Quantifying synovitis in rheumatoid arthritis using computer-assisted manual segmentation with 3 Tesla MRI scanning

PURPOSE

To investigate the reliability, validity and feasibility of a computer-assisted manual segmentation method for determining the synovial membrane volume as a surrogate measure for synovitis in patients with rheumatoid arthritis (RA).

MATERIALS AND METHODS

The 3 Tesla (T) MRI scans were acquired in 22 early RA and 16 established RA patients. Synovial membrane volumes in postcontrast T1w axial images at three wrist joint regions were determined by two nonradiologist observers using a computer-assisted manual segmentation method.

RESULTS

Intraobserver reliability, measured by intraclass correlation coefficients (ICCs), was excellent in the early (ICC = 0.99) and established (ICC = 0.99) RA cohorts. Interobserver reliability (mean ICC [95% Confidence Interval]) was moderate to excellent in the early and established RA groups (ICCs = 0.87 [0.68,0.94] and 0.88 [0.66, 0.96], respectively). There was a strong correlation between the synovial membrane volumes derived by segmentation and the RA MRI scoring system (RAMRIS) scores for synovitis at all joints in the early (Spearman rho = 0.86-0.96) and established (Spearman rho = 0.85-0.93) RA cohorts. The entire segmentation technique took 19 to 21 min per patient.

CONCLUSION

Measurement of MRI synovitis using a computer-assisted manual segmentation method demonstrated excellent intraobserver and very good interobserver reliability, content validity (represented by its strong correlation with RAMRIS synovitis), and moderate feasibility.

Measuring bone erosion and edema in rheumatoid arthritis: a comparison of manual segmentation and RAMRIS methods

PURPOSE

To investigate the reliability, feasibility, and validity of a computer-assisted manual segmentation (outlining) technique for measuring magnetic resonance imaging (MRI) bone erosion and edema at the wrist in rheumatoid arthritis (RA).

MATERIALS AND METHODS

The 3T MRI scans were obtained in 22 RA patients (<2 years). Bone erosion and edema volumes were scored by two readers using outlining and were compared with RAMRIS scores.

RESULTS

Using outlining, intraobserver reliability for erosions and edema was high: intraclass correlation coefficients (ICCs) = 0.994 (0.991, 0.997) and 0.996 (0.994, 0.998), respectively (Reader 1). Interobserver reliability was high for bone erosion (ICC [90% confidence interval, CI] = 0.80 [0.64, 0.92]) and comparable to RAMRIS scoring (ICC 0.78 [0.64, 0.92]), but was only moderate for bone edema (0.46 [0.00, 0.96]), compared with RAMRIS (ICC = 0.84 [0.73, 0.94]). The methods were highly correlated for erosion scores, r = 0.90, 0.82 (Readers 1 and 2) and moderately correlated for edema, r = 0.57, 0.87.

CONCLUSION

Segmentation (outlining) can be used to measure the volume of MRI bone erosion and edema at the wrist in RA patients. When compared with RAMRIS scoring, outlining had similar reliability for quantifying erosions but reliability was lower for bone edema, possibly reflecting difficulty delineating the borders of affected bone.

Skin-derived tenocyte-like cells for the treatment of patellar tendinopathy

BACKGROUND

Recent research of lateral elbow tendinopathy has led to the use of laboratory-amplified tenocyte-like cells.

HYPOTHESIS

Ultrasound-guided injection of autologous skin-derived tendon-like cells are effective compared with other injectable therapies for the treatment of refractory patellar tendinosis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

From 60 patellar tendons in 46 patients with refractory patellar tendinopathy, a 4-mm skin biopsy was sampled to grow tenocyte-like collagen-producing cells. Patients were allocated into 2 groups: (1) injection with laboratory-prepared, amplified collagen-producing cells derived from dermal fibroblasts and suspended in autologous plasma from centrifuged autologous whole blood or (2) injection with autologous plasma alone. Injections were made into the sites of hypoechogenicity, intrasubstance tears, and fibrillar discontinuity within the patellar tendon. The Victorian Institute of Sport Assessment (VISA) score was used to assess pain, severity, and functional disability. Ultrasound was performed to assess structural and blood flow changes, evaluating 4 criteria: tendon thickness, hypoechogenicity, intrasubstance tears, and neovascularity.

RESULTS

In the cell group, mean VISA scores improved from 44 ± 15 before treatment to 75 ± 17 at 6 months; in the plasma group, from 50 ± 18 to 70 ± 14. Estimated average difference between groups was 8.1, a significantly higher score in the cell group. Patients treated with collagen-producing cells also had significantly faster improvement and a highly significant effect of treatment, with the difference between groups estimated as 2.5 per unit increase in 1/√time. One patient treated with cell therapy had a late rupture and progressed to surgery; histopathology showed normal tendon structure.

CONCLUSION

Ultrasound-guided injection of autologous skin-derived tendon-like cells can be safely used in the short term to treat patellar tendinopathy, with faster response of treatment and significantly greater improvement in pain and function than with plasma alone.

Imaging features of foot osteoid osteoma

OBJECTIVES

We performed a retrospective review of the imaging of nine patients with a diagnosis of foot osteoid osteoma (OO).

MATERIALS AND METHODS

Radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) had been performed in all patients. Radiographic features evaluated were the identification of a nidus and cortical thickening. CT features noted were nidus location (affected bone-intramedullary, intracortical, subarticular) and nidus calcification. MRI features noted were the presence of an identifiable nidus, presence and grade of bone oedema and whether a joint effusion was identified.

RESULTS

Of the nine patients, three were female and six male, with a mean age of 21 years (range 11-39 years). Classical symptoms of OO (night pain, relief with aspirin) were identified in five of eight (62.5%) cases (in one case, the medical records could not be retrieved). In five patients the lesion was located in the hindfoot (four calcaneus, one talus), while four were in the mid- or forefoot (two metatarsal and two phalangeal). Radiographs were normal in all patients with hindfoot OO. CT identified the nidus in all cases (89%) except one terminal phalanx lesion, while MRI demonstrated a nidus in six of nine cases (67%). The nidus was of predominantly intermediate signal intensity on T1-weighted (T1W) sequences, with intermediate to high signal intensity on T2-weighted (T2W) sequences. High-grade bone marrow oedema, limited to the affected bone and adjacent soft tissue oedema was identified in all cases.

CONCLUSIONS

In a young patient with chronic hindfoot pain and a normal radiograph, MRI features suggestive of possible OO include extensive bone marrow oedema limited to one bone, with a possible nidus demonstrated in two-thirds of cases. The presence or absence of a nidus should be confirmed with high-resolution CT.

Lateral elbow tendinopathy: correlation of ultrasound findings with pain and functional disability

BACKGROUND

Lateral elbow tendinopathy is a common condition often diagnosed by ultrasound. Debate exists regarding which ultrasound findings correlate with disease severity and prognosis.

HYPOTHESIS

Sonographic predictors for tendon healing in patients with lateral elbow tendinopathy can be found by correlating initial ultrasound findings with subsequent changes in pain and functional disability scores after a period of nonoperative management.

STUDY DESIGN

Cohort study (prognosis); Level of evidence, 2.

METHODS

Sixty-two elbows (34 right, 28 left) in 62 patients (30 male, 32 female) with a clinical diagnosis of lateral elbow tendinopathy underwent sonographic evaluation of the common extensor origin after assessment with a validated outcome measure, the Patient-Rated Tennis Elbow Evaluation (PRTEE). After 6 months of nonoperative standardized treatment (physiotherapy with eccentric loading), the PRTEE questionnaire was repeated.

RESULTS

The mean pretreatment PRTEE was 78 (range, 51-97) and posttreatment score was 29 (range, 0-91). This difference in means was found to be significant (P < .0001). A positive correlation was identified between the presence of a lateral collateral ligament tear (P < .0001) and the size of the largest intrasubstance tear (P < .0001) and poor outcome. A negative correlation was identified with amount of hypoechogenicity (P = .0009). No correlation was found with age, sex, side, duration of symptoms, thickness of tendon, or amount of neovascularity.

CONCLUSION

The size of intrasubstance tears and presence of a lateral collateral ligament tear on ultrasound can be used to assess lateral elbow tendinopathy severity, indicate those who may not respond to nonoperative therapy, and potentially guide more invasive treatment. Those patients with a large intrasubstance tear or tears identified on ultrasound are less likely to respond to nonoperative treatment. Presence of neovascularity has little correlation with change in pain severity or functional disability and may be a poor predictor of prognosis.

Case report: bilateral ischial stress fractures in an elite tennis player

A case report of bilateral ischial stress fractures in an elite tennis player initially mimicking hamstring pathology is described. This is an unusual site of stress fracture. Typical sites of stress fracture are well documented; however, awareness of less common sites of stress-related bone injury can aid early diagnosis and treatment before overt fracture occurs.

Use of and satisfaction with a browser-based nurse teaching tool in a surgical intensive care unit

Our goal was to determine if a computerized teaching tool is an effective teaching method for nurses in a high-stress fast-paced intensive care unit. We also measured the level of satisfaction with this method of instruction. Thirty-six surgical intensive care nurses used a Web-based Microsoft PowerPoint presentation located on the intranet at nursing stations located on the surgical intensive care unit (SICU). The presentation was designed to provide instruction regarding the methodology and use of APACHE III prior to its implementation. Paired t-tests were performed to compare the results of a pretest and posttest. The questions were divided into two types: methodology and use. After the nurses completed their training sessions, they were asked to complete a questionnaire. The questionnaire questions were rated one a 1 to 5 scale. The average scores were higher on the posttest compared to the pretest (63.2% vs. 69.1%, p = 0.03). The methodology scores were higher on the posttest (74.3% vs. 88.2%, p = 0.001), while the use scores remained the same at 78.1% vs. 75.0%. Our Web-based teaching tool is an effective way to train nurses to understand the APACHE III medical system. The tool was effective at conveying the APACHE III medical systems methodology but was not effective in explaining the usefulness of the system. Most important, the nurses thought the browser-based teaching tool was easily accessible and an effective way to communicate new material to the medical staff.

Beta-adrenergic blockade accelerates conversion of postoperative supraventricular tachyarrhythmias

BACKGROUND

Postoperative supraventricular tachyarrhythmia is a common complication of surgery. Because chemical cardioversion is often ineffective, ventricular rate control remains a principal goal of therapy. The authors hypothesized that patients with supraventricular tachyarrhythmia after major noncardiac surgery who receive intravenous beta-adrenergic blockade for ventricular rate control would experience conversion to sinus rhythm at a rate that differs from those receiving intravenous calcium channel blockade.

METHODS

The rate of conversion to sinus rhythm at 2 and 12 h after treatment was examined in 64 cases of postoperative supraventricular tachyarrhythmia. After adenosine administration, patients who remained in supraventricular tachyarrhythmia were prospectively randomized to receive either intravenous diltiazem or intravenous esmolol for ventricular rate control (unblinded). Loading and infusion rates were adjusted to achieve equivalent degrees of ventricular rate control.

RESULTS

Patients were similar with regard to age and Apache III score. Most patients in both groups had atrial fibrillation (esmolol, 79%; diltiazem, 81%), and none experienced stable conversion with adenosine. Patients randomized to receive esmolol experienced a 59% rate of conversion to sinus rhythm within 2 h of treatment, compared with only 33% for patients randomized to receive diltiazem (intention to treat, P = 0.049; odds ratio, 2.9; 95% confidence interval, 1.046 to 7.8). After 12 h of therapy, the number of patients converting to sinus rhythm increased in both groups (esmolol, 85%; diltiazem, 62%), and the rates of conversion no longer differed significantly. Ventricular rates when supraventricular tachyarrhythmia began and after 2 and 12 h of rate control therapy were similar in the two treatment groups. The in-hospital mortality rate and length of stay in the intensive care unit were not significantly influenced by treatment group.

CONCLUSIONS

Among adenosine-resistant patients in the intensive care unit with atrial fibrillation after noncardiac surgery, intravenous esmolol produced a more rapid (2-h) conversion to sinus rhythm than did intravenous diltiazem.