Imaging Non-Specific Wrist Pain: Interobserver Agreement and Diagnostic Accuracy of SPECT/CT, MRI, CT, Bone Scan and Plain Radiographs

PURPOSE: Chronic hand and wrist pain is a common clinical issue for orthopaedic surgeons and rheumatologists. The purpose of this study was 1. To analyze the interobserver agreement of SPECT/CT, MRI, CT, bone scan and plain radiographs in patients with non-specific pain of the hand and wrist, and 2. to assess the diagnostic accuracy of these imaging methods in this selected patient population. MATERIALS AND METHODS: Thirty-two consecutive patients with non-specific pain of the hand or wrist were evaluated retrospectively. All patients had been imaged by plain radiographs, planar early-phase imaging (bone scan), late-phase imaging (SPECT/CT including bone scan and CT), and MRI. Two experienced and two inexperienced readers analyzed the images with a standardized read-out protocol. Reading criteria were lesion detection and localisation, type and etiology of the underlying pathology. Diagnostic accuracy and interobserver agreement were determined for all readers and imaging modalities. RESULTS: The most accurate modality for experienced readers was SPECT/CT (accuracy 77%), followed by MRI (56%). The best performing, though little accurate modality for inexperienced readers was also SPECT/CT (44%), followed by MRI and bone scan (38% each). The interobserver agreement of experienced readers was generally high in SPECT/CT concerning lesion detection (kappa 0.93, MRI 0.72), localisation (kappa 0.91, MRI 0.75) and etiology (kappa 0.85, MRI 0.74), while MRI yielded better results on typification of lesions (kappa 0.75, SPECT/CT 0.69). There was poor agreement between experienced and inexperienced readers in SPECT/CT and MRI. CONCLUSIONS: SPECT/CT proved to be the most helpful imaging modality in patients with non-specific wrist pain. The method was found reliable, providing high interobserver agreement, being outperformed by MRI only concerning the typification of lesions. We believe it is beneficial to integrate SPECT/CT into the diagnostic imaging algorithm of chronic wrist pain

Chlorate et bromate dans les piscines, évaluation de la situation et mesures à prendre pour minimiser ces polluants

L’eau des piscines publiques est désinfectée à l’aide de différents traitements, la chloration étant la plus fréquente. Dans les eaux de baignade les concentrations en sous-produits de désinfection (SOD) varient en fonction des caractéristiques des substances désinfectantes. Notre étude se focalise sur le chlorate et le bromate, substances persistantes et s’accumulant car elles ne sont retenues par aucun filtre et leur oxydation n’est pas possible. Celles-ci augmentent jusqu’à ce que l’eau des bassins soit totalement renouvelée. Par l’analyse statistique de 553 échantillons d’eau de baignade nous dégageons les facteurs qui influencent significativement les concentrations en chlorate ou bromate. Durant huit ans, les échantillons ont été prélevés à intervalles irréguliers dans 42 piscines. Bromate: des concentrations mesurables en bromate ne sont observées qu’avec le procédé NaBr-ozone (médiane 0,99 mg BrO3−.L−1, max 2,0 mg BrO3−.L−1) et l’eau de Javel (NaClO) (médiane 0,04 mg BrO3−.L−1, max 1,4 mg BrO3−.L−1) ; ces concentrations sont statistiquement différentes. Chlorate: les concentrations en chlorate varient énormément selon le type de désinfectant (p<0,001, test du rapport de vraisemblance) ; ce facteur a bien plus d’influence que les traitements additionnels aux UV (moyenne pression) ou à l’ozone. Les concentrations les plus élevées sont observées dans l’eau traitée avec NaClO (médiane 8,1 mg ClO3−.L−1, max. 109,4 mg ClO3−.L−1) et avec NaClO formé par électrolyse de NaCl et stocké provisoirement (médiane 5,2 mg ClO3−.L−1, max. 26,9 mg ClO3−.L−1) ; pour les deux traitements de grandes différences sont observées entre les piscines. La concentration médiane de chlorate avec l’hypochlorite de calcium est à 2,26 mg.L−1 (max. 20,3 mg ClO3−.L−1), et à 0,27 mg ClO3−.L−1 avec l’électrolyse de HCl formant l’acide hypochloreux (max. 2,7 mg ClO3−.L−1). Les différences inter-piscines sont moins accentuées. L’analyse statistique montre que les facteurs ozone, UV, bassin en plein air ou non, type de bassin ainsi que la substance utilisée pour réguler le pH influencent les concentrations en chlorate. Au vu de nos résultats et de la littérature sur la toxicité de ces substances, un catalogue de mesures est proposé pour éviter que l’eau de baignade ne soit trop fortement contaminée par ces polluants

The health technology assessment of the compulsory accident insurance scheme of hand transplantation in Switzerland

Recently the decision-making committee of the compulsory Swiss accident insurance scheme needed to make a basic decision as to whether to fund hand transplantation under that scheme or not. A Health Technology Assessment was commissioned to inform decision-making and gain experience with applicability of the method. The following were main findings from various domains. Compared with prosthesis fitting, the outcome of hand transplantation is satisfactory for function and sensibility. Complications due to immunosuppression are frequent, sometimes severe and potentially life-shortening. The direct medical costs over the entire life span calculated for a 35-year-old unilaterally amputated base case patient were CHF 528,600 (EUR 438,500) higher than for a prosthesis. There are challenging ethical, legal and organizational issues. The committee decided not to reimburse hand transplantation for ethical reasons. The Health Technology Assessment has been shown to be a useful tool for decision-making in the context of Swiss accident insurance

Die Methode des Health Technology Assessment (HTA) im Rahmen der obligatorischen Unfallversicherung : das Beispiel der Hand-Transplantation

Die Hand-Transplantation ist eine bis heute umstrittene Therapieoption für Patienten mit Handamputationen. Weltweit wurden bisher einige dutzend Patienten mit einer solchen Transplantation behandelt. Die SUVA wurde von einem Unispital angefragt, ob eine Hand-Transplantation auch in der Schweiz durch die obligatorische Unfallversicherung gedeckt würde. Um in dieser Frage einen Grundsatzentscheid fällen zu können, hat die Medizinaltarif-Kommission UVG (MTK) ein Health Technology Assessment (HTA) in Auftrag gegeben. Dieses HTA untersuchte medizinische, ökonomische, ethische, juristische und organisatorische Aspekte der Hand-Transplantation mittels Literaturrecherche, Experteninterviews und Kostenmodellierung. Basierend auf diesem Assessment hat die MTK UVG entschieden, Hand-Transplantationen in der Schweiz aufgrund des mangelnden Wirksamkeitsnachweises und ethischer Bedenken nicht zu bezahlen

Hypervigilance-avoidance pattern in spider phobia

Cognitive-motivational theories of phobias propose that patients' behavior is characterized by a hypervigilance-avoidance pattern. This implies that phobics initially direct their attention towards fear-relevant stimuli, followed by avoidance that is thought to prevent objective evaluation and habituation. However, previous experiments with highly anxious individuals confirmed initial hypervigilance and yet failed to show subsequent avoidance. In the present study, we administered a visual task in spider phobics and controls, requiring participants to search for spiders. Analyzing eye movements during visual exploration allowed the examination of spatial as well as temporal aspects of phobic behavior. Confirming the hypervigilance-avoidance hypothesis as a whole, our results showed that, relative to controls, phobics detected spiders faster, fixated closer to spiders during the initial search phase and fixated further from spiders subsequently

The role of the human posterior parietal cortex in memory-guided saccade execution: a double-pulse transcranial magnetic stimulation study

The present study investigated the role of the right posterior parietal cortex (PPC) in the triggering of memory-guided saccades by means of double-pulse transcranial magnetic stimulation (dTMS). Shortly before saccade onset, dTMS with different interstimulus intervals (ISI; 35, 50, 65 or 80 ms) was applied. For contralateral saccades, dTMS significantly decreased saccadic latency with an ISI of 80 ms and increased saccadic gain with an ISI of 65 and 80 ms. Together with the findings of a previous study during frontal eye field (FEF) stimulation the present results demonstrate similarities and differences between both regions in the execution of memory-guided saccades. Firstly, dTMS facilitates saccade triggering in both regions, but the timing is different. Secondly, dTMS over the PPC provokes a hypermetria of contralateral memory-guided saccades that was not observed during FEF stimulation. The results are discussed within the context of recent neurophysiological findings in monkeys

Residual oculomotor and exploratory deficits in patients with recovered hemineglect

Several studies on hemineglect have reported that patients recover remarkably well when assessed with neuropsychological screening tests, however, they show deficits on novel or complex tasks. We investigated whether such deficits can be revealed with eye movement analysis, applying two basic oculomotor tasks as well as two exploratory tasks. Eye movements were recorded in eight hemineglect patients at least eleven months after right-hemisphere brain damage had occurred. Sixteen healthy volunteers participated in the control group. Regarding the basic oculomotor tasks, only the overlap task revealed residual deficits in patients, suggesting that a directional deficit in disengaging attention persisted during recovery. Further residual deficits were evident in the exploratory tasks. When everyday scenes were explored, patients showed a bias in early orienting towards the ipsilateral hemispace. In a search task, they demonstrated the same orienting bias as well as a non-directional deficit concerning search times. Moreover, patients preferentially fixated in the contralateral hemispace, but did not benefit from this asymmetry in terms of search times, i.e. they did not detect contralateral targets faster than ipsilateral ones. This suggests a dissociation between oculomotor processes and attentional ones. In conclusion, we have identified behavioural aspects that seem to recover slower than others. A disengagement deficit and biases in early orienting have been the most pronounced residual oculomotor deficits

Feasibility and preliminary results of SPECT/CT arthrography of the wrist in comparison with MR arthrography in patients with suspected ulnocarpal impaction

PURPOSE To evaluate the feasibility and performance of SPECT/CT arthrography of the wrist in comparison with MR arthrography in patients with suspected ulnocarpal impaction. METHODS This prospective study included 28 wrists of 27 patients evaluated with SPECT/CT arthrography and MR arthrography. Iodine contrast medium and gadolinium were injected into the distal radioulnar and midcarpal joints. Late-phase SPECT/CT was performed 3.5 h after intravenous injection of approximately 650 MBq (99m)Tc-DPD. MR and SPECT/CT images were separately reviewed in relation to bone marrow oedema, radionuclide uptake, and tears in the scapholunate (SL) and lunotriquetral (LT) ligaments and triangular fibrocartilage complex (TFCC), and an overall diagnosis of ulnar impaction. MR, CT and SPECT/CT imaging findings were compared with each other, with the surgical findings in 12 patients and with clinical follow-up. RESULTS The quality of MR arthrography and SPECT/CT arthrography images was fully diagnostic in 23 of 28 wrists (82%) and 25 of 28 wrists (89%), respectively. SPECT/CT arthrography was not diagnostic for ligament lesions due to insufficient intraarticular contrast in one wrist. MR and SPECT/CT images showed concordant findings regarding TFCC lesions in 22 of 27 wrists (81%), SL ligament in 22 of 27 wrists (81%) and LT ligament in 23 of 27 wrists (85%). Bone marrow oedema on MR images and scintigraphic uptake were concordant in 21 of 28 wrists (75%). MR images showed partial TFCC defects in four patients with normal SPECT/CT images. MR images showed bone marrow oedema in 4 of 28 wrists (14%) without scintigraphic uptake, and scintigraphic uptake was present without MR bone marrow oedema in three wrists (11%). Regarding diagnosis of ulnar impaction the concordance rate between CT and SPECT/CT was 100% and reached 96% (27 of 28) between MR and SPECT/CT arthrography. The sensitivity and specificity of MR, CT and SPECT/CT arthrography were 93%, 100% and 100%, and 93%, 93% and 93%, respectively. CONCLUSION SPECT/CT arthrography of the wrist is feasible. Regarding diagnosis of ulnar impaction we found a high concordance with MR arthrography. SPECT/CT arthrography of the wrist is an alternative to MR arthrography in patients with contraindications to MR imaging

To look or not to look at threat? Scanpath differences within a group of spider phobics

Predicting the behavior of phobic patients in a confrontational situation is challenging. While avoidance as a major clinical component of phobias suggests that patients orient away from threat, findings based on cognitive paradigms indicate an attentional bias towards threat. Here we present eye movement data from 21 spider phobics and 21 control subjects, based on 3 basic oculomotor tasks and a visual exploration task that included close-up views of spiders. Relative to the control group, patients showed accelerated reflexive saccades in one of the basic oculomotor tasks, while the fear-relevant exploration task evoked a general slowing in their scanning behavior and pronounced oculomotor avoidance. However, this avoidance strongly varied within the patient group and was not associated with the scores from spider avoidance-sensitive questionnaire scales. We suggest that variation of oculomotor avoidance between phobics reflects different strategies of how they cope with threat in confrontational situations