US Exam Research Articles

P125 Can musculoskeletal ultrasound assessment change management decisions in rheumatoid arthritis patients with moderate disease activity?

Abstract Background/Aims To evaluate the impact of musculoskeletal ultrasound (MSUS) assessment on treatment escalation decisions in patients with moderately active rheumatoid arthritis (RA) on csDMARDs. To determine the level of concordance between MSUS assessment and Disease Activity Score in 28 joints (DAS28) in patients with moderately active RA. Methods During a four-month period, consecutive patients with: an established diagnosis of RA, a DAS-28 of 3.2-5.1, inadequate response to at least 2 csDMARDs and indication to escalate to b/tsDMARDS were enrolled. All patients underwent a MSUS exam (B and PD modes) of the bilateral five-joint count including wrists and 2nd and 3rd MCP and PIP (5USJC). The US exam was extended to symptomatic joints (tender/swollen) of the DAS 28-joint score (28USJC) and a comprehensive 78 joint count (78USJC). For each of the three US exams a total US score and a EULAR/OMERACT US (EOUS) score was calculated. A five-point Likert scale (pre and post MSUS) assessed the patient and referring clinician’s desire to escalate treatment. After the referring clinician reviewed the MSUS assessment, patients were classified into two groups according to the escalation decision. The data was analysed to identify the differences between the two groups and the correlation between the DAS-28 score and the US assessment. Results 27 patients were included. The mean (SD) age was 56.1 years (12.5), 66.7% were female and the mean time (SD) since diagnosis was 87.8 (24.9) months. 63% were anti-CCP positive and 59% were RF positive. The mean (SD) DAS 28 PCR score was 4.4 (0.7). Following MSUS assessment, there was a change in the initial decision to escalate treatment in 66.7% patients. Using the Likert score, the desire to escalate treatment reduced post US assessment across all groups (statistically significant in the patient group). Treatment escalation was associated with a higher MSUS score (univariate analysis OR > 1) across all assessments (5USJC, 28USJC, 78USJC and EOUS (p < 0,05)). The 78USJC was most reliably aligned with the treatment decision (p = 0.009). A higher swollen joint count (SJC) and higher DAS-28 score correlated with treatment escalation (p < 0.05), whilst longer disease duration was associated with a lower likelihood of treatment escalation (p < 0.05). Comparing MSUS assessment and clinical assessment, results demonstrated poor concordance between all variables of the global DAS-28 score and MSUS score, with the exception of the SJC which showed statistically significant correlation. Conclusion The addition of the MSUS assessment to the DAS 28-score in RA patient with moderately active disease has impacted the management decision in in 66.7% of our patients. The addition of MSUS to clinical assessment may allow tailoring of treatment escalation decisions. This study demonstrated poor correlation between clinical assessment with DAS-28 score and MSUS assessment in all domains other than swollen joint score. Disclosure H. Crawshaw: None. L. Rubio-Cirilo: None. H. Johnson: None. S. Jamal: None. S. Hickey: None. J. Gunn: None. I. Ali: None. G. Coombes: None. C. Acebes: None.

Pattern Recognition or Adnexal MR Scoring System: Which Is More Accurate in Evaluating Adnexal Lesions?

This study aims to compare the accuracy of the ADNEX MR scoring system and pattern recognition system to evaluate adnexal lesions indeterminate on the US exam. In this cross-sectional retrospective study, pelvic DCE-MRI of 245 patients with 340 adnexal masses was studied based on the ADNEX MR scoring system and pattern recognition system. ADNEX MR scoring system with a sensitivity of 96.6% and specificity of 91% has an accuracy of 92.9%. The pattern recognition system's sensitivity, specificity, and accuracy are 95.8%, 93.3%, and 94.7%, respectively. PPV and NPV for the ADNEX MR scoring system were 85.1 and 98.1, respectively. PPV and NPV for the pattern recognition system were 89.7% and 97.7%, respectively. The area under the ROC curve for the ADNEX MR scoring system and pattern recognition system is 0.938 (95% CI, 0.909-0.967) and 0.950 (95% CI, 0.922-0.977). Pairwise comparison of these AUCs showed no significant difference (p = 0.052). The pattern recognition system is less sensitive than the ADNEX MR scoring system, yet more specific.

The utility of point-of-care ultrasound protocol to confirm central venous catheter placement in the preterm infant.

Central vascular access is frequently required for preterm infants. Confirmation of positioning of central line is typically on chest and abdominal radiographs; POCUS is a relatively novel diagnostic method. Misdiagnosis is the main concern limiting use of this modality. The aim of this study is to validate our standard protocol accuracy in locating the central catheter position by correlating catheter position as determined by POCUS with radiographs. Premature babies < or equal to 30weeks gestation who had peripheral central lines or surgical lines were enrolled. Confirmation of line position by radiographs was compared to images obtained through a specific US protocol technique. The operator of US exam was blinded to the radiograph findings. All images were reviewed by two radiologists who were blinded to the radiograph findings. 35 central line placements were assessed. 22 lines were inserted in the UL, and 13 were inserted in the LL with a total of 91 ultrasound scans and radiographs. The position of the line was interpreted as normal in 79/91 scans with interpreter reliability of [Formula: see text]=0.778 (p < 0.001), sensitivity of 0.83 and specificity of 0.96, and positive predictive value of 0.77 and negative predictive value of 0.97. There was no significant difference between the ultrasound interpretation and the radiograph interpretation of UL and LL. Conclusion: The protocol of POCUS that we propose is a reliable tool for assessing the central line positions in preterm infants. What is Known: • POCUS is a reliable tool assessing the central line positions in preterm infants. What is New: • The protocol of POCUS that we propose is a reliable tool for assessing the central line positions in preterm infants.

Anxiety Connected with Pelvic Ultrasound in Adolescents and Their Caregivers: Comparison of Transabdominal and Transrectal Approaches

Transabdominal US (TAUS) is usually the first approach for diagnosis of reproductive tract complaints in all adolescents. However, there are instances, when transrectal US (TRUS) is more feasible. Although TRUS is considered more invasive and distressing, evidence-based data are lacking. The study aimed to evaluate the level of anxiety in adolescents subjected to TAUS and TRUS and in their caregivers. In this cross-sectional study data were prospectively gathered using two instruments: adult or child version of the State and Trait Anxiety Inventory (STAI or STAIC) and self-developed survey. TAUS and TRUS are connected with high level anxiety in patients and moderate anxiety in caregivers as measured by STAI/STAIC questionnaires; TRUS related anxiety, fear, discomfort and pain in adolescents are significantly higher as compared to TAUS; TRUS related anxiety of caregivers, as well as parent estimated fear, discomfort and pain of adolescents are significantly higher as compared to TAUS; Anticipated pain connected to TRUS, is significantly higher than the post-exam, actually experienced pain; Pain and shame are main reasons for adolescent anxiety connected with TRUS, whereas shame" and "unknown experience" contribute to TAUS related anxiety. Given high level of anxiety in both exams additional support should be provided to patients scheduled for any pelvic US exam; given even higher level of adolescent anxiety related to TRUS, specialists should be encouraged to train in TAUS and make efforts to begin with this approach; as increased caregiver anxiety may adversely affect child's reactions, anxiety reducing interventions should be oriented towards the caregivers as well as patients.

Quantitative Evaluation of an Automated Cone-Based Breast Ultrasound Scanner for MRI-3D US Image Fusion.

Breast cancer is one of the most diagnosed types of cancer worldwide. Volumetric ultrasound breast imaging, combined with MRI can improve lesion detection rate, reduce examination time, and improve lesion diagnosis. However, to our knowledge, there are no 3D US breast imaging systems available that facilitate 3D US - MRI image fusion. In this paper, a novel Automated Cone-based Breast Ultrasound System (ACBUS) is introduced. The system facilitates volumetric ultrasound acquisition of the breast in a prone position without deforming it by the US transducer. Quality of ACBUS images for reconstructions at different voxel sizes (0.25 and 0.50 mm isotropic) was compared to quality of the Automated Breast Volumetric Scanner (ABVS) (Siemens Ultrasound, Issaquah, WA, USA) in terms of signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and resolution using a custom made phantom. The ACBUS image data were registered to MRI image data utilizing surface matching and the registration accuracy was quantified using an internal marker. The technology was also evaluated in vivo. The phantom-based quantitative analysis demonstrated that ACBUS can deliver volumetric breast images with an image quality similar to the images delivered by a currently commercially available Siemens ABVS. We demonstrate on the phantom and in vivo that ACBUS enables adequate MRI-3D US fusion. To our conclusion, ACBUS might be a suitable candidate for a second-look breast US exam, patient follow-up, and US guided biopsy planning.

Practical approach to imaging diagnosis of biliary atresia, Part 1: prenatal ultrasound and magnetic resonance imaging, and postnatal ultrasound.

We present a practical approach to imaging in suspected biliary atresia, an inflammatory cholangiopathy of infancy resulting in progressive fibrosis and obliteration of extrahepatic and intrahepatic bile ducts. Left untreated or with failure of the Kasai procedure, biliary atresia progresses towards biliary cirrhosis, end-stage liver failure and death by age 3. Differentiation of biliary atresia from other nonsurgical causes of neonatal cholestasis is challenging because there is no single method for diagnosing biliary atresia, and clinical, laboratory and imaging features of this disease overlap with those of other causes of neonatal cholestasis. Concerning imaging, our systematic literature review shows that ultrasonography is the main tool for pre- and neonatal diagnosis. Key prenatal features, when present, are non-visualisation of the gallbladder, cyst in the liver hilum, heterotaxy syndrome and irregular gallbladder walls. Postnatal imaging features have a very high specificity when present, but a variable sensitivity. Triangular cord sign and abnormal gallbladder have the highest sensitivity and specificity. The presence of macro- or microcyst or polysplenia syndrome is highly specific but less sensitive. The diameter of the hepatic artery and hepatic subcapsular flow are less reliable. When present in the context of acholic stools, dilated intrahepatic bile ducts rule out biliary atresia. Importantly, a normal US exam does not rule out biliary atresia. Signs of chronic hepatopathy and portal hypertension (portosystemic derivations such as patent ductus venosus, recanalised umbilical vein, splenomegaly and ascites) should be actively identified for - but are not specific for - biliary atresia.

Reference values of normal liver stiffness in healthy children by two methods: 2D shear wave and transient elastography

TE and 2D-SWE are well-documented in studies performed on adults, but those on pediatric patients are limited. The aim of this study was to establish pediatric reference values for liver stiffness using two elastography methods: 2D-SWE and TE. We performed an observational study on 206 healthy children. All children underwent anamnesis, clinical exam, laboratory tests, US exam, TE and 2D-SWE for liver stiffness assessment. The mean liver stiffness value by 2D-SWE for all children was 3.72 ± 0.48 kPa. The mean values ranged between 3.603 ± 0.2678 kPa (3–5 years of age) and 3.774 ± 0.4038 kPa (9–11 years). The reference values varied between 4.1386 kPa (3–5 years of age) and 4.88 kPa (12–15 years). The mean liver stiffness value by TE was 3.797 ± 0.4859 kPa. The values ranged between 3.638 ± 0.4088 kPa (6–8 years of age) and 3.961 ± 0.5695 kPa (15–18 years). The cutoff values varied from 4.4064 kPa (3–5 years of age) to 5.1 kPa (15–18 years). We found a significant positive correlation between E Median values by TE and age [95% CI: 0.1160 to 0.3798, r = 0.2526, p = 0.0002]. Our findings revealed that the mean values of liver stiffness for all children on 2D-SWE and TE were almost identical, 3.72 ± 0.48 kPa versus 3.797 ± 0.4859 kPa.

Bringing Anatomy to Life: Evaluating an Ultrasound Curriculum in Medical Clinical Anatomy

IntroductionUltrasound (US) has become more prevalent across medical specialties and therefore requires training earlier in the undergraduate medical curriculum. Given the difficulty of handling, acquiring and interpreting US, early exposure is imperative. Integrated learning has been shown to be beneficial and has led to integrated curricula in medical schools across the country. Finding the right place to integrate US remains a challenge.AimThe purpose of this study is to evaluate the effectiveness of an US curriculum based on students’ perceptions of US, confidence in interpreting and acquiring US images, and performance on US exam questions.MethodsAn US curriculum was developed and incorporated into 1st year medical clinical anatomy at Tufts University School of Medicine. Student participation was voluntary and the study was granted exempt status (IRB 12737). Students completed a validated pre‐survey evaluating their confidence in using and perceptions of US on an 11‐point Likert scale. Students were asked to watch US video primers to prepare for lab. Students rotated through an US station during 5 labs, correlating with 5 different regions during the anatomy course. Students watched US being performed and gained hands on experience acquiring US images. US questions were included on written and practical exams. Students completed a post‐survey evaluating changes in confidence and perceptions of US, and open responses to questions about the quality of the US curriculum. Mean ratings on pre‐ and post‐ surveys were compared using a Mann‐Whitney U test. Performance on US based exam questions were expressed as percent correct. Narrative responses were coded by two independent evaluators and qualitative analysis was done using NVivo software to identify common themes across students’ responses.Results211 students completed the US curriculum. 93% of students had no prior exposure to US. Students reported significantly higher mean confidence ratings on understanding US, ability to operate US, obtain US images, recognize artifacts, and interpret normal anatomy images (p&lt;0.0001) after completing the US curriculum. Students also reported that US reinforced anatomy concepts and clinical correlates (9.56, ± 0.97 SD; 9.60, ± 1.05). Students disagreed with items stating learning US is too difficult for a student (1.2, ± 2.2 SD) and that it interfered with learning anatomy (0.68, ± 1.7 SD). The average percent correct on US questions for each exam was 94.2 (Back/Lower Extremity), 91.6 (Upper Extremity/Thorax), 80.6 (Abdomen/Pelvis), and 96.7 (Head/Neck). Qualitative analysis of narrative survey responses identified seven major themes and additional subthemes (see figure ).ConclusionsLimited integration of US has proven to bolster students’ perceptions of bedside US and has given them confidence in image acquisition. Students scored well above passing rate on US knowledge questions, supporting confidence and perceptions data. Qualitative and quantitative analyses found that anatomy is a good setting to teach US, and anatomy concepts and clinical applications of US reinforce each other through the combined curriculum. There is strong desire from students for more US training.Support or Funding InformationFunded by TUSM Innovations in Education GrantThe seven themes and subthemes identified from thematic analysis of first‐year students' narrative comments on the effectiveness of the US curriculum.Figure 1

Isolated syndesmosis diastasis: Computed tomography scan assessment with arthroscopic correlation

Many studies in the literature related to the investigation of the sensitivity and specificity of ultrasound examinations in lateral malleolar fractures is limited. The aim of this study is to investigate the sensitivity and specificity of ultrasound examinations performed by emergency physicians in fractures who are presented to the emergency department with blunt lateral malleolar trauma.Patients over 18 years of age who were admitted to the ED with lateral malleolar tenderness were enrolled to this study with convenience sampling. Ultrasonographic examination was performed by emergency physicians. Following the ultrasound examination, a two-sided X-ray was performed. In the case of inconsistency between the US exam and the X-ray evaluated by the emergency physician, a CT was performed on the patients. The X-ray or CT imaging evaluation of an orthopedic surgeon was accepted as the gold standard.A hundred-twenty patients were included in the study. Fractures in the lateral malleolus were detected in 47 patients. The sensitivity of X-ray in the diagnosis of lateral malleolar fractures was 92.8%, (95% CI, 79.4–98.1) and the specificity was 100% (95% CI, 89.5–100), while the sensitivity of US exam was 100% (95% CI, 94.1–100), and the specificity was 93% (95% CI, 85–97.6). X-ray gave false negative results in 3 patients, whereas US gave false positive results in 5 patients.In patients admitted to ED with lateral malleolus tenderness, the sensitivity of the ultrasound examination performed by emergency physicians regarding diagnosis of lateral malleolar fracture is higher than X-ray.

EP04.01: Systematic evaluation of the fetal subclavian arteries in mid‐trimester scan (CASSEAL protocol in a multicentric study)

To evaluate the feasibility of the systematic examination of the fetal subclavian arteries in the second trimester of pregnancy (18-22 weeks) as a part of the mid-trimester scan (CASSEAL protocol in a multicentric study). A multicentric cross-sectional study was performed on pregnant women (singleton and twin pregnancies) attending for routine US exam 7 centres in Spain (15 examiners) between 2014-2016. The visualisation of both fetal subclavian arteries in a transverse section requires a plane slightly cranial to the three vessels and trachea view (CASSEAL view IX). The normal subclavian arteries are observed at either side of the chest as vessels with an origin anterior to the trachea and an S-shaped course towards the fetal arm (figure 1). The origin of the internal mammary arteries can be observed in the proximal portion of each artery. Feasibility and maternal, fetal, and ultrasound factors affecting visualisation were evaluated. A total of 1505 cases were assessed. Visualisation of both subclavian arteries was possible in 94.4% of the cases. Factors affecting feasibility were the examiner, maternal body index, fetal occiput anterior position and the exploration time (p<0.05). During the study period, 6/1505 (0.40%) cases of aberrant right subclavian artery (ARSA) were detected, either in the subclavian artery view (View IX) or/and in the three vessels and trachea-view (View VII). All the cases were isolated with no chromosomal abnormalities. Supporting information can be found in the online version of this abstract Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Comparative study between trans-fontanelle us&amp; spiral CT scan in the diagnosis of the congenital hydrocephalus

Compared between the trans-fontal US &amp; spiral Ct scan exam in the diagnosis of congenital hydrocephalus, A series of 100 infants with age range of (20 days to 12 months) were studied over a period of 2 years in Teaching hospital in Al diwaniya city. The commonest type of hydrocephalus in this study were obstructive type (83%).The US exam showing (100%) sensitivity in detection the lateral ventricle dilatation as in spiral CT can , with (97%) in detected the 3rd ventricle dilatation in compared with (100%) for spiral CT scan &amp; (64%) in diagnosis 4th ventricle dilation with (100%) .Trans-fontal US exam showing highly sensitivity in early diagnosis of congenital hydrocephalus, with relatively low sensitivity in differentiation between the obstructive &amp; non-obstructive type (low sensitivity in detection the 4th ventricle).In conclusion trans-fontal US exam can be used as a first choice diagnostic test in the diagnosis of congenital hydrocephalus, and CT scan should be preserved for bony &amp; parenchymal abnormalities.

Emergency physician accuracy using ultrasonography to diagnose lateral malleolar fracture

ObjectiveMany studies in the literature related to the investigation of the sensitivity and specificity of ultrasound examinations in lateral malleolar fractures is limited. The aim of this study is to investigate the sensitivity and specificity of ultrasound examinations performed by emergency physicians in fractures who are presented to the emergency department with blunt lateral malleolar trauma. MethodPatients over 18years of age who were admitted to the ED with lateral malleolar tenderness were enrolled to this study with convenience sampling. Ultrasonographic examination was performed by emergency physicians. Following the ultrasound examination, a two-sided X-ray was performed. In the case of inconsistency between the US exam and the X-ray evaluated by the emergency physician, a CT was performed on the patients. The X-ray or CT imaging evaluation of an orthopedic surgeon was accepted as the gold standard. ResultsA hundred-twenty patients were included in the study. Fractures in the lateral malleolus were detected in 47 patients. The sensitivity of X-ray in the diagnosis of lateral malleolar fractures was 92.8%, (95% CI, 79.4–98.1) and the specificity was 100% (95% CI, 89.5–100), while the sensitivity of US exam was 100% (95% CI, 94.1–100), and the specificity was 93% (95% CI, 85–97.6). X-ray gave false negative results in 3 patients, whereas US gave false positive results in 5 patients. ConclusionIn patients admitted to ED with lateral malleolus tenderness, the sensitivity of the ultrasound examination performed by emergency physicians regarding diagnosis of lateral malleolar fracture is higher than X-ray.

Segmental volvulus in the neonate: A particular clinical entity

BackgroundComplete intestinal volvulus is mainly related to congenital anomalies of the so-called intestinal malrotation, whereas segmental volvulus appears as a distinct entity, mostly observed during the perinatal period. Because these two situations are still lumped together, the aim of this study was to describe the particular condition of neonatal segmental volvulus. Study designWe analyzed the circumstances of diagnosis and management of 17 consecutives neonates operated for segmental volvulus more than a 10-year period in a single institution. During the same period, 19 cases of neonatal complete midgut volvulus were operated. ResultsPrenatal US exam anomalies were observed in 16/17 (94%) of segmental volvulus, significantly more frequently than in complete volvulus (p=0.003). Intestinal malposition was described peroperatively in all cases of complete volvulus, but also in 4/17 segmental volvulus (23%). Intestinal resection was performed in 88% of segmental volvulus when only one extensive intestinal necrosis was observed in complete volvulus. Parenteral nutrition was required in all patients with segmental volvulus with a median duration of 50days (range 5–251). ConclusionSegmental volvulus occurs mainly prenatally and leads to fetal ultrasound anomalies. This situation, despite a limited length of intestinal loss, is associated to significant postnatal morbidity.Type of the study: Treatment study. Level of evidenceLevel IV.

Assessment of the accuracy in prenatal diagnosis of congenital malformations. Analysis of 101 questionnaires filled in by parents of neonates hospitalized in the Department of Congenital Malformations Polish Mother's Memorial Research Institute

Abstract Introduction: Prenatal diagnosis is an integral part of modern perinatal care. In the article results of questionnaires pertaining to the prenatal process of diagnosis are presented. Parents whose children were afflicted with congenital malformations of all types responded to enquiry Materials and methods: Between March 2014 and March 2015 150 of 355 infants were hospitalized in the Department of Pediatric Intensive Care and Congenital Malformations in Łódź, and 150 had congenital malformations. Results: 101 parents of 150 children (67,3%) have given the feedback. Anomalies were such as: of the digestive system (37%), CHD (25%), OUN (14 %), genito-urinary (13%), skeletal system (9%) and respiratory system (2%). In 65 children of 101 the defects were detected prenatally. The obstetric US exam was the most frequently pointed out as performed (more than 1200). The biochemical markers and genetic tests in were performed in 34 pregnancies. The high percentage of ability to detect malformation was reported in the group of fetal echo examinations. Conclusions: 1. Prenatal ultrasound exams were the least effective method of making appropriate prenatal diagnosis of congenital malformation. 2. Fetal echocardiography had a high level of sensitivity and specificity in detecting congenital malformations. 3. Prenatal cardiologists proved to be the most effective in detecting congenital malformations 89,3 % of detected abnormalities. 4. Biochemical exams had a positive result in only one case of Down Syndrome.

Articular ultrasonography: Interobserver reliability in rheumatoid arthritis

IntroductionUltrasonography (US) has a recent use in Rheumatology, and the reliability of the method in rheumatoid arthritis (RA) patients has yet to be clarified. ObjectiveTo test, in a RA survey, the reproducibility of musculoskeletal US performed by rheumatologists with one-year training through re-analysis by a Rheumatologist experien- ced in the method. Patients and methodsThis cross-sectional study included consecutive RA patients from our tertiary center. US exam was performed in metacarpophalangeal joints, proximal interpha- langeal joints, and wrists. Presence of synovitis, power Doppler (PD) signal, bone erosions, and cartilage changes comprised the US parameters evaluated. A kappa value in-between 0.20 and 0.40 was considered fair; in-between 0.41 and 0.60 was moderate; in-between 0.61 and 0.80 was good; and above 0.81 was excellent. ResultsWe analyzed 1,380 joints of 60 RA patients (78% females, 78% caucasoids). Mean age was 58 ± 11.56 years, mean disease duration was 9.98 ± 7.79 years, mean DAS28 was 3.82 ± 1.53, and mean HAQ was 0.91 ± 0.67. Kappa agreement for synovitis ranged from 0.30 to 0.70; for PD signal, from 0.53 to absolute agreement; for erosions, from 0.70 to 0.97; for cartilage changes, from 0.28 to 0.63. ConclusionAlthough good, moderate and excellent interobserver agreement were obtained for erosions and PD, concordance for synovitis and cartilage changes were less impressive in our patients with active RA. Further studies on standardization of scanning technique are necessary to improve musculoskeletal US reproducibility.

Ultrassonografia articular: confiabilidade interobservadores em artrite reumatoide

IntroductionUltrasonography (US) has a recent use in Rheumatology, and the reliability of the method in rheumatoid arthritis (RA) patients has yet to be clarified. ObjectiveTo test, in a RA survey, the reproducibility of musculoskeletal US performed by rheumatologists with one‐year training through re‐analysis by a Rheumatologist experienced in the method. Patients and methodsThis cross‐sectional study included consecutive RA patients from our tertiary center. US exam was performed in metacarpophalangeal joints, proximal interphalangeal joints, and wrists. Presence of synovitis, power Doppler (PD) signal, bone erosions, and cartilage changes comprised the US parameters evaluated. A kappa value in‐between 0.20 and 0.40 was considered fair; in‐between 0.41 and 0.60 was moderate; in‐between 0.61 and 0.80 was good; and above 0.81 was excellent. ResultsWe analyzed 1,380 joints of 60 RA patients (78% females, 78% caucasoids). Mean age was 58 ± 11.56 years, mean disease duration was 9.98 ± 7.79 years, mean DAS28 was 3.82 ± 1.53, and mean HAQ was 0.91 ± 0.67. Kappa agreement for synovitis ranged from 0.30 to 0.70; for PD signal, from 0.53 to absolute agreement; for erosions, from 0.70 to 0.97; for cartilage changes, from 0.28 to 0.63. ConclusionAlthough good, moderate and excellent interobserver agreement were obtained for erosions and PD, concordance for synovitis and cartilage changes were less impressive in our patients with active RA. Further studies on standardization of scanning technique are necessary to improve musculoskeletal US reproducibility.

THE PREVALENCE OF PATELLAR TENDINOPATHY IN ELITE ACADEMY RUGBY; A CLINICAL AND IMAGING STUDY WITH 12 MONTH FOLLOW UP

BackgroundPatellar tendinopathy (PT) is a challenging condition with variable outcomes. Injuries that are traditionally associated with training volume such as tendinopathies are less frequently reported in rugby but are likely...

Reply to Dr. Meyers et al regarding ‘Beyond acute appendicitis: imaging of additional pathologies of the pediatric appendix’

Sir, We would like to thank Dr. Meyers et al. [1] for their comments and question regarding our recently published article discussing alternative pathologies of the appendix beyond primary acute appendicitis [2]. When evaluating the appendix, we believe two main clinically relevant decision points must be addressed. The first is to determine whether or not the appendix is normal. If it is abnormal, the radiologist should look for any findings that would preclude urgent surgical intervention. The most frequent and straightforward such finding is that of appendiceal perforation with an associated abscess, whereby an abscess drainage procedure performed by interventional radiology staff may supplant urgent appendectomy as the primary intervention. However, as discussed in our article, there are other entities that can mimic acute bacterial appendicitis, such as cystic fibrosis and inflammatory bowel disease [2], where careful analysis of the clinical details and the imaged periappendiceal structures may provide clues that an urgent appendectomy is not warranted and that markedly different clinical management is required. Although viral appendicitis has been described, there are not sufficient data to show that it can be readily differentiated from early bacterial appendicitis by imaging [3, 4]. Therefore if the appendix appears inflamed by imaging, even if mild, and there are no clear clinical, laboratory or imaging clues to suggest that it may not be caused by acute bacterial appendicitis, an appendectomy is generally indicated, though this may be tempered by clinical examination from experienced surgical staff. Therefore the possibility of viral appendicitis does not affect the imaging algorithm at our institution (i.e. we do not think the radiologist has a role in suggesting this entity for which non-surgical management has been proposed [3]). In our standardized, structured reports for US exam of the appendix [5], we list an indeterminate category among our impression choices. This option may be employed when findings are not clear (e.g., the appendix is mildly dilated without compression but compresses normally with only mild tenderness and surrounding fluid but without adjacent fat induration) and may trigger a surgical consult, overnight monitoring or further imaging depending on the clinical scenario. This being said, we have certainly encountered cases where imaging and operative exploration both suggested mild appendiceal inflammation yet, after resection, the appendix was interpreted to be normal by the examining pathologist. Given that our pathologists are not routinely making assessments of the appendix detailed toward the exclusion of viral appendicitis, it is possible that these seemingly discordant cases could be caused by viral appendicitis. Whether a viral appendicitis can cause a clinical syndrome below the threshold of routine radiologic and histological interrogations is a different matter and cannot be addressed based on the current literature. K. R. Dietz Department of Radiology, University of Minnesota Amplatz Children’s Hospital, Minneapolis, MN, USA

The discrepancy between clinical and ultrasonographic remission in rheumatoid arthritis is not related to therapy or autoantibody status

To evaluate the clinical remission by means of power Doppler ultrasonographic (PDUS) monitoring in a group of patients with rheumatoid arthritis (RA) in clinical remission (DAS28 < 2.6). The study included 54 patients with RA in therapy with DMARDS, anti-TNF, or no therapy in clinical remission according to ACR criteria and DAS 28 < 2.6 for at least 6 months. All patients had active wrist or hand inflammation in the past. US examination evaluated the presence of active synovitis, power Doppler signal, and synovial hypertrophy on the following bilateral joints: metacarpophalangeal-proximal interphalangeal joints-flexor tendons (on 2°-3° fingers) and wrist (radiocarpal and midcarpal joints). In 19 patients, there was an agreement between clinical and US parameters. However, 35 patients with clinical remission showed a positive ultrasonographic assessment and at least an active parameter. No statistic correlation was found between US examination and antibody assessment (anti-CCP and/or RF). Patients in therapy with anti-TNF or other therapies showed similar US assessment without significant statistical differences. Among eleven patients that presented swollen and tender joints at the latest physical examination, which preceded US exam, just 5 patients had an US confirmation too. In the other patients, the PDUS did not confirm the presence of inflammation in the corresponding swollen and tender joints or showed a positive ultrasonographic assessment in other locations. The remission state is a great therapy target and not only through the biological therapy. Synovial inflammation could persist independently from type of therapy or autoantibody status.

HIDA, percutaneous transhepatic cholecysto-cholangiography and liver biopsy in infants with persistent jaundice: can a combination of PTCC and liver biopsy reduce unnecessary laparotomy?

Historically, HIDA is the initial diagnostic test in the evaluation of biliary atresia (BA). Non-excreting HIDA scans can yield false-positive results leading to negative laparotomy. Cholestatic infants must be evaluated promptly to exclude biliary atresia (BA) and other treatable hepatic conditions. Intraoperative cholangiogram (IOC) is the gold standard for diagnosing BA, but requires surgical intervention. Percutaneous transhepatic cholecysto-cholangiography (PTCC) and liver biopsy are less invasive and have been described in small case series. We hypothesized that PTCC and liver biopsy effectively exclude BA, thus avoiding unnecessary IOC. Retrospective review of cholestatic infants who underwent PTCC, biopsy or cholescintigraphy at a tertiary children's hospital from August 1998 to January 2009. Group differences were evaluated and the receiver operator curve and safety of PTCC determined. One-hundred twenty-eight cholestatic infants were reviewed. Forty-six (36%) underwent PTCC. Forty-one out of 46 (89%) had simultaneous PTCC and liver biopsy. PTCC was completed successfully in 19/23 (83%) children despite a small or absent GB on initial US. Negative laparotomy rate was 1/6 (17%) for simultaneous PTCC/liver biopsy. Complications occurred in 4/46 including bleeding (n=2), fever with elevated transaminases (n=1) and oxygen desaturations (n=1). PTCC, particularly when performed in combination with simultaneous liver biopsy, effectively excludes BA in cholestatic infants with acceptable morbidity. PTCC can frequently be performed when a contracted gallbladder is seen on initial US exam. Negative laparotomy rate is lowest when PTCC is coupled with simultaneous liver biopsy.