The sonographic quantitative assessment of the deltoid muscle to detect type 2 diabetes mellitus: a potential noninvasive and sensitive screening method?

BACKGROUND: In our previous published study, we demonstrated that a qualitatively assessed elevation in deltoid muscle echogenicity on ultrasound was both sensitive for and a strong predictor of a type 2 diabetes (T2DM) diagnosis. This study aims to evaluate if a sonographic quantitative assessment of the deltoid muscle can be used to detect T2DM. METHODS: Deltoid muscle ultrasound images from 124 patients were stored: 31 obese T2DM, 31 non-obese T2DM, 31 obese non-T2DM and 31 non-obese non-T2DM. Images were independently reviewed by 3 musculoskeletal radiologists, blinded to the patient\u27s category. Each measured the grayscale pixel intensity of the deltoid muscle and humeral cortex to calculate a muscle/bone ratio for each patient. Following a 3-week delay, the 3 radiologists independently repeated measurements on a randomly selected 40 subjects. Ratios, age, gender, race, body mass index, insulin usage and hemoglobin A(1c) were analyzed. The difference among the 4 groups was compared using analysis of variance or chi-square tests. Both univariate and multivariate linear mixed models were performed. Multivariate mixed-effects regression models were used, adjusting for demographic and clinical variables. Post hoc comparisons were done with Bonferroni adjustments to identify any differences between groups. The sample size achieved 90% power. Sensitivity and specificity were calculated based on set threshold ratios. Both intra- and inter-radiologist variability or agreement were assessed. RESULTS: A statistically significant difference in muscle/bone ratios between the groups was identified with the average ratios as follows: obese T2DM, 0.54 (P \u3c 0.001); non-obese T2DM, 0.48 (P \u3c 0.001); obese non-T2DM, 0.42 (P = 0.03); and non-obese non-T2DM, 0.35. There was excellent inter-observer agreement (intraclass correlation coefficient 0.87) and excellent intra-observer agreements (intraclass correlation coefficient 0.92, 0.95 and 0.94). Using threshold ratios, the sensitivity for detecting T2DM was 80% (95% CI 67% to 88%) with a specificity of 63% (95% CI 50% to 75%). CONCLUSIONS: The sonographic quantitative assessment of the deltoid muscle by ultrasound is sensitive and accurate for the detection of T2DM. Following further studies, this process could translate into a dedicated, simple and noninvasive screening method to detect T2DM with the prospects of identifying even a fraction of the undiagnosed persons worldwide. This could prove especially beneficial in screening of underserved and underrepresented communities

Incidental findings detected on preoperative CT imaging obtained for robotic-assisted joint replacements: clinical importance and the effect on the scheduled arthroplasty

OBJECTIVE: To determine the type and frequency of incidental findings detected on preoperative computed tomography (CT) imaging obtained for robotic-assisted joint replacements and their effect on the planned arthroplasty. MATERIALS AND METHODS: All preoperative CT examinations performed for a robotic-assisted knee or total hip arthroplasty were obtained. This resulted in 1432 examinations performed between September 2016 and February 2020 at our institution. These examinations were initially interpreted by 1 of 9 fellowship-trained musculoskeletal radiologists. Using a diagnosis search, the examination reports were then reviewed to catalog all incidental findings and further classify as significant or non-significant findings. Demographic information was obtained. In those with significant findings, a chart review was performed to record the relevant workup, outcomes, and if the planned arthroplasty was affected. RESULTS: Incidental findings were diagnosed in 740 (51.7%) patients. Of those with incidental findings, 41 (5.5%) were considered significant. A significant finding was more likely to be detected in males (P = 0.007) and on the hip protocol CT (P = 0.014). In 8 patients, these diagnoses resulted in either delay or cancelation of the arthroplasty. A planned total hip arthroplasty was more likely to be altered as compared to a knee arthroplasty (P = 0.018). CONCLUSION: Incidental findings are commonly detected by radiologists on preoperative CT imaging obtained for robotic-assisted joint replacement. Several were valuable findings and resulted in a delay or even cancelation of the planned arthroplasty after the detection of critical diagnoses, which if not identified may have resulted in devastating outcomes

Sonographic evaluation of the association between calcific tendinopathy and rotator cuff tear: a case-controlled comparison

Objectives: To compare the incidence of rotator cuff (RC) tears on shoulder ultrasounds of patients with RC calcific tendinopathy (CaT) to that of a control group without CaT. Method: In this retrospective case-control study, 50 shoulder ultrasounds of patients with CaT were compared independently by 2 musculoskeletal radiologists to 50 patients from a control group without CaT to catalog the number and type of RC tears. RC tears in the CaT group were further characterized based on location, into tears in the specific tendon(s) containing calcium versus all tendon tears. Results: RC tears were diagnosed in 38% (19/50) of the control group (16 full-thickness) as compared to 22% (11/50) with CaT (6 full-thickness). The fewer full-thickness tears in the CaT group (12%, 6 of 50) compared to that in the control group (32%, 16 of 50) was statistically significant (P = 0.016, odds ratio 0.29). Only 7 of the 11 tears in the CaT group were in a calcium-containing tendon (3 full-thickness). The fewer calcium-containing tendon tears compared to tears in the control group was also statistically significant (P = 0.006, odds ratio 0.27). Furthermore, the fewer full-thickness calcium-containing tendon tears (6%, 3/50) compared to full-thickness tears in the control group (32%, 16/50) were yet more statistically significant (P = 0.001, odds ratio 0.14). Conclusions: In patients with shoulder pain and CaT, we observed a decreased number of RC tears and especially calcium-containing tendon tears, as compared to similar demographic patients with shoulder pain but without CaT. Key Points • Patients with rotator cuff calcific tendinopathy have few rotator cuff tears, especially full-thickness tears, compared to a control group without calcific tendinopathy. • The tendons containing the calcium hydroxyapatite deposition were the least likely to have a rotator cuff tear. • Future studies could evaluate if calcium hydroxyapatite deposition provides a protective mechanism against rotator cuff tears. • Musculoskeletal ultrasound is more sensitive than MRI in the evaluation of rotator cuff calcific tendinopathy

Elbow Torque May be Predictive of Anatomic Adaptations to the Elbow After a Season of Collegiate Pitching: A Dynamic Ultrasound Study

Purpose: To determine whether elbow torque was associated with anatomic adaptations of the medial elbow following a season of competitive pitching. Methods: Pitchers from 3 collegiate baseball teams were recruited during the preseason for participation. Before the season, pitchers were recorded throwing 5 game-speed fastball pitches from a standard distance off a mound while wearing a wearable sensor baseball compression sleeve that calculates elbow torque, arm speed, arm slot, and arm rotation. Participants subsequently underwent dynamic ultrasound imaging of the medial elbow, including measurements of the ulnar collateral ligament (UCL) and ulnohumeral joint space to assess elbow laxity. Following a full season of competitive pitching, all testing was repeated, and statistical analysis comparing preseason to postseason sonographic findings was performed. Results: Twenty-eight collegiate pitchers underwent preseason sonographic and kinematic testing. Nineteen pitchers were available for postseason testing. The average age (standard deviation) and playing experience was 19.9 (1.2) and 14.7 (1.5) years. Compared with preseason, there were significant increases in postseason UCL thickness (1.92 ± 0.09 vs 1.56 ± 0.09 mm, P \u3c .01) and elbow laxity (1.77 ± 0.23 vs 1.15 ± 0.22 mm, P = .028) after a season of pitching. No significant changes in pitching kinematic measurements were observed between preseason and postseason testing. Preseason pitching kinematic measurements were significantly associated with increased UCL thickness (arm slot: beta estimate -0.03 ± 0.01, P = .011) and reduction in elbow laxity (elbow torque: beta estimate -0.03 ± 0.01, P = .04) after a season of pitching. Pitchers with increased body weight and arm length demonstrated reduced medial elbow torque during pitching (P \u3c .05). Conclusions: After a season of competitive pitching, adaptive changes of the medial elbow were demonstrated on dynamic ultrasound. However, the influence of pitching kinematic measurements on these adaptations are of small magnitude and unknown clinical significance. Although wearable sensor technology may have value in trending individual pitcher kinematics, no discrete threshold appears to predict the development of adaptive changes at the elbow. Level of Evidence: Level II, prospective observational study

Significant variability exists in preoperative planning software measures of glenoid morphology for shoulder arthroplasty

Background & Hypothesis: We sought to assess the reliability of 4 different shoulder arthroplasty 3-dimensional preoperative planning programs. Comparison was also made to manual measurements conducted by 2 fellowship-trained musculoskeletal radiologists. We hypothesized that there would be significant variation in measurements of glenoid anatomy affected by glenoid deformity. Methods: A retrospective review of computed tomography (CT) scans of patients undergoing shoulder arthroplasty was undertaken. A total of 76 computed tomographies were analyzed for glenoid version and inclination by 4 templating software systems (VIP, Blueprint, TrueSight, ExactechGPS). Inter-rater reliability was assessed via intra-class correlation coefficient (ICC). For those shoulders with glenohumeral arthritis (58/76), ICC was also calculated when sub-grouping by modified Walch classification. Lin\u27s concordance correlation coefficient was calculated for each system with 2 musculoskeletal-trained radiologists’ measurements. Results: Measurements of glenoid version and inclination differed between at least 2 programs by 5º-10º in 75% and 92% of glenoids respectively, and by \u3e10º in 18% and 45% respectively. ICC was excellent for version but only moderate for inclination. ICC was highest among Walch A glenoids for both version (near excellent) and inclination (good), and lowest among Walch D for version (near poor) and Walch B for inclination (moderate). When measuring version, VIP had the highest concordance with manual measurement; Blueprint had the lowest. For inclination Blueprint had the highest concordance; ExactechGPS had the lowest. Discussion & Conclusion: Despite overall high reliability for measures of glenoid version between 4 frequently utilized shoulder arthroplasty templating softwares, this reliability is significantly affected by glenoid deformity. The programs were overall less reliable when measuring inclination, and a similar trend of decreasing reliability with increasing glenoid deformity emerged that was not statistically significant. Concordance with manual measurement is also variable. Further research is needed to understand how this variability should be accounted for during shoulder arthroplasty preoperative planning. Level of Evidence: Level III; Retrospective Comparative Stud

Solving the Logistical Issues of Rapid MSK MR Scanning

Object or Purpose of Study: State of the art sequences and specialized hardware are beginning to allow for the reduction of the acquisition time of musculoskeletal (MSK) Magnetic Resonance (MR) scans. Shorter acquisition times should allow for more patients to be scanned in a day; however, implementing these rapid scans into the imaging workflow required changing the whole MR scheduling system. We report the challenges and benefits after incorporating rapid scan protocols into our imaging workflows. Methods: Multichannel coils were utilized, enabling the use of parallel imaging techniques to reduce routine total joint scan times to under 10 minutes [1]. MSK MR schedule slot times were reduced from 45 minutes to 30 minutes. The institution’s MR schedule was changed from a basis of 45 minute slots to 30 minute slots. After implementing the new rapid MSK scans and 30 minute slot scheduling system in 2018, we collected the scan volume, scheduling lead time, and technologist feedback for July of 2018. This data was compared to data from July of 2017. Data was obtained from a single scanner to control for extraneous factors such as technologist experience, facility workflow, schedule saturation, and patient compliance. Results: The total number of MR studies performed on the scanner increased from 261 in July of 2017 to 289 in July of 2018. Rapid MSK MR image quality was determined to be adequate for the clinical workflow. The two most prominent issues experienced were scheduling and technologist performance difficulties. 20 minute scheduling slots did not allow sufficient time for patient preparation. However, 30 minute slots were found to be ideal. The MR schedule was reorganized to be based on 30 minute slots from 45 minute slots used previously. 51 studies were reassigned 30 minute slots from 45 minute slots. 30 studies were reassigned 1 hour slots from 45 minutes. 19 studies were reassigned 1 hour slots from 1.5 hour slots. Even though many studies were increased from 45 minutes to 1 hour, we found an overall time savings from studies being reduced to 30 minutes and from 1.5 hours to 1 hour. A surprising benefit of moving to a 30-minute time slot schedule was a decrease in the lead time in scheduling for MR. By having more time slots per day available, MR studies were allowed be scheduled sooner. The mean weekly lead time for July 2017 was 15.4 days and for July 2018 was 9.2 days (p\u3c0.05). Shortened 30 minute time slots place additional burdens on the MR technologists, and highlighted differences in speed and efficiency. With the 30 minute slot workflow, there is much less buffer time for patient preparation tasks such as acquiring screening radiographs. Technologists were required to be more flexible and efficient. These changes resulted in differences in patient experience, with some patients feeling rushed. Significance: Implementing rapid MSK MR scans allowed for our institution to switch from 45-minute time slots to 30 minutes time slots for MR scheduling. As a result, our MR study volume increased and our lead time for scheduling decreased, allowing our patients to obtain their MR studies more quickly.https://scholarlycommons.henryford.com/merf2019qi/1017/thumbnail.jp

Sonographic Finding of Medial Ankle Subcutaneous Edema and Its Association with Posterior Tibial Tenosynovitis.

BACKGROUND: To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS). METHODS: Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient\u27s history. Statistical analyses included the Chi-square test and Cohen\u27s Kappa statistics for inter-observer agreement. RESULTS: A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists\u27 findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT ( CONCLUSION: A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction

Automation of Protocoling Advanced MSK Examinations Using Natural Language Processing Techniques

Imaging examination selection and protocoling are vital parts of the radiology workflow, ensuring that the most suitable exam is done for the clinical question while minimizing the patient\u27s radiation exposure. In this study, we aimed to develop an automated model for the revision of radiology examination requests using natural language processing techniques to improve the efficiency of pre-imaging radiology workflow. We extracted Musculoskeletal (MSK) magnetic resonance imaging (MRI) exam order from the radiology information system at Henry Ford Hospital in Detroit, Michigan. The pretrained transformer, DistilBERT was adjusted to create a vector representation of the free text within the orders while maintaining the meaning of the words. Then, a logistic regression-based classifier was trained to identify orders that required additional review. The model achieved 83% accuracy and had an area under the curve of 0.87

Impact of the COVID-19 pandemic on radiology physician work RVUs at a large subspecialized radiology practice

PURPOSE: As the COVID-19 pandemic continues, efforts by radiology departments to protect patients and healthcare workers and mitigate disease spread have reduced imaging volumes. This study aims to quantify the pandemic\u27s impact on physician productivity across radiology practice areas as measured by physician work Relative Value Units (wRVUs). MATERIALS AND METHODS: All signed diagnostic and procedural radiology reports were curated from January 1st to July 1st of 2019 and 2020. Physician work RVUs were assigned to each study type based on the Medicare Physician Fee Schedule. Utilizing divisional assignments, radiologist schedules were mapped to each report to generate a sum of wRVUs credited to that division for each week. Differential impact on divisions were calculated relative to a matched timeframe in 2019 and a same length pre-pandemic time period in 2020. RESULTS: All practice areas saw a substantial decrease in wRVUs from the 2020 pre- to intra-pandemic time period with a mean decrease of 51.5% (range 15.4%-76.9%). The largest declines were in Breast imaging, Musculoskeletal, and Neuroradiology, which had decreases of 76.9%, 75.3%, and 67.5%, respectively. The modalities with the greatest percentage decrease were mammography, MRI, and non-PET nuclear medicine. CONCLUSION: All radiology practice areas and modalities experienced a substantial decrease in wRVUs. The greatest decline was in Breast imaging, Neuroradiology, and Musculoskeletal radiology. Understanding the differential impact of the pandemic on practice areas will help radiology departments prepare for the potential depth and duration of the pandemic by better understanding staffing needs and the financial effects

Predictors of infraspinatus muscle degeneration in individuals with an isolated supraspinatus tendon tear

OBJECTIVE: Determine the demographic and clinical factors that predict infraspinatus muscle degeneration in individuals with an isolated supraspinatus tendon tear. MATERIALS AND METHODS: A retrospective analysis was performed using the medical records of patients who had a shoulder MRI interpreted by 1 of 3 fellowship-trained musculoskeletal radiologists since the implementation of a standardized MRI 3 T protocol within our healthcare system. Demographic (e.g., age, sex) and clinical data (e.g., tear size, muscle degeneration, co-morbidities) were collected. Patients with an isolated supraspinatus tendon tear (n = 121) were assigned to one of two groups based on whether any infraspinatus muscle degeneration was present. Logistic regression was used to assess the univariate relationships between infraspinatus muscle degeneration and patient and clinical data, while least absolute shrinkage and selector operator (LASSO) logistic regression was used to assess the multivariable relationship. RESULTS: Of the patients with an isolated supraspinatus tendon tear, 16.5% had evidence of infraspinatus muscle degeneration. The presence of infraspinatus muscle degeneration was independently associated with cardiovascular disease (P = 0.01), supraspinatus muscle degeneration (P \u3c 0.01), and subscapularis muscle degeneration (P = 0.01). When the multivariable relationship is assessed, supraspinatus muscle degeneration emerged as the only variable of significant importance for detecting infraspinatus muscle degeneration (specificity: 87.1%, sensitivity: 80.0%). CONCLUSION: Infraspinatus muscle degeneration is not uncommon in individuals with an isolated supraspinatus tear and is most associated with concomitant supraspinatus muscle degeneration. These findings highlight the need for clinicians to specifically assess the status of each rotator cuff muscle, even when the tendon itself is intact