Sickle cell disease (SCD) is a hereditary red cell disorder with clinical manifestations secondary to sickling or crescent-shaped distortion of the red blood cells. Major clinical manifestations of SCD include haemolytic anaemia and vaso-occlusive phenomena resulting in ischaemic tissue injury and organ damage. Chronic sequelae of the anaemia and vaso-occlusive processes involving the musculoskeletal system include complications related to extramedullary haematopoiesis, osteonecrosis, myonecrosis and osteomyelitis. Sickle cell bone disease is one of the commonest clinical presentations. Awareness and knowledge of the imaging features related to these complications are essential for early diagnosis and prompt management. In this article, the pathophysiology and key imaging findings related to these complications are reviewed.

OBJECTIVE Recent articles have identified the poor diagnostic yield of percutaneous needle biopsy for vertebral osteomyelitis. The current study aimed to confirm the higher accuracy of CT-guided spinal biopsy for vertebral neoplasms and to identify which biopsy technique provides the highest yield. METHODS Over a 9-year period, the radiology department at University Hospitals Case Medical Center performed 222 CT-guided biopsies of vertebral lesions, of which clinicians indicated a concern for vertebral neoplasms in 122 patients. A retrospective chart review was performed to confirm the higher sensitivity of the percutaneous intervention for vertebral neoplasms. RESULTS A core sample was obtained for all 122 biopsies of concern (100.0%). Only 6 cases (4.9%) were reported as nondiagnostic per histological sampling, and 12 cases (9.8%) were negative for disease. The question of vertebral neoplastic involvement warrants follow-up, and the current study was able to determine the subsequent diagnosis of each lesion. Of the 122 total, 94 (77.0%) core samples provided true-positive results, and the sensitivity of core biopsy measured 87.9%. The technical approach did not demonstrate any significant difference in diagnostic yield. However, when the vertebral cortex was initially pierced with a coaxial bone biopsy system and subsequently a 14-gauge spring-loaded cutting biopsy needle was coaxially advanced into lytic lesions, 14 true positives were obtained with a corresponding sensitivity of 100.0%. CONCLUSIONS This study confirms the higher sensitivity of image-guided percutaneous needle biopsy for vertebral neoplasms. In addition, it demonstrates how the use of a novel cutting needle biopsy approach, performed coaxially through a core biopsy track, provides the highest yield.

Mucolipidosis type II (I-Cell disease) is a rare autosomal recessive lysosomal disorder, resulting from functional deficiency of lysosomal enzymes due to an impaired targeting of the enzymes to lysosomes, which leads to an abnormal cell architecture and the overflow of lysosomal enzymes into the body fluids. The life expectancy of the patients is poor, with multisystem deterioration leading to death in early childhood. According to the available reports, patients with I-cell disease do not survive beyond the first decade of life. Here, we describe and illustrate various radiological-musculoskeletal manifestations of a rare case of mucolipidosis II who has been a survivor up to now, 20 years old. The course of her disease has been complicated by early severe visual compromise due to optic nerve swelling, hearing loss and mitral valve regurgitation/stenosis, bilateral carpal tunnel, and severe growth impairment. Our case demonstrates several skeletal features of dysostosis multiplex. At the age of 20, she is wheelchair bound and her medical course is complicated by recurrent pneumonia, treated with multiple hospitalizations, antibiotics, and BiPAP. She is on outpatient palliative care, Do Not Resuscitate/Do Not Intubate (DNR/DNI) status.

Radiofrequency ablation technique for treatment of OO including ablation time and temperature vary greatly between and within reported studies. This study evaluates the immediate and long-term efficacy and complication rate of a two sequential RFA technique for OO.

PURPOSE: The purpose was to evaluate skeletal muscle microcirculation by means of quantitative dynamic contrast-enhanced ultrasound (DCEUS) in patients with systemic sclerosis (SSc).METHODS: DCEUS imaging of the gastrocnemius muscle was performed with phospholipid-stabilized microbubbles filled with sulfur hexafluoride in 12 patients with SSc and 12 healthy volunteers. The fitted time intensity curves (TIC) during the first 3 minutes after administration of the contrast agent bolus were analysed. Time course parameters of the TIC were compared between patients and healthy volunteers.RESULTS: Peak enhancement, wash-in area under the curve and was-out area under the curve was decreased in the patient group versus healthy volunteers (168 versus 248 AU p = 0.291; 2193 versus 3314 p = 0.198; 4948 AU x sec versus 8948 AU x sec p = 0.037). In the SSc patients the mean transit time and wash-in perfusion index were numerically, but not statistically lower than in the healthy volunteers, but rise and fall time were similar.CONCLUSION: On the microvascular level in SSc patients versus their healthy counterpart key parameters related to blood volume were decreased and perfusion parameters showed a slight diminishment in the patient population. These results suggest a component of impaired skeletal muscle microcirculation in SSc patients.

RATIONALE AND OBJECTIVES:The Association of Program Directors in Radiology regularly surveys its members regarding issues of importance to support radiology residency programs and their directors.MATERIALS AND METHODS:This is an observational cross-sectional study using two Web-based surveys posed to the Association of Program Directors in Radiology membership in the fall of 2014 (49 items) and the spring of 2015 (46 items) on the subjects of importance to the members, including the Accreditation Council on Graduate Medical Education Milestones, the Non-Interpretative Skills Curriculum, the American Board of Radiology Core Examination, the effect of the new resident testing and program accreditation paradigms on training outcomes, the 2015 Residency Match, the Interventional Radiology/Diagnostic Radiology (IR/DR) Residency, and Program Director (PD)/Program Coordinator resources.RESULTS:Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 63rd annual meeting of the Association of University Radiologists. The maximal response rate was 33% in the fall of 2014 and 36% in the spring of 2015.CONCLUSIONS:PDs believed that the radiology Milestones, now largely implemented, did not affect overall resident evaluation, was not reflective of resident experience, and actually made evaluation of residents more difficult. PDs also felt that although the American Board of Radiology oral examination had been a better test for clinical practice preparedness, their new residents knew at least as much as before. There was little evidence of recall reemergence. The radiology training community saw a drop in residency applicant quality as demonstrated by the United States Medical Licensing Examination scores and clinical rotation grades. Because the new IR/DR Residency positions were to be funded at the expense of the traditional DR positions, the majority of PDs expected a negative effect of the impending IR/DR match on their DR recruitment. PDs were in favor of a unified clinical radiology curriculum similar to the Radiological Society of North America online physics modules.

Regarding the international medical graduates (IMG) applying to radiology, our survey results are in line with the National Resident Matching Program (NRMP) data ( 1 http://www.nrmp.org/match-data/main-residency-match-data/ Google Scholar ), which show that US medical school graduates have an overall match rate almost double that of IMG applicants. At the same time, the recent literature ( 2 Boulet J.R. Swanson D.B. Cooper R.A. et al. A comparison of the characteristics and examination performances of U.S. and non-U.S. citizen international medical graduates who sought Educational Commission for Foreign Medical Graduates certification: 1995–2004. Acad Med. 2006; 81: S116-S119 Crossref Google Scholar , 3 Benson J.A. Meskauskas J.A. Grosso L.J. Performance of U.S. citizen foreign medical graduates on certifying examinations in internal medicine. Am J Med. 1981; 71: 270-273 Abstract Full Text PDF PubMed Scopus (21) Google Scholar , 4 Shea J.A. Norcini J.J. Day S.C. et al. Performance of U. S. citizen Caribbean medical school graduates on the American Board of Internal Medicine certifying examinations, 1984–1987. Teach Learn Med. 1989; 1: 10-15 Crossref Scopus (9) Google Scholar , 5 Norcini J.J. Anderson M.B. McKinley D.W. The medical education of United States citizens who train abroad. Surgery. 2006; 140: 338-346 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar , 6 Norcini J.J. Boulet J.R. Dauphinee W.D. et al. Evaluation of quality of care provided by graduates of international medical schools. Health Aff. 2010; 29: 1461-1468 Crossref PubMed Scopus (106) Google Scholar , 7 Garibaldi R.A. Subhiyah R. Moore M.E. et al. The In-Training Examination in Internal Medicine: an analysis of resident performance over time. Ann Intern Med. 2002; 137: 505-510 Crossref PubMed Scopus (81) Google Scholar , 8 Gozu A. Kern D.E. Wright S.M. Similarities and differences between international medical graduates and U.S. medical graduates at six Maryland community-based internal medicine residency training programs. Acad Med. 2009; 84: 385-390 Crossref PubMed Scopus (28) Google Scholar ) does not offer a clear justification for such pronounced preference on the basis of clinical or academic performance. Dr. Pfeifer offers his personal experience in support of IMG radiology trainees and states that the literature quoted in our article cannot be easily extrapolated to radiology. As a spoiler alert, the recently concluded 2016 Spring Association of Program Directors in Radiology survey shows ( 9 Annual Survey Committee of the APDR Personal communications. Results of the Spring 2016 membership survey. 2016 Google Scholar ) that among program directors, who have experience training IMG residents, 78% thought that IMGs performed as well as US medical doctors (MD) at the end of training. We agree with Dr. Pfeifer that more research is needed to understand the differences in performance, if any, among different trainee cohorts and the barriers to recruitment and training of IMG residents.

The purpose of this study was to evaluate temporal alterations of the Achilles tendon volume and hydration state after cross‐country‐running. Achilles tendons of six untrained participants were examined on a 3T MR‐scanner before running, immediately afterwards, and in the following 24, 48, and 72 h. Using a 3D‐UTE sequence, caudal (CA) and cranial (CR) mid‐portion tendon areas were examined with off‐resonance saturation ratios (OSR) and T2* relaxation times. Tendon volume was measured with a self‐written Matlab‐based automated contour detection algorithm (AVAT) in submillimeter T2‐weighted MR images. A significant influence of running in caudal (P = 0.017) and cranial OSR values (P = 0.001), tendon volume (P = 0.024), and cranial T2* measurements (P = 0.046), but not in caudal T2* values (P = 0.298) were found. In detail, mean individual OSR and tendon volume measurements demonstrated a similar but inverted course in their values after exercise: initially, OSR values increased after running (and tendon volume decreased), while subsequently a decrease of OSR values (with an increase of tendon volume) could be observed. OSR and tendon volume measurements are able to detect a physiological response of tendons to a mechanical stimulus. After a transient decrease of free water in the Achilles tendon, an increase with a maximum free water content 48 h after ankle loading and a tendency toward normalization after 72 h was found.

OBJECTIVE:The purpose of this study was to determine whether simulation-based training can improve resident performance in ultrasound-guided biopsy.SUBJECTS AND METHODS:Forty radiology residents from a single academic institution enrolled in the study. Each resident performed an initial biopsy on an abdominal imaging phantom using direct ultrasound guidance. Twenty of the residents underwent a 30-minute training session with the phantom device, and 20 residents received no additional training. The residents performed a repeat biopsy of the same lesion and were graded on overall procedure time, number of skin surface punctures, number of gross needle adjustments, and subjective performance as determined by a blinded grader.RESULTS:Residents who participated in the training had a statistically significant 92.3-second reduction in procedure time (68% improvement, p = 0.01), 1.1 reduction in number of skin punctures per biopsy (50% improvement, p = 0.05), 2.5 reduction in number of needle adjustments (66% improvement, p = 0.04), and an increase of 0.85 points in score on a 5-point Likert grading scale (23% improvement, p < 0.01). Residents who did not receive any additional training did not improve in any performance metric.CONCLUSION:Simulation-based training improves overall procedure time, number of skin punctures and needle adjustments, and subjective performance.

Background: The majority of rim recession for femoroacetabular impingement (FAI) is performed anteriorly and has traditionally been assessed by the lateral center-edge (CE) angle, which correlates most closely with lateral coverage. The radiographic false-profile view permits measurement of anterior coverage via the anterior CE angle and more closely correlates with anterior coverage. Purpose: To answer the following questions: (1) How does incremental anterior rim recession change lateral and anterior CE angles? and (2) Can these changes be predicted by a formula? Study Design: Descriptive laboratory study. Methods: Twelve cadaveric hips were dissected free of soft tissue to expose the anterior acetabular rim. Incremental resections of 2.5 mm (range, 0-10 mm) were performed from the 12- to 3-o’clock position using a Dremel rotary tool. Anteroposterior hip and false-profile radiographs were obtained at each interval using a fluoroscopic C-arm. The lateral and anterior CE angles were measured by 3 orthopaedic surgeons. Results: The average preresection lateral CE angle was 35.1°, and the mean decrease in lateral CE angle from 0 to 10 mm was 9.9°; the average preresection anterior CE angle was 38.4° and the mean decrease in anterior CE angle from 0 to 10 mm was 18.2°. The anterior CE angle decreased by a factor of 1.9 when compared with the lateral CE angle ( P = 2 × 10−7). The lateral CE angle decreased by approximately 1° (1.0°) per millimeter of rim recessed. The anterior CE angle decreased by approximately 2° (1.8°) per millimeter of rim recessed. Conclusion: The lateral CE angle should not be extrapolated to reflect anterior acetabular coverage. The anterior CE angle is a superior marker and predictably decreases with rim recession at double the rate of the lateral CE angle. Clinical Relevance: The false-profile view is recommended in the perioperative workup for all patients undergoing arthroscopic treatment of pincer impingement.

Contrast enhancement of the vertebral body marrow may be seen secondary to collateral venous blood flow via the vertebral venous plexus in the setting of superior vena cava obstruction. We report a 48-year-old woman presenting with bilateral brachiocephalic vein obstruction and multilevel thoracic spine hyperdensities as seen on venous-phase CT angiography (CTA), initially concerning for sclerotic neoplastic lesions. A contrast-enhanced CT of the neck obtained 1 day prior to the chest CTA did not demonstrate any osseous abnormality, and inspection of the chest CTA demonstrated filling of perivertebral venous collateral vessels. The abnormal vertebral body enhancement was therefore feltsecondary to retrograde collateral venous flow via the basivertebral venous plexus in the setting of functional SVC obstruction. Vertebral body enhancement should be considered in patients with thoracic central venous obstruction when enhancement or apparent sclerosis of the vertebral bodies is seen on CTA.

Multiple nonmorphologic magnetic resonance sequences are available in musculoskeletal imaging that can provide additional information to better characterize and diagnose musculoskeletal disorders and diseases. These sequences include blood-oxygen-level-dependent (BOLD), arterial spin labeling (ASL), diffusion-weighted imaging (DWI), and diffusion-tensor imaging (DTI). BOLD and ASL provide different methods to evaluate skeletal muscle microperfusion. The BOLD signal reflects the ratio between oxyhemoglobin and deoxyhemoglobin. ASL uses selective tagging of inflowing blood spins in a specific region for calculating local perfusion. DWI and DTI provide information about the structural integrity of soft tissue including muscles and fibers as well as pathologies.

RATIONALE AND OBJECTIVES:The Association of Program Directors in Radiology (APDR) surveys residents' educational experiences, work responsibilities, and benefits to support radiology residency programs and their directors.MATERIALS AND METHODS:This is an observational cross-sectional study using three Web-based surveys posed to the APDR membership in the spring of 2013 (March 7-29, 2013; 44 items), the fall of 2013 (October 24 to November 15, 2013; 36 items), and the spring of 2014 (March 3-21, 2014; 49 items) on the American Board of Radiology (ABR) Core examination, organization of Clinical Competency Committees (CCCs), fellowship match, and interventional radiology (IR)-diagnostic radiology (DR) training programs.RESULTS:Responses were collected electronically, results were tallied using SurveyMonkey software, and qualitative responses were tabulated or summarized as comments. Findings were reported during the 60th and 61st annual meetings of the Association of University Radiologists, respectively. The maximal response rate was 35% in the spring 2013, 39% in the fall 2013, and 39% in the spring 2014.CONCLUSIONS:With the ABR Core examination, radiology educators increasingly included multiple choice questions in teaching conferences. "Boards frenzy" was alive and well. The number of programs with a CCC was growing, chaired primarily by the Program Director (PD), with the most commonly used tool being the rotation evaluation. In view of "fellowship frenzy" in the third year of residency, only a minority of PDs were against a fellowship match in the National Resident Matching Program (NRMP). The majority of respondents replied that the new IR/DR pathway would negatively affect the DR residency.

Diffusion-weighted imaging (DWI) is an established diagnostic tool with regards to the central nervous system (CNS) and research into its application in the musculoskeletal system has been growing. It has been shown that DWI has utility in differentiating vertebral compression fractures from malignant ones, assessing partial and complete tears of the anterior cruciate ligament (ACL), monitoring tumor response to therapy, and characterization of soft-tissue and bone tumors. DWI is however less useful in differentiating malignant vs. infectious processes. As of yet, no definitive qualitative or quantitative properties have been established due to reasons ranging from variability in acquisition protocols to overlapping imaging characteristics. Even with these limitations, DWI can still provide clinically useful information, increasing diagnostic accuracy and improving patient management when magnetic resonance imaging (MRI) findings are inconclusive. The purpose of this article is to summarize recent research into DWI applications in the musculoskeletal system.

A delicate balance exists between under and over recession of the acetabular rim during arthroscopic treatment of pincer lesions. The majority of rim recession is performed anteriorly at the location of impingement. The lateral center edge (CE) angle, as measured on an AP radiograph, is commonly used to quantify acetabular coverage. However, this index correlates most accurately to lateral coverage. The false profile view is a radiographic projection that permits measurement of anterior coverage via the anterior CE angle.

PET/MRI is an evolving hybrid imaging modality which combines the inherent strengths of MRIs soft-tissue and contrast resolution and PETs functional metabolic capabilities. Bone and soft-tissue sarcoma are a relatively rare tumor entity, relying on MRI for local staging and often on PET/CT for lymph node involvement and metastatic spread evaluation. The purpose of this article is to demonstrate the successful use of PET/MRI in two sarcoma patients. We also use these patients as a starting point to discuss how PET/MRI might be of value in sarcoma. Among its potential benefits are: superior TNM staging than either modality alone, decreased radiation dose, more sensitive and specific follow-up and better assessment of treatment response. These potentials need to be investigated in future PET/MRI soft-tissue sarcoma trials.

Magentic Resonance/positron emission tomography (PET) has been introduced recently for imaging of clinical patients. This hybrid imaging technology combines the inherent strengths of MRI with its high soft-tissue contrast and biological sequences with the inherent strengths of PET, enabling imaging of metabolism with a high sensitivity. In this article, we describe the initial experience of MR/PET in a clinical cancer center along with a review of the literature. For establishing MR/PET in a clinical setting, technical challenges, such as attenuation correction and organizational challenges, such as workflow and reimbursement, have to be overcome. The most promising initial results of MR/PET have been achieved in anatomical areas where high soft-tissue and contrast resolution is of benefit. Head and neck cancer and pelvic imaging are potential applications of this hybrid imaging technology. In the pediatric population, MR/PET can decrease the lifetime radiation dose. MR/PET protocols tailored to different types of malignancies need to be developed. After the initial exploration phase, large multicenter trials are warranted to determine clinical indications for this exciting hybrid imaging technology and thereby opening new horizons in molecular imaging.

Introduction Bone and soft tissue sarcomas are rare and heterogeneous tumor entities; more than 50 histologic subtypes of these exist. Soft tissue sarcomas account for 0.7% and 6.5% of all adult and childhood malignancies, respectively, and primary bone cancer comprises 0.2% of all malignancies. Established treatment protocols for sarcoma are multimodal and complex and include surgery, neoadjuvant chemotherapy, adjuvant chemotherapy, and radiation therapy. Most recently, targeted therapy has been introduced in the clinical setting and is being tested in a variety of trials. Metastatic disease occurs in up to 60% of patients with sarcoma who have been treated initially with curative intention, and the lung is the most common site of metastasis in most histologic subtypes of sarcoma. Improved outcomes may be attainable with earlier detection of metastatic disease and with accurate detection of local recurrence following therapy.

BACKGROUND AND PURPOSE: MR imaging and PET/CT are integrated in the work-up of head and neck cancer patients. The hybrid imaging technology 18F-FDG-PET/MR imaging combining morphological and functional information might be attractive in this patient population. The aim of the study was to compare whole-body 18F-FDG-PET/MR imaging and 18F-FDG-PET/CT in patients with head and neck cancer, both qualitatively in terms of lymph node and distant metastases detection and quantitatively in terms of standardized uptake values measured in 18F-FDG-avid lesions. MATERIALS AND METHODS: Fourteen patients with head and neck cancer underwent both whole-body PET/CT and PET/MR imaging after a single injection of 18F-FDG. Two groups of readers counted the number of lesions on PET/CT and PET/MR imaging scans. A consensus reading was performed in those cases in which the groups disagreed. Quantitative standardized uptake value measurements were performed by placing spheric ROIs over the lesions in 3 different planes. Weighted and unweighted κ statistics, correlation analysis, and the Wilcoxon signed rank test were used for statistical analysis. RESULTS: κ statistics for the number of head and neck lesion lesions counted (pooled across regions) revealed interreader agreement between groups 1 and 2 of 0.47 and 0.56, respectively. Intrareader agreement was 0.67 and 0.63. The consensus reading provided an intrareader agreement of 0.63. For the presence or absence of metastasis, interreader agreement was 0.85 and 0.70. The consensus reading provided an intrareader agreement of 0.72. The correlations between the maximum standardized uptake value in 18F-FDG-PET/MR imaging and 18F-FDG-PET/CT for primary tumors and lymph node and metastatic lesions were very high (Spearman r = 1.00, 0.93, and 0.92, respectively). CONCLUSIONS: In patients with head and neck cancer, 18F-FDG-PET/MR imaging and 18F-FDG-PET/CT provide comparable results in the detection of lymph node and distant metastases. Standardized uptake values derived from 18F-FDG-PET/MR imaging can be used reliably in this patient population.