Elisabeth Albrecht-Beste

Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography

Objectives: To compare the ability of two different dedicated extremity MRI (E-MRI) units and conventional radiography (CR) for identifying bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints. Methods: CR and two MRI examinations (using 0.2 T Esaote Artoscan and 0.2 T portable MagneVu MV1000 units) of 418 bones in the dominant wrist and second to fifth MCP joints of 15 patients with RA and 4 healthy controls were performed and evaluated blindly for bones being visible and for erosions. Results: In MCP joints, MagneVu visualised 18.5% of bones entirely and 71.1% were 67–99% visualised. In wrists, MagneVu visualised 1.5% of bones entirely, 39.8% were 67–99% visualised and 19% were not visualised at all. Artoscan and CR visualised all bones entirely. Artoscan, MagneVu and CR found 22, 19 and 15 bones with erosions in MCP joints and 66, 40 and 13 bones with erosions in wrist joints, respectively. With the previously validated Artoscan unit as standard reference, MagneVu and CR had sensitivities of 0.82 and 0.55, respectively, in MCP joint bones and 0.41 and 0.14 in wrist bones. Specificities of CR and MagneVu were comparable (0.82–0.99). The MagneVu unit was particularly more sensitive than CR for metacarpal heads and carpal bones. MagneVu MRI and CR detected 100% and 89%, respectively, of large erosions (Outcome Measures in Rheumatoid Arthritis Clinical Trials–Rheumatoid Arthritis MRI Scoring System (OMERACT-RAMRIS) score >1 on Artoscan) in MCP joints and 69% and 15.8% of large erosions in wrists. Conclusions: Both E-MRI units detected more erosions than CR, in particular due to a higher sensitivity in metacarpal heads and carpal bones. The MagneVu unit detected fewer erosions than the Artoscan unit due to a lower average image quality and a smaller proportion of bones being visualised.

Reproducibility of ultrasound and magnetic resonance imaging measurements of tendon size

Purpose: To investigate the intra- and inter-tester reproducibility of measurements of the Achilles tendon, tibialis anterior tendon, and the tibialis posterior tendon in football players using ultrasound (US) and magnetic resonance imaging (MRI). Material and Methods: Eleven asymptomatic football players were examined. Using a standardized US scanning protocol, the tendons were examined by two observers with US for thickness, width, and cross-sectional area. One observer conducted the procedure twice. The subjects also underwent an MRI examination, and the assessment of tendon size was conducted twice by two observers. Results: The best reproducibility judged by coefficient of variation (CV) and 95% confidence interval was determined for the Achilles tendon on both US and MRI. The variability of US on measurements on the tibialis anterior and tibialis posterior tendons was less than that when using MRI. In 12 out of 18 measurements, there were systematic differences between observers as judged by one-sided F-test. Conclusion: The reproducibility of the three tendons was limited. Precaution should be taken when looking for minor quantitative changes, i.e., training-induced hypertrophy, and when doing so, the Achilles tendon should be used.

Does low-field dedicated extremity MRI (E-MRI) reliably detect bone erosions in rheumatoid arthritis? A comparison of two different E-MRI units and conventional radiography with high-resolution CT scanning

Objectives: To compare the ability of two different E-MRI units and conventional radiography (CR) to identify bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints with CT scanning as the standard reference method. Methods: 20 patients with RA and 5 controls underwent CR, CT and two E-MRI examinations (Esaote Biomedica Artoscan and MagneVu MV1000) of one hand during a 2-week period. In all modalities, each bone of the wrist and MCP joints was blindly evaluated for erosions. MagneVu images were also assessed for the proportion of each bone being visualised. Results: 550 bones were examined. CT, Artoscan, MagneVu and CR detected 188, 116, 55 and 45 bones with erosions, respectively. The majority were located in the carpal bones. The sensitivity of the Artoscan for detecting erosions was higher than that of the MagneVu and CR (MCP joints: 0.68, 0.54 and 0.57, respectively; wrists: 0.50, 0.23 and 0.29). Corresponding specificities for detecting erosions were 0.94, 0.93 and 0.99, respectively, in the MCP joints and 0.92, 0.98 and 0.98 in the wrist. The MagneVu allowed visualisation of 1.5 cm of the ventral-dorsal diameter of the bone. In the wrist, 31.6% of bones were visualised entirely and 37.9% of bones were 67–99% visualised. In MCP joints, 84.2% of bones were visualised entirely and 15.8% of bones were 67–99% visualised. Conclusion: With CT as the reference method for detecting erosions in RA hands, the Artoscan showed higher sensitivity than the MagneVu and CR. All imaging modalities had high specificities. The better performance of the Artoscan should be considered when selecting an imaging method in RA.

Simulation-Based Abdominal Ultrasound Training – A Systematic Review

PURPOSE The aim is to provide a complete overview of the different simulation-based training options for abdominal ultrasound and to explore the evidence of their effect. MATERIALS AND METHODS This systematic review was performed according to the PRISMA guidelines and Medline, Embase, Web of Science, and the Cochrane Library was searched. Articles were divided into three categories based on study design (randomized controlled trials, before-and-after studies and descriptive studies) and assessed for level of evidence using the Oxford Centre for Evidence Based Medicine (OCEBM) system and for bias using the Cochrane Collaboration risk of bias assessment tool. RESULTS Seventeen studies were included in the analysis: four randomized controlled trials, eight before-and-after studies with pre- and post-test evaluations, and five descriptive studies. No studies scored the highest level of evidence, and 14 had the lowest level. Bias was high for 11 studies, low for four, and unclear for two. No studies used a test with established evidence of validity or examined the correlation between obtained skills on the simulators and real-life clinical skills. Only one study used blinded assessors. CONCLUSION The included studies were heterogeneous in the choice of simulator, study design, participants, and outcome measures, and the level of evidence for effect was inadequate. In all studies simulation training was equally or more beneficial than other instructions or no instructions. Study designs had significant built-in bias and confounding issues; therefore, further research should be based on randomized controlled trials using tests with validity evidence and blinded assessors.

Clinical utility of 18 F-FDG positron emission tomography/computed tomography scan vs. 99m Tc-HMPAO white blood cell single-photon emission computed tomography in extra-cardiac work-up of infective endocarditis

The extra-cardiac work-up in infective endocarditis (IE) comprises a search for primary and secondary infective foci. Whether 18FDG-PET/CT or WBC-SPECT/CT is superior in detection of clinically relevant extra-cardiac manifestations in IE is unexplored. The objectives of this study were to identify the numbers of positive findings detected by each imaging modality, to evaluate the clinical relevance of these findings and to define the reproducibility for extra-cardiac foci in patients with definite IE. Each modality was evaluated for numbers and location of positive extra-cardiac foci in patients with definite IE. A team of 2 × 2 cardiologists evaluated each finding to determine clinical relevance. Clinical utility was determined by 4 criteria converted into an ordinal scale. Using the manifestation with highest clinical utility rating in each patient, the clinical impact of the two imaging modalities was expressed in a clinical utility score. To evaluate reproducibility for each modality, an imaging core laboratory reviewed all findings. In 55 IE patients, 91 pathological foci were found by FDG-PET/CT and 37 foci were identified by WBC-SPECT/CT (p < 0.001). The clinical utility of FDG-PET/CT was significantly higher than that of WBC-SPECT/CT when comparing clinical utility score (2.06 vs. 1.17; p = 0.01). In assessment of extra-cardiac diagnostics in IE, inter-observer reproducibility was substantial for WBC-SPECT/CT (k 0.69, 95% CI 0.49–0.89) and substantial to excellent for FDG-PET/CT (k 0.79, 95% CI 0.61–0.98). FDG-PET/CT has a significantly higher clinical utility score than WBC SPECT/CT and is potentially superior to WBC-SPECT/CT in detection of extra-cardiac pathology in patients with IE.

Ultrasound in Pre-Graduate Medical Education.

The European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) recently published a student edition of their course book for free download at http://www.efsumb.org. Technological advancements have made the equipment better and cheaper and several handheld ultrasound devices are now about the size of a smartphone 1 . Certified radiologists must master the imaging modality and many other medical specialists also use ultrasound in their daily practice. The easy accessibility and increased use dictate that all future physicians should have some knowledge of ultrasound. However, its place in the curriculum of medical schools has not been defined and is currently very varied. Ultrasound can be taught in theory and in practice but can also be used as an educational tool to teach anatomy, physiology, pathology, and traumatology. One of the first descriptions of this is from the Hannover Medical School where they combined the anatomy course with hands-on ultrasound workshops performed by medical students on other students 2 . The students liked the interactivity and felt that it improved their understanding of clinical anatomy. Several studies have confirmed that students like to use ultrasound 3 4 , but more importantly it has also been shown that ultrasound anatomy sessions are “a highly effective method for facilitating student learning and significantly enhance knowledge of living clinical anatomy” 5 . Scanning of peers is easy to arrange unless it conflicts with the students’ boundaries of modesty or religious beliefs. However, only normal anatomy and physiology can be studied in this way and arranging the scanning of the right patients is logistically difficult and perhaps even unethical for large classes. Virtual-reality simulators deliver a multitude of different “standardized patients” that can be used for teaching pathology and traumatology although the simulators are costly and their fidelity is still not optimal 6 . Using ultrasound as an educational tool does not automatically make the students competent in performing ultrasound procedures. George Miller described the framework for acquiring competence as a four-layer pyramid 7 . Theoretical knowledge (“knows” and “knows how”) is the necessary foundation and base upon which clinical competence must be build. This can be acquired through books on ultrasound or be taught in traditional classes or at lectures. The third layer of the pyramid (“shows how”) relates to performance in a simulated environment, e. g. scanning of fellow students or simulators. This hands-on training is necessary before reaching the top level of competence (“does”): actual performance on patients. Unfortunately, it requires a lot more resources than traditional lectures and self-study. Expensive ultrasound training should be established according to best available evidence in order to ensure optimal learning output. An ultrasound machine or simulator per student provides maximum hands-on time but a recent study on the effects of simulator-based ultrasound training found that training in pairs (“dyad practice”) actually improved the efficacy of training and was not inferior to individual practice in terms of skills transfer 8 . The high instructor-to-trainee ratio is also a concern in hands-on ultrasound classes but it is important to realize that the instructor does not have to be constantly standing next to the trainee operating the probe. A single instructor can provide direction and feedback to four pairs of trainees on a rotating basis and the resulting “directed, self-regulated learning” has a potential long-term benefit 9 . Performing ultrasound assessment with established pass/fail standards at the end of ultrasound courses can also increase motivation and the retention of skills 10 11 . It might be feasible to establish efficient ultrasound courses for medical students but is it possible to make all young doctors competent? A group from the UK successfully trained inexperienced undergraduate students to scan the abdominal aorta and concluded: “It is time for the medical education community to address whether focused ultrasound training should accompany traditional clinical skills, such as using a stethoscope, in UK medical school curricula” 12 . However, it is important to acknowledge that new junior physicians with limited, isolated skills in ultrasound must be very aware of their limitations. Incompetent operators could lead to inadequate investigation and treatment due to false-negative findings as well as unnecessary interventions due to false-positive findings. EFSUMB has defined minimum training requirements for specific areas of ultrasound 13 . Moreover, a recent survey among more than 600 young obstetricians/gynecologists found that “trainees required more than 24 months of clinical experience and 12 – 24 days of training in specialized ultrasound units in order to feel confident about performing transvaginal and transabdominal ultrasound scans independently” 14 . It is clear that it is not possible to fit either the official requirements or the expectations of young doctors into an already busy curriculum at medical schools. In conclusion, ultrasound should be used systematically as an easily accessible and exciting educational tool in the curriculum of modern medical schools. Medical students should acquire theoretical knowledge of the modality and any hands-on training should adhere to evidence-based principles. Achieving real clinical competence in ultrasound requires extensive (post-graduate) training and is outside the scope of medical schools.

Brown Tumors Due to Primary Hyperparathyroidism in a Patient with Parathyroid Carcinoma Mimicking Skeletal Metastases on (18)F-FDG PET/CT.

Parathyroid carcinoma only represents <1% of all cases of primary hyperparathyroidism (PHPT). Even rare, chronic PHPT may lead to excessive osteoclast activity, and the increased resorption leads to destruction of cortical bone and formation of fibrous cysts with deposits of hemosiderin—so-called brown tumors. These benign, osteolytic lesions may demonstrate FDG-avidity on 18F-FDG PET/CT, and as such are misinterpreted as skeletal metastases. Regression of the lesions may occur following successful treatment. We present a case demonstrating the diagnostic work-up and follow-up of a patient with PHPT due to parathyroid carcinoma and with presence of brown tumors on 18F-FDG PET/CT, visualizing the possible role of this imaging modality in the evaluation of treatment response in these patients.

Development of a reliable simulation-based test for diagnostic abdominal ultrasound with a pass/fail standard usable for mastery learning

BackgroundThis study aimed to develop a test with validity evidence for abdominal diagnostic ultrasound with a pass/fail-standard to facilitate mastery learning.MethodThe simulator had 150 real-life patient abdominal scans of which 15 cases with 44 findings were selected, representing level 1 from The European Federation of Societies for Ultrasound in Medicine and Biology. Four groups of experience levels were constructed: Novices (medical students), trainees (first-year radiology residents), intermediates (third- to fourth-year radiology residents) and advanced (physicians with ultrasound fellowship). Participants were tested in a standardized setup and scored by two blinded reviewers prior to an item analysis.ResultsThe item analysis excluded 14 diagnoses. Both internal consistency (Cronbach’s alpha 0.96) and inter-rater reliability (0.99) were good and there were statistically significant differences (p < 0.001) between all four groups, except the intermediate and advanced groups (p = 1.0). There was a statistically significant correlation between experience and test scores (Pearson’s r = 0.82, p < 0.001). The pass/fail-standard failed all novices (no false positives) and passed all advanced (no false negatives). All intermediate participants and six out of 14 trainees passed.ConclusionWe developed a test for diagnostic abdominal ultrasound with solid validity evidence and a pass/fail-standard without any false-positive or false-negative scores.Key Points• Ultrasound training can benefit from competency-based education based on reliable tests.• This simulation-based test can differentiate between competency levels of ultrasound examiners.• This test is suitable for competency-based education, e.g. mastery learning.• We provide a pass/fail standard without false-negative or false-positive scores.

Determining procedures for simulation-based training in radiology: a nationwide needs assessment

ObjectivesNew training modalities such as simulation are widely accepted in radiology; however, development of effective simulation-based training programs is challenging. They are often unstructured and based on convenience or coincidence. The study objective was to perform a nationwide needs assessment to identify and prioritize technical procedures that should be included in a simulation-based curriculum.MethodsA needs assessment using the Delphi method was completed among 91 key leaders in radiology. Round 1 identified technical procedures that radiologists should learn. Round 2 explored frequency of procedure, number of radiologists performing the procedure, risk and/or discomfort for patients, and feasibility for simulation. Round 3 was elimination and prioritization of procedures.ResultsResponse rates were 67 %, 70 % and 66 %, respectively. In Round 1, 22 technical procedures were included. Round 2 resulted in pre-prioritization of procedures. In round 3, 13 procedures were included in the final prioritized list. The three highly prioritized procedures were ultrasound-guided (US) histological biopsy and fine-needle aspiration, US-guided needle puncture and catheter drainage, and basic abdominal ultrasound.ConclusionA needs assessment identified and prioritized 13 technical procedures to include in a simulation-based curriculum. The list may be used as guide for development of training programs.Key Points• Simulation-based training can supplement training on patients in radiology.• Development of simulation-based training should follow a structured approach.• The CAMES Needs Assessment Formula explores needs for simulation training.• A national Delphi study identified and prioritized procedures suitable for simulation training.• The prioritized list serves as guide for development of courses in radiology.

Angiosarcoma of the Scalp: Metastatic Pulmonary Cystic Lesions Initially Misinterpreted as Benign Findings on 18F-FDG PET/CT

Angiosarcomas are rare and only represent about 2% of all soft tissue sarcomas. They arise from vascular or lymphatic endothelial cells and are most commonly located in the heart, liver, breast, and skin. Cutaneous angiosarcoma of the scalp is highly malignant and with dismal prognosis. Reported five-year survival is <30%. The mainstay of treatment is surgical resection and adjuvant radiation therapy, but failure rates following local therapy are high. Cutaneous angiosarcoma of the scalp has a predilection for pulmonary metastases with a variety of morphologic patterns on imaging. Metastatic disease in terms of pulmonary thin-walled, cystic lesions, may not be hypermetabolic on 18F-FDG PET and, as such, could be misinterpreted as benign findings. We present a case demonstrating the diagnostic uncertainty and delay in an elderly male with angiosarcoma of the scalp presenting with metastatic lung lesions following failure of local therapy.