Osteoporosis identification among previously undiagnosed individuals with vertebral fractures

Because osteoporosis is under-recognized in patients with vertebral fractures, we evaluated characteristics associated with osteoporosis identification. Most patients with vertebral fractures did not receive evaluation or treatment for osteoporosis. Black, younger, and male participants were particularly unlikely to have had recognized osteoporosis, which could increase their risk of negative outcomes.

INTRODUCTION

Vertebral fractures may be identified on imaging but fail to prompt evaluation for osteoporosis. Our objective was to evaluate characteristics associated with clinical osteoporosis recognition in patients who had vertebral fractures detected on their thoracolumbar spine imaging reports.

METHODS

We prospectively identified individuals who received imaging of the lower spine at primary care clinics in 4 large healthcare systems who were eligible for osteoporosis screening and lacked indications of osteoporosis diagnoses or treatments in the prior year. We evaluated characteristics of participants with identified vertebral fractures that were associated with recognition of osteoporosis (diagnosis code in the health record; receipt of bone mineral density scans; and/or prescriptions for anti-osteoporotic medications). We used mixed models to estimate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

A total of 114,005 participants (47% female; mean age 65 (interquartile range: 57-72) years) were evaluated. Of the 8579 (7%) participants with vertebral fractures identified, 3784 (44%) had recognition of osteoporosis within the subsequent year. In adjusted regressions, Black participants (OR (95% CI): 0.74 (0.57, 0.97)), younger participants (age 50-60: 0.48 (0.42, 0.54); age 61-64: 0.70 (0.60, 0.81)), and males (0.39 (0.35, 0.43)) were less likely to have recognized osteoporosis compared to white participants, adults aged 65 + years, or females.

CONCLUSION

Individuals with identified vertebral fractures commonly did not have recognition of osteoporosis within a year, particularly those who were younger, Black, or male. Providers and healthcare systems should consider efforts to improve evaluation of osteoporosis in patients with vertebral fractures.

Ambient temperature and solar insolation are associated with decreased prevalence of SSRI-treated psychiatric disorders

Serotonergic function is known to fluctuate in association with light and temperature. Serotonin-related behaviors and disorders similarly vary with climatic exposure, but the associations are complex. This complexity may reflect the importance of dose and timing of exposure, as well as acclimation. This cross-sectional study tests how average climate exposures (ambient temperature and solar insolation) vary with the prevalence of a group of SSRI-treated disorders. For comparison, we similarly studied a group of disorders not treated by SSRIs (i.e substance use disorders). Psychiatric prevalence data were obtained from the Collaborative Psychiatric Epidemiology Surveys (CPES). Average yearly solar insolation was obtained from NASA's NLDAS-2 Forcing Dataset Information. Average yearly temperature was obtained from NOAA's US Climate Normals. Logistic regression models were generated to assess the relationship between these two climatic factors and the prevalence of SSRI-treated and substance use disorders. Age, gender, race, income, and education were included in the models to control for possible confounding. Temperature and insolation were significantly associated with the SSRI-responsive group. For an average 1 GJ/m²/year increase, OR was 0.90 (95% CI 0.85-0.96, p = 0.001), and for an average 10 °F increase, OR was 0.93 (95% CI 0.88-0.97, p = 0.001). This relationship was not seen with substance use disorders (insolation OR: 0.97, p = 0.682; temperature OR: 0.96, p = 0.481). These results warrant further investigation, but they support the hypothesis that chronic exposure to increased temperature and light positively impact serotonin function, and are associated with reduced prevalence of some psychiatric disorders. They also support further investigation of light and hyperthermia treatments.

Multiplexing strategies for monolithic crystal PET detector modules

To reduce the number of output channels and associated cost in PET detectors, strategies to multiplex the signal channels have been investigated by several researchers. This work aims to find an optimal multiplexing strategy for detector modules consisting of a monolithic LYSO scintillator coupled to a 64-channel PMT. We apply simulated multiplexing strategies to measured data from two continuous miniature crystal element (cMiCE) detector modules. The strategies tested include standard methods such as row column summation and its variants, as well as new data-driven methods involving the principal components of measured data and variants of those components. The detector positioning resolution and bias are measured for each multiplexing strategy and the results are compared. The mean FWHM over the entire detector was 1.23 mm for no multiplexing (64 channels). Using 16 principal component channels yielded a mean FWHM resolution of 1.21 mm, while traditional row/column summation (16 channels) yielded 1.28 mm. Using 8 principal component output channels resulted in a resolution of 1.30 mm. Using the principal components of the calibration data to guide the multiplexing scheme appears to be a viable method for reducing the number of output data channels. Further study is needed to determine if the depth-of-interaction resolution can be preserved with this multiplexing scheme.

Automatic localization and identification of vertebrae in arbitrary field-of-view CT scans

This paper presents a new method for automatic localization and identification of vertebrae in arbitrary field-of-view CT scans. No assumptions are made about which section of the spine is visible or to which extent. Thus, our approach is more general than previous work while being computationally efficient. Our algorithm is based on regression forests and probabilistic graphical models. The discriminative, regression part aims at roughly detecting the visible part of the spine. Accurate localization and identification of individual vertebrae is achieved through a generative model capturing spinal shape and appearance. The system is evaluated quantitatively on 200 CT scans, the largest dataset reported for this purpose. We obtain an overall median localization error of less than 6mm, with an identification rate of 81%.

Development of a PC-based radiological imaging workstation. 1988

Low-cost image processing systems which can provide convenient access to image processing and analysis techniques hold great potential as diagnostic and research tools in medical imaging. At the University of Washington, we have developed a PC-based medium performance image processing system for use as an experimental radiological workstation. The workstation uses a standard IBM PC/AT personal computer augmented with a custom designed image processor implemented on two IBM PC/AT prototyping boards. Features of the system include up to 52 512 × 512 × 8 bit frame buffers (4 on the image processor board and up to 48 in the host computer memory) and a 512 × 512 × 4 bit graphics overlay memory, hardware zoom, pan and scroll, pseudo coloring, and a 60 Hz noninterlaced display. Many image processing and analysis functions are provided in this workstation, and all user requests are supported in an interactive fashion. For example, arithmetic and logical point operations between two 512 × 512 frame buffers require approximately 170 ms, while computationally intensive functions such as an 11 × 11 convolution or a full screen geometric transformation (warping) can be completed in less than 10 seconds. A full screen 2-D Fast Fourier Transform (FFT) and Inverse FFT (IFFT) based on the row-column method can be completed in less than 20 seconds. The developed system can easily be configured into a DIN/PACS workstation or a biological imaging system. Hardware and software details of this workstation as well as user interface functions implemented will be discussed in the paper.

MR nerve imaging in a prospective cohort of patients with suspected carpal tunnel syndrome

OBJECTIVES

To evaluate the reliability and diagnostic accuracy of high-resolution MRI of the median nerve in a prospectively assembled cohort of subjects with clinically suspected carpal tunnel syndrome (CTS).

METHODS

The authors prospectively identified 120 subjects with clinically suspected CTS from five Seattle-area clinics. All subjects completed a hand-pain diagram and underwent a standardized nerve conduction study (NCS). The reference standard for determining CTS status was a classic or probable hand pain diagram and NCS with a difference >0.3 ms between the 8-cm median and ulnar peak latencies. Readers graded multiple imaging parameters of the MRI on four-point scales. The authors also performed quantitative measurements of both the median nerve and carpal tunnel cross-sectional areas. NCS and MRI were interpreted without knowledge of the other study or the hand pain diagram.

RESULTS

Intrareader reliability was substantial to near perfect (kappa = 0.76 to 0.88). Interreader agreement was lower but still substantial (kappa = 0.60 to 0.67). Sensitivity of MRI was greatest for the overall impression of the images (96%) followed by increased median nerve signal (91%); however, specificities were low (33 to 38%). The length of abnormal signal on T2-weighted images was significantly correlated with nerve conduction latency, and median nerve area was larger at the distal radioulnar joint (15.8 vs 11.8 mm(2)) in patients with CTS. A logistic regression model combining these two MR variables had a receiver operating characteristic area under the curve of 0.85.

CONCLUSIONS

The reliability of MRI is high but the diagnostic accuracy is only moderate compared with a research-definition reference standard.

An investigation of the importance of myocardial anisotropy in finite-element modeling of the heart: methodology and application to the estimation of defibrillation efficacy

Finite-element (FE) modeling has been widely used in studies of bioelectric phenomena of tissues, including ventricular defibrillation. Most FE models, whether built from anatomical atlases or subject-specific tomographic images, treat the myocardium as an isotropic tissue. However, myocardium has been experimentally shown to have significant anisotropy in its resistivities, although myocardial fiber directions are difficult to measure on a subject-specific basis. In this paper, we: 1). propose a method to incorporate a widely known myocardial fiber direction model to a specific individual and 2). assess the effects of myocardial anisotropy on myocardial voltage gradients computed for a study of implantable defibrillators. The thoracic FE model was built from CT images of a young pig, and the myocardial fiber structures were incorporated via elastic mapping. Our results demonstrate a good mapping of geometry between the source and target hearts with an average root-mean-square error of less than 2.3 mm and a mapped fiber pattern similar to those known to exist in vivo. With the mapped fiber information, we showed that the estimated minimal myocardial voltage gradient over 80% of the myocardium differs by less than 10% between using an isotropic and anisotropic myocardial models. Thus, myocardial anisotropy is expected to have only a small effect on estimates of defibrillation threshold obtained from computed voltage gradients. On the other hand, anisotropy may be essential if defibrillation efficacy is analyzed by transmembrane voltage of the myocardial cells.

A finite-element study of the effects of electrode position on the measured impedance change in impedance cardiography

Traditional impedance cardiography (ICG) technique uses band electrodes both for delivering current to and measuring impedance change in the thorax. The use of spot electrodes increases the ease of electrode placement and comfort level for patients. Research has shown that changes in thoracic impedance can have multiple causes. In this study, we used finite element modeling to investigate the sources of impedance change for both band-electrode and spot-electrode ICG, and focused on how differences in electrode location affect the contribution of different sources to changes in impedance. The ultimate purpose is to identify the optimal electrode type and placement for the sensing of stroke volume (SV). Our models were built on sets of end-diastolic and end-systolic magnetic resonance images of a healthy human subject. The results showed that the effect of ventricular contraction is opposite to that of the other changes in systole: the expansion of major vessels, decrease in blood resistivity due to increased blood flow velocity, and decrease in lung resistivity due to increased blood perfusion. Ventricular contraction, the only factor that tends to increase systolic impedance, has a larger effect than any of the other factors. When spot electrodes are placed on the anterior chest wall near the heart, ventricular contraction is so dominant that the measured impedance increases from end-diastole to end-systole, and the change represents 82% of the contribution from ventricular contraction. When using the common band-electrode configuration, the change in measured impedance is a more balanced combination of the four effects, and ventricular contraction is overcome by the other three factors so that the impedance decreases. These results suggest that the belief that ICG can be used to directly measure SV based on the change in the whole thoracic impedance may be invalid, and that spot electrodes may be more useful for understanding local physiological events such as ventricular volume change. These findings are supported by previously reported experimental observations.

Image acquisition: ultrasound, computed tomography, and magnetic resonance imaging

As the transition toward total digital image acquisition continues, radiology is transcending the current standard of two-dimensional (2-D) cross-sectional anatomic imaging to more complex models. Among these are three-dimensional (3-D) anatomic images, constructed either from a synthesis of traditional 2-D data sets, or directly from volumetrically acquired data. However, current trends are moving beyond mere anatomic imaging to include physiological data once mainly obtained via nuclear medicine. Recent magnetic resonance pulse sequences, in addition to Doppler and harmonic ultrasound methods, are providing insight into blood flow, oxygenation, and metabolite concentrations non-invasively. Through image registration techniques, these data (even from differing modalities) are being assembled into 2-D and 3-D "fusion" images that promise to revolutionize diagnosis. Furthermore, with improvements in miniaturization, reliability, speed, built-in intelligence, and ease of use, these new developments are finding their way into use by nonspecialists. For instance, a new hand-held ultrasound unit will likely become a common tool among emergency medical teams, military medical teams, and in NASA's manned space program. Portable computed tomography (CT) scanners are already being used in the operating room. The increasing sophistication of imaging instruments will bring about a complementary increase in ease of use for both scanning and data interpretation, bringing diagnostic imaging and therapeutic capabilities closer to the patient, rather than the converse.

A fast calibration method for 3-D tracking of ultrasound images using a spatial localizer

We have developed a fast calibration method for computing the position and orientation of 2-D ultrasound (US) images in 3-D space where a position sensor is mounted on the US probe. This calibration is required in the fields of 3-D ultrasound and registration of ultrasound with other imaging modalities. Most of the existing calibration methods require a complex and tedious experimental procedure. Our method is simple and it is based on a custom-built phantom. Thirty N-fiducials (markers in the shape of the letter "N") embedded in the phantom provide the basis for our calibration procedure. We calibrated a 3.5-MHz sector phased-array probe with a magnetic position sensor, and we studied the accuracy and precision of our method. A typical calibration procedure requires approximately 2 min. We conclude that we can achieve accurate and precise calibration using a single US image, provided that a large number (approximately ten) of N-fiducials are captured within the US image, enabling a representative sampling of the imaging plane.

The Longitudinal Assessment of Imaging and Disability of the Back (LAIDBack) Study: baseline data

STUDY DESIGN

Prospective cohort study of randomly selected Veterans Affairs (VA) outpatients.

OBJECTIVE

To determine the prevalence of magnetic resonance imaging (MRI) findings in the lumbar spine among persons without current low back pain or sciatica and to examine which findings are related to age or previous back symptoms.

SUMMARY OF BACKGROUND INFORMATION

Previous studies of patients without low back pain have not explored the possible association of various MRI findings to past symptoms.

METHODS

We randomly selected an age-stratified sample of subjects without low back pain in the past 4 months from clinics at a VA hospital. We collected information on demographics, comorbidity, functional status, and quality of life. MR images were obtained using a standardized protocol through each of the five lumbar disc levels.

RESULTS

Of 148 subjects, 69 (46%) had never experienced low back pain. There were 123 subjects (83%) with moderate to severe desiccation of one or more discs, 95 (64%) with one or more bulging discs, and 83 (56%) with loss of disc height. Forty-eight subjects (32%) had at least one disc protrusion and 9 (6%) had one or more disc extrusions.

CONCLUSION

Many MR imaging findings have a high prevalence in subjects without low back pain. These findings are therefore of limited diagnostic use. The less common findings of moderate or severe central stenosis, root compression, and extrusions are likely to be diagnostically and clinically relevant.

Validating clustering for gene expression data

MOTIVATION

Many clustering algorithms have been proposed for the analysis of gene expression data, but little guidance is available to help choose among them. We provide a systematic framework for assessing the results of clustering algorithms. Clustering algorithms attempt to partition the genes into groups exhibiting similar patterns of variation in expression level. Our methodology is to apply a clustering algorithm to the data from all but one experimental condition. The remaining condition is used to assess the predictive power of the resulting clusters-meaningful clusters should exhibit less variation in the remaining condition than clusters formed by chance.

RESULTS

We successfully applied our methodology to compare six clustering algorithms on four gene expression data sets. We found our quantitative measures of cluster quality to be positively correlated with external standards of cluster quality.

Edge-guided boundary delineation in prostate ultrasound images

Accurate detection of prostate boundaries is required in many diagnostic and treatment procedures for prostate disease. In this paper, a new paradigm for guided edge delineation is described, which involves presenting automatically detected prostate edges as a visual guide to the observer, followed by manual editing. This approach enables robust delineation of the prostate boundaries, making it suitable for routine clinical use. The edge-detection algorithm is comprised of three stages. An algorithm called sticks is used to enhance contrast and at the same time reduce speckle in the transrectal ultrasound prostate image. The resulting image is further smoothed using an anisotropic diffusion filter. In the third stage, some basic prior knowledge of the prostate, such as shape and echo pattern, is used to detect the most probable edges describing the prostate. Finally, patient-specific anatomic information is integrated during manual linking of the detected edges. The algorithm was tested on 125 images from 16 patients. The performance of the algorithm was statistically evaluated by employing five expert observers. Based on this study, we found that consistency in prostate delineation increases when automatically detected edges are used as visual guide during outlining, while the accuracy of the detected edges was found to be at least as good as those of the human observers. The use of edge guidance for boundary delineation can also be extended to other applications in medical imaging where poor contrast in the images and the complexity in the anatomy limit the clinical usability of fully automatic edge-detection techniques.

Ghost imaging for targeting breast masses with MR imaging: a phantom study

RATIONALE AND OBJECTIVES

The purpose of this study was to test the accuracy of ghost magnetic resonance (MR) imaging for guiding core biopsies of simulated breast masses in a tissue phantom.

MATERIALS AND METHODS

A tissue MR phantom implanted with 20 grapes as targets was placed into an interventional breast MR coil. The locations of the centers of the targets were determined, recorded, and saved as ghost images. A nonmagnetic phantom needle was constructed to avoid imprecision secondary to magnetic field inhomogeneity and was used to determine the three-dimensional location of the needle tip in the center of each grape on the ghost image. Once the positions were determined, the true needle was placed and biopsy specimens were taken. The needle was inspected for the presence of pulp after each pass. Each grape was inspected to determine the location of the needle track in relation to the center of the grape. The duration of the procedure was recorded.

RESULTS

All grapes were hit by the biopsy needle, as demonstrated either by pulp within the needle or by a needle track within the grape. Seventeen of the 20 grapes (85%) were hit centrally. Three were sampled eccentrically, up to 5-6 mm from the center. Each biopsy took approximately 1 hour.

CONCLUSION

These results suggest that ghost imaging may be ideal for needle guidance in core biopsy or preoperative localization, as it extends the period of visibility after a bolus injection of contrast material. Additionally, using a phantom needle for localization appears to overcome imprecision due to magnetic field inhomogeneity of the needle.

Interactive 3-D registration of ultrasound and magnetic resonance images based on a magnetic position sensor

The use of stereotactic systems has been one of the main approaches for image-based guidance of the surgical tool within the brain. The main limitation of stereotactic systems is that they are based on preoperative images that might become outdated and invalid during the course of surgery. Ultrasound (US) is considered the most practical and cost-effective intraoperative imaging modality, but US images inherently have a low signal-to-noise ratio. Integrating intraoperative US with stereotactic systems has recently been attempted. In this paper, we present a new system for interactively registering two-dimensional US and three-dimensional magnetic resonance (MR) images. This registration is based on tracking the US probe with a dc magnetic position sensor. We have performed an extensive analysis of the errors of our system by using a custom-built phantom. The registration error between the MR and the position sensor space was found to have a mean value of 1.78 mm and a standard deviation of 0.18 mm. The registration error between US and MR space was dependent on the distance of the target point from the US probe face. For a 3.5-MHz phased one-dimensional array transducer and a depth of 6 cm, the mean value of the registration error was 2.00 mm and the standard deviation was 0.75 mm. The registered MR images were reconstructed using either zeroth-order or first-order interpolation. The ease of use and the interactive nature of our system (approximately 6.5 frames/s for 344 x 310 images and first-order interpolation on a Pentium II 450 MHz) demonstrates its potential to be used in the operating room.

Differential attenuation method for simultaneous estimation of activity and attenuation in multiemission single photon emission computed tomography

A penalized weighted least squares reconstruction algorithm is described that simultaneously estimates activity and attenuation distributions from emission sinogram data alone. This estimation technique is based on differential attenuation information and is applicable to any single photon emission computed tomography imaging isotope with emissions at two or more distinct energies, after accurate compensation for Compton scatter. A rotation-based forward projector is used to efficiently model photon attenuation at multiple emission energies, as well as distance-dependent spatial resolution. The algorithm was tested using simulated scatter-free 201T1 projection data from a single-slice numerical cardiac phantom with and without cold myocardial defects. Poisson noise was added to the projection data to mimic clinically realistic count densities. The activity estimates resulting from the proposed method had fewer artifacts and were substantially more accurate than images reconstructed with filtered backprojection without compensation for attenuation. Several techniques were employed to reduce the time required for the iterative routine to converge and to reduce the sensitivity of the solution to noise in the projection data. These included: (1) a preconditioning image variable transformation; (2) a coarse-to-fine grid initialization schedule; and (3) a convex hull image mask determined directly from the data. The combined effect of these techniques substantially reduced the compute time required for the reconstruction.

Analysis of defibrillation efficacy from myocardial voltage gradients with finite element modeling

Increasing defibrillation efficacy by lowering the defibrillation threshold (DFT) is an important goal in positioning implantable cardioverter-defibrillator electrodes. Clinically, the DFT is difficult to estimate noninvasively. It has been suggested that the DFT relates to the myocardial voltage gradient distribution, but this relation has not been quantitatively demonstrated. We analyzed the relation between the experimentally measured DFT's and the simulated myocardial voltage gradients provided by finite element modeling. We performed a series of experiments in 11 pigs to measure the DFT's, and created and solved three-dimensional subject-specific finite element models to assess the correlation between the computed myocardial voltage gradient histograms and the DFT's. Our data show a statistically significant correlation between the DFT and the left ventricular voltage gradient distribution, with the septal region being more significant (correlation coefficient of 0.74) than other myocardial regions. The correlation between the DFT and the right ventricular and the atrial voltage gradient, on the other hand, is not significant.

MR contrast media in neuroimaging: a critical review of the literature

BACKGROUND AND PURPOSE

MR contrast media are commonly used but do not have evidence-based guidelines for their application. This investigation seeks to define specific methodological problems in the MR contrast media literature and to suggest guidelines for an improved study design.

METHODS

To evaluate the reported clinical efficacy of MR contrast media in neuroimaging, we performed a critical review of the literature. From 728 clinical studies retrieved via MEDLINE, we identified 108 articles that evaluated contrast media efficacy for a minimum of 20 patients per study. The articles were randomly assigned to four readers (a fifth reader reviewed all of the articles) who were blinded to article titles, authors, institutions, and journals of publication. The readers applied objective, well-established methodological criteria to assign each article a rating of A, B, C, or D.

RESULTS

One hundred one of 108 articles received a D rating, six received a C rating, and one received a B rating. In general, the Methods sections of the evaluated articles did not contain details that would allow the reader to calculate reliable measures of diagnostic accuracy, such as sensitivity and specificity. Specifically, a common problem was failure to establish and uniformly apply an acceptable standard of reference. In addition, images were not always interpreted independently from the reference standard. Radiologists and clinicians need to determine the applicability of any published study to their own practices. Unfortunately, the studies we reviewed commonly lacked clear descriptions of patient demographics, the spectrum of symptomatology, and the procedure for assembling the study cohort. Finally, small sample sizes with inadequate controls were presented in almost all of the articles.

CONCLUSION

Although MR contrast media are widely used and play an essential role in lesion detection and confidence of interpretation, no rigorous studies exist to establish valid sensitivity and specificity estimates for their application. On the basis of this review, we herein describe basic methods to document improvements in technology. Such studies are essential to devise measures of diagnostic accuracy, which can form the basis for further studies that will assess diagnostic and therapeutic impact and, ultimately, patient outcomes.

Geometric effects on resistivity measurements with four-electrode probes in isotropic and anisotropic tissues

We studied via computer simulation the effects of electrode diameter, electrode length, interelectrode spacing, and tissue size on the accuracy of measured tissue resistivities and anisotropy ratios obtained with the widely used four-electrode technique. Such measurements commonly assume an ideal situation in which the four electrodes are infinitesimally small and the tissue is semi-infinite. Our study shows that these geometric factors can significantly affect measured resistivities, particularly for anisotropic tissues. The measured anisotropy ratio is decreased by either 1) increasing the electrode diameter or length relative to the interelectrode spacing of the probe or 2) decreasing tissue size. We have provided an equation for estimating errors in the measured anisotropy ratio from the parameters of electrode and tissue geometries. The simulation findings are supported by our in vitro experimental results.

Rapid MR imaging versus plain radiography in patients with low back pain: initial results of a randomized study

PURPOSE

To demonstrate the feasibility of a randomized trial to compare rapid magnetic resonance (MR) imaging with plain radiography as the initial imaging study in patients with low back pain, to test measures of the decision-making process and patient outcomes, and to offer a model for using randomized clinical trials to evaluate diagnostic tests.

MATERIALS AND METHODS

The authors randomly selected 62 patients with low back pain to undergo either rapid MR imaging or plain radiography. The authors measured functional status, satisfaction, and general health status at baseline and at 3 months. The modified Roland scale was the primary outcome measure. In addition, the authors examined diagnostic and therapeutic decision making and resources used by each group.

RESULTS

There were no statistically significant differences between the two patient groups with respect to outcome (Roland score: MR imaging = 12.5, radiography = 12.1). MR imaging provided more useful information to clinicians and resulted in greater patient reassurance.

CONCLUSION

Randomly selecting patients to undergo imaging examinations and measuring outcomes is feasible; however, a larger, multicenter study is necessary to determine whether rapid MR imaging is a cost-effective replacement for plain radiography in patients with low back pain.

Sensitivity of transvenous defibrillation models to adaptive mesh density and resolution: the potential for interactive solution times

The voltage gradients induced in ventricular myocardium by an electric shock have been shown to correlate to the probability of the shock producing a successful defibrillation. Finite element modeling is one method for computing these voltage gradients, although the meshing of complex biomedical domains is difficult on a patient-specific basis. We recently described an adaptive algorithm that automates the generation of finite element meshes for complex 3-D domains from bitmapped images. This article examines the sensitivity of the computed distribution of ventricular voltage gradients to the resolution of the images and to the adapted density of the mesh. The results allow us to establish an adaptation stopping criterion and a minimum input image resolution for modeling transvenous defibrillation. The sensitivity to adapted mesh density was analyzed by comparing voltage gradient histograms from successively finer meshes to histograms from a uniform mesh at the maximum possible density. Comparisons were made using the Kolmogorov-Smirnov test with the number of samples required to detect a 5% difference in the histograms at the 0.05 significance level. Adaptation to a global current density error estimate of 5% or less was required in order to achieve acceptance of the null hypothesis that the distributions were the same in all cases. Defibrillation efficacy, however, is predicted from the voltage gradient in the first quartile, and the results suggest that this region of the cumulative histogram converges faster during mesh adaptation than the histogram as a whole. We also compared histograms from models generated from successively finer input images. The histogram of each model was compared with the histogram obtained from the finest possible resolution. In all cases, the null hypothesis of no difference was accepted at resolutions of 2.3 x 2.3 x 3.0 mm. The average time required to build and adapt models to a 5% accuracy at the first quartile at this resolution was 1.8 min. on a common workstation. We believe that this demonstrates a potential for the eventual synthesis of finite element computations into interactive electrode placement tools on a subject-specific basis.

Energy-based scatter corrections for scintillation camera images of iodine-131

The use of high-dose 131I antibody therapy requires accurate measurement of normal tissue uptake to optimize the therapeutic dose. One of the factors limiting the accuracy of such measurements is scatter and collimator septal penetration. This study evaluated two classes of energy-based scatter corrections for quantitative 131I imaging: window-based and spectrum-fitting.

METHODS

The window-based approaches estimate scatter from data in two or three energy windows placed on either side of the 364-keV photopeak using empirical weighting factors. A set of images from spheres in an elliptical phantom were used to evaluate each of the window-based corrections. The spectrum-fitting technique estimates detected scatter at each pixel by fitting the observed energy spectrum with a function that models the photopeak and scatter, and which incorporates the response function of the camera. This technique was evaluated using a set of Rollo phantom images.

RESULTS

All of the window-based methods performed significantly better than a single photopeak window (338-389 keV), but the weighting factors were found to depend on the object being imaged. For images contaminated with scatter, the spectrum-fitting method significantly improved quantitation over photopeak windowing. Little difference, however, between any of the methods was observed for images containing small amounts of scatter.

CONCLUSION

Most clinical 131I imaging protocols will benefit from qualitative and quantitative improvements provided by the spectrum-fitting scatter correction. The technique offers the practical advantage that it does not require phantom-based calibrations. Finally, our results suggest that septal penetration and scatter in the collimator and other detector-head components are important sources of error in quantitative 131I images.

Automatic fetal head measurements from sonographic images

RATIONALE AND OBJECTIVES

We designed an image processing technique to automatically measure the biparietal diameter (BPD) and head circumference (HC) from prenatal sonograms. We evaluated the performance of the algorithm by comparing the resulting measurements with those made by experienced sonographers.

METHODS

Thirty-five digitized sonograms of the fetal head were obtained during routine imaging. The BPD and HC were automatically computed by detecting the inner and outer boundaries of the fetal skull using the computer vision technique known as the "active contour model." Six experienced sonographers also measured the BPD and HC on these images.

RESULTS

The algorithm failed to locate the boundaries in two of the 35 cases. For the remaining cases, the mean absolute difference between the automated measurements and the average of the six observers was 1.4% for BPD and 2.9% for HC. The correlations were .999 for the BPD and .994 for the HC. The computer's measurements were no different from the six observers' measurements than the observers' measurements were from one another.

CONCLUSION

The tested algorithm effectively and accurately measures BPD and HC automatically. We are currently in the process of integrating this algorithm into an ultrasound machine.

Interreader reliability for a new classification of lumbar disk disease

RATIONALE AND OBJECTIVES

The nomenclature that divides disk herniations into protrusions and extrusions may increase the specificity of magnetic resonance (MR) imaging for clinically important lesions. Our goal was to determine this terminology's interreader reliability.

METHODS

Three readers who were unaware of patients' histories independently read MR images of 34 consecutive patients with back pain. Readers classified disks at the lowest three lumbar levels as normal, bulging, protruded, or extruded. Kappa and weighted kappa values were the primary measures of agreement.

RESULTS

Weighted kappa values showed fair-to-moderate agreement. Kappas for the dichotomous decision of extrusion present or absent were more variable, ranging from 0 to .78. Major disagreements (greater than a single category) occurred with 6.2% of all comparisons and in 10 of 34 volunteers; five involved extrusions.

CONCLUSION

Overall, readers achieved moderate agreement for this new nomenclature. However, agreement for the presence or absence of an extrusion was less reliable.

Scatter and attenuation correction for 111In based on energy spectrum fitting

A combined scatter and attenuation correction that does not require a transmission scan is proposed for 111In imaging. Estimates of the unscattered intensity at both 171 and 245 keV are obtained by fitting the observed energy spectrum at each pixel or region of interest using the measured scatter-free spectrum and a simple model for scatter. The scatter model for the 171 keV peak accounts for scatter contributed by both the 171 and 245 keV emissions. After correcting for scatter, the attenuation is estimated from the observed ratio of photopeak intensities using the known difference in attenuation at the two emission energies and a model based on a point source in water. Accurate scatter correction is a prerequisite for the success of this method because scatter from the higher energy emission will otherwise contaminate the lower photopeak. This differential attenuation method (DAM) of estimating attenuation is demonstrated and calibrated using a series of point source measurements with a wedge-shaped attenuator. The observed absolute and differential attenuation are in good agreement with the narrow-beam linear attenuation coefficients for water. Estimates of precision suggest a depth resolution of 1.0-2.5 cm for realistic count densities over the clinically relevant depth range (0-25 cm). The accuracy of DAM in a more realistic attenuation environment is assessed using a hot sphere inside the anthropomorphic data spectrum torso phantom viewed from several angles (with differing attenuation). Finally, the potential of DAM for SPECT attenuation correction was investigated by computer simulation using the SIMSET Monte Carlo software. Preliminary results based on measured planar data and simulated SPECT data indicate that DAM can improve the quality and quantitative accuracy of 111In images. In one SPECT simulation study, the average error in tumor to soft-tissue ratios was reduced from 32% for uncorrected data to 8% for data corrected with DAM. However, the technique is susceptible to significant noise amplification and can cause substantial streak artifacts in low-count SPECT studies if sufficient smoothing of the depth estimates is not performed.

Intraoperative ultrasound for monitoring anterior cervical vertebrectomy. Technical note

The authors describe the use of intraoperative ultrasonography with a small high-frequency (15 mHz) probe for evaluation of the extent of lateral bone removal during anterior cervical vertebrectomy. The relationship of the bone resection margins to the lateral aspect of the spinal cord was visualized. Postoperative computerized tomography scans revealed the extent of bone removal to be similar to that demonstrated by ultrasound. Intraoperative ultrasonography may be useful during anterior cervical surgery to assure adequate decompression of the spinal canal and spinal cord.

Ulnar nerve entrapment at the elbow: correlation of magnetic resonance imaging, clinical, electrodiagnostic, and intraoperative findings

The diagnosis of ulnar nerve entrapment at the elbow has relied primarily on clinical and electrodiagnostic findings. Recently, magnetic resonance imaging (MRI) has been used in the evaluation of peripheral nerve entrapment disorders to document signal and configuration changes in nerves. We performed a prospective study on a population of 31 elbows in 27 patients with ulnar nerve entrapment at the elbow. The study correlated MRI findings with clinical, electrodiagnostic, and operative findings. A control population consisting of 10 asymptomatic subjects also was studied by MRI. Electrodiagnostic evaluation confirmed ulnar neuropathy in 24 (77%) elbows of the 31, with localization to the elbow region in 21 (68%). MRI, using a short tau inversion recovery sequence, demonstrated increased signal of the ulnar nerve in 30 (97%) elbows of the 31 and enlargement of the ulnar nerve in 23 (74%). No MRI abnormalities were found in the control population. MRI signal increase of the ulnar nerve occurred an average of 27 mm proximal to the distal humerus and extended distally an average of 4 mm below the distal humerus. The mean total length of increased ulnar nerve signal was 34 mm. Ulnar nerve enlargement occurred an average of 19 mm proximal to the distal humerus and extended distally an average of 8 mm above the distal humerus. The mean total length of ulnar nerve enlargement was 12 mm. The 12 patients who underwent a surgical procedure for ulnar nerve entrapment were found to have ulnar nerve compression, with 9 (75%) having excellent and 3 (25%) having good postoperative results. In this study, MRI was both sensitive and specific in diagnosing ulnar nerve entrapment at the elbow as defined by clinical, electrodiagnostic, and operative findings.

An efficient tissue classifier for building patient-specific finite element models from X-ray CT images

We developed an efficient semiautomatic tissue classifier for X-ray computed tomography (CT) images which can be used to build patient- or animal-specific finite element (FE) models for bioelectric studies. The classifier uses a gray scale histogram for each tissue type and three-dimensional (3-D) neighborhood information. A total of 537 CT images from four animals (pigs) were classified with an average accuracy of 96.5% compared to manual classification by a radiologist. The use of 3-D, as opposed to 2-D, information reduced the error rate by 78%. Models generated using minimal or full manual editing yielded substantially identical voltage profiles. For the purpose of calculating voltage gradients or current densities in specific tissues, such as the myocardium, the appropriate slices need to be fully edited, however. Our classifier offers an approach to building FE models from image information with a level of manual effort that can be adjusted to the need of the application.

Magnetic resonance neurography for cervical radiculopathy: a preliminary report

Magnetic resonance neurography was used to directly image cervical spinal nerves in patients with clinical and radiographic evidence of cervical radiculopathy. A magnetic resonance imaging phased-array coil system was used to obtain high-resolution coronal T1-weighted spin echo, coronal/axial T2-weighted fast spin echo with fat saturation, and coronal/axial fast short tau inversion recovery weighted images of the cervical spine and spinal nerves. Three patients with neck and upper extremity pain and one asymptomatic volunteer were studied. The T2-weighted and the fast short tau inversion recovery images demonstrated markedly increased signal in the proximal portion of the affected spinal nerves. In two patients, contrast-to-noise measurements of the affected spinal nerves showed a markedly increased intensity compared with that of the noninvolved spinal nerves. Our findings demonstrate that phased-array coils used in conjunction with magnetic resonance neurography sequences can detect signal abnormalities within compressed cervical spinal nerves in patients with corresponding radicular symptoms and findings. This technique may prove to be helpful in evaluating patients with multilevel disc and/or spondylotic disease of the cervical spine.

Object-free adaptive meshing in highly heterogeneous 3-D domains

Traditional approaches to the generation of finite element meshes are well suited for modeling the homogeneous or mildly heterogeneous domains presented by man-made objects, but are difficult to apply to the complex 3-D domains encountered in some biomedical applications. In this paper, we describe an adaptive algorithm that automates the modeling of these domains. The method differs from traditional approaches in that no explicit description is required of the boundaries between objects with dissimilar material properties. The algorithm uses images of the tissue class to build irregular meshes, and continuity is enforced by constraining the solution at irregular nodes. Local estimates of the error in the flux solution are used to refine the mesh. For an analytic problem with a rapid change along a spherical boundary, the adaptive method converges to a 1% voltage error using 25% of the degrees of freedom required by a uniform refinement, and to a 5% voltage gradient error using 11% of the degrees of freedom. For a defibrillation model in a pig thorax, the voltage gradient solution in the ventricles of the heart converges to within 5% of a uniform mesh solution using less than 8% of the memory and processing resources required by a uniform mesh, which has been the only practical alternative for subject-specific modeling.

A multiple active contour model for cardiac boundary detection on echocardiographic sequences

Tracing of left-ventricular epicardial and endocardial borders on echocardiographic sequences is essential for quantification of cardiac function. The authors designed a method based on an extension of active contour models to detect both epicardial and endocardial borders on short-axis cardiac sequences spanning the entire cardiac cycle. They validated the results by comparing the computer-generated boundaries to the boundaries manually outlined by four expert observers on 44 clinical data sets. The mean boundary distance between the computer-generated boundaries and the manually outlined boundaries was 2.80 mm (sigma=1.28 mm) for the epicardium and 3.61 (sigma=1.68 mm) for the endocardium. These distances were comparable to interobserver distances, which had a mean of 3.79 mm (sigma=1.53 mm) for epicardial borders and 2.67 mm (sigma=0.88 mm) for endocardial borders. The correlation coefficient between the areas enclosed by the computer-generated boundaries and the average manually outlined boundaries was 0.95 for epicardium and 0.91 for endocardium. The algorithm is fairly insensitive to the choice of the initial curve. Thus, the authors have developed an effective and robust algorithm to extract left-ventricular boundaries from echocardiographic sequences.

Multiwindow scatter correction techniques in single-photon imaging

We studied the performance of linear scatter correction methods for single-photon imaging with Tc-99m and Tl-201, using a numerical model of the Rollo phantom and measurements with a gamma camera modified to record position and energy information in list mode form. We compared the performance of these methods to per-image optimized linear methods and to locally adaptive linear methods, and developed estimates of the limits on accuracy of scatter correction imposed by the presence of Poisson noise. For both Tc-99m and Tl-201 imaging at a fixed depth, particularly at low count rates, the performance of dual-window methods, or of adaptive methods, is near the best possible for linear methods. Smoothing of the scatter estimate results in minor improvement for Tl-201. Substantial gaps between the performance of any of these linear methods and the limits imposed by Poisson noise remain and are due primarily to bias, with the gap for Tl-201 being larger than that for Tc-99m.

Carpal tunnel syndrome: correlation of magnetic resonance imaging, clinical, electrodiagnostic, and intraoperative findings

We undertook a prospective study of 43 wrists in 32 patients who had been clinically diagnosed as having carpal tunnel syndrome (study group) and 5 wrists in people who had no symptoms (control group), correlating the clinical, electrodiagnostic, intraoperative, and magnetic resonance imaging (MRI) findings. MRI of the carpal tunnel and thenar eminence was performed, using coronal and axial T1- and T2-weighted, proton density, and short tau inversion recovery sequences. Abnormalities of the median nerve, as revealed by MRI, were found in 43 of 43 (100%) wrists in the study group and in 0 of 5 (0%) wrists in the control group. Increased signal of the median nerve was seen in 41 of 43 (95%) wrists, increased signal of the flexor tendon sheath in 41 of 43 (95%), volar bowing of the flexor retinaculum in 39 of 43 (91%), increased distance between the flexor tendons in 37 of 43 (86%), and abnormal nerve configuration in 28 of 43 (65%). Increased short tau inversion recovery signal of the thenar muscles was found in 5 of 43 (12%) wrists, all of which had undergone severe denervation changes, as revealed by electromyography. Operative release was performed for 27 of 43 (63%) wrists, and follow-up was obtained for 42 of 43 (98%). A good or excellent postoperative outcome resulted for 20 of 27 (74%) patients, a fair outcome for 2 of 27 (7%), and a poor outcome for 4 of 27 (15%), and 1 of 27 (4%) patients was lost to follow-up. For patients undergoing carpal tunnel release whose MRI revealed an abnormal nerve configuration, the outcome was improved, with good or excellent results in 15 of 18 (83%) patients. No association with outcome was seen with median nerve or flexor tendon signal changes, increased interspace between the flexor tendons, or flexor retinaculum bowing. Our results indicate that MRI is a sensitive diagnostic modality that can demonstrate signal and configurational abnormalities of the median nerve in patients diagnosed with carpal tunnel syndrome. Increased signal of the thenar muscles, as revealed by MRI, using short tau inversion recovery sequences, occurs only in muscles that have undergone severe denervation changes, as revealed by electromyography.

Similarities in degenerative findings on magnetic resonance images of the lumbar spines of identical twins

Although the etiology of most degenerative changes in the lumbar spine is unclear, genetic factors may play an important role. To investigate this link, we reviewed magnetic resonance images of the lumbar spines of identical twins to assess the degree of similarities in degenerative findings in the discs. Observers who were blinded to twinship evaluated sagittal T1-weighted and T2-weighted magnetic resonance images of the lumbar spines of forty male identical twins (twenty pairs) with respect to changes in the end plates, desiccation of the discs, bulging or herniated discs, and decrease in the height of the disc space. Similarities between co-twins were significantly greater than would be expected by chance. Whereas smoking status and age explained 0 to 15 per cent of the variability in the various degenerative findings in the discs, 26 to 72 per cent of the variability was explained with the addition of a variable representing co-twin status. These findings are compatible with a marked genetic influence and warrant further investigation.

Persistent feeding arteries to angiographically completely embolized arteriovenous malformation demonstrated by intraoperative color-flow Doppler testing: report of two cases

Two cases of arteriovenous malformation (AVM) treated preoperatively by endovascular embolization that appeared to be completely occluded after embolization are presented. Seven and 12 days later, respectively, these patients underwent resection of their AVM. At the time of surgery, intraoperative color-flow Doppler studies revealed persistent feeding arteries to an active residual nidus of the AVM. The significance of this finding is presented in light of previous published literature.

Predicting cardiothoracic voltages during high energy shocks: methodology and comparison of experimental to finite element model data

Finite element modeling has been used as a method to investigate the voltage distribution within the thorax during high energy shocks. However, there have been few quantitative methods developed to assess how well the calculations derived from the models correspond to measured voltages. In this paper, we present a methodology for recording thoracic voltages and the results of comparisons of these voltages to those predicted by finite element models. We constructed detailed 3-D subject-specific thorax models of six pigs based on their individual CT images. The models were correlated with the results of experiments conducted on the animals to measure the voltage distribution in the thorax at 52 locations during synchronized high energy shocks. One transthoracic and two transvenous electrode configurations were used in the study. The measured voltage values were compared to the model predictions resulting in a correlation coefficient of 0.927 +/- 0.036 (average +/- standard deviation) and a relative rms error of 22.13 +/- 5.99%. The model predictions of voltage gradient within the myocardium were also examined revealing differences in the percent of the myocardium above a threshold value for various electrode configurations and variability between individual animals. This variability reinforces the potential benefit of patient-specific modeling.

Quality control of cathode-ray tube monitors for medical imaging using a simple photometer

As computer monitors are used more in medical imaging and the use of picture archiving and communication system workstations with multiple monitors is increasing, quality control protocols become necessary to track subtle variations in performance characteristics. Several tests based on previously published work were applied to 10 monitors of three different types over a period of 5 months. Each test is explained, and the results are shown. For example, without corrective adjustments, 2 monitors from the same workstation showed a small but steady decline in maximum luminance of 8.1% and 7.6% over the course of 11 weeks that was not perceptible. From this experience, we took the first step toward developing a practical and useful quality control protocol. The proposed protocol requires only a photometer and the ability to generate the Society of Motion Picture and Television Engineers (SMPTE) test pattern, and takes approximately 5 minutes per monitor per week to gather data.

Computational studies of transthoracic and transvenous defibrillation in a detailed 3-D human thorax model

A method for constructing and solving detailed patient-specific 3-D finite element models of the human thorax is presented for use in defibrillation studies. The method utilizes the patient's own X-ray CT scan and a simplified meshing scheme to quickly and efficiently generate a model typically composed of approximately 400,000 elements. A parameter sensitivity study on one human thorax model to examine the effects of variation in assigned tissue resistivity values, level of anatomical detail included in the model, and number of CT slices used to produce the model is presented. Of the seven tissue types examined, the average left ventricular (LV) myocardial voltage gradient was most sensitive to the values of myocardial and blood resistivity. Incorrectly simplifying the model, for example modeling the heart as a homogeneous structure by ignoring the blood in the chambers, caused the average LV myocardial voltage gradient to increase by 12%. The sensitivity of the model to variations in electrode size and position was also examined. Small changes (< 2.0 cm) in electrode position caused average LV myocardial voltage gradient values to increase by up to 12%. We conclude that patient-specific 3-D finite element modeling of human thoracic electric fields is feasible and may reduce the empiric approach to insertion of implantable defibrillators and improve transthoracic defibrillation techniques.

Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury

The evaluation of peripheral nerve disorders has traditionally relied on a clinical history, physical examination, and electrodiagnostic studies. Recent studies have used magnetic resonance imaging (MRI) to evaluate a variety of both nerve and muscle disorders. In this article, we describe the use of MRI, using short-tau inversion recovery (STIR) sequences, to evaluate muscle signal characteristics in a variety of peripheral nerve disorders. A total of 32 patients were studied, and 12 representative cases are discussed in detail. Increased STIR signal in muscle was seen in cases of severe axonotmetic injuries involving the transection of axons producing severe denervation changes on electromyography. The increased STIR signal in denervated muscles was seen as early as 4 days after the onset of clinical symptoms, which is significantly earlier than changes detected on electromyography. The MRI signal changes were reversible when the recovery of motor function occurred as a result of further muscle innervation. In cases of neurapraxic nerve injuries, characterized by conduction block without axonal loss, the STIR signal in muscle was normal. These findings show that MRI using STIR sequences provides a panoramic visual representation of denervated muscles useful in localizing and grading the severity of peripheral nerve injury secondary to either disease or trauma. MRI using STIR sequences may therefore play an important role in the prediction of clinical outcome and the formulation of appropriate therapy early after peripheral nerve injury.

The clinical efficacy of magnetic resonance imaging in neuroimaging

PURPOSE

To assess the clinical efficacy of magnetic resonance imaging (MRI) for neuroimaging and to provide guidelines for clinical practice.

STUDY SELECTION

After a comprehensive literature search, studies of the diagnostic accuracy of MRI alone or compared with other tests and of any impact on therapeutic choices or patient outcomes were reviewed by independent readers, followed by discussion to reach consensus conclusions.

DATA EXTRACTION

Of 3125 citations retrieved, 156 studies with original data could be rated according to methodologic criteria for study design. One article contributed grade A quality information about diagnostic accuracy, 28 were graded B or C, and 113 were graded D. One randomized trial and 2 comparison studies contributed grade B or C information about the impact on therapeutic choices. Only 2 studies surveyed health status before and after magnetic resonance scanning.

RESULTS

For most abnormalities, the sensitivity of MRI is equal to or better than competing technologies. Magnetic resonance imaging shows greater contrast and detail than computed tomography (CT) but also shows more clinically silent abnormalities or incidental findings. A few studies found a modest impact on therapeutic choices but no impact on quality of life or disability. Costs for MRI are high. Computed tomography is sufficient for initial diagnosis of most mass lesions or intracranial hemorrhages requiring immediate intervention. Magnetic resonance imaging is more accurate in the temporal lobes, posterior fossa, brainstem, and spinal cord. For lumbar radiculopathy, MRI and plain spinal CT are as accurate as post-myelographic CT and are less invasive. The role of magnetic resonance angiography for carotid artery stenosis is being studied.

CONCLUSIONS

Although suggestions for appropriate use of MRI in clinical practice can be made, the supporting evidence in published studies is weak. Firm guidelines for appropriate use of MRI should be based on further clinical research using more rigorous methods.

Measurement of tumor resection volumes from computerized images. Technical note

The authors describe a method for quantitation of the area and volume of the resection cavity in patients who have undergone surgery for brain tumors. Using a slide scanner and Image 1.27, a public domain program for the Apple Macintosh II computer, computerized tomography scans and magnetic resonance images can be digitized and analyzed for a particular region of interest, such as the area and volume of tumor on preoperative and postresection scans. Phantom scans were used to analyze the accuracy of the program and the program users. User error was estimated at 2%, program error was 4.5%. This methodology is proposed as a means of retrospectively calculating the extent of tumor resection.

Diagnosis of lumbar spinal stenosis in adults: a metaanalysis of the accuracy of CT, MR, and myelography

We undertook a literature synthesis of CT, MR, and myelographic studies to evaluate what is known about the diagnostic accuracy of these imaging tests for the diagnosis of lumbar spinal stenosis in adults without prior surgery. From 116 possibly relevant studies, we reviewed 14 articles that included cases of spinal stenosis with a reference standard other than the imaging tests of interest. Of the studies we reviewed, two involved only MR, nine only CT, and three used both; six studies included myelography. Rating categories of A, B, C, or D were assigned for the quality of research methods used to estimate diagnostic accuracy. All studies received either a C or D rating. Common methodologic problems were failure to assemble a representative cohort for study, small sample size, and failure to maintain independence between image readings and reference standards. Sensitivity ranged from 0.81 to 0.97 for MR, from 0.70 to 1.0 for CT, and from 0.67 to 0.78 myelography. Studies varied greatly in case selection, definition of test and disease categories, and geographic locale, so no pooled estimates could be derived. In asymptomatic patients, abnormal findings appeared on CT or MR in 4-28% of cases and were more common in the elderly. Published studies of the value of CT and MR for the diagnosis of lumbar stenosis lack methodologic rigor and do not permit strong conclusions about the relative diagnostic accuracies of these procedures. For the present, the choice between MR or CT depends on issues such as costs, reimbursements, access to equipment, skill of radiologists, and patient safety. Better studies will be needed to document claims for improvements in imaging accuracy as MR technologies evolve. These studies should emphasize larger sample sizes, more attention to research designs that avoid methodologic biases, and the contribution of imaging diagnoses to ultimate clinical outcome.

Hardware and software requirements for a picture archiving and communication system's diagnostic workstations

Electronic systems (picture archiving and communications systems [PACS]) for image and multimedia data distribution, archiving, and transmission, represent the future of radiology. The workstation is the point of contact between a PACS and the radiologist or referring physician. Therefore, the acceptance of PACS is highly dependent on workstation functionality and performance. This paper, based on our experience in evaluating commercial workstations and on a review of recent literature, describes hardware and software requirements for diagnostic workstations that could be used for making primary diagnoses in a radiology department. Requirements for PACS workstations for use in referring clinics are also briefly described. These workstations must be able to handle the large volume of images to be viewed efficiently, add new functionality to improve the productivity of physicians, technologists, and other health care providers, and provide enough flexibility to allow the electronic systems to grow as medical imaging technology evolves.

The use of importance sampling techniques to improve the efficiency of photon tracking in emission tomography simulations

Monte Carlo simulations are widely used to study the transmission and scattering of gamma rays. Use of this method for simulations of emission tomographs suffers from geometric inefficiency resulting from the low solid angle of acceptance of most tomograph designs. We have applied several importance sampling techniques--stratification, forced detection, and weight control through Russian roulette and splitting--to increase the computational efficiency of the Monte Carlo method 10- to 300-fold. A description of these techniques, their validation, and sample performance results are given. Application of importance sampling methods makes it practical to study photon scattering in heterogeneous attenuators on workstations and minicomputers.

Partial volume tissue classification of multichannel magnetic resonance images-a mixel model

A single volume element (voxel) in a medical image may be composed of a mixture of multiple tissue types. The authors call voxels which contain multiple tissue classes mixels. A statistical mixel image model based on Markov random field (MRF) theory and an algorithm for the classification of mixels are presented. The authors concentrate on the classification of multichannel magnetic resonance (MR) images of the brain although the algorithm has other applications. The authors also present a method for compensating for the gray-level variation of MR images between different slices, which is primarily caused by the inhomogeneity of the RF field produced by the imaging coil.

Resampling estimates of precision in emission tomography

Methods for estimating the regional variance in emission tomography images which arise from the Poisson nature of the raw data are discussed. The methods are based on the bootstrap and jackknife methods of statistical resampling theory. The bootstrap is implemented in time-of-flight PET (positron emission tomography); the same techniques can be applied to non-time-of-flight PET and SPECT (single-photon-emission computed tomography). The estimates are validated by comparing them to those obtained by repetition of emission scans, using data from a time-of-flight positron emission tomograph. Simple expressions for the accuracy of the estimates are given. The present approach is computationally feasible and can be applied to any reconstruction technique as long as the data are acquired in a raw, uncorrected form.

Superficial- and deep-tissue temperature increases in anesthetized dogs during exposure to high specific absorption rates in a 1.5-T MR imager

Superficial- and deep-tissue heating was measured in five dogs during high-specific-absorption-rate radiofrequency (RF) irradiation to see whether significant temperature changes could be produced by a 1.5-T clinical magnetic resonance imager. The RF power output employed was 6.3 times that required for routine imaging. Temperature probes were placed in both deep and superficial tissues, and temperatures were recorded before, during, and after exposure. In each dog, there was a linear temperature increase of several degrees during RF exposure; the maximal average change was 4.6 degrees C in the urinary bladder. The temperature increase was slightly greater in deep tissues than in superficial tissues. The calculated specific absorption rate, based on the temperature change, averaged 7.9 W/kg for all five dogs. These findings argue for continued caution in the design and operation of imagers capable of high specific absorption rates, particularly when they are used for imaging infants or patients with altered thermoregulatory capability.

Complex fractures of the proximal humerus: role of CT in treatment

The authors reviewed the computed tomography (CT) scans, plain radiographs, and subsequent treatment of 17 patients with complex proximal humeral fractures. CT scans and radiographs were compared in the demonstration of fracture lines, displacement of fracture fragments, rotation of fragments relative to their normal positions, and status of the head and articular surface of the humerus. The impact of CT findings on the decision to treat with surgery versus closed reduction and on the choice of surgical procedure was assessed. Surgery was not performed in nine patients because CT scans showed no significant displacement of fragments previously judged displaced or "indeterminate" on radiographs. Surgery was performed in eight patients; CT demonstrated significant abnormalities not definitely shown with radiography. In six of these eight patients, CT scans demonstrated unsuspected abnormalities that directed the choice of surgical procedure. CT scans provide clinically useful information for the treatment of complex proximal humeral fractures when radiographs provide inadequate or indefinite information.