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OBJECT Screening, management, and follow-up of Grade 3 and 4 blunt carotid artery injuries (BCAIs) remain controversial. These high-grade BCAIs were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. METHODS A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries from August 2003 to April 2013 was performed, and Grade 3 and 4 BCAIs were identified. The authors define Grade 3 injuries as stenosis of the vessel greater than 50%, or the development of a pseudoaneurysm, and Grade 4 injuries as complete vessel occlusion. Demographic information, imaging findings, number of images obtained per individual, length of radiographic follow-up examination, radiographic outcome at end of follow-up period, treatment(s), and documentation of ischemic stroke or transient ischemic attack (TIA) were recorded. RESULTS Fifty-three Grade 3 BCAIs in 44 patients and 5 Grade 4 BCAIs in 5 patients were identified and had available follow-up information. The mean follow-up duration for Grade 3 BCAIs was 113 days, and the mean follow-up for Grade 4 BCAIs was 78 days. Final imaging of Grade 3 BCAIs showed that 53% of cases were radiographically stable, 11% had resolved, and 11% were improved, whereas 25% had radiographically worsened. In terms of treatment, 75% of patients received aspirin (ASA) alone, 5% received various medications, and 2% received no treatment. Eighteen percent of the patients in the Grade 3 BCAI group underwent endovascular intervention, and in all of these cases, treatment with ASA was continued after the procedure. Final imaging of the Grade 4 BCAIs showed that 60% remained stable (with persistent occlusion), whereas the remaining arteries improved (with recanalization of the vessel). All patients in the Grade 4 BCAI follow-up group were treated with ASA, although in 1 patient treatment was transitioned to Coumadin. There were 3 cases of cerebral infarction that appeared to be related to Grade 3 BCAIs (7% of 44 patients in the Grade 3 group), and 1 case of stroke that appeared to be related to a Grade 4 BCAI. All identified cases of stroke developed soon after hospital admission. CONCLUSIONS Although the posttraumatic cerebral infarction rate may be overestimated, the results of this study suggest that the Grade 3 and 4 BCAIs carry the highest stroke risk of the blunt cerebrovascular injuries, and those infarctions were identified on or shortly after hospital admission. Despite a 40% recanalization rate in the Grade 4 BCAI group and an 89% rate of persistent pseudoaneurysm in the Grade 3 BCAI group, follow-up imaging showed progressive worsening without radiographic improvement in only a small number of patients, and these findings alone did not correlate with adverse clinical outcome. Follow-up protocols may require amending; however, further prospective studies are needed to make conclusive changes as they relate to management.

Object Osteopetrosis is a rare congenital metabolic bone disease. There are very few reports in the literature associating cerebellar tonsillar herniation (CTH) and hydrocephalus requiring neurosurgical attention. The authors present cases of osteopetrosis requiring neurosurgical intervention from their practice and offer a detailed account of the literature. Methods A retrospective review was conducted at the authors' institution, and all children with osteopetrosis requiring neurosurgical attention were identified. Medical charts and radiographic studies were reviewed. Data including age at presentation, sex, symptoms at presentation, age at follow-up, the presence of any neurological comorbidities, and surgical procedures performed were recorded. Results Four patients were identified as having osteopetrosis requiring neurosurgical attention at the authors' institution between January 1, 2005, and January 1, 2014. There were 3 females and 1 male with an average age at presentation of 11.1 years; patients were observed for a mean of 4.4 years. All of the patients were identified as harboring jugular foraminal stenosis and CTH. Seventy-five percent of these patients developed hydrocephalus, and in those cases a triventricular pattern of dilation was noted. One patient developed syringomyelia. Three of the 4 patients underwent neurosurgical procedures. Cerebrospinal fluid diversion was performed in 2 patients via a ventriculoperitoneal shunt in one case and an endoscopic third ventriculostomy (ETV) in the other. The former patient required a proximal revision at 2 years for bony overgrowth at the site of the bur hole. Two patients underwent a suboccipital decompression. In patients undergoing CSF diversion, there was improvement in ventricle size. Conclusions Variable degrees of hindbrain crowding and/or CTH are mentioned throughout the literature, suggesting that this entity is nearly always present in this patient population. The progressive triventricular hydrocephalus seen in these cases results from a complex combination of both communicating and noncommunicating pathology, which may depend on the type of osteopetrosis, age at presentation, and the presence and degree of venous collateralization, and it appears that the hydrocephalus is more prevalent and more likely to be treated in infants and in the younger, school-aged population. The acquired hindbrain fullness in conjunction with the triventricular pattern of hydrocephalus has kept the authors enthusiastic regarding the use of ETV in these complicated cases.

Evidence is emerging that isolated traumatic subarachnoid hemorrhage (ITSAH) may be a milder form of traumatic brain injury (TBI). If true, ITSAH may not benefit from intensive care unit (ICU) admission, which would, in turn, decrease resource utilization. We conducted a retrospective review of all TBI admissions to our institution between February 2010 and November 2012 to compare the presentation and clinical course of subjects with ITSAH to all other TBI. We then performed descriptive statistics on the subset of ITSAH subjects presenting with a Glasgow Coma Score (GCS) of 13–15. Of 698 subjects, 102 had ITSAH and 596 had any other intracranial hemorrhage pattern. Compared to all other TBI, ITSAH had significantly lower injury severity scores (p

Endometriosis is a common disease; however, ectopic mullerian tissue within the spine is a rare entity with the potential for producing significant neurological compromise. There are several postulated etiologies for this phenomenon, and only a few case reports are available in the world literature. Knowledge of this rare phenomenon is of paramount importance, since early diagnosis can lead to lessened neurological morbidity. In this manuscript, we present a case report, discuss gynecological and neurosurgical perspectives relating to the treatment strategies for managing this entity, and propose an alternative explanation for such an occurrence from a neurogenetic standpoint. We present a case of spinal mullerianosis within the conus medullaris which was managed symptomatically for several years with an intracystic drain and subcutaneous reservoir. Over the years, it became clear that there was a cyclical presentation to her clinical malady, which at times was severe. Ultimately, she required surgical resection which aided in her diagnosis and subsequent treatment. Intraspinal mullerianosis is a rare location for an otherwise common disease in women and has the potential to create significant neurological morbidity by creating a mass lesion. Although the exact etiology remains unclear, the histogenic theories of embryologic origin appear most plausible. Treatment strategies for this condition may include hormonal therapy, obstetrical surgery, or open spinal surgery. This unusual and poorly understood disease should be considered in the differential diagnosis for intraspinal lesions presenting with hemorrhage in the clinical context of cyclical neurological symptoms.

Object The optimal management of Chiari malformations in the setting of craniosynostosis is not well established. In this report the authors describe their outcomes with the combined technique of simultaneous suboccipital decompression (SOD) during posterior cranial vault remodeling (PCVR). Methods A retrospective review was performed of all patients undergoing PCVR and simultaneous SOD. Demographic data, diagnosis, imaging studies, operative intervention, and clinical follow-up were evaluated. Results Thirty-four patients were identified as having undergone a simultaneous PCVR/SOD for Chiari malformation associated with craniosynostosis. Eighty-eight percent of these patients had syndromic, multisutural craniosynostosis, and the remaining patients had unilateral lambdoid craniosynostosis. There were no postoperative complications as a direct result from this combined procedure. Two patients required a subsequent direct approach for decompression of the Chiari malformation. The interval between these subsequent surgeries was 3 years and 19 months. Conclusions Chiari malformations are commonly associated with syndromic, complex craniosynostosis and isolated lambdoid craniosynostosis. In appropriately selected patients, a combined posterior cranial vault enlargement and SOD of the foramen magnum is associated with a low complication rate and appears to be an effective procedure.

Although intracerebral schwannomas are typically regarded as benign intracranial tumors, malignancy and recurrence have been reported among patients harboring such neoplasms. The available literature consists of case reports and small series that present variable characteristics distinguishing these unusual lesions. Little advancement has been made to further the understanding and management of these tumors. The authors present 3 cases from their institution that highlight the difference between typical benign intracerebral schwannomas and histopathological variants that may portend more aggressive behavior. Also provided is a review of the literature in the hope of gaining a better understanding of these rare tumors.

Scheduled repeat head computed tomography after mild traumatic brain injury has been shown to have limited use for predicting the need for an intervention. We hypothesized that repeat computed tomography in persons with intracranial hemorrhage and a Glasgow Coma Scale (GCS) score of 13 to 15, without clinical progression of neurologic symptoms, does not impact the need for neurosurgical intervention or discharge GCS scores.This prospective cohort study followed all patients presenting to our urban Level I trauma center with intracranial hemorrhage and a GCS score of 13 to 15 from February 2010 to December 2010. Subjects were divided into two groups: those in whom repeat CT scans were performed routinely (ROUTINE) and those in whom they were performed selectively (SELECTIVE) based on changes in clinical examination. CT scanning decisions were made at the discretion of the neurosurgical service attending physician.One hundred forty-five patients met the inclusion criteria (ROUTINE, n = 92; SELECTIVE, n = 53). Group demographics, including age, sex, and presenting GCS score were not significantly different. Of SELECTIVE patients, six (11%) required a repeat head computed tomography for a neurologic change, with one having a radiographic progression of hemorrhage (16%) versus 26 (28%) of 92 in the ROUTINE group showing a radiographic progression. No patient in either group required medical or neurosurgical intervention based on repeat scan. The number of CT scans performed differed between the two groups (three scans in ROUTINE vs. one scan in SELECTIVE, p0.001), as did the intensive care unit (2 days vs. 1 day, p0.001) and hospital (5 days vs. 2 days, p0.001) lengths of stay. Discharge GCS score was similar for both groups (15 vs. 15, p = 0.37). One death occurred in the SELECTIVE group, unrelated to intracranial findings. The negative predictive value of a repeat CT scan leading to neurosurgical intervention with no change in clinical examination was 100% for both groups.A practice of selective repeat head CT scans in patients with traumatic brain injury admitted with a GCS score of 13 to 15 decreases use of the test and is associated with decreased hospital length of stay, without impacting discharge GCS scores.Diagnostic study, level II.

Recent software developments enable interactive, real-time axial, 2D and 3D CT display on an iPad by cloud computing from a server for remote rendering. The purpose of this study was to compare radiologists' interpretative performance on the iPad to interpretation on the conventional picture archive and communication system (PACS). Fifty de-identified contrast-enhanced CT exams performed for suspected pulmonary embolism were compiled as an educational tool to prepare our residents for night call. Two junior radiology attendings blindly interpreted the cases twice, one reader used the PACS first, and the other interpreted on the iPad first. After an interval of at least 2 weeks, the cases were reinterpreted in different order using the other display technique. Sensitivity, specificity, and accuracy for identification of pulmonary embolism were compared for each interpretation method. Pulmonary embolism was present in 25 patients, ranging from main pulmonary artery to subsegmental thrombi. Both readers interpreted 98 % of cases correctly regardless of display platform. There was no significant difference in sensitivity (98 vs 100 %, p = 1.0), specificity (98 vs 96 %, p = 1.0), or accuracy (98 vs 98 %, p = 1.0) for interpretation with the iPad vs the PACS, respectively. CT interpretation on an iPad enabled accurate identification of pulmonary embolism, equivalent to display on the PACS. This mobile device has the potential to expand radiologists' availability for consultation and expedite emergency patient management.

SummaryObjectiveTo determine whether computer-based analysis can detect features predictive of osteoarthritis (OA) development in radiographically normal knees.MethodA systematic computer-aided image analysis method weighted neighbor distances using a compound hierarchy of algorithms representing morphology (WND-CHARM) was used to analyze pairs of weight-bearing knee X-rays. Initial X-rays were all scored as normal Kellgren–Lawrence (KL) grade 0, and on follow-up approximately 20 years later either developed OA (defined as KL grade=2) or remained normal.ResultsThe computer-aided method predicted whether a knee would change from KL grade 0 to grade 3 with 72% accuracy (P

The authors report their experience using preoperative chest radiography and intraoperative ultrasonography for percutaneous positioning of the distal end of the catheter when placing ventriculoatrial (VA) shunts in patients with hydrocephalus. The distal portion of VA shunt catheters were percutaneously placed into the internal jugular vein with the aid of intraoperative ultrasonography in 14 consecutive adults. In all cases, the technique was easy, there were no postoperative complications, and postoperative chest radiography demonstrated good positioning of the distal catheter tip. One patient presented with a shunt infection and needed a shunt replacement. The authors therefore conclude that percutaneous placement of a VA shunt under preoperative radiographic guidance and ultrasonographic monitoring is a safe, effective, and reliable technique that is simple to learn.

We describe a method for automated detection of radiographic osteoarthritis (OA) in knee X-ray images. The detection is based on the Kellgren-Lawrence (KL) classification grades, which correspond to the different stages of OA severity. The classifier was built using manually classified X-rays, representing the first four KL grades ( normal, doubtful, minimal, and moderate). Image analysis is performed by first identifying a set of image content descriptors and image transforms that are informative for the detection of OA in the X-rays and assigning weights to these image features using Fisher scores. Then, a simple weighted nearest neighbor rule is used in order to predict the KL grade to which a given test X-ray sample belongs. The dataset used in the experiment contained 350 X-ray images classified manually by their KL grades. Experimental results show that moderate OA (KL grade 3) and minimal OA (KL grade 2) can be differentiated from normal cases with accuracy of 91.5% and 80.4%, respectively. Doubtful OA (KL grade 1) was detected automatically with a much lower accuracy of 57%. The source code developed and used in this study is available for free download at www.openmicroscopy.org.

Rheumatoid arthritis (RA), a systemic auto-immune disease affecting 0.5–1% of the population worldwide, is characterized by chronic joint inflammation and, in severe cases, joint erosions (1). Although the mechanisms of initiation and propagation of RA remain incompletely defined, autoimmunity and inflammatory effector pathways appear to play important pathogenetic roles. The notable efficacy of tumor necrosis factor (TNF) inhibitors has established that TNFα plays a central role in RA, and the therapeutic effects of rituximab and abatacept strongly indicate roles for B cells and T cells, respectively (2,3). Although the specific autoantigens that drive B cells and T cells in RA remained elusive for decades, recent advances have identified protein citrullination as a primary focus of the RA-specific autoantibody response (4). Citrulline is generated posttranslationally by the deimination of arginine, and autoantibodies in RA recognize various naturally citrullinated proteins (including fibrin, vimentin, and filaggrin), as well as cyclic citrullinated peptides (CCPs) derived from them (5-7). Together with the extraordinary specificity (90–99%) of anti-CCP antibodies in RA (8,9), the observation that anti-CCP antibodies are frequently present early in the disease process and often precede development of the diagnostic phenotype (10-13) strongly suggests that these antibodies are markers of the specific events that initiate autoimmunity in RA. The citrullination reaction is catalyzed by a family of enzymes known as peptidyl arginine deiminases (PADs). There are 5 isoforms (14), differentially expressed in various cells. PAD type 4 (PAD-4) has received particular attention in RA, since it is expressed in myelomonocytes, can be detected in inflamed RA synovium (14,15), and has recently been genetically associated with RA. The first group to describe the genetic association of PADI4 variants with RA defined 2 common haplotypes of the PADI4 gene segregated by 4 exonic single-nucleotide polymorphisms (SNPs) in linkage disequilibrium. These 2 haplotypes were designated “susceptible (haplotype 2)” or “nonsusceptible (haplo-type 1)” based on their relative frequency in a group of Japanese patients with RA versus controls (16). The odds ratio (OR) for association of the susceptibility haplotype with RA was 1.4. In several other populations, similar associations of PADI4 susceptibility haplotypes with RA were observed, although the magnitude of the effect was lower (17-20). In some studies, no association of PADI4 genotype with RA was observed (21-23). Suzuki et al showed a modest increase in RNA stability for the susceptibility haplotype, and proposed that the genetic effect of PADI4 is mediated through increased PAD-4 levels and activity, with enhanced citrullination and increased levels of anti-CCP antibodies (16). Significant direct support for this model is still lacking, prompting us to explore whether additional mechanisms might mediate some of the genetic effect of PADI4. We demonstrate here that autoantibodies against PAD-4 protein are a highly specific marker of RA. In a cross-sectional cohort of RA patients, these antibodies were independently associated with a more severe RA phenotype, characterized by worse joint damage and erosions. Notably, anti–PAD-4 autoantibodies were associated with the PADI4 susceptibility haplotype (OR 2.59), particularly with the heterozygous diplotype (OR 4.02). Interestingly, the epitopes recognized by anti–PAD-4 antibodies include the N-terminal region of PAD-4 containing the polymorphisms associated with RA susceptibility. Taken together, the specificity of the antibody response for the polymorphic N-terminal region of PAD-4, the magnitude of the association of autoantibody with susceptibility genotype, and the association of the strongest anti–PAD-4 autoantibody responses with RA severity are striking. They implicate unique PAD-4 structure and/or function in the generation of a PAD-4–specific immune response and, potentially, the downstream augmentation of joint damage in RA.

Pathologic fracture is a significant problem for individuals with metastatic bone disease. Current guidelines for prophylactic internal fixation are neither reliable nor easily applied. The purpose of this study was to validate dual-energy X-ray absorptiometry (DXA) as an accurate method for estimating torsional bone strength of diaphyseal bone with endosteal lytic lesions. Endosteal lesions of varying sizes were simulated in the diaphyses of 12 adult cadaveric femurs. Unaltered contralateral femurs served as matched controls. Machined lesions ranged from 3 to 6.5 cm in length, 1 to 3 cm in width, 15 to 48 cm2 in elliptical area, with 10% to 100% removal of the cortical thickness. Morphology and density data obtained from DXA images were used to estimate torsional strength. All femora were mechanically tested to failure in torsion. Physically measured torsional strength was not significantly correlated to lesion elliptical area (r = 0.542, p > 0.05) or percentage cortical thickness removed (r = 0.257, p > 0.05). Measured torsional strength was significantly correlated to DXA-based torsional strength estimates (r = 0.855, p

OBJECT Grade 3 and 4 blunt vertebral artery (VA) injuries may carry a different natural course from that of lower-grade blunt VA injuries. Proper screening, management, and follow-up of these injuries remain controversial. Grade 3 and 4 blunt VA injuries were analyzed to define their natural history and establish a rational management plan based on lesion progression and cerebral infarction. METHODS A retrospective review of a prospectively maintained database of all blunt traumatic carotid and vertebral artery injuries from August 2003 to April 2013 was performed, and Grade 3 and 4 blunt VA injuries were identified. Grade 3 injuries were defined as stenosis of the vessel greater than 50% or the development of a pseudoaneurysm, and Grade 4 injuries were defined as complete vessel occlusion. Demographic information, radiographic imaging findings, number of imaging sessions performed per individual, length of radiographic follow-up, radiographic outcome at end of follow-up, treatment(s) provided, and documentation of ischemic stroke or transient ischemic attack were recorded. RESULTS A total of 79 high-grade (Grade 3 and 4) blunt VA injuries in 67 patients were identified. Fifty-nine patients with 66 high-grade blunt VA injuries were available for follow-up. There were 17 patients with 23 Grade 3 injuries and 42 patients with 43 Grade 4 injuries. The mean follow-up duration was 58 days for Grade 3 and 67 days for Grade 4 blunt VA injuries. Repeat imaging of Grade 3 blunt VA injuries showed that 39% of injuries were radiographically stable, 43% resolved, and 13% improved, while 1 injury radiographically worsened. Repeat imaging of the Grade 4 blunt VA injuries showed that 65% of injuries were radiographically stable (persistent occlusion), 30% improved (recanalization of the vessel), and in 2 cases (5%) the injury resolved. All Grade 3 injuries that were treated were managed with aspirin or clopidogrel alone, as were the majority of Grade 4 injuries. There were 3 cerebral infarctions thought to be related to Grade 4 blunt VA injuries, which were likely present on admission. All 3 of these patients died at a mean of 13.7 days after hospital admission. No cerebral infarctions directly related to Grade 3 blunt VA injuries were identified. CONCLUSIONS The majority of high-grade blunt VA injuries remain stable or are improved at final follow-up. Despite a 4% rate of radiographic worsening in the Grade 3 blunt VA injury group and a 35% recanalization rate in the Grade 4 blunt VA injury group, there were no adverse clinical outcomes associated with these radiographic changes. No cerebral infarctions were noted in the Grade 3 group. A 7% stroke rate was identified in the Grade 4 blunt VA injury group; however, this was confined to the immediate postinjury period and was associated with 100% mortality. While these data suggest that these high-grade vertebral artery injuries may require less intensive radiographic follow-up, future prospective studies are needed to make conclusive changes related to treatment and management.

As a basis for venous thromboembolism (VTE) prophylaxis after traumatic brain injury (TBI), we have previously published an algorithm known as the Parkland Protocol. Patients are classified by risk for spontaneous progression of hemorrhage with chemoprophylaxis regimens tailored to each tier. We sought to validate this schema. In our algorithm, patients with any of the following are classified “low risk” for spontaneous progression: subdural hemorrhage ≤8 mm thick; epidural hemorrhage ≤8 mm thick; contusions ≤20 mm in diameter; a single contusion per lobe; any amount of subarachnoid hemorrhage; or any amount of intraventricular hemorrhage. Patients with any injury exceeding these are “moderate risk” for progression, and any patient receiving a monitor or craniotomy is “high risk.” From February 2010 to November 2012, TBI patients were entered into a dedicated database tracking injury types and sizes, risk category at presentation, and progression on subsequent computed tomgraphies (CTs). The cohort (n=414) was classified as low risk (n=200), moderate risk (n=75), or high risk (n=139) after first CT. After repeat CT scan, radiographic progression was noted in 27% of low-risk, 53% of moderate-risk, and 58% of high-risk subjects. Omnibus analysis of variance test for differences in progression rates was highly significant (p

Object Screening of blunt vertebral artery (VA) injuries has increased since research has shown that they occur at a higher incidence than originally reported. Grade 1 and 2 injuries are the most common form of blunt VA injury. Proper screening, management, and follow-up of these injuries remain controversial. In this report, imaging, progression, treatment, and outcomes of Grade 1 and 2 blunt VA injuries were analyzed to better define their natural history and to establish a rational management plan based upon their risk of progression and cerebral infarct. Methods A retrospective review of all blunt traumatic carotid artery and VA injuries from December 2003 to April 2013 was performed. For the purposes of this report, focus was given to Grade 1 and 2 VA injuries. Grade 1 injuries were defined as a vessel lumen stenosis of less than 25%, and Grade 2 injuries were defined as vessel lumen stenosis between 25% and 50%. Demographic information, radiological imaging, number of images performed per individual, length of radiological follow-up, radiological outcome at the end of follow-up, treatment provided, and documentation of stroke or transient ischemic attack were recorded. Results One hundred eighty-seven Grade 1 and 2 VA injuries in 143 patients were identified. Of these 143 patients, 120 with 152 Grade 1 or 2 blunt VA injuries were available for follow-up. The mean duration of follow-up was 40 days. Repeat imaging showed that 148 (97.4%) Grade 1 or 2 blunt VA injuries were stable, improved, or resolved on final follow-up imaging. Seventy-nine patients (66%) were treated with aspirin, whereas 35 patients (29%) received no treatment. The remaining patients were treated with other antiplatelet agents or anticoagulant medication. Neuroimaging demonstrated 2 cases (1.7%) with posterior circulation infarcts that were believed to be related to their blunt VA injuries, both of which occurred during the initial hospitalization and within the first 4 days after injury. Conclusions Although follow-up imaging showed progressive worsening without radiological improvement in only a small number of patients with low-grade blunt VA injuries, these findings did not correlate with adverse clinical outcome. The posttraumatic cerebral infarction rate of 1.7% may be overestimated, and the use of acetylsalicylic acid or other antiplatelet or anticoagulant medication did not correlate with radiological changes or rate of cerebral infarction. While these data suggest the possibility that these low-grade VA injuries may not require treatment or follow-up, future prospective studies are needed to make conclusive changes related to management.

Objective To describe the clinical features and familial distribution of rheumatoid arthritis (RA) in the Pima Indians. Methods From 1965 through 1990, all cases of RA as defined by the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 criteria or all cases of seropositive, erosive disease as defined by the Rome criteria were identified in individuals who were age 20 years and older and were of 50% or more Pima/Tohono-O'odham heritage. Radiographs were reviewed by 2 musculoskeletal radiologists who were blinded to case status. Kinship coefficients were used to evaluate familial aggregation. Results Eighty-eight RA cases were identified from this population-based sample. Over 66% of the cases had seropositive disease, over 60% had erosive disease, and over 40% had subcutaneous nodules. Of the 88 RA cases, 40 were members of families with more than 1 RA case. The remainder were simplex cases. Conclusion In this population, clinical markers of severe RA were present in a majority of cases. The presence of familial aggregation for RA in the Pima Indians suggests underlying genetic factors in disease pathogenesis.

Objective To evaluate the familial aggregation of osteoarthritis (OA) in a cohort of healthy volunteers drawn from a community setting. Methods Hand radiographs obtained between 1978 and 1991 and bilateral standing knee radiographs obtained between 1984 and 1991 were read for changes of OA, using Kellgren-Lawrence (K-L) scales. The hand sites were distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and first carpometacarpal (CMC1) joints. For each joint group, the presence of OA in at least 1 joint in a joint group, the number of affected digits in each joint group, and the sum of the K-L grade across all joints were analyzed. Polyarticular OA was recorded if there were OA findings in 2 of 3 hand joint groups plus 1 or both knees. Data from 167 families with hand radiographs, 157 families with knee radiographs, and 148 families with both hand and knee radiographs were analyzed for sib-sib correlations. Results After adjustment for age, sex, and body mass index, clinically relevant sib-sib common correlations were found for OA of the DIP, PIP, and CMC1 joints, for OA at 2 or 3 hand sites, and for polyarticular OA (r = 0.33-0.81) when OA was defined according to the number of affected joints or as the sum of the K-L grade across all joints. Conclusion These results from a cohort of volunteers drawn from a community setting and ascertained without regard to OA status demonstrate familial aggregation of OA and contribute to the evidence for heritability of OA.

BACKGROUND: Specific morphological factors contribute to the hemodynamics of the anterior communicating artery (AComA). No study has examined the role of the A2 segment on AComA aneurysm presence and rupture. OBJECTIVE: To examine the possibility that the ratio between A1 and A2 segments (A1-2 ratio) represents an independent risk factor for presence and rupture of AComA aneurysms (AComAAs). METHODS: A retrospective review of an institutional aneurysm database was performed; patients with ruptured and unruptured AComAAs were identified. Two control groups were selected: group A (posterior circulation aneurysms) and group B (patients without intracranial aneurysms or other vascular malformations). Measurements of A1 and A2 diameters were obtained from digital subtraction angiography (64.1% of 3-D rotational digital subtraction angiography), and the A1-2 ratio calculated. RESULTS: From January 2009 to April 2011, 156 patients were identified (52 AComAAs, 54 control group A, and 50 control group B). Mean age at the time of presentation was 56.09 years. Compared with both control groups, patients with AComAAs had greater A1 diameter (P < .01) and A1-2 ratio (P < .001) and smaller A2 diameter (P < .01). The A1-2 ratio correlated positively with the presence of AComAAs (P < .001). Ruptured AComAAs were smaller than unruptured ones (5.91 mm vs 9.25 mm, P = .02) and associated with a higher A1-2 Ratio (P = .02). The presence of a dominant A1 did not predict AComAA rupture (P = .15). The A1-2 ratio correlated positively with the presence of ruptured AComAAs (P = .04). CONCLUSION: A1-2 ratio correlates positively with the presence and rupture of AComAAs and may facilitate treatment decision in cases of small, unruptured AComAAs.

Objective. To examine the association between selfreported knee pain and radiographic features of osteoarthritis (OA) of the knee. Methods. A sample of participants in the Baltimore Longitudinal Study of Aging (452 Caucasian males and 223 Caucasian females) completed questionnaires and underwent a standing radiograph of both knees at the same biennial visit between 1984 and 1989. Radiographs were interpreted using both the Kellgren-Lawrence and individual features scales. Odds ratios were calculated for the association of radiographic features with knee pain after adjustment for age, sex, and body mass index. Results. Overall, 156 (23%) persons reported ever having knee pain, and 104 (15%) reported current knee pain (within the previous year). Both ever knee pain and current knee pain were significantly associated with the presence of definite knee OA (Kellgren-Lawrence grade ≥2) and with the presence of all individual features. There was a direct relationship between all measures of severity of radiographic OA and knee pain. Conclusion. These data demonstrate that radiographic features of knee OA are significantly associated with knee pain. The data also support the continued use of the Kellgren-Lawrence grading scale for defining knee OA in population studies.

PURPOSE: To compare spiral computed tomography (CT) with interscan spacing of 4-5 mm versus 8-10 mm for detection rate and level of confidence in diagnosis of pulmonary nodules. MATERIALS AND METHODS: Four radiologists (two junior and two senior faculty members) retrospectively reviewed 67 spiral CT studies with one to six nodules per study. Every second image was masked, which resulted in 8-mm sections every 8 or 10 mm; then all images reconstructed every 4 or 5 mm were reviewed. Lesions were classified as definite, probable, or possible. RESULTS: Narrow interscan spacing yielded more lesions overall (583 vs 566, P < .025) and more definite lesions and fewer equivocal lesions (482 vs 431 and 101 vs 135, respectively; P < .055). The greatest effects were in the reduction of possible lesions (50 vs 88, P < .001) and in the reduction of false-positive diagnoses made by less experienced radiologists. CONCLUSION: Increased reconstruction frequency of spiral CT volume data sets improves detection of pulmonary ...

BACKGROUND We have created a theoretical algorithm for venous thromboembolism prophylaxis after traumatic brain injury (TBI) known as the Parkland Protocol, which stratifies patients into low-, medium-, and high-risk categories for spontaneous progression of hemorrhage. This prospective study characterizes the incidence and timing of radiographic progression of the TBI patterns in these categories. METHODS Inclusion criterion was presentation with intracranial blood between February 2010 and March 2011; exclusion was receipt of only one computed tomographic scan of the head during the inpatient stay or preinjury warfarin. At admission, all patients were preliminarily categorized per the Parkland Protocol as follows: low risk (LR), patients meeting the modified Berne-Norwood criteria; moderate risk (MR), injuries larger than the modified Berne-Norwood criteria without requiring a neurosurgical procedure; high risk (HR), any patient with a craniotomy/monitor. RESULTS A total of 245 patients with intracranial hemorrhage were enrolled during the 13-month study period. Of patients preliminarily classified as LR at admission (n = 136), progression was seen in 25.0%. Spontaneous worsening was seen in 7.4% of LR patients at 24 hours after injury, and no LR patients progressed at 72 hours after injury. In patients initially classified as MR at admission (n = 42), progression was seen in 42.9%, with 91.5% of patients demonstrating stable computed tomographic head scans at 72 hours after injury. In patients initially classified as HR (n = 67), 64.2% demonstrated spontaneous progression of their TBI patterns, with 10.5% continuing to progress at 72 hours after injury. Most repeat scans were performed as routinely scheduled studies (81-91%). CONCLUSION Increases in the incidence of spontaneous worsening were seen as severities of injury progressed from the Parkland Protocol's LR to MR to HR arms. The time frames for these spontaneous worsenings seem to be such that the protocol's theoretical recommendations for venous thromboembolism prophylaxis are worth pursuing as future points of investigation.

Objective. To examine the relationship between serum levels of insulin-like growth factor 1 (IGF-1) and osteoarthritis (OA) of the knee. Methods. Serum IGF-1 levels were compared in 162 male and 101 female subjects age ≥20 stratified by presence of radiographic changes of OA of the knee. Results. Mean serum IGF-1 levels were significantly lower in subjects with knee OA; however, after adjustment for age-related changes in IGF-1 levels, these differences were no longer significant. Conclusion. These data fail to support the hypothesis that serum IGF-1 levels are reduced in subjects with OA of the knee independent of the known age-related changes in these levels.

Radiation therapy is an important modality in the treatment of a wide variety of neoplasms. Skeletal complications of radiation therapy include alterations in bone growth, radiation osteitis with secondary stress fractures, and radiation-induced sarcoma. Routine follow-up of patients who are asymptomatic may show radiation changes that must be differentiated from recurrent disease. In symptomatic patients who are examined for metastatic disease, imaging findings may suggest stress fractures related to prior radiation therapy or, rarely, radiation-induced tumors. Correlation of the clinical presentation, radiation ports, and radiologic findings will often help in the differential diagnosis in these patients.

Amyloidosis is a rare systemic disease caused by extracellular deposition of an insoluble protein. Although it is usually seen in a systemic form, 10%-20% of cases can be localized. Systemic amyloidosis is subclassified into an idiopathic primary form and a secondary or reactive form. Patients with primary amyloidosis have no underlying condition or disease. Men are affected more than women, and the mean age at presentation is 55-60 years. Some causes of secondary amyloidosis are multiple myeloma (10%-15%), rheumatoid arthritis (20%-25%), tuberculosis (50%), or familial Mediterranean fever (26%-40%). Radiographic studies of 90 patients with biopsy-proved primary or secondary amyloidosis were reviewed. Computed tomographic (CT) scans demonstrated a wide spectrum of disease in the cardiothoracic, gastrointestinal, genitourinary, and musculoskeletal systems. Amyloid deposition simulated both inflammatory and neoplastic conditions. Amorphous or irregular calcifications were occasionally identified within the amyloid deposit. Definitive diagnosis requires biopsy confirmation, as CT findings are nonspecific.

The term thigh splints has been used to describe an avulsion injury at the adductor insertion sites of the femur. The condition is analogous to the much more common shin splints. The authors describe this condition in a 17-year-old female high school soccer player. Her clinical history and initial radiographic study suggested osteoid osteoma. However, the delayed-phase radionuclide bone scan showed similar increased uptake at symmetric skeletal locations in the proximal femurs at the site of the junction of adductor brevis and adductor longus insertions, confirming a diagnosis of avulsion injury. No hyperemia was evident on blood-flow images.

Introduction Although cardiovascular morbidity and mortality are increased in rheumatoid arthritis, little is known about the burden of subclinical coronary atherosclerosis in these patients. Methods Using computed tomography, coronary artery calcification was measured in 195 men and women with rheumatoid arthritis aged 45 to 84 years without clinical cardiovascular disease and compared with 1,073 controls without rheumatoid arthritis enrolled in the Baltimore cohort of the Multi-Ethnic Study of Atherosclerosis. Results The prevalence of coronary calcification (Agatston score > 0) was significantly higher in men, but not women, with rheumatoid arthritis after adjusting for sociodemographic and cardiovascular risk factors (prevalence ratio = 1.19; P = 0.012). Among participants with prevalent calcification, those with rheumatoid arthritis had adjusted mean Agatston scores 53 units higher than controls (P = 0.002); a difference greater for men than women (P for interaction = 0.017). In all analyses, serum IL-6 attenuated the association between rheumatoid arthritis and coronary calcification, suggesting its role as a potential mediator of enhanced atherosclerosis. Notably, increasing severity of rheumatoid arthritis was associated with a higher prevalence and extent of coronary calcification among both men and women with rheumatoid arthritis, and for all age categories. The largest percentage difference in coronary arterial calcification between rheumatoid arthritis patients and their nonrheumatoid arthritis counterparts was observed in the youngest age category. Conclusions Increasing rheumatoid arthritis disease severity was associated with a higher prevalence and greater extent of coronary artery calcification, potentially mediated through an atherogenic effect of chronic systemic inflammation. Gender and age differences in association with coronary calcification suggest that preventive measures should be emphasized in men with rheumatoid arthritis, and considered even in younger rheumatoid arthritis patients with low levels of traditional cardiovascular risk factors.

In this prospective analysis of the natural history of osteoarthritis (OA) of the hand, the incidence and progression of various radiographic features of OA were examined in 177 men who participated in the Baltimore Longitudinal Study of Aging. Subjects who were less than 60 years old were selected based on the availability of at least 4 hand radiographs taken during at least 20 years of followup, while subjects who were age 60 or older were required to have had at least 4 hand radiographs taken during only 14 years of followup. Individual joints of the hands were graded for the presence and severity of 5 features of OA: osteophytes, joint space narrowing, subchondral sclerosis, lateral deformity, and cortical collapse. They were also graded according to the global Kellgren/Lawrence scale. The incidence and rate of progression of OA, as measured by all scales, increased in progressively older age groups. Cox's proportional hazards models showed that isolated doubtful osteophytes (Kellgren/Lawrence grade 1) and isolated joint space narrowing predicted the development of the radiographic features of OA. The rate of OA progression slowed as the severity increased. We conclude that, in men, the incidence of radiographic features of hand OA increases with age. Regardless of age, the earliest radiographic signs of OA are joint space narrowing and doubtful osteophytes.

We have presented a case of an osteoma of the clavicle in a 41-year-old man. The possibility of alternate diagnoses--in particular, ancient osteochondroma, posttraumatic hyperostosis, and parosteal osteosarcoma--was addressed. However, the pathological examination was most consistent with the diagnosis of osteoma. This benign bone lesion is most often found in the calvarium, jaw, and face. Osteomas of long bones remain extremely rare, except in the setting of Gardner's syndrome.

OBJECTIVE: Our objective was to identify reasons for the difficulty in diagnosing retained intrapericardial sponges and to determine ways to improve diagnostic accuracy. CONCLUSION: All three intrapericardially retained sponges were in the posterior pericardium, a region not visible to the surgeon. Radiographic detection of the sponges on standard anteroposterior projections is difficult because of exposure factors, other confusing linear markers, and metallic densities such as sternal sutures. However, knowledge of the typical location of a lost sponge and use of lateral radiographic projections may aid in early detection of this rare complication.

This study was designed to test whether, using curved beam theory, a structural model of the proximal femur derived from two-dimensional dual energy x-ray absorptiometry could be used to predict femoral strength in an experimental simulation of a fall on the greater trochanter. A set of 22 fresh cadaveric femoral specimens were scanned with use of two-dimensional dual energy x-ray absorptiometry and then were tested to failure in a materials testing system, under three-point loading, with the ground impact vector, aligned within the plane and along the bisector of the femoral neck-shaft angle. Failure locations generally corresponded to stress peak locations predicted by the curved beam model. Predicted failure loads correlated well with measured failure loads for femoral neck fractures (r = 0.89; percent SE of estimate = 23%) and somewhat less well for intertrochanteric fractures (r = 0.83; percent SE of estimate = 29%). Overall predictions for failure load calculated from the maximum stress peak value over both locations corresponded to measured failure loads with an r value of 0.91 (percent SE of estimate = 21%). This kind of structural approach to the analysis of data for hip bone mass has the potential to provide mechanistic interpretations of the statistical associations frequently shown between conventional bone mineral measures and either hip fracture risk in vivo or bone strength in vitro.

OBJECTIVE--To examine the association between hand and knee osteoarthritis (OA) in a community based population. METHODS--Radiographs of 695 participants aged > or = 40 years in the Baltimore Longitudinal Study of Aging were read for changes of OA, using Kellgren-Lawrence grade > or = 2 as the case definition. RESULTS--Logistic regression analyses, adjusting for age, gender and body mass index, revealed a significant association between OA in the knee and the following joint groups: distal and proximal interphalangeal (DIP, PIP) and Hand2 (OA in two or more hand joint groups) for grade 2-4 and grade 3-4 disease, and the first carpometacarpal (CMC1) joint for grade 3-4 disease. CONCLUSION--There is an association between OA in hand sites and the knee. The strength of the associations increases with increasing disease severity. For the PIP site, there is a trend toward increasing strength of association for increasing numbers of affected joints and bilateral disease.

Objective : The goal of this study was to demonstrate the feasibility and test the diagnostic performance of a new technology, 3D volumetric holography, for imaging pelvic fractures. The management of pelvic fractures may be complex, and advanced imaging studies such as CT are frequently indicated. Multiplanar CT reformations and 3D renderings provide clinically useful and complementary display of the directly acquired CT data. With the recent availability of volumetric multiple exposure holograms, produced from serial image data, it is now possible to produce true 3D images of the pelvis. In the hologram, one may view the CT data in 3D or as individual planar slices constituting the whole 3D pelvis. The diagnostic performance of the volumetric multiple exposure holograms was tested against routine radiography, CT, and 3D volumetric CT reconstructions. Materials and Methods : Routine radiography and CT were performed in 15 patients with suspected pelvic fractures. Volumetric multiple exposure holograms and 3D volumetric CT reconstructions were created from the CT data. Axial and multiplanar reformation CT images were used as the standard for fracture, diastasis, and intraarticular fragment detection. Results : Radiograms detected 39 of 50 of the fractures and diastases and no intraarticular fragments. The 3D CT reconstructions and the holograms viewed as 3D objects alone missed two small fractures of the anterior column and one hip with intraarticular bone fragments. When the volumetric multiple exposure holograms were viewed as a 3D object and as individual planar slices constituting the whole, their results were the same as the standard. Conclusion : Volumetric multiple exposure holograms were as sensitive and specific as axial CT and multiplanar reformations in detecting fracture pathology. By containing and making available, from one image, both planar and 3D information, volumetric multiple exposure holograms detected subtle anatomical features that were hidden by overlapping structures in the radiographs and the 3D CT images.

To examine the association of upper extremity bone mass with osteoarthritis (OA) of the knee, bilateral standing knee radiographs, taken between 1985 and 1991, in 430 Caucasian male and 266 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging, were read by one investigator for grade of OA using Kellgren-Lawrence scales. Several measures of upper extremity bone mass, size, and density, including combined cortical thickness (CCT), total width and percentage of cortical area of the second metacarpal, and bone mineral content (BMC), width, and density of the distal third of the left radius measured with single photon absorptiometry, were assessed at the same visit. In univariate analyses, men and women with definite knee OA were significantly older, men had significantly greater radial width, and women had significantly lower bone mass as measured by both CCT and BMC. After adjustment for age and body weight, however, men with knee OA had significantly higher BMC and radial width while neither of these measures of upper extremity bone mass and size was significantly associated with the presence of definite knee OA in women. Neither measure of upper extremity bone density was significantly associated with definite knee OA in either sex. These data suggest that, although men (but not women) with definite knee OA have significantly higher levels of adjusted radial bone mass and size, subjects with knee OA do not have significantly higher levels of adjusted bone mineral density at either upper extremity site.

The aim of this study was to estimate the prevalence and pattern of radiographic changes of osteoarthritis (OA) of the knee by age and gender in Caucasian participants in the Baltimore Longitudinal Study of Aging. Bilateral standing weight-bearing radiographs of the knee in 547 male and 351 female subjects (aged 20 and above) were read for changes of knee OA using Kellgren-Lawrence and individual features scales. Prevalence of definite (Kellgren-Lawrence grade > or = 2 changes) knee OA increased with advancing age in both sexes. Approximately 50 percent in both sexes showed bilateral involvement. Men aged 59 and below were more likely to have unilateral impairment than men aged 60 and above; no such differences were found in females. These data demonstrate that age and gender influence both the prevalence and pattern of radiographic changes of knee OA.

An angioleiomyoma adjacent to the sciatic nerve was responsible for an 11-year history of pain and dysfunction in the sciatic nerve distribution, which required numerous therapeutic procedures and intermittent use of narcotic analgesics. Diagnosis was finally made when results of a sciatic nerve block suggested possible mechanical compression of the nerve and computed tomography examination of the pelvis was extended further caudal than usual, demonstrating the tumor adjacent to the sciatic nerve near the ischial tuberosity. Only one previous case of nerve dysfunction due to impingement by an angioleiomyoma has been reported.

The association of obesity and body fat distribution with hand osteoarthritis was studied in 317 Caucasian female subjects aged 40 years and above in the Baltimore Longitudinal Study of Aging. Bilateral hand radiographs taken between 1978 and 1991 were read by one investigator for grade of osteoarthritis using Kellgren-Lawrence scales. Possible risk factors, assessed at same visit as the first radiograph during this interval, included age and measures of obesity, per cent body fat, and fat distribution. Results of bivariate analyses showed that increasing grade of hand osteoarthritis was associated with increasing age, greater mean levels of waist-hip ratio and per cent body fat; there was no association with body mass index. After adjustment for age, however, none of these independent variables remained significantly associated with grade of hand osteoarthritis. These data fail to support hypotheses that measures of obesity are associated with hand osteoarthritis in women independent of their known age-related changes.

The greater hip fracture rate among elderly women is generally ascribed to differences in femoral neck strength between the sexes. Strength of a given bone is a function of both its material properties and the magnitudes of mechanical stresses within it. This study examined the hypothesis that these apparent strength differences between the sexes are due to dissimilarities in the restructuring of the femoral neck with age, which result in higher stresses in elderly women. Using Hip Strength Analysis, a computer program developed by the authors, femoral neck cross-sectional geometric properties for stress analyses were derived from bone mineral image data of 409 community living, white subjects ranging from 19 to 93 years of age. Though both sexes show declines in femoral neck bone mineral density (BMD) and cross-sectional area with age, only females show a decline in the cross-sectional moment of inertia (CSMI, a geometric index of bone rigidity). The lack of decline in male CSMI appears to be a result of a small but significant increase in femoral neck girth. Similar age-related changes have been observed in the femoral shaft by others. The net effect of these observed changes is that mechanical stresses in the femoral neck of females appear to increase at three times the rate per decade of those of males. These results lend support to the hypothesis that the higher fracture rate in elderly women is due, at least in part, to elevated levels of mechanical stress, resulting from a combination of greater bone loss and less compensatory geometric restructuring with age.

Bone lesions in leiomyosarcoma are uncommon. When encountered, they are usually a late manifestation of disease seen in the setting of widespread systemic metastases. We present five cases of metastatic leiomyosarcoma, including one in which a bone lesion predated detection of a primary gastric leiomyosarcoma and one in which bone metastases signaled disease recurrence. Computed tomography in 14 of 16 osseous leiomyosarcomas demonstrated a lytic, non-expansile pattern.

Tumoral calcinosis is a rare disorder manifest by large calcific periarticular masses. Associated bone destruction has been described previously only once. The radiographic and computed tomographic (CT) findings of bone erosion in a case of tumoral calcinosis in a renal dialysis patient are presented. Although the presence of bone destruction may suggest a neoplasm, it does not exclude the diagnosis of tumoral calcinosis.

Sixty-two patients with breast cancer had thoracic computed tomography (CT) scans and conventional chest radiographic (CXR) examinations separated by an average of 29 days. CT served as the gold standard showing 13 cases with enlarged internal mammary nodes 0.4 to 7 cm in diameter. Original CXR interpretations were available. Additionally, these films were reinterpreted, without knowledge of the CT results, with special attention to the retrosternal region on the lateral film including the use of a bright light and comparison to prior lateral views. Original CXR interpretations detected only one (7 cm) enlarged node. Sensitivity was 8% and specificity 100%. Reinterpretation of the CXRs, without knowledge of the CT results, with special attention to the retrosternal region yielded five true positive and seven false positive determinations for a sensitivity of 38% and specificity of 86%. No enlarged node under 2.5 cm in diameter was detected on CXR. Sensitivity of CXR can be considerably improved by careful evaluation of the retrosternal space, but at the cost of considerable increase in false positive examinations. CT is necessary to achieve reasonable sensitivity and specificity in the detection of internal mammary lymphadenopathy.

The authors performed percutaneous transthoracic needle biopsy (PTNB) in 13 patients with acquired immunodeficiency syndrome (AIDS) and previously undiagnosed focal pulmonary lesions. Findings with PTNB were diagnostic in 11 of 13 cases. Complications included minimal hemoptysis in one case and small pneumothoraxes in two cases, one of which required chest tube drainage. The authors did not experience the high complication rate reported previously by some authors who used this diagnostic procedure in AIDS patients. In cases in which findings at fiberoptic bronchoscopy with transbronchial biopsy and lavage failed to provide a diagnosis, PTNB provided a reliable, relatively safe diagnostic tool to establish the cause of pulmonary masses or focal infiltrates in AIDS patients.

Computed tomography (CT) was used in a prospective study of the sacroiliac joints in 86 patients with Crohn disease to determine the type and frequency of sacroiliac joint abnormalities present in this population. The CT findings were correlated with review of the clinical history in 64 patients. Computed tomography demonstrated changes of sacroiliitis in 29% of the study group. This high prevalence of sacroiliac joint abnormality was found even in those under 30 years of age. It exceeds the 11–19% previously reported from plain film examination, reflecting the greater sensitivity of CT. In the subgroup of 64 patients studied clinically, 19 (30%) had abnormal sacroiliac joints on CT, but only 2 (3%) reported symptoms related to the sacroiliac joints.

The computed tomographic (CT) appearance of extensive intra-abdominal extramedullary hematopoiesis is illustrated in a 51-year old woman with agnogenic myeloid metaplasia. The CT images closely simulate peritoneal carcinomatosis or peritoneal mesothelioma.

Rationale and objectives The authors present an atlas of individual radiographic features of osteoarthritis of the knee and evaluate the inter- and intra-reader reliability of trained readers using this atlas. Methods Four trained readers graded 30 standing anterior-posterior knee radiographs for eight selected features of osteoarthritis (medial and lateral osteophytes, joint space narrowing, and sclerosis; osteophytes of the tibial spines and chondrocalcinosis) as well as the Kellgren-Lawrence global scale. Inter- and intra-reader reliability were calculated using intraclass correlation coefficients. Results For all features except sclerosis and osteophytes of the tibial spines, inter-reader reliability ranged from 0.63 to 0.83, whereas intra-reader reliability ranged from 0.82 to 0.95. Conclusion Using this atlas, trained readers are reliable in measuring the presence and severity of individual radiographic features of osteoarthritis of the knee. This atlas should be useful in clinical and epidemiologic studies of osteoarthritis of the knee.

We developed and evaluated scales for grading the prevalence and progression of the individual radiographic features of osteoarthritis (OA) of the hand. Four equally time-spaced hand radiographs from 50 participants in the Baltimore Longitudinal Study of Aging, who were followed for at least 20 years, were read separately and "blindly" by 4 experienced, trained readers. Eleven hand joints were individually assessed for the presence of osteophytes, joint space narrowing, subchondral cysts, subchondral sclerosis, lateral deformity, and cortical collapse, and were also graded using the Kellgren/Lawrence scale, a global estimate of OA. The intraclass correlation coefficient was used to determine cross-sectional inter- and intrareader reliability. Interreader agreement on OA progression was evaluated using life-table analysis. Each of the grading scales for the individual radiographic features of OA of the hand, except for cysts, were cross-sectionally reliable between readers. Each reader was able to reproduce his original scores almost perfectly when grading the radiographs a second time. Using these scales, the different readers agreed on all the features of longitudinal progression of OA of the hand, except cysts. We believe that this method for grading hand radiographs for OA has proved to be reliable for both cross-sectional and longitudinal studies.

A total of 125 patients with progressing advanced prostatic cancer were entered into a chemotherapy study comparing cyclophosphamide, 5 fluorouracil, and standard therapy. Parameters of response were studied in 110 patients who could be evaluated. Thirty-six patients (33 per cent) were considered to have an objective response, that is, becoming stable (29 patients) or in partial regression (7 patients). Negative response parameters (predictors of a poor response to chemotherapy or standard therapy leading to progress) included (1) bone marrow evidence of prostatic cancer, (2) abnormal liver scan, (3) prior radiation therapy (indirectly through increased toxicity to chemotherapy), and (4) luck of bilateral orchiectomy prior to randomization. Positive indicators (predictors of good responses) included (1) reduction of primary tumor mass, especially after administration of 5 fluorouracil or cyclophosphamide, and (2) hemoglobin values. There were more objective responders to cyclophosphamide than standard therapy whether the hemoglobin was initially normal or low. Indeterminate parameters of response included weight gain, presence of bony or soft tissue metastases, relief of pain, performance status, excretory urography, and biochemical determinations of liver and renal function.