Imaging

Two imaging modalities independently predicted progressive joint erosion in patients with early rheumatoid arthritis as a group, but the tests performed only slightly better than did clinical and demographic variables for individual prognoses, judging from findings of a 1-year study published in Annals of the Rheumatic Diseases.

Among 79 patients who completed quarterly follow-ups with a battery of imaging and nonimaging measures, 53 (67%) showed erosive progression. On a group level, results of ultrasound grey-scale (USGS) findings of inflammation and magnetic resonance images showing bone marrow edema each were significant predictors that erosive disease progression would be detected by MRI.

Patients with USGS inflammation in the dominant wrist were twice as likely to develop erosive progression and patients with MRI bone marrow edema in the dominant wrist were 28% more likely to develop erosive progression compared with patients without these imaging findings, Dr. Pernille Bøyesen and associates reported (Ann. Rheum. Dis. 2011;70:176-9 [doi: 10.1136/ard.2009.126953]).

On an individual level, however, the imaging modalities were not dramatically better than clinical and demographic variables to predict erosive progression of early RA. USGS inflammation, synovitis on MRI, and bone marrow edema that was visible on MRI performed slightly better than using antibody to cyclic citrullinated protein, rheumatoid factor, and disease activity score based on a 28-joint count, reported Dr. Bøyesen of Diakonhjemmet Hospital, Oslo.

USGS inflammation was the best of 12 imaging modalities and measures of disease severity in identifying patients at risk of developing erosions on MRI, with a sensitivity of 78%, a specificity of 55%, a positive likelihood ration of 1.75, and accuracy of 70%.

Future studies are needed using composite indices of disease progression, including modern imaging modalities, to determine their value as predictors of an individual patient’s likelihood of disease progression, the investigators concluded.

The study appears to be the first to confirm previous data suggesting that measuring inflammation by ultrasound can help predict subsequent joint damage, they noted. The findings also confirmed previous data identifying bone marrow edema on MRI as an independent predictor of joint damage.

Other imaging modalities in the study included digital x-ray radiogrammetry (DXR) of cortical bone mineral density in the hand. Results showed only trends toward higher levels of synovitis on MRI and bone density loss on DXR in patients with erosive progression of disease at 1 year. The findings did not support previous studies that reported cortical hand bone mineral density to be independently predictive of erosive progression, perhaps due to the small size of the study, Dr. Bøyesen added.

Given the comprehensive comparison of imaging modalities in the study, however, 84 patients can be considered a large number, the investigators noted.

The multivariate analyses controlled for the effects of age, sex, and other independent variables.

The investigators declared having no conflicts of interest. The study was funded by the Eastern Norway Regional Health Authority, the Research Council of Norway, the Norwegian Rheumatism Association, the Norwegian Women Public Health Association, the Grethe Harbitz Legacy, and the Marie and Else Mustad Legacy.

Two imaging modalities independently predicted progressive joint erosion in patients with early rheumatoid arthritis as a group, but the tests performed only slightly better than did clinical and demographic variables for individual prognoses, judging from findings of a 1-year study published in Annals of the Rheumatic Diseases.

Among 79 patients who completed quarterly follow-ups with a battery of imaging and nonimaging measures, 53 (67%) showed erosive progression. On a group level, results of ultrasound grey-scale (USGS) findings of inflammation and magnetic resonance images showing bone marrow edema each were significant predictors that erosive disease progression would be detected by MRI.

Patients with USGS inflammation in the dominant wrist were twice as likely to develop erosive progression and patients with MRI bone marrow edema in the dominant wrist were 28% more likely to develop erosive progression compared with patients without these imaging findings, Dr. Pernille Bøyesen and associates reported (Ann. Rheum. Dis. 2011;70:176-9 [doi: 10.1136/ard.2009.126953]).

On an individual level, however, the imaging modalities were not dramatically better than clinical and demographic variables to predict erosive progression of early RA. USGS inflammation, synovitis on MRI, and bone marrow edema that was visible on MRI performed slightly better than using antibody to cyclic citrullinated protein, rheumatoid factor, and disease activity score based on a 28-joint count, reported Dr. Bøyesen of Diakonhjemmet Hospital, Oslo.

USGS inflammation was the best of 12 imaging modalities and measures of disease severity in identifying patients at risk of developing erosions on MRI, with a sensitivity of 78%, a specificity of 55%, a positive likelihood ration of 1.75, and accuracy of 70%.

Future studies are needed using composite indices of disease progression, including modern imaging modalities, to determine their value as predictors of an individual patient’s likelihood of disease progression, the investigators concluded.

The study appears to be the first to confirm previous data suggesting that measuring inflammation by ultrasound can help predict subsequent joint damage, they noted. The findings also confirmed previous data identifying bone marrow edema on MRI as an independent predictor of joint damage.

Other imaging modalities in the study included digital x-ray radiogrammetry (DXR) of cortical bone mineral density in the hand. Results showed only trends toward higher levels of synovitis on MRI and bone density loss on DXR in patients with erosive progression of disease at 1 year. The findings did not support previous studies that reported cortical hand bone mineral density to be independently predictive of erosive progression, perhaps due to the small size of the study, Dr. Bøyesen added.

Given the comprehensive comparison of imaging modalities in the study, however, 84 patients can be considered a large number, the investigators noted.

The multivariate analyses controlled for the effects of age, sex, and other independent variables.

The investigators declared having no conflicts of interest. The study was funded by the Eastern Norway Regional Health Authority, the Research Council of Norway, the Norwegian Rheumatism Association, the Norwegian Women Public Health Association, the Grethe Harbitz Legacy, and the Marie and Else Mustad Legacy.

Two imaging modalities independently predicted progressive joint erosion in patients with early rheumatoid arthritis as a group, but the tests performed only slightly better than did clinical and demographic variables for individual prognoses, judging from findings of a 1-year study published in Annals of the Rheumatic Diseases.

Among 79 patients who completed quarterly follow-ups with a battery of imaging and nonimaging measures, 53 (67%) showed erosive progression. On a group level, results of ultrasound grey-scale (USGS) findings of inflammation and magnetic resonance images showing bone marrow edema each were significant predictors that erosive disease progression would be detected by MRI.

Patients with USGS inflammation in the dominant wrist were twice as likely to develop erosive progression and patients with MRI bone marrow edema in the dominant wrist were 28% more likely to develop erosive progression compared with patients without these imaging findings, Dr. Pernille Bøyesen and associates reported (Ann. Rheum. Dis. 2011;70:176-9 [doi: 10.1136/ard.2009.126953]).

On an individual level, however, the imaging modalities were not dramatically better than clinical and demographic variables to predict erosive progression of early RA. USGS inflammation, synovitis on MRI, and bone marrow edema that was visible on MRI performed slightly better than using antibody to cyclic citrullinated protein, rheumatoid factor, and disease activity score based on a 28-joint count, reported Dr. Bøyesen of Diakonhjemmet Hospital, Oslo.

USGS inflammation was the best of 12 imaging modalities and measures of disease severity in identifying patients at risk of developing erosions on MRI, with a sensitivity of 78%, a specificity of 55%, a positive likelihood ration of 1.75, and accuracy of 70%.

Future studies are needed using composite indices of disease progression, including modern imaging modalities, to determine their value as predictors of an individual patient’s likelihood of disease progression, the investigators concluded.

The study appears to be the first to confirm previous data suggesting that measuring inflammation by ultrasound can help predict subsequent joint damage, they noted. The findings also confirmed previous data identifying bone marrow edema on MRI as an independent predictor of joint damage.

Other imaging modalities in the study included digital x-ray radiogrammetry (DXR) of cortical bone mineral density in the hand. Results showed only trends toward higher levels of synovitis on MRI and bone density loss on DXR in patients with erosive progression of disease at 1 year. The findings did not support previous studies that reported cortical hand bone mineral density to be independently predictive of erosive progression, perhaps due to the small size of the study, Dr. Bøyesen added.

Given the comprehensive comparison of imaging modalities in the study, however, 84 patients can be considered a large number, the investigators noted.

The multivariate analyses controlled for the effects of age, sex, and other independent variables.

The investigators declared having no conflicts of interest. The study was funded by the Eastern Norway Regional Health Authority, the Research Council of Norway, the Norwegian Rheumatism Association, the Norwegian Women Public Health Association, the Grethe Harbitz Legacy, and the Marie and Else Mustad Legacy.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

CHICAGO — Repeated myocardial perfusion imaging is common and associated with high cumulative radiation doses that are well within the range believed to increase cancer risk, according to a large, single-center study.

This retrospective study of 1,097 consecutive patients who underwent MPI at Columbia University Medical Center, New York, in the first 100 days of 2006 showed that 39% of them received more than one MPI during the study period running from 1988 through June 2008; 18% had at least three MPIs, and 5% had five or more, Dr. Andrew J. Einstein reported at the annual scientific sessions of the American Heart Association.

Among patients with multiple MPIs, the median time between the imaging studies was just under 2 years. However, 56% of patients with multiple MPIs had two within 2 years, and 28% had two within 1 year.

Patients with more than one MPI had a median 121-mSv cumulative estimated effective radiation dose from all medical sources. That’s more than in Japanese atomic bomb survivors, as documented in the landmark Life Span Study. By comparison, 1 year’s background radiation exposure is about 3 mSv, noted Dr. Einstein, a cardiologist at Columbia.

The radiation burden accruing from CT scans has drawn much attention in recent years, but in fact MPI entails the highest radiation exposure of all imaging procedures. Moreover, MPI is booming in popularity: The volume in the United States rose from fewer than 3 million of the imaging procedures in 1990 to 9.3 million in 2002.

In the Columbia University series, men, whites, and patients with health insurance had significantly greater likelihood of undergoing multiple MPIs, compared with women, nonwhites, and the uninsured. They also received higher cumulative radiation doses over the 20-year study period. But whether this increased utilization resulted in improved cardiovascular outcomes requires further study.

The great majority of MPIs ordered in the Columbia study were medically justified as an aid to therapeutic decision making, given that more than 80% of initial MPIs and 90% of repeat procedures were performed in patients with known cardiac disease or symptoms consistent with it. But in ordering these imaging studies, physicians often don’t consider that patients with heart disease undergo numerous additional procedures involving radiation exposure, including cardiac catheterizations. Indeed, the 1,097 patients in this study had a median of 15 procedures involving radiation exposure, including 4 high-dose procedures, Dr. Einstein noted.

Alternative tests without radiation exposure include stress MRI, stress echocardiography, and exercise ECG. Lower radiation exposure alternatives to MPI for use in ruling out cardiac causes of atypical symptoms are CT angiography and percutaneous angiography, he said.

In addition to utilizing tests other than MPI when appropriate, another means of reducing cumulative radiation doses is to avoid the dual-isotope MPI imaging protocol, which typically entails more than twice as great a radiation dose than does technetium-99m MPI, the cardiologist added.

Although the high cumulative radiation doses documented in the Columbia study are "certainly a matter of concern and an important target for improvement," in Dr. Einstein’s view it is worth bearing in mind that solid tumors generally don’t develop until at least 5-10 years following radiation exposure. Patients undergoing MPI are typically older than the general population, and they have a shorter-than-average life expectancy for their age because of their cardiac disease. So the risk:benefit ratio of radiation exposure from MPIs isn’t the same as a similar exposure would be in healthy young adults.

The study was published simultaneously with his presentation at the American Heart Association meeting (JAMA 2010;304:2137-44).

Dr. Einstein’s study was supported by the National Institutes of Health and university research grants. He declared having served as a consultant to the International Atomic Energy Agency as well as GE Healthcare.

LONDON – Magnetic resonance imaging should be used as early as possible to scan the neonatal brain if there are any unexplained symptoms, or if hemorrhagic or thrombotic lesions are suspected.

In the case of thrombosis, it’s important to scan early to decide whether anticoagulation is required, neonatal imaging expert Dr. Mary A. Rutherford of Imperial College London said at the Excellence in Paediatrics annual meeting.

However, Dr. Rutherford, who trained as a pediatrician, noted that for acquired injuries, the use of conventional MRI should be delayed 1-4 weeks, as hypoxic-ischemic brain injury is easier to detect 7 days after the insult.

MRI can be used for a variety of diagnostic and prognostic reasons in full-term neonates; it can help to establish the cause of symptoms, identify brain abnormalities, and determine the likely timing of any injury to the developing brain, she said. Neonatal MRI can also help predict outcomes, provide information for risk management and, in these days of increased medicolegal vigilance, perhaps help clinicians avoid the threat of litigation.

Today, most clinical departments will have an MRI scanner that uses field strengths of 1.5-3 Tesla, which are fine for neonatal imaging, Dr. Rutherford said. "What you really need," she noted, "is an interested radiologist or radiographer." Myelination occurs during the first 2 years of life, so an experienced pediatric or radiology image interpreter is also required.

As access to MRI scanners may be limited, it’s important to be ready as soon as a scanner is free, Dr. Rutherford advised. This means that the neonate must be suitably prepared prior to the scan. Choral hydrate, given 15 minutes before the scan, may be used to keep the neonate sedated temporarily, and ear protection must be worn. The neonate’s head and body should then be "wrapped and fixed" as carefully as possibly into position inside the scanner, so there is little chance of any waking or movement during the scan.

Ventilation may be needed during the scan, and a pediatric staff member needs to be with the baby at all times. Pulse oximetry can be used to monitor the neonate while the scan is in progress.

"MRI is an expensive technology, and you really want to make sure that you get the best possible results from all the effort that is put in by trying to put a baby into an MRI scanner," Dr. Rutherford said.

A key element to successful scanning is ensuring that the MRI coil used fits as closely as possibly to the neonate’s head. "Poor coil choice or head positioning results in poor image quality," she warned.

Motion is another common reason for poor quality images, so motion-resistant sequences need to be considered. T1-weighted (transverse/sagittal), T2-weighted (transverse), and diffusion-weighted imaging may all be appropriate sequences to use. Magnetic resonance venography and angiography can provide useful information about thrombosis or stroke, respectively.

"In this day and age, all infants with a neonatal encephalopathy require – and deserve to have – the benefit of an MR scan," Dr. Rutherford said. Other candidates for MRI include neonates with seizures, severe jaundice, abnormal cranial ultrasound findings, unexplained neurologic signs, dysmorphic features, and where a co-twin has died in utero.

Neonates with unexplained symptoms or who are at risk of hemorrhagic/thrombotic lesions require prompt MRI, as soon as access to a scanner can be arranged.

"You will also want to image fairly quickly in cases of severe neonatal encephalopathy, especially if you are considering withdrawing active treatment," Dr. Rutherford said.

By contrast, for acquired injuries, she noted, "If we want to get the best possible detection of any acquired injury, then we should think about imaging probably between 1 and 4 weeks post insult." Diffusion-weighted imaging is best for identifying early ischemic lesions.

With regards to preterm neonates, routine MRI scanning is not recommended, but early scanning is perhaps advisable if there are unexplained symptoms or withdrawal of care is being considered.

Dr. Rutherford is the editor of "MRI of the Neonatal Brain," (Philadelphia: Saunders, Ltd., 2001). More information: MRI of the Neonatal Brain.

LONDON – Magnetic resonance imaging should be used as early as possible to scan the neonatal brain if there are any unexplained symptoms, or if hemorrhagic or thrombotic lesions are suspected.

In the case of thrombosis, it’s important to scan early to decide whether anticoagulation is required, neonatal imaging expert Dr. Mary A. Rutherford of Imperial College London said at the Excellence in Paediatrics annual meeting.

However, Dr. Rutherford, who trained as a pediatrician, noted that for acquired injuries, the use of conventional MRI should be delayed 1-4 weeks, as hypoxic-ischemic brain injury is easier to detect 7 days after the insult.

MRI can be used for a variety of diagnostic and prognostic reasons in full-term neonates; it can help to establish the cause of symptoms, identify brain abnormalities, and determine the likely timing of any injury to the developing brain, she said. Neonatal MRI can also help predict outcomes, provide information for risk management and, in these days of increased medicolegal vigilance, perhaps help clinicians avoid the threat of litigation.

Today, most clinical departments will have an MRI scanner that uses field strengths of 1.5-3 Tesla, which are fine for neonatal imaging, Dr. Rutherford said. "What you really need," she noted, "is an interested radiologist or radiographer." Myelination occurs during the first 2 years of life, so an experienced pediatric or radiology image interpreter is also required.

As access to MRI scanners may be limited, it’s important to be ready as soon as a scanner is free, Dr. Rutherford advised. This means that the neonate must be suitably prepared prior to the scan. Choral hydrate, given 15 minutes before the scan, may be used to keep the neonate sedated temporarily, and ear protection must be worn. The neonate’s head and body should then be "wrapped and fixed" as carefully as possibly into position inside the scanner, so there is little chance of any waking or movement during the scan.

Ventilation may be needed during the scan, and a pediatric staff member needs to be with the baby at all times. Pulse oximetry can be used to monitor the neonate while the scan is in progress.

"MRI is an expensive technology, and you really want to make sure that you get the best possible results from all the effort that is put in by trying to put a baby into an MRI scanner," Dr. Rutherford said.

A key element to successful scanning is ensuring that the MRI coil used fits as closely as possibly to the neonate’s head. "Poor coil choice or head positioning results in poor image quality," she warned.

Motion is another common reason for poor quality images, so motion-resistant sequences need to be considered. T1-weighted (transverse/sagittal), T2-weighted (transverse), and diffusion-weighted imaging may all be appropriate sequences to use. Magnetic resonance venography and angiography can provide useful information about thrombosis or stroke, respectively.

"In this day and age, all infants with a neonatal encephalopathy require – and deserve to have – the benefit of an MR scan," Dr. Rutherford said. Other candidates for MRI include neonates with seizures, severe jaundice, abnormal cranial ultrasound findings, unexplained neurologic signs, dysmorphic features, and where a co-twin has died in utero.

Neonates with unexplained symptoms or who are at risk of hemorrhagic/thrombotic lesions require prompt MRI, as soon as access to a scanner can be arranged.

"You will also want to image fairly quickly in cases of severe neonatal encephalopathy, especially if you are considering withdrawing active treatment," Dr. Rutherford said.

By contrast, for acquired injuries, she noted, "If we want to get the best possible detection of any acquired injury, then we should think about imaging probably between 1 and 4 weeks post insult." Diffusion-weighted imaging is best for identifying early ischemic lesions.

With regards to preterm neonates, routine MRI scanning is not recommended, but early scanning is perhaps advisable if there are unexplained symptoms or withdrawal of care is being considered.

Dr. Rutherford is the editor of "MRI of the Neonatal Brain," (Philadelphia: Saunders, Ltd., 2001). More information: MRI of the Neonatal Brain.

LONDON – Magnetic resonance imaging should be used as early as possible to scan the neonatal brain if there are any unexplained symptoms, or if hemorrhagic or thrombotic lesions are suspected.

In the case of thrombosis, it’s important to scan early to decide whether anticoagulation is required, neonatal imaging expert Dr. Mary A. Rutherford of Imperial College London said at the Excellence in Paediatrics annual meeting.

However, Dr. Rutherford, who trained as a pediatrician, noted that for acquired injuries, the use of conventional MRI should be delayed 1-4 weeks, as hypoxic-ischemic brain injury is easier to detect 7 days after the insult.

MRI can be used for a variety of diagnostic and prognostic reasons in full-term neonates; it can help to establish the cause of symptoms, identify brain abnormalities, and determine the likely timing of any injury to the developing brain, she said. Neonatal MRI can also help predict outcomes, provide information for risk management and, in these days of increased medicolegal vigilance, perhaps help clinicians avoid the threat of litigation.

Today, most clinical departments will have an MRI scanner that uses field strengths of 1.5-3 Tesla, which are fine for neonatal imaging, Dr. Rutherford said. "What you really need," she noted, "is an interested radiologist or radiographer." Myelination occurs during the first 2 years of life, so an experienced pediatric or radiology image interpreter is also required.

As access to MRI scanners may be limited, it’s important to be ready as soon as a scanner is free, Dr. Rutherford advised. This means that the neonate must be suitably prepared prior to the scan. Choral hydrate, given 15 minutes before the scan, may be used to keep the neonate sedated temporarily, and ear protection must be worn. The neonate’s head and body should then be "wrapped and fixed" as carefully as possibly into position inside the scanner, so there is little chance of any waking or movement during the scan.

Ventilation may be needed during the scan, and a pediatric staff member needs to be with the baby at all times. Pulse oximetry can be used to monitor the neonate while the scan is in progress.

"MRI is an expensive technology, and you really want to make sure that you get the best possible results from all the effort that is put in by trying to put a baby into an MRI scanner," Dr. Rutherford said.

A key element to successful scanning is ensuring that the MRI coil used fits as closely as possibly to the neonate’s head. "Poor coil choice or head positioning results in poor image quality," she warned.

Motion is another common reason for poor quality images, so motion-resistant sequences need to be considered. T1-weighted (transverse/sagittal), T2-weighted (transverse), and diffusion-weighted imaging may all be appropriate sequences to use. Magnetic resonance venography and angiography can provide useful information about thrombosis or stroke, respectively.

"In this day and age, all infants with a neonatal encephalopathy require – and deserve to have – the benefit of an MR scan," Dr. Rutherford said. Other candidates for MRI include neonates with seizures, severe jaundice, abnormal cranial ultrasound findings, unexplained neurologic signs, dysmorphic features, and where a co-twin has died in utero.

Neonates with unexplained symptoms or who are at risk of hemorrhagic/thrombotic lesions require prompt MRI, as soon as access to a scanner can be arranged.

"You will also want to image fairly quickly in cases of severe neonatal encephalopathy, especially if you are considering withdrawing active treatment," Dr. Rutherford said.

By contrast, for acquired injuries, she noted, "If we want to get the best possible detection of any acquired injury, then we should think about imaging probably between 1 and 4 weeks post insult." Diffusion-weighted imaging is best for identifying early ischemic lesions.

With regards to preterm neonates, routine MRI scanning is not recommended, but early scanning is perhaps advisable if there are unexplained symptoms or withdrawal of care is being considered.

Dr. Rutherford is the editor of "MRI of the Neonatal Brain," (Philadelphia: Saunders, Ltd., 2001). More information: MRI of the Neonatal Brain.

For symptomatic patients who undergo cardiac computed tomography angiography to evaluate suspected coronary artery disease, a finding of no CAD conveys an excellent prognosis, according to a meta-analysis of 18 studies of diagnostic cardiac computed tomography angiography (CCTA).

The meta-analysis clearly showed that the low (0.16%) annualized event rate that follows such negative test results is comparable to the background event rate among healthy, low-risk individuals in the general population. It is also comparable to the event rates observed after risk-stratification modalities such as stress echocardiography and myocardial perfusion scanning, said Dr. Edward A. Hulten of the cardiology service at Walter Reed Army Medical Center, Washington, and his associates.

The diagnostic accuracy of CCTA has been reported in more than 50 studies, but the technology's prognostic value has been less well established, the investigators observed. This meta-analysis shows that “the concept that CCTA offers anatomic but not prognostic value compared with widely used functional stress testing is no longer accurate,” they wrote.

Dr. Hulten and his colleagues performed a meta-analysis of prospective and retrospective observational studies in which 9,592 patients suspected of having CAD were evaluated using CCTA and followed for a median of 20 months. Seventeen of these studies were rated as good quality.

For the patients whose CCTA results indicated no CAD, the annualized rate of major adverse cardiovascular events (MACE) was 0.16%. There were no coronary revascularizations, myocardial infarctions, or admissions for unstable angina; the only events were from all-cause mortality.

“Considered in concert with the wealth of data regarding the high anatomic accuracy for CCTA, these results are convincing for CCTA to effectively diagnose CAD and convey risk strata for future adverse cardiovascular events,” the researchers said (J. Am. Coll. Cardiol. 2010;57 [doi:10.1016/jacc.2010.10.011]).

Positive results on CCTA correlated with major adverse cardiovascular events. The average annualized MACE rate for a finding of CAD was 8.8% per year (vs. 0.17% per year for negative findings). Revascularization procedures accounted for most of these events; the annualized rate of death or MI was 3.2% vs. 0.15 for positive vs. negative scans. Moreover, the rate of adverse events increased as the severity of coronary artery disease on CCTA exam increased.

Although a negative CCTA scan can be considered strongly predictive of an excellent outcome, the reverse is not true: A positive CCTA scan cannot be considered strongly predictive of future adverse events. With the annualized MACE rate at only 8.8%, the great majority of patients found on CCTA to have coronary disease also have good outcomes in the 20 months' follow-up, Dr. Hulten and his associates pointed out.

They also noted that many of the authors of studies included in the meta-analysis “reported prognosis based on a relatively simple classification of CAD luminal stenosis, specifically, no CAD, nonobstructive CAD, or potentially obstructive CAD (greater than 50% stenosis).” With studies defining “normal” CCTA in slightly different ways, it was not possible to have stratification details that would be clinically informative, the authors wrote. They also noted that their research included data from “different generations of CT scanning technology” the newer of which are known to have improved image quality and accuracy.

As in many other many studies of noninvasive coronary risk stratification tests, the investigators wrote, a limitation of their study is verification bias: “The observed increase in MACE is driven in part by coronary revascularization, demonstrating evidence of a work-up or verification bias. That is, patients with CCTA evidence of a greater than 50% stenosis are more likely to undergo catheterization and subsequent revascularization.”

For symptomatic patients who undergo cardiac computed tomography angiography to evaluate suspected coronary artery disease, a finding of no CAD conveys an excellent prognosis, according to a meta-analysis of 18 studies of diagnostic cardiac computed tomography angiography (CCTA).

The meta-analysis clearly showed that the low (0.16%) annualized event rate that follows such negative test results is comparable to the background event rate among healthy, low-risk individuals in the general population. It is also comparable to the event rates observed after risk-stratification modalities such as stress echocardiography and myocardial perfusion scanning, said Dr. Edward A. Hulten of the cardiology service at Walter Reed Army Medical Center, Washington, and his associates.

The diagnostic accuracy of CCTA has been reported in more than 50 studies, but the technology's prognostic value has been less well established, the investigators observed. This meta-analysis shows that “the concept that CCTA offers anatomic but not prognostic value compared with widely used functional stress testing is no longer accurate,” they wrote.

Dr. Hulten and his colleagues performed a meta-analysis of prospective and retrospective observational studies in which 9,592 patients suspected of having CAD were evaluated using CCTA and followed for a median of 20 months. Seventeen of these studies were rated as good quality.

For the patients whose CCTA results indicated no CAD, the annualized rate of major adverse cardiovascular events (MACE) was 0.16%. There were no coronary revascularizations, myocardial infarctions, or admissions for unstable angina; the only events were from all-cause mortality.

“Considered in concert with the wealth of data regarding the high anatomic accuracy for CCTA, these results are convincing for CCTA to effectively diagnose CAD and convey risk strata for future adverse cardiovascular events,” the researchers said (J. Am. Coll. Cardiol. 2010;57 [doi:10.1016/jacc.2010.10.011]).

Positive results on CCTA correlated with major adverse cardiovascular events. The average annualized MACE rate for a finding of CAD was 8.8% per year (vs. 0.17% per year for negative findings). Revascularization procedures accounted for most of these events; the annualized rate of death or MI was 3.2% vs. 0.15 for positive vs. negative scans. Moreover, the rate of adverse events increased as the severity of coronary artery disease on CCTA exam increased.

Although a negative CCTA scan can be considered strongly predictive of an excellent outcome, the reverse is not true: A positive CCTA scan cannot be considered strongly predictive of future adverse events. With the annualized MACE rate at only 8.8%, the great majority of patients found on CCTA to have coronary disease also have good outcomes in the 20 months' follow-up, Dr. Hulten and his associates pointed out.

They also noted that many of the authors of studies included in the meta-analysis “reported prognosis based on a relatively simple classification of CAD luminal stenosis, specifically, no CAD, nonobstructive CAD, or potentially obstructive CAD (greater than 50% stenosis).” With studies defining “normal” CCTA in slightly different ways, it was not possible to have stratification details that would be clinically informative, the authors wrote. They also noted that their research included data from “different generations of CT scanning technology” the newer of which are known to have improved image quality and accuracy.

As in many other many studies of noninvasive coronary risk stratification tests, the investigators wrote, a limitation of their study is verification bias: “The observed increase in MACE is driven in part by coronary revascularization, demonstrating evidence of a work-up or verification bias. That is, patients with CCTA evidence of a greater than 50% stenosis are more likely to undergo catheterization and subsequent revascularization.”

For symptomatic patients who undergo cardiac computed tomography angiography to evaluate suspected coronary artery disease, a finding of no CAD conveys an excellent prognosis, according to a meta-analysis of 18 studies of diagnostic cardiac computed tomography angiography (CCTA).

The meta-analysis clearly showed that the low (0.16%) annualized event rate that follows such negative test results is comparable to the background event rate among healthy, low-risk individuals in the general population. It is also comparable to the event rates observed after risk-stratification modalities such as stress echocardiography and myocardial perfusion scanning, said Dr. Edward A. Hulten of the cardiology service at Walter Reed Army Medical Center, Washington, and his associates.

The diagnostic accuracy of CCTA has been reported in more than 50 studies, but the technology's prognostic value has been less well established, the investigators observed. This meta-analysis shows that “the concept that CCTA offers anatomic but not prognostic value compared with widely used functional stress testing is no longer accurate,” they wrote.

Dr. Hulten and his colleagues performed a meta-analysis of prospective and retrospective observational studies in which 9,592 patients suspected of having CAD were evaluated using CCTA and followed for a median of 20 months. Seventeen of these studies were rated as good quality.

For the patients whose CCTA results indicated no CAD, the annualized rate of major adverse cardiovascular events (MACE) was 0.16%. There were no coronary revascularizations, myocardial infarctions, or admissions for unstable angina; the only events were from all-cause mortality.

“Considered in concert with the wealth of data regarding the high anatomic accuracy for CCTA, these results are convincing for CCTA to effectively diagnose CAD and convey risk strata for future adverse cardiovascular events,” the researchers said (J. Am. Coll. Cardiol. 2010;57 [doi:10.1016/jacc.2010.10.011]).

Positive results on CCTA correlated with major adverse cardiovascular events. The average annualized MACE rate for a finding of CAD was 8.8% per year (vs. 0.17% per year for negative findings). Revascularization procedures accounted for most of these events; the annualized rate of death or MI was 3.2% vs. 0.15 for positive vs. negative scans. Moreover, the rate of adverse events increased as the severity of coronary artery disease on CCTA exam increased.

Although a negative CCTA scan can be considered strongly predictive of an excellent outcome, the reverse is not true: A positive CCTA scan cannot be considered strongly predictive of future adverse events. With the annualized MACE rate at only 8.8%, the great majority of patients found on CCTA to have coronary disease also have good outcomes in the 20 months' follow-up, Dr. Hulten and his associates pointed out.

They also noted that many of the authors of studies included in the meta-analysis “reported prognosis based on a relatively simple classification of CAD luminal stenosis, specifically, no CAD, nonobstructive CAD, or potentially obstructive CAD (greater than 50% stenosis).” With studies defining “normal” CCTA in slightly different ways, it was not possible to have stratification details that would be clinically informative, the authors wrote. They also noted that their research included data from “different generations of CT scanning technology” the newer of which are known to have improved image quality and accuracy.

As in many other many studies of noninvasive coronary risk stratification tests, the investigators wrote, a limitation of their study is verification bias: “The observed increase in MACE is driven in part by coronary revascularization, demonstrating evidence of a work-up or verification bias. That is, patients with CCTA evidence of a greater than 50% stenosis are more likely to undergo catheterization and subsequent revascularization.”

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ST. LOUIS — Focused cardiac ultrasonography, or FOCUS, can expedite the diagnostic evaluation of cardiac symptoms at the patient's bedside – allowing for earlier, possibly life-saving interventions – and has become a fundamental tool in the emergency department, according to a joint consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.

FOCUS enables clinicians to determine whether pericardial effusion is present, assess global cardiac systolic function, identify marked right and left ventricular enlargement, and assess intravascular volume, according to the statement (J. Am. Soc. Echocardiogr. 2010;23:1225-30). It can provide guidance for pericardiocentesis and confirm the placement of transvenous pacing wire.

The statement outlines specific clinical scenarios in which FOCUS can affect clinical decision making and patient care:

▸ Cardiac trauma. Performed as part of the FAST (focused assessment with sonography in trauma) exam, FOCUS can help identify possible cardiac injury, such as cardiac hemorrhage, that requires surgical intervention by looking for the presence of pericardial effusion as well as the presence or absence of organized ventricular contractility. FOCUS also can help diagnose cardiac contusions by looking for depressed wall motion and decreased myocardial contractility.

▸ Cardiac arrest. Clinicians can improve the outcome of cardiopulmonary resuscitation by using FOCUS to distinguish among asystole, pulseless electrical activity (PEA), and pseudo-PEA. FOCUS also can help identify causes of PEA, allowing for earlier treatment and the return of spontaneous circulation.

FOCUS can improve outcomes by determining a cardiac cause of the cardiac arrest and by guiding lifesaving procedures at the patient's bedside.

▸ Hypotension/shock. FOCUS can help the clinician determine if the shock is cardiogenic, thus allowing for aggressive early intervention to prevent organ dysfunction. In this case, the exam looks for the presence of pericardial effusion and evaluates global cardiac function, right ventricular size, and inferior vena cava size/collapsibility as a marker of central venous pressure.

FOCUS can determine the presence, size, and functional relevance of a pericardial effusion as a cause of hemodynamic instability. Also, it can expedite pericardiocentesis while reducing complications and increasing the success rate.

▸ Dyspnea/shortness of breath. FOCUS can help rule out pericardial effusion, identify global left ventricular systolic dysfunction, and assess the size of the right ventricle as a proxy for indicating the presence or absence of a hemodynamically significant pulmonary embolus. Still, a complete evaluation of these patients should include comprehensive echocardiography to evaluate diastolic function and pulmonary artery pressures, and to help diagnose pericardial and valvular heart disease.

▸ Chest pain. FOCUS may be helpful in the evaluation of patients with a hemodynamically significant pulmonary embolus or the screening of patients for aortic dissection. When aortic dissection is suspected, the clinician can use FOCUS to look for pericardial or pleural effusions and to assess the diameter of the aortic root. (An aortic root diameter greater than 4 cm is suspicious for type A dissection.) The authors caution that a negative FOCUS exam does not definitively rule out aortic dissection; additional imaging and diagnostic studies are necessary.

FOCUS training should include the presentation of positive and negative cases of various cardiac pathologies. Any program that uses FOCUS should have a quality assurance program that reviews scan quality by comparing interpretations with pathological and surgical data, clinical outcomes, and final diagnoses.

ATLANTA – Ultrasound guidance led to a significant increase in the number of noneffusive knees with osteoarthritis that responded to corticosteroid injections, based on data from a randomized trial of 94 knees. The findings were presented at the annual meeting of the American College of Rheumatology.

The accuracy rate for knee injections in OA varies widely, said Dr. Wilmer Sibbitt, professor of rheumatology and neurology at the University of New Mexico Health Sciences Center in Albuquerque.

Injections of medication or removal of fluid from the knee joints have historically been guided by the physician’s hands-on examination of the knee, but ultrasound guidance is becoming more common as a way to improve accuracy, said Dr. Sibbitt.

"Ultrasound is being used presently for injections, and there aren’t good outcome studies to determine whether this increased accuracy provides better results, and whether it increases or reduces costs," he said in an interview.

Dr. Sibbitt and colleagues randomized adults with knee OA to receive joint injections guided by ultrasound or with the conventional palpation guidance. For the sonographically guided injections, the researchers used a one-handed reciprocating procedure device syringe that enabled them to hold the ultrasound transducer in one hand and the dual chamber syringe in the other. The injection consisted of 80 mg of triamcinolone acetonide.

The researchers evaluated patients’ pain at baseline, during the injection, 2 weeks later, and 6 months later, using an established pain rating scale.

Compared with the conventional injection group, ultrasound-guided injections yielded a 48% reduction in pain during the injection, and a 42% reduction in pain scores at follow-up. In addition, significantly more knees in the ultrasound group than in the control group responded well to the injections and significantly fewer knees in the ultrasound group than in the control group did not respond well.

The researchers also evaluated the cost-effectiveness of ultrasound-guided injections. The ultrasound-guided injection was associated with a $48 reduction in patient costs per year, and a $593 reduction in outpatient costs per year.

The study was limited by its small size, and additional research is needed to confirm the results. But the findings suggest that sonographic needle guidance improves the performance, clinical outcomes, and effectiveness of knee injections for OA patients, Dr. Sibbitt said.

Dr. Sibbitt disclosed receiving consulting fees from multiple companies including Becton Dickinson, Ferring Pharmaceuticals, Avasca Medical, and Meditech Duopross. He also disclosed stock, stock options, or bond holdings in multiple companies including Celgene, Apple, Avasca, and Java Inc. He has received research grants from the National Institutes of Health.

ATLANTA – Ultrasound guidance led to a significant increase in the number of noneffusive knees with osteoarthritis that responded to corticosteroid injections, based on data from a randomized trial of 94 knees. The findings were presented at the annual meeting of the American College of Rheumatology.

The accuracy rate for knee injections in OA varies widely, said Dr. Wilmer Sibbitt, professor of rheumatology and neurology at the University of New Mexico Health Sciences Center in Albuquerque.

Injections of medication or removal of fluid from the knee joints have historically been guided by the physician’s hands-on examination of the knee, but ultrasound guidance is becoming more common as a way to improve accuracy, said Dr. Sibbitt.

"Ultrasound is being used presently for injections, and there aren’t good outcome studies to determine whether this increased accuracy provides better results, and whether it increases or reduces costs," he said in an interview.

Dr. Sibbitt and colleagues randomized adults with knee OA to receive joint injections guided by ultrasound or with the conventional palpation guidance. For the sonographically guided injections, the researchers used a one-handed reciprocating procedure device syringe that enabled them to hold the ultrasound transducer in one hand and the dual chamber syringe in the other. The injection consisted of 80 mg of triamcinolone acetonide.

The researchers evaluated patients’ pain at baseline, during the injection, 2 weeks later, and 6 months later, using an established pain rating scale.

Compared with the conventional injection group, ultrasound-guided injections yielded a 48% reduction in pain during the injection, and a 42% reduction in pain scores at follow-up. In addition, significantly more knees in the ultrasound group than in the control group responded well to the injections and significantly fewer knees in the ultrasound group than in the control group did not respond well.

The researchers also evaluated the cost-effectiveness of ultrasound-guided injections. The ultrasound-guided injection was associated with a $48 reduction in patient costs per year, and a $593 reduction in outpatient costs per year.

The study was limited by its small size, and additional research is needed to confirm the results. But the findings suggest that sonographic needle guidance improves the performance, clinical outcomes, and effectiveness of knee injections for OA patients, Dr. Sibbitt said.

Dr. Sibbitt disclosed receiving consulting fees from multiple companies including Becton Dickinson, Ferring Pharmaceuticals, Avasca Medical, and Meditech Duopross. He also disclosed stock, stock options, or bond holdings in multiple companies including Celgene, Apple, Avasca, and Java Inc. He has received research grants from the National Institutes of Health.

ATLANTA – Ultrasound guidance led to a significant increase in the number of noneffusive knees with osteoarthritis that responded to corticosteroid injections, based on data from a randomized trial of 94 knees. The findings were presented at the annual meeting of the American College of Rheumatology.

The accuracy rate for knee injections in OA varies widely, said Dr. Wilmer Sibbitt, professor of rheumatology and neurology at the University of New Mexico Health Sciences Center in Albuquerque.

Injections of medication or removal of fluid from the knee joints have historically been guided by the physician’s hands-on examination of the knee, but ultrasound guidance is becoming more common as a way to improve accuracy, said Dr. Sibbitt.

"Ultrasound is being used presently for injections, and there aren’t good outcome studies to determine whether this increased accuracy provides better results, and whether it increases or reduces costs," he said in an interview.

Dr. Sibbitt and colleagues randomized adults with knee OA to receive joint injections guided by ultrasound or with the conventional palpation guidance. For the sonographically guided injections, the researchers used a one-handed reciprocating procedure device syringe that enabled them to hold the ultrasound transducer in one hand and the dual chamber syringe in the other. The injection consisted of 80 mg of triamcinolone acetonide.

The researchers evaluated patients’ pain at baseline, during the injection, 2 weeks later, and 6 months later, using an established pain rating scale.

Compared with the conventional injection group, ultrasound-guided injections yielded a 48% reduction in pain during the injection, and a 42% reduction in pain scores at follow-up. In addition, significantly more knees in the ultrasound group than in the control group responded well to the injections and significantly fewer knees in the ultrasound group than in the control group did not respond well.

The researchers also evaluated the cost-effectiveness of ultrasound-guided injections. The ultrasound-guided injection was associated with a $48 reduction in patient costs per year, and a $593 reduction in outpatient costs per year.

The study was limited by its small size, and additional research is needed to confirm the results. But the findings suggest that sonographic needle guidance improves the performance, clinical outcomes, and effectiveness of knee injections for OA patients, Dr. Sibbitt said.

Dr. Sibbitt disclosed receiving consulting fees from multiple companies including Becton Dickinson, Ferring Pharmaceuticals, Avasca Medical, and Meditech Duopross. He also disclosed stock, stock options, or bond holdings in multiple companies including Celgene, Apple, Avasca, and Java Inc. He has received research grants from the National Institutes of Health.