biomarker for acamprosate treatment outcome in alcohol-dependent subjects.

Acamprosate has been widely used since the Food and Drug Administration approved the medication for treatment of alcohol use disorders (AUDs) in 2004. Although the detailed molecular mechanism of acamprosate remains unclear, it has been largely known that acamprosate inhibits glutamate action in the brain. However, AUD is a complex and heterogeneous disorder. Thus, biomarkers are required to prescribe this medication to patients who will have the highest likelihood of responding positively. To identify pharmacometabolomic biomarkers of acamprosate response, we utilized serum samples from 120 alcohol-dependent subjects, including 71 responders (maintained continuous abstinence) and 49 non-responders (any alcohol use) during 12 weeks of acamprosate treatment. Notably, baseline serum glutamate levels were significantly higher in responders compared with non-responders. Importantly, serum glutamate levels of responders are normalized after acamprosate treatment, whereas there was no significant glutamate change in non-responders. Subsequent functional studies in animal models revealed that, in the absence of alcohol, acamprosate activates glutamine synthetase, which synthesizes glutamine from glutamate and ammonia. These results suggest that acamprosate reduces serum glutamate levels for those who have elevated baseline serum glutamate levels among responders. Taken together, our findings demonstrate that elevated baseline serum glutamate levels are a potential biomarker associated with positive acamprosate response, which is an important step towards development of a personalized approach to treatment for AUD.

Correlation of the Patient Reported Outcomes Measurement Information System with legacy outcomes measures in assessment of response to lumbar transforaminal epidural steroid injections.

BACKGROUND AND PURPOSE: The Patient Reported Outcomes Measurement Information System is a newly developed outcomes measure promulgated by the National Institutes of Health. This study compares changes in pain and physical function-related measures of this system with changes on the Numeric Rating Pain Scale, Roland Morris Disability Index, and the European Quality of Life scale 5D questionnaire in patients undergoing transformational epidural steroid injections for radicular pain. MATERIALS AND METHODS: One hundred ninety-nine patients undergoing transforaminal epidural steroid injections for radicular pain were enrolled in the study. Before the procedure, they rated the intensity of their pain by using the 0-10 Numeric Rating Pain Scale, Roland Morris Disability Index, and European Quality of Life scale 5D questionnaire. Patients completed the Patient Reported Outcomes Measurement Information System Physical Function, Pain Behavior, and Pain Interference short forms before transforaminal epidural steroid injections and at 3 and 6 months. Seventy and 43 subjects replied at 3- and 6-month follow-up. Spearman rank correlations were used to assess the correlation between the instruments. The minimally important differences were calculated for each measurement tool as an indicator of meaningful change. RESULTS: All instruments were responsive in detecting changes at 3- and 6-month follow-up (P < .0001). There was significant correlation between changes in Patient Reported Outcomes Measurement Information System scores and legacy questionnaires from baseline to 3 months (P < .05). There were, however, no significant correlations in changes from 3 to 6 months with any of the instruments. CONCLUSIONS: The studied Patient Reported Outcomes Measurement Information System domains offered responsive and correlative psychometric properties compared with legacy instruments in a population of patients undergoing transforaminal epidural steroid injections for radicular pain.

Genetic markers associated with abstinence length in alcohol-dependent subjects treated with acamprosate.

Acamprosate supports abstinence in some alcohol-dependent subjects, yet predictors of response are unknown. To identify response biomarkers, we investigated associations of abstinence length with polymorphisms in candidate genes in glycine and glutamate neurotransmission pathways and genes previously implicated in acamprosate response. Association analyses were conducted in the discovery sample of 225 alcohol-dependent subjects treated with acamprosate for 3 months in community-based treatment programs in the United States. Data from 110 alcohol-dependent males treated with acamprosate in the study PREDICT were used for replication of the top association findings. Statistical models were adjusted for relevant covariates, including recruitment site and baseline clinical variables associated with response. In the discovery sample, shorter abstinence was associated with increased intensity of alcohol craving and lower number of days between the last drink and initiation of acamprosate treatment. After adjustment for covariates, length of abstinence was associated with the GRIN2B rs2058878 (P=4.6 × 10(-5)). In the replication sample, shorter abstinence was associated with increased craving, increased depressive mood score and higher alcohol consumption. Association of abstinence length with GRIN2B rs2058878 was marginally significant (P=0.0675); as in the discovery sample, the minor A allele was associated with longer abstinence. Furthermore, rs2300272, which is in strong linkage disequilibrium with rs2058878, was also associated with abstinence length (P=0.049). This is the first report of a replicated association of genetic markers with the length of abstinence in acamprosate-treated alcoholics. Investigation of the underlying mechanisms of this association and its usefulness for individualized treatment selection should follow.

Immediate pain response does not predict long-term outcome of CT-guided cervical transforaminal epidural steroid injections.

BACKGROUND AND PURPOSE: Imaging-guided cervical transforaminal epidural steroid injections have been shown to decrease verbal numerical pain scores and improve functionality (Roland Morris Disability Index). These injections are often administered in combination with local anesthetic. The purpose of this study was to determine if the immediate postprocedure VNPS predicts the long-term effectiveness of the injection. MATERIALS AND METHODS: A quality assurance data base review of 247 patient records was used to document the VNPS and RMDI of patients undergoing a single CT-guided CTESI. Pain scores were recorded before the procedure, immediately after the procedure, at 2 weeks, and at 2 months. The RMDI was recorded before the procedure, at 2 weeks, and at 2 months. Spearman rank correlation analysis and logistic regression models were used to determine if the immediate postprocedure or 2-week VNPS correlated with or predicted the longer-term VNPS and RMDI as measured at 2 weeks and 2 months. RESULTS: There was not a strong correlation between the pain score obtained immediately after the procedure and the 2-month outcome of the VNPS or RMDI. The pain scores at 2 weeks did correlate with the 2-month outcomes. The 2-week VNPS also was a significant predictor of patients who would achieve a >50% improvement in VNPS or RMDI at 2 months. CONCLUSIONS: Pain scores obtained immediately after completion of a single CT-guided CTESI do not predict the long-term effectiveness of this procedure. However, patient response at 2 weeks does correlate with the long-term effectiveness of these injections as measured by the VNPS and the RMDI.

Hypovitaminosis D in psychogeriatric inpatients.

OBJECTIVES: This study investigated the rate of hypovitaminosis D in psychogeriatric inpatients and explored whether any associations exist between vitamin D levels, cognitive function, and psychiatric diagnoses. DESIGN: Retrospective medical record review from November 2000 through November 2010. SETTING: Geriatric psychiatric ward of an academic tertiary care hospital. PARTICIPANTS: Psychiatric inpatients aged 65 years or older. MEASUREMENTS AND ANALYSIS METHODS: Serum 25-hydroxyvitamin D [25(OH)D] levels were measured at admission. Associations between 25(OH)D levels, Mini-Mental State Examination (MMSE) scores were analyzed using Spearman correlations, and psychiatric diagnoses were analyzed using logistic regression models and Fisher's exact tests. RESULTS: In 141 subjects (mean age, 77.8 years; 86 [61%] female; 135 [96%] white), the most frequent diagnoses were major depressive disorder in 81 patients (57%), dementia in 38 (27%), delirium in 13 (9%), anxiety in 12 (8.5%), and bipolar disorder in 11 (8%). Mean MMSE score was 24±6.4 (range, 3-30). Forty-three subjects (30.4%) had mild to moderate vitamin D deficiency [25(OH)D, 10-24 ng/mL], and 6 (4.2%) had severe deficiency [25(OH)D <10 ng/mL]. CONCLUSIONS: Hypovitaminosis D was common in elderly psychiatric inpatients. No associations were found between vitamin D levels and global cognitive function or psychiatric diagnoses.

Safety and efficacy of CT-guided transforaminal cervical epidural steroid injections using a posterior approach.

BACKGROUND AND PURPOSE: Image-guided cervical transforaminal epidural injections play an important role in the management of cervical radicular pain syndromes. The safety and efficacy of these injections via an anterolateral approach has been well-studied. The goal of this retrospective review was to determine the safety and efficacy of CT-guided transforaminal epidural injections by using a posterior approach. MATERIALS AND METHODS: Retrospective review of patient records was used to define VNPS and RMDI of patients undergoing CT-guided transforaminal cervical epidural injections between 2006 and 2010. Pain scores were recorded preprocedure, immediately postprocedure, at 2 weeks, and at 2 months. The RMDI was recorded preprocedure, at 2 weeks, and at 2 months. Data analysis of 247 patients was completed. Differences in VNPS scores and the RMDI were then compared on the basis of a CT-guided approach (anterolateral versus posterior). RESULTS: There was no statistical difference in the degree of pain relief and improvement in the RMDI between the CT-guided transforaminal anterolateral approach and the posterior approach at 2 weeks and at 2 months. Both groups demonstrated a statistically significant improvement in pain scores and the RMDI. Approximately 35% of patients in both groups demonstrated >50% pain relief at 2 months. There were no serious complications in either group. CONCLUSIONS: CT-guided transforaminal cervical epidural injections by using a posterior approach are safe and effective.