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Introduction The aim of this study was to determine the incidence of lateral incisor root resorption associated with impacted maxillary canines and determine predisposing factors that may be used to predict its occurrence. Methods Cone beam computerised tomographic images of 133 patients presenting with 186 impacted canines were examined for lateral incisor root resorption. A control sample consisted of 30 lateral incisors on the side of the non-impacted canine. The studied canine-associated variables were gender, type of impaction, location of the canine both meso-distally and vertically and the long axis angulation to the midline. Axial images were primarily used to diagnose resorption. Results The estimated percentage of lateral root resorption in the sample was 17% (range 11.8– 23.9%) confirmed at a 95% confidence interval. A significant association was observed between the level of overlap of the canine across the lateral incisor, measured in sectors, and the probability of lateral incisor root resorption. The probability approximately doubled for each additional sector of canine overlap. No other significant association was noted related to all the other variables examined. Conclusions The incidence of lateral incisor root resorption associated with impacted maxillary canines was lower in the present study compared with many previous reports. However, resorption remains a common clinical finding. In order to screen for lateral incisor resorption, it is recommended that a cone beam image be prescribed when there is a mesial overlap of an impacted canine across the lateral incisor midline.

Background Minimising unnecessary tests is a global health economic priority with multiple initiatives in place to avoid inappropriate healthcare utilisation(1) and harm. Anti-nuclear antibody (ANA) testing is frequently performed as a diagnostic test for autoimmune conditions, such as systemic lupus erythematosus (SLE) or as a screening test in patients with inflammatory or musculoskeletal symptoms. The value of serial testing in the monitoring of such conditions is unclear and false positive tests can lead to unnecessary further investigation and increased patient anxiety(2) Objectives To evaluate the frequency of repeated ANA testing as a prelude to Electronic Medical Record (EMR) test alert design in an Australian healthcare network. The primary endpoint was calculation of the total cost associated with repeated testing and whether a longitudinal change in ANA resulted in any new ANA associated rheumatological diagnoses. Our secondary endpoint was the examination of baseline ANA testing behaviours. Methods We retrospectively analysed data from a multi-centre tertiary health network in Melbourne, Australia across a 7-year period (19 March 2011 to 23 July 2018). ANA and other autoimmune test results were obtained from the hospital pathology system with a positive ANA cut off set at 1:160. Clinical information was sourced from clinical information systems on patients who had a change in ANA result from negative to positive on repeat testing. The associated cost of repeated ANA testing was calculated based on the baseline cost to the public system. Results A total of 36,715 ANA tests (excluding 980 cancelled same-day requests) were performed in 28,840 patients. Of these, 14,058 (38.3%) were positive with females accounting for 9,265 (65.9%, p Conclusion Repeat ANA testing after a negative result had limited utility in the diagnosis of ANA associated rheumatological conditions with a positive predictive value of only 0.01, and resulted in high cost. New technology and clinical alert systems may help reduce unnecessary testing with potential significant direct cost savings when extrapolated across the Australian healthcare system. References [1] Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. ‘Choosing Wisely’: a growing international campaign. BMJ Qual Saf. 2015;24(2):167-74. [2] Abeles AM, Abeles M. The clinical utility of a positive antinuclear antibody test result. The American journal of medicine. 2013;126(4):342-8. Disclosure of Interests Ai Li Yeo: None declared, Jason Ong: None declared, Kathryn Connelly: None declared, Suong Le: None declared, Ronnie Ptasznik: None declared, Jane Ross: None declared, Eric F. Morand Grant/research support from: AstraZeneca, Bristol Myers Squibb, Janssen, Merck Serono, and UCB, Consultant for: AstraZeneca, Eli Lilly, Janssen, and Merck Serono, Speakers bureau: AstraZeneca, Michelle Leech: None declared

Introduction Point-of-care ultrasound (PoCUS) is a rapidly growing area, providing physicians with a valuable diagnostic tool for patient assessment. This paper describes a collaborative model, utilising radiology department ultrasound expertise, to train and credential physicians in PoCUS. A 6-year experience of the implementation and outcomes of the programme established within the emergency departments of a large, multi-campus hospital network are presented. Methods A collaborative model was initially developed and implemented between radiology and emergency departments. Key elements of the programme included hospital executive support, close collaboration with stakeholders, resource allocation, appointment of a sonographer educator, clear scope of practise and robust quality processes. Results Participation grew from 36 emergency physicians in 2011 to 96 physicians in 2016. A total 11064 scans were logged with the programme in the 6-year period. Routine quality audit of 61.8% (6836/11064) of all scans included 2836 Focussed Assessment by Sonography in Trauma (FAST) and 1422 Abdominal Aortic Aneurysm (AAA) examinations. False-positive or false-negative diagnoses occurred in 3.6% (102/2836) FAST and 1.3% (19/1422) AAA cases. No adverse clinical outcomes were reported to involve programme-compliant scans. Conclusion A collaborative model to train and credential physicians in PoCUS has been successfully implemented. The programme grew significantly, produced excellent quality outcomes and resolved many issues of potential conflict related to PoCUS.

Computed tomography (CT) coronary angiogram (CTCA) is commonly used for diagnostic evaluation of low-moderate risk patients due to its excellent performance and cost-effectiveness. However, previous cost analyses have not factored in the burden of management of pulmonary nodules, which are a common occurrence. We sought to describe the frequency and characteristics of lung nodules on CTCA in an Australian tertiary hospital, and to assess cost impacts.Consecutive CTCAs performed in the calendar year 2012 were retrospectively identified from the imaging department database. Subjects were excluded if they were under the age of 35, had known malignancy or findings identified prior to CTCA. Patients were stratified on smoking history and nodule size.Of the 2479 CTCAs included, full-field imaging revealed nodules in 358 patients (13.9%). The nodules were generally small (73%6mm), multiple (63%) and in the lower lobe (83.4%). There was no significant difference when stratified for smoking, with 60% of nodules detected in never-smokers. A minimum of 445 subsequent scans was required for nodule surveillance, resulting in an additional overall cost of $63.62 per CTCA. Limited-Field-of-View (L-FOV) would have identified only 22 nodules, with a cost of $6.14 for every CTCA performed, a cost saving of $57 per patient.Indeterminate pulmonary nodules are a common incidental finding on CTCA and prevalence appears to be independent of smoking status. There is a consequent significant cost burden that has not previously been recognised. Use of L-FOV reduces the number of nodules identified, with a significant cost benefit, but this has to be balanced against the ethical and medico-legal issues inherent in not reconstructing the irradiated lung.

Neonatal cranial ultrasound is routinely performed to screen preterm infants for complications of prematurity. A key component of this examination is the measurement of the lateral ventricles to identify and monitor ventriculomegaly. This study assesses the two-dimensional (2-D) interobserver error of neonatal cranial lateral ventricle measurements on 40 neonates who were undergoing cranial ultrasound in the neonatal intensive care unit. Three-dimensional (3-D) volumes were obtained using a matrix transducer. Lateral ventricle (LV) measurements were subsequently measured on a departmental 3-D workstation by two workstation sonographers. The interobserver error of this technique was calculated and compared with the conventional 2-D technique. Both techniques demonstrated acceptable interobserver variability although the established 2-D technique had less variation. This identifies a potential role for 3-D analysis in the neonatal cranial ultrasound examination. It also affirms the potential of 3-D ultrasound in performing similar small measurements in other clinical settings.

Background: This study investigated changes in tendon vascularity in 102 (67 men and 35 women) volleyball players over a 6 month competitive season. Methods: Athletes were examined with both grey scale ultrasound and standardised colour Doppler settings. Vessel length and pain were measured each month on five separate occasions. Vascular tendons were divided into (i) those that were vascular on all occasions (persistent vascularity) and (ii) those that were vascular on more than two but less than five occasions (intermittent vascularity). Results: A total of 41 of the 133 abnormal tendons were vascular on two or more occasions. Of these, 16 had persistent vascularity and 25 had intermittent vascularity. There was no significant difference in the prevalence of vascularity between men and women. None of the tendons had a pattern of vascularity over the season that could be clearly interpreted as the onset or resolution of vascularity. Subjects with changes in both tendons were more likely to have persistent vascularity (p = 0.045). Vessels were longer in tendons with persistent vascularity (p

SUMMARY: Dialysis-related amyloidosis (DRA), associated with beta-2 microglobulin deposition, is a common cause of morbidity in patients with renal failure undergoing chronic dialysis. The non-invasive diagnosis of DRA in its early stages is difficult. High resolution ultrasound (US) was used to examine the shoulder, hip and knee joints of 25 chronic haemodialysis patients, and features distinctive of DRA were determined. Distinctive US features were associated with increased total duration of dialysis (15 ± 5 vs 4 ± 2 years), carpal tunnel syndrome (9/10 cases) and shoulder joint discomfort (19 vs three joints). These features include altered rotator cuff echogenicity (hyperechoic and hypoechoic areas; 20/48 joints), hypoechoic material in the biceps sheath (16/48), erosions of bone (15/48) and reduced biceps tendon fibril echogenicity (12/48). These changes are unique in the experience of the current authors, but histological proof that they are definitely the result of DRA has not yet been possible. Tears of the rotator cuff tendons (14/50) were not consistently associated with symptoms (7/14). Tendon thickness was also increased (as has been described previously). The hip capsule thickness was increased in patients with signs of DRA in the shoulder, but no specific changes in texture were seen. Asymptomatic knee joint effusions were present in 40/50 joints (80%). These features detectable on high resolution US allow the non-invasive early detection of DRA and are useful in the diagnosis and management of this condition.

BackgroundAmeloblastoma is a locally aggressive odontogenic neoplasm. With local recurrence rates reaching 90%, only completeness of excision can facilitate cure. Surgical clearance has widely been based on pre-operative imaging to guide operative excision margins, however use of intra-operative specimen x-ray or frozen-section has been sought to improve clearance rates, and advanced imaging technologies in this role have been proposed. This manuscript aims to quantify the evidence for evaluating intra-operative resection margins and present the current standard in this role.MethodThe current study comprises the first reported comparison of imaging modalities for assessing ameloblastoma margins. A case is presented in which margins are assessed with each of clinical assessment based on preoperative imaging, intra-operative specimen x-ray, intra-operative specimen computed tomography (CT) and definitive histology. Each modality is compared quantitatively. These results are compared to the literature through means of systematic review of current evidence.ResultsA comparative study highlights the role for CT imaging over plain radiography. With no other comparative studies and a paucity of high level evidence establishing a role for intra-operative margin assessment in ameloblastoma in the literature, only level 4 evidence supporting the use of frozen section and specimen x-ray, and only one level 4 study assesses intra-operative CT.ConclusionThe current study suggests that intra-operative specimen CT offers an improvement over existing techniques in this role. While establishing a gold-standard will require higher level comparative studies, the use of intra-operative CT can facilitate accurate single-stage resection.

The aims of this double-blind, randomized, placebo-controlled trial were to determine whether ultrasound-guided extracorporeal shock wave therapy (ESWT) reduced pain and improved function in patients with lateral epicondylitis (tennis elbow) in the short term and intermediate term.Sixty-eight patients from community-based referring doctors were randomized to receive 3 ESWT treatments or 3 treatments at a subtherapeutic dose given at weekly intervals. Seven outcome measures relating to pain and function were collected at followup evaluations at 6 weeks, 3 months, and 6 months after completion of the treatment. The mean changes in outcome variables from baseline to 6 weeks, 3 months, and 6 months were compared for the 2 groups.The groups did not differ on demographic or clinical characteristics at baseline and there were significant improvements in almost all outcome measures for both groups over the 6-month followup period, but there were no differences between the groups even after adjusting for duration of symptoms.Our study found little evidence to support the use of ESWT for the treatment of lateral epicondylitis and is in keeping with recent systematic reviews of ESWT for lateral epicondylitis that have drawn similar conclusions.

Objective: Patellar tendon injury, defined by tendon abnormality (TA) on imaging and by pain, is common among volleyball players, but little is known about change in this injury over a volleyball season. Increased activity in the season compared with the off season may result in the development of TA and/or pain. This study investigated the behaviour of TA and pain over a competitive volleyball season. Methods: Tendon abnormality and pain were measured in 101 volleyball players at the beginning and end of a season. Pain was measured with the single leg decline squat test, which loads the patellar tendon, and TA was detected with ultrasound imaging. Hours of weekly activity were measured and compared during the season and the off season. The proportion of tendons that underwent development and resolution in TA and/or pain over the season was investigated. Results: Hours of weekly activity was greater during the season than in the off season. Most of the tendons investigated (66.3%) did not undergo a change in TA or pain over the season. Tendon abnormality and/or pain developed in 16.6% of tendons and resolved in 11.2%. Conclusions: The tendons of volleyball players respond variably to the increased load over the season. Change in TA and pain does not appear to be entirely dependent upon load.

To The Editor: Dr. Ogden and colleagues recently reported the results of a trial of shock-wave treatment for chronic plantar fasciitis in “Electrohydraulic High-Energy Shock-Wave Treatment for Chronic Plantar Fasciitis” (2004;86:2216-28). We seek clarification about whether this is a reanalysis of a previously published trial1, and, if so, why the sample sizes are substantially different. While the results appear similar, the authors now claim a significant difference in the mean score for the subjective self-assessment of pain at twelve weeks favoring the active treatment group (p = 0.014). While this cannot be verified from the data presented, as no measures of variance are provided, independent t test comparison of mean scores for subjective self-assessment of pain at twelve …

ContextExtracorporeal shock wave therapy (ESWT) is increasingly used for plantar fasciitis, but limited evidence supports its use.ObjectiveTo determine whether ultrasound-guided ESWT reduces pain and improves function in patients with plantar fasciitis.DesignDouble-blind, randomized, placebo-controlled trial conducted between April 1999 and June 2001.SettingParticipants were recruited from the community-based referring physicians (primary care physicians, rheumatologists, orthopedic surgeons, and sports physicians) of a radiology group in Melbourne, Australia.ParticipantsWe screened 178 patients and enrolled 166; 160 completed the 15-week protocol. Entry criteria included age at least 18 years with plantar fasciitis, defined as heel pain maximal over the plantar aspect of the foot of at least 6 weeks' duration, and an ultrasound-confirmed lesion, defined as thickening of the origin of the plantar fascia of at least 4 mm, hypoechogenicity, and alterations in the normal fibrillary pattern.InterventionsPatients were randomly assigned to receive either ultrasound-guided ESWT given weekly for 3 weeks to a total dose of at least 1000 mJ/mm2 (n = 81), or identical placebo to a total dose of 6.0 mJ/mm2 (n = 85).Main Outcome MeasuresOverall, morning, and activity pain, measured on a visual analog scale; Maryland Foot Score; walking ability; Short-Form–36 Health Survey (SF-36) score; and Problem Elicitation Technique score, measured at 6 and 12 weeks after treatment completion.ResultsAt 6 and 12 weeks, there were significant improvements in overall pain in both the active group and placebo group (mean [SD] improvement, 18.1 [30.6] and 19.8 [33.7] at 6 weeks [P = .74 for between-group difference], and 26.3 [34.8] and 25.7 [34.9] at 12 weeks [P = .99], respectively). Similar improvements in both groups were also observed for morning and activity pain, walking ability, Maryland Foot Score, Problem Elicitation Technique, and SF-36. There were no statistically significant differences in the degree of improvement between treatment groups for any measured outcomes.ConclusionWe found no evidence to support a beneficial effect on pain, function, and quality of life of ultrasound-guided ESWT over placebo in patients with ultrasound-proven plantar fasciitis 6 and 12 weeks following treatment.