Search

Background: Accurate assessment of knee kinematics is important in the diagnosis and quantification of knee disorders and to determine the effect of orthopaedic interventions. Despite previous studies showing the usefulness of dynamic imaging and providing valuable insights in knee kinematics, dynamic imaging is not widely used in clinics due to a variety of causes. In this study normative knee kinematics of 100 healthy subjects is established using a fully automatic workflow feasible for use in the clinic., Methods: One-hundred volunteers were recruited and a dynamic CT scan was made during a flexion extension movement. Image data was automatically segmented and dynamic and static images were superimposed using image registration. Coordinate systems for the femur, patella and tibia were automatically calculated as well as their dynamic position and orientation., Results: Dynamic CT scans weremade withan effective radiation dose of 0.08 mSv. The median tibial internal rotation was 4° and valgus rotation is 5° at full flexion. Femoral rollback of the lateral condyle was 7 mm versus 2 mm of the medial condyle. The median patella flexion reached 65% of tibiofemoral flexion and the median tilt and rotation were 5° and 0° at full flexion, respectively. The median mediolateral translation of the patella was 3 mm (medially) in the first 30° of flexion., Conclusion: The current study presents TF and PF kinematic data of 97 healthy individuals, providing a unique dataset of normative knee kinematics. The short scanning time, simple motion and, automatic analysis make the methods presented suitable for daily clinical practice., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 The Author(s). Published by Elsevier B.V. All rights reserved.)

BACKGROUND. Because thick-section images (typically 3-5 mm) have low image noise, radiologists typically use them to perform clinical interpretation, although they may additionally refer to thin-section images (typically 0.5-0.625 mm) for problem solving. Deep learning reconstruction (DLR) can yield thin-section images with low noise. OBJECTIVE. The purpose of this study is to compare abdominopelvic CT image quality between thin-section DLR images and thin- and thick-section hybrid iterative reconstruction (HIR) images. METHODS. This retrospective study included 50 patients (31 men and 19 women; median age, 64 years) who underwent abdominopelvic CT between June 15, 2020, and July 29, 2020. Images were reconstructed at 0.5-mm section using DLR and at 0.5-mm and 3.0-mm sections using HIR. Five radiologists independently performed pairwise comparisons (0.5-mm DLR and either 0.5-mm or 3.0-mm HIR) and recorded the preferred image for subjective image quality measures (scale, -2 to 2). The pooled scores of readers were compared with a score of 0 (denoting no preference). Image noise was quantified using the SD of ROIs on regions of homogeneous liver. RESULTS. For comparison of 0.5-mm DLR images and 0.5-mm HIR images, the median pooled score was 2 (indicating a definite preference for DLR) for noise and overall image quality and 1 (denoting a slight preference for DLR) for sharpness and natural appearance. For comparison of 0.5-mm DLR and 3.0-mm HIR, the median pooled score was 1 for the four previously mentioned measures. These assessments were all significantly different ( p < .001) from 0. For artifacts, the median pooled score for both comparisons was 0, which was not significant for comparison with 3.0-mm HIR ( p = .03) but was significant for comparison with 0.5-mm HIR ( p < .001) due to imbalance in scores of 1 ( n = 28) and -1 (slight preference for HIR, n = 1). Noise for 0.5-mm DLR was lower by mean differences of 12.8 HU compared with 0.5-mm HIR and 4.4 HU compared with 3.0-mm HIR (both p < .001). CONCLUSION. Thin-section DLR improves subjective image quality and reduces image noise compared with currently used thin- and thick-section HIR, without causing additional artifacts. CLINICAL IMPACT. Although further diagnostic performance studies are warranted, the findings suggest the possibility of replacing current use of both thin- and thick-section HIR with the use of thin-section DLR only during clinical interpretations.

Background: Failed back surgery syndrome (FBSS) is an umbrella term referring to painful sensations experienced by patients after spinal surgery, mostly of neuropathic nature. Adequate treatment of FBSS is challenging, as its etiology is believed to be multifactorial and still not fully clarified. Accurate identification of the source of pain is difficult but pivotal to establish the most appropriate treatment strategy. Although the clinical utility of imaging in FBSS patients is still contentious, objective parameters are highly warranted to map different phenotypes of FBSS and tailor each subsequent therapy., Main Body: Since technological developments have weakened the applicability of prior research, this educational review outlined the recent evidence (i.e., from January 2005 onwards) after a systematic literature search. The state of the art on multiple imaging modalities in FBSS patients was reviewed. Future directions related to functional MRI and the development of imaging biomarkers have also been discussed., Conclusion: Besides the fact that more imaging studies correlated with symptomatology in the postoperative setting are warranted, the current educational review outlined that contrast-enhanced MRI and MR neurography have been suggested as valuable imaging protocols to assess alterations in the spine of FBSS patients. The use of imaging biomarkers to study correlations between imaging features and symptomatology might hold future potential; however, more research is required before any promising hypotheses can be drawn., (© 2022. The Author(s).)

Accurate assessment of knee kinematics is important to investigate knee pathology and the effect of orthopaedic interventions. Anatomical coordinate systems are used to describe knee kinematics but inherently show interpersonal differences. The purpose of this study was to determine the sensitivity of an anatomical coordinate system of the knee to anatomical variation, and to establish its effect on the description of knee kinematics. A statistical shape model of the knee was made based on a CT dataset. The statistical shape model was used to generate shapes with a specific variation. A coordinate system was calculated and the rotations relative to a mean coordinate system were calculated. From a dynamic CT dataset, knee kinematics were calculated for a flexion-extension movement. The largest rotational changes of the coordinate systems were then applied to the knee kinematics. The femoral and tibial coordinate system were relatively insensitive to anatomical variation, while the patellar coordinate system showed a larger sensitivity. Hence, tibiofemoral kinematics could be calculated with an accuracy of <5.01°, while patellofemoral kinematics showed a noticeably larger range of uncertainty (<13.48°). The findings from this study can be used to investigate whether differences in knee kinematics are due to anatomy or pathology., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Proximal full-thickness free hamstring tendon injury (ie, tendon avulsion or rupture) is a severe injury. Treatment decision making relies on clinical factors and magnetic resonance imaging (MRI) variables; it specifically relies on which tendons are injured as well as the extent of tendon retraction. According to a worldwide evaluation of current practice, discontinuity of both proximal tendons and retraction of >2 cm are used as surgical indications. However, both the diagnosis and the use of MRI variables in decision making may be fraught with uncertainty in clinical practice. A reliable standardized MRI assessment is required., Purpose: To propose an MRI assessment for acute proximal full-thickness free hamstring tendon injury and to evaluate its interater reliability., Study Design: Cohort study (diagnosis); Level of evidence, 2., Methods: We included 40 MRI scans of patients with acute (≤4 weeks of injury) proximal full-thickness free hamstring tendon injury. Three musculoskeletal radiologists assessed proximal full-thickness free hamstring tendon discontinuity using the novel "dropped ice cream sign" and tendon retraction (in mm). Quantification of tendon retraction (in mm) was performed using 2 different methods: (1) a direct (ie, shortest distance between the center of the hamstring origin and the tendon stump) method and (2) a combined craniocaudal/mediolateral measurement method. Absolute and relative interrater reliability were calculated., Results: We found an almost perfect interrater agreement (kappa = 0.87) for assessment of full-thickness tendon discontinuity using the dropped ice cream sign. Interrater agreement for the direct and craniocaudal retraction measurements was good for both the conjoint (intraclass correlation coefficient [ICC], 0.88 and 0.83) and the semimembranosus tendons (ICC, 0.81 and 0.79). The mediolateral retraction measurement yielded only moderate to poor reliability for the conjoint (ICC, 0.53) and semimembranosus tendons (ICC, 0.41)., Conclusion: The standardized MRI assessment to identify proximal hamstring tendon discontinuity and quantify tendon retraction is reliable. We recommend using the novel dropped ice cream sign and the direct retraction measurement in clinical practice and research.

In clinically suspected acute full-thickness proximal hamstring tendon avulsions, MRI is the gold standard for evaluating the extent of the injury. MRI variables such as full-thickness free tendon discontinuity, extent of tendon retraction (>20 mm), and continuity of the sacrotuberous ligament with the conjoint tendon (STL-CT) are used in treatment decision-making. The objective was to assess the intra- and inter-rater reliability of these relevant MRI variables after acute full-thickness proximal hamstring tendon avulsion. Three musculoskeletal radiologists assessed MRIs of 40 patients with an acute full-thickness proximal hamstring tendon avulsion. MRI variables included assessment of free tendon discontinuity and continuity of the STL-CT and extent of tendon retraction. Absolute and relative intra- and inter-rater reliability were calculated. Intra- and inter-rater reliability for the assessment of tendon discontinuity was substantial (Kappa [ĸ]=0.78;0.77). For the retraction measurement of the conjoint and semimembranosus tendons, intra-rater reliability was moderate and poor (Intraclass correlation coefficient (ICC)=0.74;0.45), inter-rater reliability was moderate (ICC=0.73;0.57). Intra- and inter-rater reliability of the STL-CT continuity assessment was substantial and fair (ĸ=0.74;0.31). In conclusion, MRI assessment for full-thickness free tendon discontinuity is reliable. However, assessment of extent of tendon retraction and STL-CT continuity is not reliable enough to guide the treatment decision-making process., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Recurrent subluxation or dislocation of the extensor carpi ulnaris (ECU) tendon from the ulnar groove is an important cause of ulnar-sided wrist pain. Demonstration of ECU subluxation on MRI is of unclear clinical significance. Previous studies have suggested wrist positioning can affect the ECU's position relative to the ulnar groove. This study evaluates the relationship between ECU subluxation and wrist positioning on MRI, and separately their association with ulnar-sided symptoms., Methods: 161 wrist MRI scans of 141 patients from four hospitals were retrospectively evaluated for wrist position (defined by radio-ulnar angle), degree of ECU subluxation and the presence of ulnar-sided symptoms and MRI abnormalities. 30 scans were scored by two different raters to assess interrater reliability. A linear regression model was constructed to assess the relation between wrist positioning and subluxation, accounting for other variables. A logistic regression model was constructed to evaluate which variables are predictive of ulnar-sided symptoms., Results: ECU subluxation was neither significantly correlated to wrist position (p = 0.338) nor predictive of the presence of ulnar-sided symptoms (odds ratio 1.28, 95% CI 0.39-4.18). ECU position varied widely for all wrist positions and subluxation occurred in all wrist positions, both in symptomatic and asymptomatic subjects. No trend was observed towards more frequent subluxation in supination, contrary to previous studies. Interrater reliability for radioulnar angle and ECU displacement was excellent (intraclass correlation coefficient for consistency 0.993 and 0.943, respectively)., Conclusion: ECU subluxation occurs frequently in all wrist positions, irrespective of ulnar-sided symptoms, and is not associated with ulnar-sided symptoms., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Diffuse idiopathic skeletal hyperostosis (DISH) is often theorized to be an ossification of the anterior longitudinal ligament (ALL). Using computed tomography (CT) imaging and cryomacrotome sectioning, we investigated the spatial relationship between the ALL and newly formed bone in DISH to test this hypothesis. In the current study, four human cadaveric spines diagnosed with DISH using CT imaging were frozen and sectioned using a cryomacrotome. Photographs were obtained of the specimen at 125 µm intervals. Manual segmentations of the ALL on cryomacrotome photographs were projected onto the three-dimensional reconstructed CT scans. The presence and location of newly formed bone were assessed in relationship to the location of the ALL. The ALL could be identified and segmented on the photographs at all levels. The ALL was located at the midline at levels where no new bone had formed. At the locations where new bone had abundantly formed, the ALL was displaced towards to the contralateral side and not replaced by bony tissue. The displacement of the-morphologically normal appearing-ALL away from the newly formed bone implies that newly formed bone in DISH may not originate from the ALL. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society J Orthop Res 36:2491-2496, 2018., (© 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society.)

Objective: Diffuse idiopathic skeletal hyperostosis (DISH) is characterized by flowing bony bridges on the right side of the spine. Knowledge of the development of these spinal bridges is limited. The current longitudinal computed tomography (CT) study was designed to bridge this gap., Methods: Chest CT scans from elderly males with 2 scans (interval ≥ 2.5 yrs) were retrospectively included. Using the Resnick criteria, a pre-DISH group and a definite DISH group were identified. A scoring system based on the completeness of a bone bridge (score 0-3), extent of fluency, and location of the new bone was created to evaluate the progression of bone formation., Results: In total, 145 of 1367 subjects were allocated to the DISH groups with a mean followup period of 5 years. Overall prevalence of a complete bone bridge increased in the pre-DISH group (11.3% to 31.0%) and in the definite DISH group (45.0% to 55.8%). The mean bridge score increased significantly in both the pre-DISH and definite DISH group (p < 0.001). The new bone gradually became more flowing and expanded circumferentially., Conclusion: Over the mean course of 5 years, the new bone developed from incomplete, pointy bone bridges to more flowing complete bridges. This suggests an ongoing and measurable bone-forming process that continues to progress, also in established cases of DISH.

Diffuse idiopathic skeletal hyperostosis (DISH) is an increasingly prevalent ankylosing condition. Patients with DISH have an increased risk of spinal fractures, hypothetically the result of biomechanical changes in the spine. The aim of this study was to analyze the occurrence of biomechanical stress shielding in patients with DISH. To do this, bone mineral density (BMD) was measured longitudinally in the vertebral bodies of subjects with and without DISH and in the newly formed bone of subjects with DISH. The presence of DISH was evaluated using Resnick criteria on two chest computed tomography (CT) scans taken at least 2.5 years apart from subjects over 50 years of age. Three groups were identified: pre-DISH (individuals who developed DISH after the first CT scan), definite DISH (individuals who had DISH on both CT scans), and controls (individuals with no DISH). Hounsfield units (HU) were measured in the newly formed bone and in predefined anterior and posterior portions of the involved vertebral bodies. Mean BMD of the newly formed bone increased significantly (mean ΔHU 137.5; p < 0.01) during a mean interval of 5 years in the cranial, middle, and caudally involved vertebral segments of both DISH groups. Mean BMD of the vertebral bodies in the ankylotic segments in the DISH groups did not significantly differ from that of the non-ankylotic vertebral bodies of the same subject. In contrast to our hypothesis, the HU value of the vertebral body decreased more in the control group than in the DISH groups; however, statistical significance was only reached at the cranial level in the anterior part of the vertebral body (p = 0.048). Our data suggest that 1) vertebral BMD is not influenced by the presence of DISH and 2) increased spinal stiffness may play a more important role than vertebral BMD in the increased fracture risk of and the typical fracture patterns observed in individuals with DISH., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Crystalline-induced arthropathies impose substantial morbidity but can be challenging to diagnose, especially in early phases. The most common crystalline arthropathies are gout (monosodium urate deposition), calcium pyrophosphate dihydrate deposition, and hydroxyapatite deposition disease. Computed tomography (CT) and MR imaging provide 3-dimensional information on osseous structures, periarticular soft tissue, and tophi with superior spatial resolution. Dual-source CT (dual-energy CT [DECT]) offers the further advantage of selectively identifying crystalline deposits. CT, MR imaging, and DECT can be of value in problematic cases and can potentially be used for disease monitoring. Further research is necessary to elucidate their added value., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: To evaluate and improve the interobserver agreement for the CT-based diagnosis of diffuse idiopathic skeletal hyperostosis (DISH)., Methods: Six hundred participants of the CT arm of a lung cancer screening trial were randomly divided into two groups. The first 300 CTs were scored by five observers for the presence of DISH based on the original Resnick criteria for radiographs. After analysis of the data a consensus meeting was organised and the criteria were slightly modified regarding the definition of 'contiguous', the definition of 'flowing ossifications' and the viewing plane and window level. Subsequently, the second set of 300 CTs was scored by the same observers. κ ≥ 0.61 was considered good agreement., Results: The 600 male participants were on average 63.5 (SD 5.3) years old and had smoked on average 38.0 pack-years. In the first round κ values ranged from 0.32 to 0.74 and 7 out of 10 values were below 0.61. After the consensus meeting the interobserver agreement ranged from 0.51 to 0.86 and 3 out of 10 values were below 0.61. The agreement improved significantly., Conclusions: This is the first study that reports interobserver agreement for the diagnosis of DISH on chest CT, showing mostly good agreement for modified Resnick criteria., Key Points: • DISH is diagnosed on fluoroscopic and radiographic examinations using Resnick criteria • Evaluation of DISH on chest CT was modestly reproducible with the Resnick criteria • A consensus meeting and Resnick criteria modification improved inter-rater reliability for DISH • Reproducible CT criteria for DISH aids research into this poorly understood entity.

Background: Differentiating physiological left ventricular hypertrophy (LVH) in athletes from pathological hypertrophic cardiomyopathy (HCM) can be challenging. This study assesses the ability of cardiac MRI (CMR) to distinguish between physiological LVH (so-called athlete's heart) and HCM., Methods: 45 patients with HCM (71% men and 20% athletic) and 734 healthy control participants (60% men and 75% athletic) underwent CMR. Quantitative ventricular parameters were used for multivariate logistic regression with age, gender, sport status and left ventricular (LV) end-diastolic volume (EDV) to ED ventricular wall mass (EDM) ratio as covariates. A second model added the LV EDV : right ventricular (RV) EDV ratio. The performance of the model was subsequently tested., Results: LV EDM was greater in patients with HCM (74 g/m2) compared with healthy athletes/non-athletes (53/41 g/m2), while LV EDV was largest in athletes (114 ml/m2) as compared with non-athletes (94 ml/m2) and patients with HCM (88 ml/m2). The LV EDV : EDM ratio was significantly lower in patients with HCM compared with healthy controls and athletes (1.30/2.39/2.25, p<0.05). The LV EDV : RV EDV ratio was significantly greater in patients with HCM (1.10) than in healthy participants (non-athletes/athletes 0.94/0.93). The regression model resulted in high sensitivity and specificity levels in all and borderline-LVH participants (as defined by septal wall thickness). Corresponding areas under the receiver operator characteristic (ROC) curves were 0.995 (all participants) and 0.992 (borderline-LVH participants only). Adding the LV EDV : RV EDV ratio yielded no additional improvement., Conclusions: A model incorporating the LV EDV : EDM ratio can help distinguish HCM from physiological hypertrophy in athletes. This also applies to cases with borderline LVH, which present the greatest diagnostic challenge in clinical practice., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Purpose of Review: A large number of studies investigating the correlation between severity of atopic dermatitis and various biomarkers have been published over the past decades. The aim of this review was to identify, evaluate and synthesize the evidence examining the correlation of biomarkers with disease severity in atopic dermatitis patients, something that has not been performed previously., Recent Findings: Three electronic databases were systematically searched and relevant studies were selected for inclusion. A total of 222 articles, reporting on 115 different biomarkers in 30 063 patients, were critically appraised. Studies were divided into two main groups. The first group consisted of longitudinal randomized controlled trials and cohort studies, which reported measurements at multiple time points. The second contained cross-sectional studies that reported only one measurement per patient. Out of 222 articles, 108 articles reported sufficient data for meta-analysis. Only four biomarkers were eligible for meta-analysis in the longitudinal group, and nine in the cross-sectional group., Summary: Serum thymus and activation-regulated chemokine (TARC) was found to be the most reliable biomarker studied, showing pooled correlation coefficients of 0.60 (95% CI 0.48-0.70) and 0.64 (95% CI 0.57-0.70) in longitudinal and cross-sectional studies, respectively. Additional biomarkers that could prove useful but require additional research include serum cutaneous T-cell attracting chemokine (CTACK), sE-selectin, macrophage-derived chemokine (MDC), lactate dehydrogenase (LDH) and interleukin (IL)-18.

Objectives: Opportunistic screening for osteoporosis using computed tomography (CT) examinations that happen to visualise the spine can be used to identify patients with osteoporosis. We sought to verify the diagnostic performance of vertebral Hounsfield unit (HU) measurements on routine CT examinations for diagnosing osteoporosis in a separate, external population., Methods: Consecutive patients who underwent a CT examination of the chest or abdomen and had also received a dual-energy X-ray absorptiometry (DXA) test were retrospectively included. CTs were evaluated for vertebral fractures and vertebral attenuation (density) values were measured. Diagnostic performance measures and the area under the receiver operator characteristics curve (AUC) for diagnosing osteoporosis were calculated., Results: Three hundred and two patients with a mean age of 57.9 years were included, of which 82 (27%) had osteoporosis according to DXA and 65 (22%) had vertebral fractures. The diagnostic performance for vertebral HU measurements was modest, with a maximal AUC of 0.74 (0.68 - 0.80). At that optimal threshold the sensitivity was 62% (51 - 72%) and the specificity was 79% (74 - 84%)., Conclusions: We confirmed that simple trabecular vertebral density measurements on routine CT contain diagnostic information related to bone mineral density as measured by DXA, albeit with substantially lower diagnostic accuracy than previously reported., Key Points: • We externally validated the value of vertebral trabecular bone attenuation for osteoporosis • These diagnostic performance measures were, however, substantially lower than previously reported • This information might be useful when considering the implementation of opportunistic osteoporosis screening.

Osteoporosis and cardiovascular disease often coexist. Vertebral fractures incidentally imaged in the course of routine care might be able to contribute to the prediction of cardiovascular events. Following a case-cohort design, 5,679 patients undergoing chest CT were followed for a median duration of 4.4 years. Cases were defined as patients who subsequently developed a cardiovascular event (n = 493). The presence and severity of vertebral fractures, as well as aortic, coronary and valvular calcifications on CT were investigated. Cases were more likely to be male (69 vs 60 %) and older (66 vs 61 years old). Prevalent vertebral fractures conferred an elevated risk of cardiovascular events after adjustment for age and gender [hazard ratio (HR) of 1.28, 95 % confidence interval (CI) 1.07 to 1.54]. This effect remained moderate after correction for cardiovascular calcifications (HR 1.20, CI 0.99-1.44). However, in terms of discrimination, vertebral fractures did not have substantial incremental prognostic value after correction (C-index was 0.683 vs 0.682 for models with and without vertebral fractures respectively). Prevalent vertebral fractures on routine clinical chest CT are related to future cardiovascular events but do not have additional prognostic value to models that already include age, gender and cardiovascular calcifications.

Objectives: Further survival benefits may be gained from low-dose chest computed tomography (CT) by assessing vertebral fractures and bone density. We sought to assess the association between CT-measured vertebral fractures and bone density with all-cause mortality in lung cancer screening participants., Methods: Following a case-cohort design, lung cancer screening trial participants (N = 3,673) who died (N = 196) during a median follow-up of 6 years (inter-quartile range: 5.7-6.3) were identified and added to a random sample of N = 383 from the trial. We assessed vertebral fractures using Genant's semiquantative method on sagittal reconstructions and measured bone density (Hounsfield Units (HU)) in vertebrae. Cox proportional hazards modelling was used to determine if vertebral fractures or bone density were independently predictive of mortality., Results: The prevalence of vertebral fractures was 35% (95% confidence interval 30-40%) among survivors and 51% (44-58%) amongst cases. After adjusting for age, gender, smoking status, pack years smoked, coronary and aortic calcium volume and pulmonary emphysema, the adjusted hazard ratio (HR) for vertebral fracture was 2.04 (1.43-2.92). For each 10 HU decline in trabecular bone density, the adjusted HR was 1.08 (1.02-1.15)., Conclusions: Vertebral fractures and bone density are independently associated with all-cause mortality., Key Points: • Lung cancer screening chest computed tomography contains additional, potentially useful information. • Vertebral fractures and bone density are independently predictive of mortality. • This finding has implications for screening and management decisions.

Subclinical or undiagnosed vertebral fractures on routine chest computed tomography (CT) may be useful for detecting patients at increased risk of future hip fractures who might benefit from preventive interventions. We investigated whether prevalent vertebral fractures on routine chest CT are associated with future hip fractures. From a source population of 5679 patients ≥40 years old undergoing chest CT in one of three Dutch hospitals between 2002 and 2005, patients hospitalized for hip fractures (n = 149) during a median follow-up of 4.4 years were identified. Following a case-cohort design, a random sample of 576 patients was drawn from the source population and added to the cases. In this group, the presence and severity of vertebral fractures was determined using semiquantitative vertebral fracture assessment and multivariate case-cohort appropriate Cox modeling. We found that cases were older (69 versus 63 years) and more often female (48% versus 38%) than the source population. Compared with those with no fracture, patients with any vertebral fracture had triple the risk of future hip fracture (age- and gender-adjusted hazard ratio [HR] = 3.1, 95% confidence interval [CI] 2.1-4.7). This HR rose to 3.8 (CI 2.6-5.6) if mild fractures were discounted. Future fracture risk increased significantly with increasing severity of vertebral fracture status: from mild (HR = 2.4, CI 1.5-3.7) and moderate (HR = 4.8, CI 2.5-9.2) to severe (HR = 6.7, CI 2.9-15.5). The same was true for having higher cumulative fracture grades: 1 to 3 (HR = 2.7, CI 1.8-4.1), 4 to 6 (HR = 4.8, CI 2.2-10.5), or ≥7 (HR = 11.2, CI 3.7-34.6). In conclusion, prevalent vertebral fractures on routine clinical chest CT are associated with future hip fracture risk., (© 2014 American Society for Bone and Mineral Research.)

Purpose: This meta-analysis was designed to evaluate the utility of preoperative axillary ultrasound combined with US-guided lymph node biopsy if indicated (AUS ± biopsy), in terms of staging the axilla and preventing two-step axillary surgery in the form of sentinel node biopsy (SNB) followed by completion axillary lymph node (ALN) dissection., Methods: We systematically searched electronic databases for studies that addressed preoperative assessment of ALN status by AUS ± biopsy. A pooled estimate was calculated for the false-negative rate (FNR) of AUS ± biopsy (defined as the proportion of women with a negative AUS ± biopsy result subsequently proven to have a positive axilla) and sensitivity (defined as the proportion of women with a positive AUS ± biopsy result among all women with a tumor positive axilla)., Results: The pooled FNR was 25 % (95 % confidence interval [CI] = 24-27) and the pooled sensitivity was 50 % (95 % CI = 43-57). There was substantial heterogeneity across studies for both FNR (I (2) = 69.42) and sensitivity (I (2) = 93.25), which was not explained by between-study differences in biopsy technique, mean/median tumor size, biopsy indication, or study design. Sensitivity was increased in studies with a high prevalence of ALN metastases., Conclusions: Preoperative axillary ultrasound-guided biopsy is a useful step in the process of axillary staging. Approximately 50 % of women with axillary involvement can be identified preoperatively. Still, one in four women with an ultrasound-guided biopsy-"proven" negative axilla has a positive SNB.

Background: Uncertainty remains about possible cardiac adaptation to resistance training. Androgenic anabolic steroids (AAS) use plays a potential role and may have adverse cardiovascular effects., Objective: To elucidate the effect of resistance training and of AAS-use on cardiac dimensions and function., Participants: Cardiac magnetic resonance (CMR) were performed in 156 male subjects aged 18-40 years: 52 non-athletes (maximum of 3 exercise hours/week), 52 strength-endurance (high dynamic-high static, HD-HS) athletes and 52 strength (low dynamic-high static, LD-HS) trained athletes (athletes ≥ 6 exercise hours/week). 28 LD-HS athletes denied and 24 admitted to AAS use for an average duration of 5 years (range 3 months-20 years)., Results: No significant differences were found between non-athletes and non-AAS-using LD-HS athletes. AAS-using LD-HS athletes had significantly larger LV and RV volumes and LV wall mass than non-AAS-using LD-HS athletes, but lower than HD-HS athletes. In comparison to all other groups AAS-using LD-HS athletes showed lower ejection fractions of both ventricles (LV/RV EF 51/48% versus 55-57/51-52%) and lower E/A ratios (LV/RV 1.5/1.2 versus 1.9-2.0/1.4-1.5) as an indirect measure of diastolic function. Linear regression models demonstrated a significant effect of AAS-use on LV EDV, LV EDM, systolic function and mitral valve E/A ratio (all ANOVA-tests p<0.05)., Conclusions: Strength athletes who use AAS show significantly different cardiac dimensions and biventricular systolic dysfunction and impaired ventricular inflow as compared to non-athletes and non-AAS-using strength athletes. Increased ventricular volume and mass did not exceed that of strength-endurance athletes. These findings may help raise awareness of the consequences of AAS use., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Objectives: To evaluate the reliability of semiquantitative Vertebral Fracture Assessment (VFA) on chest Computed Tomography (CT)., Methods: Four observers performed VFA twice upon sagittal reconstructions of 50 routine clinical chest CTs. Intra- and interobserver agreement (absolute agreement or 95% Limits of Agreement) and reliability (Cohen's kappa or intraclass correlation coefficient(ICC)) were calculated for the visual VFA measures (fracture present, worst fracture grade, cumulative fracture grade on patient level) and for percentage height loss of each fractured vertebra compared to the adjacent vertebrae., Results: Observers classified 24-38% patients as having at least one vertebral fracture, giving rise to kappa's of 0.73-0.84 (intraobserver) and 0.56-0.81 (interobserver). For worst fracture grade we found good intraobserver (76-88%) and interobserver (74-88%) agreement, and excellent reliability with square-weighted kappa's of 0.84-0.90 (intraobserver) and 0.84-0.94 (interobserver). For cumulative fracture grade the 95% Limits of Agreement were maximally ±1,99 (intraobserver) and ±2,69 (interobserver) and the reliability (ICC) varied from 0.84-0.94 (intraobserver) and 0.74-0.94 (interobserver). For percentage height-loss on a vertebral level the 95% Limits of Agreement were maximally ±11,75% (intraobserver) and ±12,53% (interobserver). The ICC was 0.59-0.90 (intraobserver) and 0.53-0-82 (interobserver). Further investigation is needed to evaluate the prognostic value of this approach., Conclusion: In conclusion, these results demonstrate acceptable reproducibility of VFA on CT.

Objectives: The aim of this study was to derivate and validate a prediction model for cardiovascular events based on quantification of coronary and aortic calcium volume in lung cancer screening chest computed tomography (CT)., Background: CT-based lung cancer screening in heavy smokers is a very timely topic. Given that the heavily smoking screening population is also at risk for cardiovascular disease, CT-based screening may provide the opportunity to additionally identify participants at high cardiovascular risk., Methods: Inspiratory screening CT of the chest was obtained in 3,648 screening participants. Next, smoking characteristics, patient demographics, and physician-diagnosed cardiovascular events were collected from 10 years before the screening CT (i.e., cardiovascular history) until 3 years after the screening CT (i.e., follow-up time). Cox proportional hazards analysis was used to derivate and validate a prediction model for cardiovascular risk. Age, smoking status, smoking history, and cardiovascular history, together with automatically quantified coronary and aortic calcium volume from the screening CT, were included as independent predictors. The primary outcome measure was the discriminatory value of the model., Results: Incident cardiovascular events occurred in 145 of 1,834 males (derivation cohort) and 118 of 1,725 males and 2 of 89 females (validation cohort). The model showed good discrimination in the validation cohort with a C-statistic of 0.71 (95% confidence interval: 0.67 to 0.76). When high risk was defined as a 3-year risk of 6% and higher, 589 of 1,725 males were regarded as high risk and 72 of 118 of all events were correctly predicted by the model., Conclusions: Quantification of coronary and aortic calcium volumes in lung cancer screening CT images-information that is readily available-can be used to predict cardiovascular risk. Such an approach might prove useful in the reduction of cardiovascular morbidity and mortality and may enhance the cost-effectiveness of CT-based screening in heavy smokers., (Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Beyond lung cancer, screening CT contains additional information on other smoking related diseases (e.g. chronic obstructive pulmonary disease, COPD). Since pulmonary function testing is not regularly incorporated in lung cancer screening, imaging biomarkers for COPD are likely to provide important surrogate measures for disease evaluation. Therefore, this study aims to determine the independent diagnostic value of CT emphysema, CT air trapping and CT bronchial wall thickness for COPD in low-dose screening CT scans., Methods: Prebronchodilator spirometry and volumetric inspiratory and expiratory chest CT were obtained on the same day in 1140 male lung cancer screening participants. Emphysema, air trapping and bronchial wall thickness were automatically quantified in the CT scans. Logistic regression analysis was performed to derivate a model to diagnose COPD. The model was internally validated using bootstrapping techniques., Results: Each of the three CT biomarkers independently contributed diagnostic value for COPD, additional to age, body mass index, smoking history and smoking status. The diagnostic model that included all three CT biomarkers had a sensitivity and specificity of 73.2% and 88.%, respectively. The positive and negative predictive value were 80.2% and 84.2%, respectively. Of all participants, 82.8% was assigned the correct status. The C-statistic was 0.87, and the Net Reclassification Index compared to a model without any CT biomarkers was 44.4%. However, the added value of the expiratory CT data was limited, with an increase in Net Reclassification Index of 4.5% compared to a model with only inspiratory CT data., Conclusion: Quantitatively assessed CT emphysema, air trapping and bronchial wall thickness each contain independent diagnostic information for COPD, and these imaging biomarkers might prove useful in the absence of lung function testing and may influence lung cancer screening strategy. Inspiratory CT biomarkers alone may be sufficient to identify patients with COPD in lung cancer screening setting.

Background: Physiological cardiac adaptation in athletes is influenced by body surface area, gender, age, training intensity and sport type. This study assesses the influence of sport category and provides a physiological reference for sport category and gender., Methods: Three hundred and eighty-one subjects (mean age 25±5 years, range 18 to 39 years; 61% men) underwent cardiac MRI and ECG: 114 healthy non-athletes (≤3 training h/week) and 267 healthy elite athletes (mean 17±6.6 training h/week). Athletes performed low-dynamic high-static (LD-HS, n=42), high-dynamic low-static (HD-LS, n=144) or high-dynamic high-static sports (HD-HS, n=81)., Results: Left ventricular (LV) end-diastolic volume (EDV) index (ml/m(2)) for non-athletes/LD-HS/HD-LS/HD-HS, respectively, was 101/107/122/129 in men and 90/103/106/111 in women. LV end-diastolic mass (EDM) index (g/m(2)) for non-athletes/LD-HS/HD-LS/HD-HS was, respectively, 47/49/57/69 for men and 34/38/42/51 for women. Left or right ventricular EDV ratios were alike in all groups. LV EDV/EDM ratios were similar in non-athletes/LD-HS/HD-LS athletes, and only lower in HD-HS athletes, disproving selective ventricular wall thickening in LD-HS athletes. Multivariate linear regression demonstrated HD-LS and HD-HS sport category coefficients (p<0.01) larger than those of training hours, gender and age (LV EDV/EDM coefficients for sport category LD-HS 6/0.75, HD-LS 16/7, HD-HS 21/17). ECG abnormalities were most frequent in HD-HS athletes and in male subjects., Conclusions: This study demonstrates a balanced cardiac adaptation with preserved ratios of LV/right ventricular volume (in all sport categories) and LV volume/wall mass (in LD-HS and HD-LS sports). Sport category has a strong impact on cardiac adaptation. HD-HS sports show the largest changes, whereas LD-HS sports show dimensions similar to non-athletes.

Purpose: Left ventricular (LV) trabeculation may be more pronounced in ethnic African than in Caucasian (European) athletes, leading to possible incorrect diagnosis of left ventricular non-compaction cardiomyopathy (LVNC). This study investigates ethnic differences in LV hypertrabeculation amongst elite athletes with cardiac magnetic resonance (CMR) and electrocardiography (ECG)., Methods: 38 elite male football (soccer) players (mean age 23.0, range 19-34 years, 28/38 European, 10/38 African) underwent CMR and ECG. Hypertrabeculation was assessed using the ratio of non-compacted to compacted myocardium (NC/C ratio) on long-axis and short-axis segments. ECGs were systematically rated., Results: No significant differences were seen in ventricular volumes, wall mass or E/A ratio, whereas biventricular ejection fraction (EF) was significantly lower in African athletes (European/African athletes LVEF 55/50 %, p = 0.02; RVEF 51/48 %, p = 0.05). Average NC/C ratio was greater in African athletes but only significantly at mid-ventricular level (European/African athletes: apical 0.91/1.00, p = 0.65; mid-ventricular 0.89/1.45, p < 0.05; basal 0.40/0.46, p = 0.67). ECG readings demonstrated no significant group differences, and no correlation between ECG anomalies and hypertrabeculation., Conclusions: A greater degree of LV hypertrabeculation is seen in healthy African athletes, combined with biventricular EF reduction at rest. Recognition of this phenomenon is necessary to avoid misdiagnosis of LVNC.

Background: Chemotherapy treatment induces parenchymal changes that potentially affect imaging of CRLM. The purpose of this meta-analysis was to provide values of diagnostic performance of magnetic resonance imaging (MRI), computed tomography (CT), fluorodeoxyglucose positron emission tomography (FDG-PET), and FDG-PET/CT for preoperative detection of colorectal liver metastases (CRLM) in patients treated with neoadjuvant chemotherapy., Methods: A comprehensive search was performed for original articles published from inception to 2011 assessing diagnostic performance of MRI, CT, FDG-PET, or FDG-PET/CT for preoperative evaluation of CRLM following chemotherapy. Intraoperative findings and/or histology were used as reference standard. For each imaging modality we calculated pooled sensitivities for patients who received neoadjuvant chemotherapy as well as for chemonaive patients, defined as number of malignant lesions detected divided by number of malignant lesions as confirmed by the reference standard., Results: A total of 11 papers, comprising 223 patients with 906 lesions, were included. Substantial variation in study design, patient characteristics, imaging features, and reference tests was observed. Pooled sensitivity estimates of MRI, CT, FDG-PET, and FDG-PET/CT were 85.7% (69.7-94.0%), 69.9% (65.6-73.9%), 54.5% (46.7-62.1%), and 51.7% (37.8-65.4%), respectively. In chemonaive patients, sensitivity rates were 80.5% (67.0-89.4%) for CT, 81.3% (64.1-91.4%) for FDG-PET, and 71.0% (64.3-76.9%) for FDG-PET/CT. Specificity could not be calculated because of non-reporting of "true negative lesions.", Conclusion: In the neoadjuvant setting, MRI appears to be the most appropriate imaging modality for preoperative assessment of patients with CRLM. CT is the second-best diagnostic modality and should be used in the absence of MRI. Diagnostic accuracy of FDG-PET and PET-CT is strongly affected by chemotherapy.

Objectives: To determine the prevalence of clinically relevant unrequested extra-cardiac imaging findings on cardiac Computed Tomography (CT) and explanatory factors thereof., Methods: A systematic review of studies drawn from online electronic databases followed by meta-analysis with meta-regression was performed. The prevalence of clinically relevant unrequested findings and potentially explanatory variables were extracted (proportion of smokers, mean age of patients, use of full FOV, proportion of men, years since publication)., Results: Nineteen radiological studies comprising 12922 patients met the inclusion criteria. The pooled prevalence of clinically relevant unrequested findings was 13% (95% confidence interval 9-18, range: 3-39%). The large differences in prevalence observed were not explained by the predefined (potentially explanatory) variables., Conclusions: Clinically relevant extra-cardiac findings are common in patients undergoing routine cardiac CT, and their prevalence differs substantially between studies. These differences may be due to unreported factors such as different definitions of clinical relevance and differences between populations. We present suggestions for basic reporting which may improve the interpretability and comparability of future research.

Background: Incidental CT findings may provide an opportunity for early detection of chronic obstructive pulmonary disease (COPD), which may prove important in CT-based lung cancer screening setting. We aimed to determine the diagnostic performance of human observers to visually evaluate COPD presence on CT images, in comparison to automated evaluation using quantitative CT measures., Methods: This study was approved by the Dutch Ministry of Health and the institutional review board. All participants provided written informed consent. We studied 266 heavy smokers enrolled in a lung cancer screening trial. All subjects underwent volumetric inspiratory and expiratory chest computed tomography (CT). Pulmonary function testing was used as the reference standard for COPD. We evaluated the diagnostic performance of eight observers and one automated model based on quantitative CT measures., Results: The prevalence of COPD in the study population was 44% (118/266), of whom 62% (73/118) had mild disease. The diagnostic accuracy was 74.1% in the automated evaluation, and ranged between 58.3% and 74.3% for the visual evaluation of CT images. The positive predictive value was 74.3% in the automated evaluation, and ranged between 52.9% and 74.7% for the visual evaluation. Interobserver variation was substantial, even within the subgroup of experienced observers. Agreement within observers yielded kappa values between 0.28 and 0.68, regardless of the level of expertise. The agreement between the observers and the automated CT model showed kappa values of 0.12-0.35., Conclusions: Visual evaluation of COPD presence on chest CT images provides at best modest accuracy and is associated with substantial interobserver variation. Automated evaluation of COPD subjects using quantitative CT measures appears superior to visual evaluation by human observers.

Context: Smoking is a major risk factor for both cancer and chronic obstructive pulmonary disease (COPD). Computed tomography (CT)-based lung cancer screening may provide an opportunity to detect additional individuals with COPD at an early stage., Objective: To determine whether low-dose lung cancer screening CT scans can be used to identify participants with COPD., Design, Setting, and Patients: Single-center prospective cross-sectional study within an ongoing lung cancer screening trial. Prebronchodilator pulmonary function testing with inspiratory and expiratory CT on the same day was obtained from 1140 male participants between July 2007 and September 2008. Computed tomographic emphysema was defined as percentage of voxels less than -950 Hounsfield units (HU), and CT air trapping was defined as the expiratory:inspiratory ratio of mean lung density. Chronic obstructive pulmonary disease was defined as the ratio of forced expiratory volume in the first second to forced vital capacity (FEV(1)/FVC) of less than 70%. Logistic regression was used to develop a diagnostic prediction model for airflow limitation., Main Outcome Measures: Diagnostic accuracy of COPD diagnosis using pulmonary function tests as the reference standard., Results: Four hundred thirty-seven participants (38%) had COPD according to lung function testing. A diagnostic model with CT emphysema, CT air trapping, body mass index, pack-years, and smoking status corrected for overoptimism (internal validation) yielded an area under the receiver operating characteristic curve of 0.83 (95% CI, 0.81-0.86). Using the point of optimal accuracy, the model identified 274 participants with COPD with 85 false-positives, a sensitivity of 63% (95% CI, 58%-67%), specificity of 88% (95% CI, 85%-90%), positive predictive value of 76% (95% CI, 72%-81%); and negative predictive value of 79% (95% CI, 76%-82%). The diagnostic model showed an area under the receiver operating characteristic curve of 0.87 (95% CI, 0.86-0.88) for participants with symptoms and 0.78 (95% CI, 0.76-0.80) for those without symptoms., Conclusion: Among men who are current and former heavy smokers, low-dose inspiratory and expiratory CT scans obtained for lung cancer screening can identify participants with COPD, with a sensitivity of 63% and a specificity of 88%.

Background: Routine computed tomography (CT) examinations contain an abundance of findings unrelated to the diagnostic question. Those with prognostic significance may contribute to early detection and treatment of disease, irrelevant findings can be ignored. We aimed to assess the association between unrequested chest CT findings in lungs, mediastinum and pleura and future cardiovascular events., Methods: Multi-center case-cohort study in 5 tertiary and 3 secondary care hospitals involving 10410 subjects who underwent routine chest CT for non-cardiovascular reasons. 493 cardiovascular hospitalizations or deaths were recorded during an average follow-up time of 17.8 months. 1191 patients were randomly sampled to serve as a control subcohort. Hazard ratios and annualized event rates were calculated., Results: Abnormalities in the lung (26-44%), pleura (14-15%) and mediastinum (20%) were common. Hazard ratios after adjustment for age and sex were for airway wall thickening 2.26 (1.59-3.22), ground glass opacities 2.50 (1.72-3.62), consolidations 1.97 (1.12-3.47), pleural effusions 2.77 (1.81-4.25) and lymph-nodes 2.04 (1.40-2.96). Corresponding annual event rates were 5.5%, 6.0%, 3.8%, 10.2% and 4.4%., Conclusions: We have identified several common chest CT findings that are predictive for future risk of cardiovascular events and found that other findings have little utility for this. The added value of the non-vascular predictors to established vascular calcifications on CT remains to be determined.

Object: Valid outcome assessment tools specific for spinal trauma patients are necessary to establish the efficacy of different treatment options. So far, no validated specific outcome measures are available for this patient population. The purpose of this study was to assess the current state of outcome measurement in spinal trauma patients and to address the question of whether this group is adequately served by current disease-specific and generic health-related quality-of-life instruments., Methods: A number of widely used outcome measures deemed most appropriate were reviewed, and their applicability to spinal trauma outcome discussed. An overview of recent movements in the theoretical foundations of outcome assessment, as it pertains to spinal trauma patients has been attempted, along with a discussion of domains important for spinal trauma. Commonly used outcome measures that are recommended for use in trauma patients were reviewed from the perspective of spinal trauma. The authors further sought to select a number of spine trauma-relevant domains from the WHO's comprehensive International Classification of Functioning, Disability and Health (ICF) as a benchmark for assessing the content coverage of the commonly used outcome measurements reviewed., Results: The study showed that there are no psychometrically validated outcome measurements for the spinal trauma population and there are no commonly used outcome measures that provide adequate content coverage for spinal trauma domains., Conclusions: Spinal trauma patients are currently followed either as a subset of the polytrauma population in the acute and early postacute setting or as a subset of neurological injury in the long-term revalidation medicine setting.

We describe the rationale for a new study examining the prognostic value of unrequested findings in diagnostic imaging. The deployment of more advanced imaging modalities in routine care means that such findings are being detected with increasing frequency. However, as the prognostic significance of many types of unrequested findings is unknown, the optimal response to such findings remains uncertain and in many cases an overly defensive approach is adopted, to the detriment of patient-care. Additionally, novel and promising image findings that are newly available on many routine scans cannot be used to improve patient care until their prognostic value is properly determined. The PROVIDI study seeks to address these issues using an innovative multi-center case-cohort study design. PROVIDI is to consist of a series of studies investigating specific, selected disease entities and clusters. Computed Tomography images from the participating hospitals are reviewed for unrequested findings. Subsequently, this data is pooled with outcome data from a central population registry. Study populations consist of patients with endpoints relevant to the (group of) disease(s) under study along with a random control sample from the cohort. This innovative design allows PROVIDI to evaluate selected unrequested image findings for their true prognostic value in a series of manageable studies. By incorporating unrequested image findings and outcomes data relevant to patients, truly meaningful conclusions about the prognostic value of unrequested and emerging image findings can be reached and used to improve patient-care.

Background: Growing awareness of the biomechanical contribution of the medial patellofemoral ligament has led to an upsurge in the publication of techniques and trials dealing with reconstructive techniques, warranting a review that includes the most recent evidence., Study Design: Systematic review., Methods: The authors undertook a systematic electronic search and rigorous screening process to find and identify published evidence describing the outcomes of medial patellofemoral ligament reconstruction., Results: Fourteen trials were included for analysis. Although they showed generally excellent outcomes for medial patellofemoral ligament reconstruction modalities, there were several recurring weaknesses. Most were small case series, many had limited follow-up, and a majority employed other adjunctive techniques besides medial patellofemoral ligament reconstruction, making it difficult to distinguish the determining factors in their outcomes., Conclusion: There is limited but growing evidence that a medial patellofemoral ligament-based surgical approach to patellofemoral instability leads to excellent functional outcomes.