Management of COPD: Is there a role for quantitative imaging?

While the recent development of quantitative imaging methods have led to their increased use in the diagnosis and management of many chronic diseases, medical imaging still plays a limited role in the management of chronic obstructive pulmonary disease (COPD). In this review we highlight three pulmonary imaging modalities: computed tomography (CT), magnetic resonance imaging (MRI) and optical coherence tomography (OCT) imaging and the COPD biomarkers that may be helpful for managing COPD patients. We discussed the current role imaging plays in COPD management as well as the potential role quantitative imaging will play by identifying imaging phenotypes to enable more effective COPD management and improved outcomes.     

Is there a role for agonist gastrin-releasing peptide receptor radioligands in tumour imaging?

Gastrin-releasing peptide (GRP) has been shown to be a tumour growth stimulating agent for a number of normal and human cancer cell lines. The tumour growth effect is a direct result of GRP binding to membrane G-protein coupled GRP receptors (GRP-R) on the cell surface. Available data on the role of GRP and GRP-R in human lung, prostate, breast, colorectal and gastric carcinoma are reviewed and it is suggested that radiolabelled agonists are preferable to antagonists for imaging and therapy as they appear to be internalised, yielding a higher target/background ratio. The use of rhenium or indium radiolabels for therapy may provide a new approach to GRP/bombesin expressing tumours.     

Is there a role for CT in the neonate?

Choice of imaging modalities should be based on scientific proof and best practice guidelines. However, in the neonatal age group there is a paucity of medical evidence, and imaging is often guided by local experience, availability of equipment and expertise, and by logistical factors. This paper discusses possible indications for CT in the neonate, the associated radiation protection issues, common CT findings and potential pitfalls in technique and image interpretation. Due to the particular range of abnormalities in this age group, imaging must be tailored to the individual, and should in most cases be done in specialist units.     

Rotator Cuff Repair: Is there any role for acromioplasty?

Objectives: Acromioplasty has been one of the most common techniques amongst orthopedic surgeries in the past decade. However, its efficacy in arthroscopic surgeries of rotator cuff repair is still debatable. The purpose of this study is to compare the arthroscopic rotator cuff repair with or without acromioplasty in patients with complete rotator cuff tear.

Methods: In this prospective cohort study, patients with complete rotator cuff tear (acromion type II or III Bigliani) and a history of failure to the conservative treatment for at least 6 months were evaluated for eligibility. Patients, based on the time interval, were placed in one of two groups: arthroscopic rotator cuff repair with (RCR-A group) and without acromioplasty (RCR group). Patients were assessed for two years in term of pain intensity by VAS criteria and shoulder functional status by Quick-DASH, Constant score and simple shoulder test criteria.

Results: In the baseline assessment, RCR-A group (34 patients) and RCR group (33 patients) were similar. Comparing patients in two groups in relation to SST, Quick-DASH and VAS scores preoperatively showed there is no significant difference between the two groups. The SST, Quick-DASH and VAS scores improved significantly in both groups at both the 6-month and 2-year follow-ups (all P < 0.001). The extent of progress in the functional scores was similar in both groups (P > 0.05).

Conclusion: Arthroscopic rotator cuff repair without acromioplasty may be as reliable and useful as conventional rotator cuff repair with acromioplasty. Thus, acromioplasty cannot be recommended as a routine technique in every rotator cuff repair.     

Nonoperative management of traumatic splenic injuries: is there a role for proximal splenic artery embolization?

OBJECTIVE: The objective of our study was to evaluate our experience with transcatheter proximal (i.e., main) splenic artery embolization (TPSAE) in the nonsurgical management of patients with grade III-V splenic injuries, according to the American Association for the Surgery of Trauma (AAST) guidelines, and patients with splenic injuries associated with CT evidence of active contrast extravasation or blush (or cases meeting both criteria). MATERIALS AND METHODS: The records of patients with traumatic splenic injuries admitted during a 52-month period were retrospectively reviewed for patient age and sex, mechanism of injury, injury severity score (ISS), RBC transfusion requirements, AAST splenic injury CT grade, presence of active contrast extravasation or blush on CT examination, and amount of hemoperitoneum on CT examination. Demographics, CT findings, transfusion requirements, and outcome were compared using the Student's t test or chi-square test in patients undergoing standard nonoperative management and nonoperative management TPSAE-that is, TPSAE followed by nonoperative management. RESULTS: Of the 79 identified patients with splenic trauma, 67 were managed nonoperatively. Thirty-seven patients (28 men, nine women; mean age, 40 years; mean ISS, 28.8) underwent nonoperative management TPSAE and 30 patients (27 men, three women; mean age, 37 years; mean ISS, 25.1) underwent nonoperative management. Age, sex, and ISS were not significantly different between the two groups. TPSAE was always technically feasible. Splenic injuries were significantly more severe in the nonoperative management TPSAE group than in the nonoperative management group with respect to the mean splenic injury AAST CT grade (3.7 vs 2, respectively; p < 0.0001), active contrast extravasation or blush (38% [14/37] vs 3% [1/30], respectively; p = 0.0005), and hemoperitoneum grade (1.6 vs 0.8, respectively; p = 0.0006). Secondary splenectomy rate was lower in the nonoperative management TPSAE group (2.7% [1/37] vs 10% [3/30]). No procedure-related complications were encountered during early and delayed clinical follow-up. CONCLUSION: TPSAE is a feasible and safe adjunct to observation in the nonoperative management of severe traumatic splenic injuries. The secondary splenectomy rate using nonoperative management TPSAE (2.7%) is among the lowest reported despite a selection of severe injuries.     

Contrast-enhanced MR angiography of abdominal vessels: Is there still a role for angiography?

The purpose of this review article is to describe recent advantages in contrast-enhanced (CE) three-dimensional (3D) magnetic resonance angiography (MRA) in comparison with other vascular imaging techniques, and to discuss their current clinical applications for the imaging of abdominal vessels. Principles and technical considerations are presented and clinical applications are reviewed for different vascular diseases. In ruptured aortic aneurysms and acute dissections CT is the method of first choice. Contrast-enhanced 3D MRA can be well used for therapeutic planning and follow-up in patients with stable disease. A comprehensive MR examination including CE 3D MRA, MR urography and MR nephrogram has the potential to replace the conventional studies for the evaluation of renal vascular disease. It is an accurate method for imaging the origins of coeliac and superior mesenteric arteries, although the image resolution is too low for reliable assessment of the inferior mesenteric artery. Contrast-enhanced 3D MRA has emerged as the method of choice for studying the portal venous system in liver transplant recipients, in patients with portal hypertension and in cases with abdominal tumours for preoperative evaluation. Additional non-invasive flow measurements are useful in monitoring portal hypertension. The abdominal veins can be well imaged using unenhanced MR techniques. Imaging may be facilitated with intravascular contrast media. Contrast-enhanced 3D MRA can replace intra-arterial DSA for diagnosis, therapy planning and follow-up in patients with abdominal vascular disease. Catheter-based arteriography will still be used for interventional procedures such as percutaneous transluminal angioplasty, stent placement and embolisation.     

Is there a role for exercise in the prevention of osteoporotic fractures?

OBJECTIVES: To examine whether there is a role for exercise in improving bone mineral density (BMD), particularly in postmenopausal women. The effects of different types of exercise are examined together with their effects at selected skeletal sites. The role of activity in reducing falls and hip fractures will also be considered as well as the potentially negative effects of excessive exercise. METHODS: A literature search over the past 20 years was conducted and landmark papers selected. RESULTS: Certain types of exercise have been found to exert moderate benefits on BMD of the wrist, spine, and hip. Most studies do not detect a difference between the effects of endurance activities and strength training for BMD of the spine. It has been more difficult to isolate the optimal type of activity for effecting an osteogenic response at the hip, but recent evidence suggests that high impact work such as stepping and jumping may be effective at this site. The combination of hormone replacement therapy and exercise would appear to be more effective than either intervention on its own. Certain types of exercises have additional benefits, such as muscle strengthening, which could reduce the incidence of falls. Excessive exercise can lead to menstrual disturbances in female athletes and this in turn can cause bone loss, particularly from the spine. CONCLUSIONS: Exercise across the life span should be encouraged in order to maximise peak bone mass, reduce age related bone loss, and maintain muscle strength and balance. Although the effects of exercise on BMD later in life are small, epidemiological evidence suggests that being active can nearly halve the incidence of hip fractures in the older population. This effect is most probably multifactorial through the positive effects on bone, muscle strength, balance, and joint flexibility. Younger women should be aware of the dangers to the skeleton of menstrual disorders.     

Is there an added role for diffusion weighted imaging in the staging of cervical carcinoma?

Objective

To assess the diagnostic accuracy of diffusion weighted imaging (DWI-MRI) being a non-contrast based MR sequence versus dynamic contrast enhanced MRI (DCE-MRI) in the preoperative loco-regional staging of the cervical carcinoma.

Is there any role for diffusion weighted magnetic resonance imaging before transthoracic CT guided biopsy?

Aim of the work

To evaluate the role of diffusion weighted imaging (DWI) in the planning for CT guided biopsy of lung and mediastinal lesions.

Is there a role for free breathing non-contrast steady-state free precession renal MRA imaging for assessing live donors? A preliminary study

Objective

Accurate pre-operative evaluation of renal vascular anatomy is essential for successful renal harvest in live donor transplantation. Non-contrast renal MR angiographic (MRA) techniques are potentially well suited to the screening of donors; however, their restricted imaging field of view (FOV) has previously been an important limitation. We sought to assess whether the addition of a large FOV balanced fast field echo (BFFE) steady-state free precession (SSFP) sequence to non-contrast SSFP MRA could overcome this problem. Comparison with contrast-enhanced MRA (CE MRA) and findings at surgery were performed.

Methods

22 potential renal donors each underwent SSFP and CE MRA. 11 out of 22 potential donors subsequently underwent a donor nephrectomy.

Results

All images were diagnostic. Both SSFP MRA and CE MRA identified an equal number of arteries. Surgery confirmed two accessory renal arteries, both demonstrated with both imaging techniques. A third accessory vessel was identified with both techniques on a kidney contralateral to the donated organ. 6 out of 11 procured kidneys demonstrated early branch arteries at surgery, 5 out of 6 of which had been depicted on both SSFP and CE MRA. The median grading of image quality for main renal arteries was slightly better for CE MRA (p=0.048), but for accessory vessels it was better for SSFP MRA.

Conclusion

This pilot study indicates that by combining free-breathing SSFP MRA with large-FOV bFFE images, an accurate depiction of renal vascular anatomy without the need for intravenous contrast administration can be obtained, as compared with surgical findings and CE MRA.Living donor transplantation is becoming an increasingly important treatment option for end-stage renal failure (ESRF). The high prevalence of anatomical variants in renal vascular anatomy underscores the importance of accurate pre-operative evaluation of the vascular anatomy [1,2], particularly in patients undergoing a laparoscopic approach, as the surgical field of view (FOV) is limited. Multiple renal arteries in the donor kidney result in a substantial increase in the risk of complications. Moreover, the presence of accessory arteries and early branches of the renal arteries, as well as variants in venous anatomy, can all affect the surgical decision for suitability for donor harvest [3,4].Although there has been some debate about the optimal imaging strategy for potential renal donors [5-7], with concerns raised over the ability of contrast-enhanced MR angiography (CE MRA) to detect all renal arteries [8], there is evidence to support the sole use of CE MRA for this purpose [9]. Non-contrast MRA techniques have been used for several years, but have been generally overshadowed by the more popular contrast-enhanced techniques [10]. CT angiography is a proven tool in this domain. It also has the ability to detect parenchymal abnormalities and calculi; however, its use of ionising radiation is a disadvantage that should be considered when evaluating a donor population [11,12].Balanced steady-state free precession (SSFP) MRA provides a high signal-to-noise ratio (SNR) of blood and a unique T₁/T₂ weighting [13]. SSFP MRA is a non-contrast technique that has been used for the imaging of renal vasculature in several studies [14-16]. SSFP MRA utilises an intrinsically fast sequence and is flow-compensated in all three axes [17]. For renal vascular imaging, SSFP MRA can be combined with cardiac triggering, respiratory navigator gating and slab-selection inversion for background signal suppression [18]. While a number of studies indicate that SSFP MRA can provide an alternative to CE MRA in the investigation of atherosclerotic renal artery stenosis [18,19], the role of SSFP MRA in renal donor assessment remains uncertain, with concerns about the limited FOV resulting in the failure to identify accessory arteries [20]. We hypothesise that, with the addition of axial and coronal high-resolution breath-hold balanced fast field echo (BFFE) SSFP sequences to provide a large FOV, accurate localisation of vessels could be achieved prior to the planning of the SSFP MRA. We sought to compare the accuracy of free-breathing, non-contrast, balanced SSFP MRA with CE MRA and intra-operative findings at the time of renal harvest.