Publications by authors named "Mats Geijer"

89 Publications

Gut dysbiosis associated with worse disease activity and physical function in axial spondyloarthritis.

Arthritis Res Ther 2022 02 12;24(1):42. Epub 2022 Feb 12.

Section of Rheumatology, Department of Clinical Sciences Lund, Lund University, Kioskgatan 5, 22185, Lund, Sweden.

Background: Based on clinical and genetic associations, axial spondyloarthritis (axSpA) and inflammatory bowel disease (IBD) are suspected to have a linked pathogenesis. Gut dysbiosis, intrinsic to IBD, has also been observed in axSpA. It is, however, not established to what degree gut dysbiosis is associated with axSpA disease severity. The objective of this study was to compare gut dysbiosis frequency between controls, non-radiographic axial spondyloarthritis (nr-axSpA), and ankylosing spondylitis (AS) patients and investigate whether gut dysbiosis is cross-sectionally associated with axSpA disease activity, physical function, mobility, or pain.

Methods: Gut dysbiosis was assessed by 16SrRNA analysis of feces from 44/88 nr-axSpA/AS patients (ASAS/mNY criteria) without inflammatory bowel disease (IBD) and 46 controls without IBD or rheumatic disease. The GA-map™ Dysbiosis Test was used, grading gut microbiota aberrations on a 1-5 scale, where ≥3 denotes dysbiosis. Proportions with dysbiosis were compared between the groups. Furthermore, standard axSpA measures of disease activity, function, mobility, and pain were compared between patients (nr-axSpA and AS combined) with and without dysbiosis, univariately, and adjusted for relevant confounders (ANCOVA).

Results: Gut dysbiosis was more frequent in AS than controls (36% versus 17%, p=0.023), while nr-axSpA (25% dysbiosis) did not differ significantly from either AS or controls. Univariately, most axSpA measures were significantly worse in patients with dysbiosis versus those without: ASDAS-CRP between-group difference 0.6 (95% CI 0.2-0.9); BASDAI 1.6 (0.8-2.4); evaluator's global disease activity assessment (Likert scale 0-4) 0.3 (0.1-0.5), BASFI 1.5 (0.6-2.4), and VAS pain (cm) 1.3 (0.4-2.2). Differences remained significant after adjustment for demographics, lifestyle factors, treatments, gut inflammation (fecal calprotectin ≥50 mg/kg), and gut symptoms, except for VAS pain. BASMI and CRP were not associated with dysbiosis.

Conclusion: Gut dysbiosis, more frequent in AS patients than controls, is associated with worse axSpA disease activity and physical function, seemingly irrespective of both gut inflammation and treatments. This provides further evidence for an important link between disturbances in gastrointestinal homeostasis and axSpA.
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http://dx.doi.org/10.1186/s13075-022-02733-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8840679PMC
February 2022

Immediate Full Weight-Bearing Versus Partial Weight-Bearing After Plate Fixation of Distal Femur Fractures in Elderly Patients. A Randomized Controlled Trial.

Geriatr Orthop Surg Rehabil 2021 6;12:21514593211055889. Epub 2021 Dec 6.

Department of Orthopedics, Sahlgrenska University Hospital, Gothenburg, Sweden.

Introduction: After surgery for distal femur fractures in elderly patients, weight-bearing is commonly restricted. Immediate non-restrictive weight-bearing might have beneficial effects. There are no randomized studies on the topic. The purpose of this study was to compare the functional outcome between immediate full weight-bearing (FWB) as tolerated and partial weight-bearing (PWB) during the first 8 weeks following plate fixation of distal femur fractures in elderly patients.

Methods: Patients aged 65 years or older with distal femur fractures of AO/OTA types 33 A2, A3, B1, B2, C1, and C2 were included. Exclusion criteria were impaired cognitive function, concomitant injuries, or inability to follow the postoperative regimen. Internal fixation was achieved with an anatomical lateral distal femur plate applied as a strictly bridge-plating construct. The primary outcome measure was the function index of the short musculoskeletal functional assessment (SMFA) after 52 weeks from injury.

Results: Thirty-two patients were randomized to FWB (n = 11) or PWB (n = 21). After 16 and 52 weeks, there were no differences in the mean SMFA function index between FWB and PWB (36 vs 43, = .42 and 52 vs 40, = .18, respectively) nor in the mean EuroQol 5-dimension index or range of motion (ROM). Overall, the SMFA function index was higher at 52 weeks compared with before injury (44 vs 30, = .001) as was the mean bothersome index (37 vs 21, = .011). There was no clear difference in the occurrence of adverse events between the treatment groups.

Conclusions: There were no differences in functional outcome, adverse events, or ROM between immediate FWB and PWB following plate fixation for a distal femur fracture in elderly patients. A distal femur fracture has a negative effect on the functional status of elderly patients that persists at least up to 1 year following injury.
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http://dx.doi.org/10.1177/21514593211055889DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8822340PMC
December 2021

Magnetic resonance imaging of the brachial plexus. Part 2: Traumatic injuries.

Eur J Radiol Open 2022 22;9:100397. Epub 2022 Jan 22.

Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Umeå, Sweden.

The most common indications for magnetic resonance imaging (MRI) of the brachial plexus (BP) are traumatic injuries. The role of MRI of the BP has increased because of recent trends favoring earlier surgery. Determining preganglionic vs. postganglionic injury is essential, as different treatment strategies are required. Thus, MRI of the BP should be supplemented with cervical spine MRI to assess the intradural part of the spinal nerves, including highly T2-weighted techniques. Acute preganglionic injuries usually manifest as various combinations of post-traumatic pseudomeningocele, the absence of roots, deformity of nerve root sleeves, displacement of the spinal cord, hemorrhage in the spinal canal, presence of scars in the spinal canal, denervation of the back muscles, and syrinx. Spinal nerve root absence is more specific than pseudomeningocele on MRI. Acute postganglionic injuries can present as lesions in continuity or tears. The following signs indicate injury to the BP: side-to-side difference, swelling, partial, or total BP rupture. Injury patterns and localization are associated with the mechanism of trauma, which implies a significant role for MRI in the work-up of patients. The identification and description of traumatic lesions involving the brachial plexus need to be systematic and detailed. Using an appropriate MRI protocol, obtaining details about the injury, applying a systematic anatomical approach, and correlating imaging findings to relevant clinical data to make a correct diagnosis. Information about the presence or suspicion of root avulsion should always be provided.
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http://dx.doi.org/10.1016/j.ejro.2022.100397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8789590PMC
January 2022

Magnetic resonance imaging of the brachial plexus. Part 1: Anatomical considerations, magnetic resonance techniques, and non-traumatic lesions.

Eur J Radiol Open 2022 20;9:100392. Epub 2021 Dec 20.

Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

For magnetic resonance imaging (MRI) of non-traumatic brachial plexus (BP) lesions, sequences with contrast injection should be considered in the differentiation between tumors, infection, postoperative conditions, and post-radiation changes. The most common non-traumatic inflammatory BP neuropathy is radiation neuropathy. T2-weighted images may help to distinguish neoplastic infiltration showing a high signal from radiation-induced neuropathy with fibrosis presenting a low signal. MRI findings in inflammatory BP neuropathy are usually absent or discrete. Diffuse edema of the BP localized mainly in the supraclavicular part of BP, with side-to-side differences, and shoulder muscle denervation may be found on MRI. BP infection is caused by direct infiltration from septic arthritis of the shoulder joint, spondylodiscitis, or lung empyema. MRI may help to narrow down the list of differential diagnoses of tumors. The most common tumor of BP is metastasis. The most common primary tumor of BP is neurofibroma, which is visible as fusiform thickening of a nerve. In its solitary state, it may be challenging to differentiate from a schwannoma. The most common MRI finding is a neurogenic variant of thoracic outlet syndrome with an asymmetry of signal and thickness of the BP with edema. In abduction, a loss of fat directly related to the BP may be seen. Diffusion tensor imaging is a promising novel MRI sequences; however, the small diameter of the nerves contributing to the BP and susceptibility to artifacts may be challenging in obtaining sufficiently high-quality images.
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http://dx.doi.org/10.1016/j.ejro.2021.100392DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8695258PMC
December 2021

Change and consistency in over 100 years.

Acta Radiol 2021 Nov 22;62(11):1435-1442. Epub 2021 Oct 22.

University of Copenhagen, Copenhagen University Hospital, Herlev & Gentofte, Herlev, Denmark.

celebrates its 100th anniversary in 2021. In this article, the foundation of the journal and its editors are described. During 100 years, the manuscript structure changed from single-author verbose monographs to multi-author collaborations on statistically analyzed research subjects. The authorship changed from purely Nordic authors to a truly international cadre of authors, and the size of the journal increased considerably, in issues per year, printed pages, and published articles per year. The Foundation of Acta Radiologica has been able to give out two prizes, the Xenia Forsselliana and the Acta Radiologica International Scientific Prize for the best manuscripts each year. The increasing submissions of manuscripts is an indication that Acta Radiologica will continue to publish important scientific results for many years to come.
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http://dx.doi.org/10.1177/02841851211054174DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649460PMC
November 2021

The development of musculoskeletal radiology for 100 years as presented in the pages of .

Acta Radiol 2021 Nov 19;62(11):1460-1472. Epub 2021 Oct 19.

Department of Clinical Science, Intervention and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.

During the last 100 years, musculoskeletal radiology has developed from bone-only radiography performed by everyone to a dedicated subspecialty, still secure in its origins in radiography but having expanded into all modalities of imaging. Like other subspecialties in radiology, it has become heavily dependent on cross-sectional and functional imaging, and musculoskeletal interventions play an important role in tumor diagnosis and treatment and in joint diseases. All these developments are reflected in the pages in , as shown in this review.
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http://dx.doi.org/10.1177/02841851211050866DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8647486PMC
November 2021

Prevalence and factors related to sleep apnoea in ankylosing spondylitis.

Clin Rheumatol 2022 Feb 28;41(2):491-498. Epub 2021 Sep 28.

Department of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden.

An increased prevalence of obstructive sleep apnoea (OSA) has been suggested in patients with ankylosing spondylitis (AS) in a few controlled studies. We aimed to study the prevalence of OSA compared to controls and to investigate if disease-related and non-disease-related factors were determinants of OSA in AS patients. One hundred and fifty-five patients with AS were included in the Backbone study, a cross-sectional study that investigates severity and comorbidities in AS. Controls were recruited from the Swedish CArdioPulmonary bioImage Study. To evaluate OSA, the participants were asked to undergo home sleep-monitoring during one night's sleep. For each AS patient 45-70 years old, four controls were matched for sex, age, weight, and height. OSA was defined as an apnoea-hypopnoea index (AHI) ≥ 5 events/hour. Sixty-three patients with AS were examined with home sleep-monitoring, and 179 controls were matched with 46 patients, 45-70 years. Twenty-two out of 46 (47.8%) patients with AS vs. 91/179 (50.8%) controls had OSA (AHI ≥ 5 events/hour), P = 0.72. No differences in the sleep measurements were noted in AS patients vs. controls. In logistic regression analysis adjusted for age and sex, higher age, higher BMI, and lesser chest expansion were associated with the presence of OSA in the 63 AS patients. In the current study, patients with AS did not have a higher prevalence of OSA compared to matched controls. AS patients with OSA had higher BMI, were older, and had lesser chest expansion because of more severe AS compared to patients without OSA. Key points • Patients with ankylosing spondylitis did not have a higher prevalence of obstructive sleep apnoea versus matched controls. • Patients with ankylosing spondylitis and obstructive sleep apnoea were older and had higher body mass index versus patients without obstructive sleep apnoea. • Patients with ankylosing spondylitis and obstructive sleep apnoea had lesser chest expansion versus patients without obstructive sleep apnoea.
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http://dx.doi.org/10.1007/s10067-021-05924-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8782774PMC
February 2022

Visualization of wrist anatomy-a comparison between 7T and 3T MRI.

Eur Radiol 2022 Feb 11;32(2):1362-1370. Epub 2021 Aug 11.

Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden.

Objective: Injuries to the wrist are, due to its small size and complex anatomical structures, difficult to assess by MR, and surgical interventions such as diagnostic arthroscopy are often necessary. Therefore, improved visualization using non-invasive methods could be of clinical value. As a first step of improvement, the purpose of this study was to evaluate visualization of anatomical structures at 7T compared with 3T MR.

Methods: Eighteen healthy volunteers (three males and three females from each age decade between 20 and 49 years) were examined with 7T and 3T MR. Four musculoskeletal radiologists graded 2D and 3D images on a five-level grading scale for visibility of ligaments, cartilage, nerves, trabecular bone, and tendons, as well as overall image quality (i.e., edge sharpness, perceived tissue contrast, and presence of artefacts). Statistical analysis was done using a visual grading characteristics (VGC) analysis.

Results: Visibility of cartilage, trabecular bone, tendons, nerves, and ligaments was graded significantly higher at 7T with an area under the curve (AUC) of 0.62-0.88 (95% confidence interval [CI] 0.50-0.97, p = < 0.0001-0.03) using either 2D or 3D imaging. Imaging with 3T was not graded as superior to 7T for any structure. Image quality was also significantly superior at 7T, except for artefacts, where no significant differences were found.

Conclusions: Tendons, trabecular bone, nerves, and ligaments were all significantly better visualized at 7T compared to 3T.

Key Points: • MRI of the wrist at 7T with a commercially available wrist coil is feasible at similar acquisition times as for 3T MRI. • The current study showed 7T to be superior to 3T in the visualization of anatomical structures of the wrist, including ligaments, tendons, nerves, and trabecular bone. • Image quality was significantly superior at 7T, except for artefacts, where no significant differences were found.
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http://dx.doi.org/10.1007/s00330-021-08165-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8795032PMC
February 2022

The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions.

J Ultrason 2021 8;21(84):22-33. Epub 2021 Mar 8.

Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.

Introduction: Percutaneous ultrasound-guided core needle biopsy is a well-established method in the diagnosis of musculoskeletal tumors. It is unclear which factors contribute the most to a successful biopsy. The aim of the study was to determine the value of ultrasound-guided core needle biopsy of solid lesions in the musculoskeletal system using a 16-gauge needle.

Material And Methods: A retrospective analysis performed at a regional sarcoma center over one year included patients referred for ultrasound-guided biopsy of musculoskeletal soft tissue lesions. At least 6 months' clinical and radiological follow-up, results from repeat or excisional biopsy, or interventional treatment, served as outcome reference. The biopsy procedure and yield were analyzed. The biopsy was classified as 'diagnostic' when a definitive diagnosis could be made on the first biopsy, and 'accurate' when only the malignant or benign nature of the tumor could be determined.

Results: From 102 referrals for biopsy of soft tissue lesions in 2019, a total of 73 biopsies of solid lesions with a 16-gauge cutting needle were included (73 patients). There were 34 males and 39 females, with a mean age of 57.7 years. The overall proportion of diagnostic biopsies was 84%, for malignant lesions 88% and benign lesions 81%. The tumor could be classified as malignant or benign in 12 patients (16%) (accurate biopsy). It was possible to discriminate between malignant and benign lesions in each case. The majority of biopsied lesions were benign 64% ( = 47).

Conclusion: The diagnostic value of ultrasound-guided percutaneous core needle biopsy of musculoskeletal soft tissue lesions performed with 16-gauge needle is good, with a high rate of diagnostic biopsies, both for benign and malignant lesions.
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http://dx.doi.org/10.15557/JoU.2021.0004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8008202PMC
March 2021

Visualization of wrist ligaments with 3D and 2D magnetic resonance imaging at 3 Tesla.

Acta Radiol 2022 Mar 3;63(3):368-375. Epub 2021 Mar 3.

Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Background: Wrist ligaments are challenging to visualize using magnetic resonance imaging (MRI). Injuries involving the scapholunate ligament (SLL), the lunotriquetral ligament (LTL), and the triangular fibrocartilage complex (TFCC) are common and difficult to diagnose, often requiring diagnostic arthroscopy.

Purpose: To compare the visualization of wrist ligaments on a three-dimensional (3D) sequence with two-dimensional (2D) sequences on 3-T MRI.

Material And Methods: Eighteen healthy volunteers were examined with a 3D SPACE (sampling perfection with application optimized contrasts using different flip angle evolution) sequence and 2D coronal, axial, and sagittal proton density-weighted (PD) sequences. Four musculoskeletal radiologists graded the anatomical visibility of the SLL, LTL, TFCC, and the image quality, using five grades in a visual grading characteristics (VGC) evaluation. After Bonferroni correction, a value ≤0.005 was considered statistically significant.

Results: The 3D images were graded significantly better than the 2D images in the visualization of the dorsal and palmar parts of the SLL and the LTL. Regarding the TFCC, the 3D images were graded significantly better for visualization of the foveal attachment. 2D imaging was not found significantly superior to 3D imaging in any aspect.

Conclusion: The 3D SPACE sequence was scored as superior to the 2D sequences at 3 T in the assessment of the SLL, the LTL, and the foveal attachment of the TFCC. Thus, 3D SPACE can replace 2D PD sequences when these ligaments need to be assessed.
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http://dx.doi.org/10.1177/0284185121994044DOI Listing
March 2022

Health-related quality of life in early psoriatic arthritis compared with early rheumatoid arthritis and a general population.

Semin Arthritis Rheum 2021 02 29;51(1):246-252. Epub 2020 Dec 29.

Department of Rheumatology, Skåne University Hospital and Lund University, Malmö, Sweden.

Objective: Both psoriatic arthritis (PsA) and rheumatoid arthritis (RA) have a significant impact on quality of life, but few reports have compared the two diseases. The current study assessed health-related quality of life (HRQoL) in PsA at diagnosis and after five years compared with early rheumatoid arthritis (RA) and a matched general population.

Methods: Patients with early PsA and early RA included in two Swedish registries with HRQoL data measured by the Medical Outcomes Study Short Form 36 (SF-36) at baseline and at five years follow-up were included. Differences in SF-36 scores compared with the general population were calculated for each patient. Physical function, disease activity, the delay before diagnosis, pain, and general wellbeing were used as explanatory variables. Statistical tests included t-tests and univariate and multivariate linear regression.

Results: PsA (n = 166) and RA (n = 133) patients of both sexes had significantly reduced HRQoL at disease onset. After five years, PsA patients still had impairments in several domains of SF-36, whereas RA patients had an almost normalized HRQoL. The time from symptom onset to diagnosis, disease activity, and disability independently contributed to the reduced improvement in PsA.

Conclusion: Both early PsA and RA are characterized by severely reduced HRQoL. Despite more severe disease at inclusion, normalization of HRQoL is seen in patients with RA but not PsA. This may be due to delay in the diagnosis of PsA or more powerful interventions in RA. Earlier detection, lifestyle intervention, and more aggressive management strategies may be needed for PsA.
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http://dx.doi.org/10.1016/j.semarthrit.2020.10.010DOI Listing
February 2021

Anti-CD74 IgA autoantibodies in radiographic axial spondyloarthritis: a longitudinal Swedish study.

Rheumatology (Oxford) 2021 09;60(9):4085-4093

Department of Public Health and Clinical Medicine, Rheumatology.

Objectives: Antibodies against anti-CD74 are related to axial spondyloarthritis (axSpA). The objectives were (i) to study IgA anti-CD74 in radiographic (r)-axSpA patients in the Backbone cohort and to calculate the sensitivity and specificity of anti-CD74, (ii) to study the fluctuation of IgA anti-CD74 levels in prospectively collected samples, and (iii) to explore the relation between IgA anti-CD74 and radiographic spinal changes.

Methods: IgA anti-CD74 was analysed by ELISA in 155 patients with r-axSpA and age- and sex-matched controls. BASDAI, ASDAS, BASFI and BASMI were assessed and spinal radiographs were scored for r-axSpA-related changes with mSASSS. Previously donated samples, before inclusion in the Backbone study, were identified in the Medical Biobank of Northern Sweden.

Results: A total of 155 patients comprising 69% men and 31% women, age [mean (s.d.)] 55.5 (11.4) years and 152 (98.1%) HLA-B27 positive, were included. The plasma level of IgA anti-CD74 was significantly higher in the patients [median (interquartile range), 12.9 (7.9-17.9) U/ml] compared with controls [10.9 (7.2-14.6) U/ml, P = 0.003]. IgA anti-CD74 was above the cut-off level of 20 U/ml in 36/155 (23.2%) patients and in 15/151 (9.9%) controls (P = 0.002). Multivariable logistic regression analyses revealed ≥1 syndesmophyte associated with IgA anti-CD74 (odds ratio 5.64; 95% CI: 1.02, 35.58; P = 0.048) adjusted for hsCRP, smoking, BMI, sex and age. No distinct pattern of IgA anti-CD74 over time was revealed.

Conclusion: Plasma levels of IgA anti-CD74 were increased in r-axSpA and independently associated with radiographic spinal changes, which suggests that IgA anti-CD74 could play a role in the pathogenies of r-axSpA.
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http://dx.doi.org/10.1093/rheumatology/keaa882DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8410007PMC
September 2021

Elevated serum level of hepatocyte growth factor predicts development of new syndesmophytes in men with ankylosing spondylitis.

Rheumatology (Oxford) 2021 04;60(4):1804-1813

Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

Objectives: To study baseline serum hepatocyte growth factor (s-HGF) as a predictor of spinal radiographic progression overall and by sex and to analyse factors correlated to changes in s-HGF in patients with AS.

Methods: At baseline and the 5-year follow-up, s-HGF was analysed with ELISA. Spinal radiographs were graded according to modified Stoke Ankylosing Spondylitis Spinal Score. Radiographic progression was defined as ≥2 modified Stoke Ankylosing Spondylitis Spinal Score units/5 years or development of ≥1 syndesmophyte. Logistic regression analyses were used.

Results: Of 204 baseline participants, 163 (80%) completed all examinations at the 5-year follow-up (54% men). Baseline s-HGF was significantly higher in men who developed ≥1 syndesmophyte compared with non-progressors, median (interquartile range) baseline s-HGF 1551 (1449-1898) vs 1436 (1200-1569) pg/ml, P = 0.003. The calculated optimal cut-off point for baseline s-HGF ≥1520 pg/ml showed a sensitivity of 70%, a specificity of 69% and univariate odds radio (95% CI) of 5.25 (1.69, 14.10) as predictor of development of ≥1 new syndesmophyte in men. Baseline s-HGF ≥1520 pg/ml remained significantly associated with development of ≥1 new syndesmophyte in men in an analysis adjusted for the baseline variables age, smoking, presence of syndesmophytes and CRP, odds radio 3.97 (1.36, 11.60). In women, no association with HGF and radiographic progression was found. Changes in s-HGF were positively correlated with changes in ESR and CRP.

Conclusion: In this prospective cohort study elevated s-HGF was shown to be associated with development of new syndesmophytes in men with AS.
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http://dx.doi.org/10.1093/rheumatology/keaa460DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8023989PMC
April 2021

Pre- and postoperative offset and femoral neck version measurements and validation using 3D computed tomography in total hip arthroplasty.

Acta Radiol Open 2020 Oct 8;9(10):2058460120964911. Epub 2020 Oct 8.

Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.

Background: Restoration of a correct biomechanical situation after total hip arthroplasty is important.

Purpose: To evaluate proximal femoral symmetry of acetabular and femoral offset and femoral neck anteversion pre- and postoperatively in hip arthroplasty by semi-automated 3D-CT and to validate the software measurements by inter- and intraobserver agreement calculations.

Material And Methods: In low-dose CT on 71 patients before and after unilateral total hip arthroplasty, two observers used a digital 3D templating software to measure acetabular offset, true and functional femoral offset, and femoral neck anteversion. Observer agreements were calculated using intraclass correlation. Hip measurements were compared in each patient and between pre- and postoperative measurements.

Results: Preoperatively, acetabular offset (2.4 mm), true (2.2 mm), and functional global offset (2.7 mm) were significantly larger on the osteoarthritic side without side-to-side differences for true and functional femoral offset or femoral neck anteversion. Postoperatively, acetabular offset was significantly smaller on the operated side (2.1 mm) with a concomitantly increased true (2.5 mm) and functional femoral offset (1.5 mm), resulting in symmetric true and functional global offsets. There were no differences in postoperative femoral neck anteversion. Inter- and intraobserver agreements were near-perfect, ranging between 0.92 and 0.98 with narrow confidence intervals (0.77-0.98 to 0.94-0.99).

Conclusion: Acetabular and concomitantly global offset are generally increased in hip osteoarthritis. Postoperative acetabular offset was reduced, and femoral offset increased to maintain global offset. 3D measurements were reproducible with near-perfect observer agreements. 3D data sets should be used for pre- and postoperative measurements in hip arthroplasty.
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http://dx.doi.org/10.1177/2058460120964911DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7549166PMC
October 2020

Traumatic and non-traumatic bone marrow edema in ankle MRI: a pictorial essay.

Insights Imaging 2020 Aug 17;11(1):97. Epub 2020 Aug 17.

Department of Musculoskeletal Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden.

Bone marrow edema (BME) is one of the most common findings on magnetic resonance imaging (MRI) after an ankle injury but can be present even without a history of trauma. This article will provide a systematic overview of the most common disorders in the ankle and foot associated with BME.The presence of BME is an unspecific but sensitive sign of primary pathology and may act as a guide to correct and systematic interpretation of the MR examination. The distribution of BME allows for a determination of the trauma mechanism and a correct assessment of soft tissue injury. The BME pattern following an inversion injury involves the lateral malleolus, the medial part of the talar body, and the medial part of the distal tibia. In other cases, a consideration of the distribution of BME may indicate the mechanism of injury or impingement. Bone in direct contact with a tendon may lead to alterations in the bone marrow signal where BME may indicate tendinopathy or dynamic tendon dysfunction. Changed mechanical forces between bones in coalition may lead to BME. Degenerative changes or minor cartilage damage may lead to subchondral BME. Early avascular necrosis, inflammation, or stress fracture may lead to more diffuse BME; therefore, a detailed medical history is crucial for correct diagnosis.A systematic analysis of BME on MRI can help to determine the trauma mechanism and thus assess soft tissue injuries and help to differentiate between different etiologies of nontraumatic BME.
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http://dx.doi.org/10.1186/s13244-020-00900-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431516PMC
August 2020

Loss of supervillin causes myopathy with myofibrillar disorganization and autophagic vacuoles.

Brain 2020 08;143(8):2406-2420

Institute of Human Genetics, Medical Faculty, RWTH Aachen University, Aachen, Germany.

The muscle specific isoform of the supervillin protein (SV2), encoded by the SVIL gene, is a large sarcolemmal myosin II- and F-actin-binding protein. Supervillin (SV2) binds and co-localizes with costameric dystrophin and binds nebulin, potentially attaching the sarcolemma to myofibrillar Z-lines. Despite its important role in muscle cell physiology suggested by various in vitro studies, there are so far no reports of any human disease caused by SVIL mutations. We here report four patients from two unrelated, consanguineous families with a childhood/adolescence onset of a myopathy associated with homozygous loss-of-function mutations in SVIL. Wide neck, anteverted shoulders and prominent trapezius muscles together with variable contractures were characteristic features. All patients showed increased levels of serum creatine kinase but no or minor muscle weakness. Mild cardiac manifestations were observed. Muscle biopsies showed complete loss of large supervillin isoforms in muscle fibres by western blot and immunohistochemical analyses. Light and electron microscopic investigations revealed a structural myopathy with numerous lobulated muscle fibres and considerable myofibrillar alterations with a coarse and irregular intermyofibrillar network. Autophagic vacuoles, as well as frequent and extensive deposits of lipoproteins, including immature lipofuscin, were observed. Several sarcolemma-associated proteins, including dystrophin and sarcoglycans, were partially mis-localized. The results demonstrate the importance of the supervillin (SV2) protein for the structural integrity of muscle fibres in humans and show that recessive loss-of-function mutations in SVIL cause a distinctive and novel myopathy.
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http://dx.doi.org/10.1093/brain/awaa206DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447519PMC
August 2020

Biomechanical Properties of Common Carotid Arteries Assessed by Circumferential 2D Strain and β Stiffness Index in Patients With Ankylosing Spondylitis.

J Rheumatol 2021 03 1;48(3):352-360. Epub 2020 Jul 1.

P. Lindqvist, BSc, Department of Surgical and Perioperative Sciences, Clinical Physiology, Umeå University, Umeå, Sweden.

Objective: Ankylosing spondylitis (AS) is associated with an elevated risk of cardiovascular disease (CVD) related to atherosclerosis, preceded by arterial stiffness. We aimed to examine common carotid artery (CCA) biomechanical properties using ultrasound to calculate β stiffness index (indicating arterial stiffness) and, a more recently developed technique, 2-dimensional (2D) speckle tracking strain (indicating arterial motion and deformation, strain) to (1) compare with age- and sex-matched controls, and (2) analyze relationships between strain and stiffness with disease characteristics and traditional risk factors for CVD in patients with AS.

Methods: In this cross-sectional study, a cohort of 149 patients with AS, mean age 55.3 ± 11.2 years, 102 (68.5%) men, and 146 (98%) HLA-B27-positive, were examined. Bilateral CCA were examined for circumferential 2D strain and β stiffness index. A subgroup of 46 patients was compared with 46 age- and sex-matched controls, both groups without hypertensive disease, diabetes, myocardial infarction, or stroke.

Results: Mean bilateral circumferential 2D strain was lower in AS patients compared with controls (7.9 ± 2.6% vs 10.3 ± 1.9%, < 0.001), whereas mean bilateral β stiffness index was higher (13.1 ± 1.7 mmHg/mm vs 12.3 ± 1.3 mmHg/mm, = 0.02). In multivariable linear regression analyses, strain was associated with age, erythrocyte sedimentation rate, history of anterior uveitis, and treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARD) and/or biological DMARD (R 0.33), while stiffness was associated with age (R 0.19).

Conclusion: Both CCA circumferential 2D strain and β stiffness index differed between patients with AS and controls. Strain was associated with AS-related factors and age, whereas only age was associated with stiffness, suggesting that the obtained results reflect different pathogenic vascular processes.
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http://dx.doi.org/10.3899/jrheum.200146DOI Listing
March 2021

Effect of symmetrical restoration for the migration of uncemented total hip arthroplasty: a randomized RSA study with 75 patients and 5-year follow-up.

J Orthop Surg Res 2020 Jun 17;15(1):225. Epub 2020 Jun 17.

Department of Orthopedics, Skåne University Hospital, Clinical Sciences, Lund University, Lund, Sweden.

Background: Inferior placement of a femoral stem is predictive for early loosening and failure, but does restoration of the original hip anatomy benefit the function and survival of a total hip replacement?

Methods: Seventy-five patients with primary unilateral hip osteoarthritis operated with an uncemented anatomical stem were randomized for either standard or modular stems. We used 50 ABG II stems with modular necks and 25 standard stems (control group). We measured the symmetry in hip anatomy between healthy and operated side. The anatomical restoration variables were anteversion, global offset, and femoral offset/acetabular offset (FO/AO) quota. We performed measurements using a CT-based 3D templating and measuring software. Migratory behavior of the stems was then measured postoperatively with repeated radiostereometry (RSA) examinations over 5 years.

Results: Both stem types showed an early (within 3 months) good stabilization after an initial slight rotation into retroversion and subsidence. There were no significant differences in RSA migration between modular and standard stems. Postoperative anteversion and FO/AO quota had no impact on stem migration. The standard stem tended to result in insufficient global offset (GO), whereas the modular stem did not.

Conclusions: The modular stem gave good symmetrical anatomical restoration and, like the standard version, a benign migratory behavior. Anteversion, GO, and FO/AO quota had no significant impact on stem migration. It therefore seems to be of no importance whether we choose a modular or a standard stem with regard to postoperative stem migration for this stem type. We overestimated the effect anatomical parameters have on stem movement; hence, we believe the study to be underpowered.

Trial Registration: ClinicalTrials.gov identifier: NCT01512550. Registered 19 January 2012-retrospectively registered.
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http://dx.doi.org/10.1186/s13018-020-01736-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301498PMC
June 2020

Can iterative reconstruction algorithms replace tube loading compensation in low kVp hepatic CT? Subjective versus objective image quality.

Acta Radiol Open 2020 Mar 16;9(3):2058460120910575. Epub 2020 Mar 16.

Department of Medical Imaging and Physiology, Skåne University Hospital, Lund University, Lund, Sweden.

Background: Hepatic computed tomography (CT) with decreased peak kilovoltage (kVp) may be used to reduce contrast medium doses in patients at risk of contrast-induced acute kidney injury (CI-AKI); however, it increases image noise. To preserve image quality, noise has been controlled by X-ray tube loading (mAs) compensation (TLC), i.e. increased mAs. Another option to control image noise would be to use iterative reconstructions (IR) algorithms without TLC (No-TLC). It is unclear whether this may preserve image quality or only reduce image noise.

Purpose: To evaluate image quality of 80 kVp hepatic CT with TLC and filtered back projection (FBP) compared with 80 kVp with No-TLC and IR algorithms (SAFIRE 3 and 5) in patients with eGFR <45 mL/min.

Material And Methods: Forty patients (BMI 18-32 kg/m) were examined with both protocols following injection of 300 mg I/kg. Hepatic attenuation, image noise, enhancement, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and subjective image quality were evaluated for each patient.

Results: Comparing TLC/FBP with No-TLC/IR-S5, there were no significant differences regarding hepatic attenuation, image noise, enhancement, SNR and CNR: 114 vs. 115 HU, 14 vs. 14 HU, 55 vs. 57 HU, 8.0 vs. 8.4, and 3.8 vs. 4.0 in median, respectively. No-TLC/IR-S3 resulted in higher image noise and lower SNR and CNR than TLC/FBP. Subjective image quality scoring with visual grading showed statistically significantly inferior scores for IR-S5 images.

Conclusion: CT of 80 kVp to reduce contrast medium dose in patients at risk of CI-AKI combined with IR algorithms with unchanged tube loading to control image noise does not provide sufficient diagnostic quality.
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http://dx.doi.org/10.1177/2058460120910575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076580PMC
March 2020

80-kV hepatic CT to reduce contrast medium dose in azotemic patients: a feasibility study.

Acta Radiol 2020 Apr 3;61(4):441-449. Epub 2019 Aug 3.

Institute of Clinical Sciences, Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.

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http://dx.doi.org/10.1177/0284185119866807DOI Listing
April 2020

Elevated faecal calprotectin is linked to worse disease status in axial spondyloarthritis: results from the SPARTAKUS cohort.

Rheumatology (Oxford) 2019 07;58(7):1176-1187

Department of Clinical Sciences Lund, Rheumatology, Lund University, Lund.

Objectives: To examine faecal calprotectin (F-calprotectin) levels and presence of anti-Saccharomyces cerevisiae antibodies (ASCA) and their associations with disease subtype and current status in axial SpA (axSpA).

Methods: F-calprotectin and ASCA in serum were compared between consecutive patients with a clinical axSpA diagnosis, classified as non-radiographic axSpA (nr-axSpA; n = 40) or AS (n = 90), and with healthy controls (n = 35). Furthermore, standard axSpA outcome measures were compared between axSpA patients (nr-axSpA and AS combined) with elevated vs normal F-calprotectin, ASCA IgA and IgG, respectively.

Results: Elevated F-calprotectin (⩾50 mg/kg) was observed in 27% of nr-axSpA patients, 38% of AS patients and 6% of controls. F-calprotectin was significantly higher in AS vs nr-axSpA [AS: geometric mean 41 (95% CI 32, 54) mg/kg; nr-axSpA: 24 (95% CI 16, 38) mg/kg; P = 0.037], and in each axSpA subtype vs controls. Overall, worse disease activity and physical function scores were observed among axSpA patients with elevated vs normal F-calprotectin levels, with significant differences regarding patient's visual analogue scale for global health, ASDAS using CRP, and BASFI (adjusted for age, sex, NSAID use, anti-rheumatic treatments, and CRP). ASCA titres and seropositivity (⩾10 U/ml) were similar in nr-axSpA (IgA/IgG-seropositivity: 8%/26%) and AS (7%/28%), and clinical outcome measures did not differ between patients with elevated vs normal ASCA IgA or IgG, respectively. Compared with controls (IgA/IgG-seropositivity: 0%/17%), ASCA IgA was significantly higher in both axSpA subtypes, and IgG was significantly higher in the AS group.

Conclusion: In patients with axSpA, gut inflammation measured by elevated F-calprotectin is associated with worse disease activity and physical function, and may be a marker of more severe disease.
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http://dx.doi.org/10.1093/rheumatology/key427DOI Listing
July 2019

Intermediate-Term Outcome After Distal Radius Fracture in Patients With Poor Outcome at 1 Year: A Register Study With a 2- to 12-Year Follow-Up.

J Hand Surg Am 2019 Jan 27;44(1):39-45. Epub 2018 Nov 27.

Department of Orthopedics, Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden.

Purpose: Most patients recover well from a distal radius fracture (DRF). However, approximately one-fifth have severe disability after 1 year when evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In the present study, we evaluated this subgroup of patients in our register with an inferior outcome. We hypothesized that the patient-reported outcome would improve with time.

Methods: Since 2001, patients 18 years and older with a DRF, at the Department of Orthopedics, Skåne University Hospital (Lund, Sweden) are prospectively registered in the Lund Wrist Fracture Register. We have previously defined a DASH score above 35 at the 1-year follow-up as the cutoff of major disability. Between 2003 and 2012, 17% of the patients (445 of 2,571) in the register exceeded this cutoff. Three hundred eighty-eight were women and 57 men and the mean age was 69 years (range, 18-95 years). One-fourth had been surgically treated. In December 2014, 2 to 12 years after the fracture, a follow-up DASH questionnaire was sent to the 346 of 445 patients still alive.

Results: Seventy-three patients (27%) had initially been treated surgically and 196 (73%) nonsurgically for their DRF. Two hundred sixty-nine of 346 patients (78%) returned the follow-up DASH questionnaire at 2 to 12 years (mean, 5.5 years) after the fracture. The overall median DASH score improved from 50 at 1 year to 36 at the 2- to 12-year follow-up, (P < .05). Forty-seven percent had improved to a score below the cutoff 35, but 53% remained at a high suboptimal level.

Conclusions: The subjective outcome after a DRF improves over time for patients with an inferior result at 1 year, but more than half of the patients continue to have major disability.

Type Of Study/level Of Evidence: Prognostic II.
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http://dx.doi.org/10.1016/j.jhsa.2018.10.015DOI Listing
January 2019

Association between muscle strength, histopathology, and magnetic resonance imaging in sporadic inclusion body myositis.

Acta Neurol Scand 2019 Feb 8;139(2):177-182. Epub 2018 Nov 8.

Neuromuscular Centre, Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.

Objectives: Inclusion body myositis is characterized by inflammatory and degenerative changes, but the temporal relation of these events is unknown.

Materials And Methods: In nineteen patients with inclusion body myositis, muscle strength was correlated with inflammatory and degenerative findings on magnetic resonance imaging (MRI) and in muscle biopsies in three different muscles (tibialis anterior, vastus lateralis, and biceps brachii). Muscle strength, measured with a handheld dynamometer, was described as percentage of muscle strength in age- and sex-matched normal individuals. The muscles were categorized as the strongest, the intermediate, and the weakest muscle in each individual. T1-weighted sequences on MRI were used to evaluate the degree of fatty infiltration and muscle atrophy and STIR sequences to evaluate edematous changes.

Results: The vastus lateralis, which in general was the weakest muscle, was significantly more atrophic compared to the other two muscles and also demonstrated most edema. The biceps brachii had in most cases an intermediate degree of weakness and atrophy but the most pronounced inflammatory cell infiltration on biopsy. Cytochrome c oxidase-negative muscle fibers were significantly more prevalent in the vastus lateralis and biceps brachii muscles than in the tibialis anterior and thus correlated with muscular atrophy, indicating that this is a secondary change. Inflammatory changes as assessed by MRI and muscle biopsy were seen in all muscles irrespective of atrophy and thus appear to be prevalent at all stages of the disease.

Conclusions: Our study could not provide an answer to the question which comes first, the inflammation or the degenerative changes.
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http://dx.doi.org/10.1111/ane.13040DOI Listing
February 2019

Preoperative CT of cardiac veins for planning left ventricular lead placement in cardiac resynchronization therapy.

Acta Radiol 2019 Jul 10;60(7):859-865. Epub 2018 Oct 10.

2 Department of Clinical Sciences, Arrhythmia Section, Lund University, Skane University Hospital, Lund, Sweden.

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http://dx.doi.org/10.1177/0284185118803796DOI Listing
July 2019

A five-year prospective study of spinal radiographic progression and its predictors in men and women with ankylosing spondylitis.

Arthritis Res Ther 2018 08 3;20(1):162. Epub 2018 Aug 3.

Department of Rheumatology and Inflammation Research, Sahlgrenska Academy at University of Gothenburg, Box 480, 405 30, Gothenburg, Sweden.

Background: Knowledge about predictors of new spinal bone formation in patients with ankylosing spondylitis (AS) is limited. AS-related spinal alterations are more common in men; however, knowledge of whether predictors differ between sexes is lacking. Our objectives were to study spinal radiographic progression in patients with AS and investigate predictors of progression overall and by sex.

Methods: Swedish patients with AS, age (mean ± SD) 50 ± 13 years, were included in a longitudinal study. At baseline and at 5-year follow up, spinal radiographs were graded according to the modified Stoke Ankylosing Spondylitis Spine Score (mSASSS). Predictors were assessed by questionnaires, spinal mobility tests and blood samples.

Results: Of 204 patients included, 166 (81%) were re-examined and 54% were men. Men had significantly higher mean mSASSS at baseline and higher mean increase in mSASSS than women (1.9 ± 2.8 vs. 1.2 ± 3.3; p = 0.005) More men than women developed new syndesmophytes (30% vs. 12%; p = 0.007). Multivariate logistic regression analyses with progression ≥ 2 mSASSS units over 5 years or development of new syndesmophytes as the dependent variable showed that presence of baseline AS-related spinal radiographic alterations and obesity (OR 3.78, 95% CI 1.3 to 11.2) were independent predictors of spinal radiographic progression in both sexes. High C-reactive protein (CRP) was a significant predictor in men, with only a trend seen in women. Smoking predicted progression in men whereas high Bath Ankylosing Spondylitis Metrology Index (BASMI) and exposure to bisphosphonates during follow up (OR 4.78, 95% CI 1.1 to 20.1) predicted progression in women.

Conclusion: This first report on sex-specific predictors of spinal radiographic progression shows that predictors may partly differ between the sexes. New predictors identified were obesity in both sexes and exposure to bisphosphonates in women. Among previously known predictors, baseline AS-related spinal radiographic alterations predicted radiographic progression in both sexes, high CRP was a predictor in men (with a trend in women) and smoking was a predictor only in men.

Trial Registration: ClinicalTrials.gov , NCT00858819 . Registered on 9 March 2009. Last updated 28 May 2015.
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http://dx.doi.org/10.1186/s13075-018-1665-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6091099PMC
August 2018

Impact of donor chest radiography on clinical outcome after lung transplantation.

Acta Radiol Open 2018 Jun 14;7(6):2058460118781419. Epub 2018 Jun 14.

Centre for Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.

Background: Organ donation guidelines recommend a "clear" conventional bedside chest radiograph before lung transplantation despite only moderate accuracy for cardiopulmonary abnormalities.

Purpose: To evaluate the influence of donor image interpretation on lung transplantation outcome in recipients by following early and late complications, one-year survival, and to correlate imaging findings and blood gas analysis with lung transplantation outcome in recipients.

Material And Methods: In 35 lung donors from a single institution clinical reports and study reviews of imaging findings of the mandatory bedside chest radiographs and blood gas analyses were compared with clinical outcome in 38 recipients. Hospitalization time, peri- and postoperative complications, early complications (primary graft dysfunction, infection), 30-day and one-year survival, and forced expiratory volume in 1 s percentage of predicted normal value (FEV1%) at one-year follow-up were analyzed.

Results: Findings in clinical reports and study reviews differed substantially, e.g. regarding reported decompensation, edema, infection, and atelectasis. No correlation was shown between imaging findings in clinical report or study review and blood gas analyses in the lung donors compared to postoperative outcome in recipients.

Conclusion: The interpretation of the mandatory chest radiograph in its present form does not influence one-year outcome in lung transplantation. Larger imaging studies or a change in clinical routine including computed tomography may provide evidence for future guidelines.
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http://dx.doi.org/10.1177/2058460118781419DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024291PMC
June 2018

Added value of double reading in diagnostic radiology,a systematic review.

Insights Imaging 2018 Jun 28;9(3):287-301. Epub 2018 Mar 28.

Department of Radiology, Faculty of Medicine and Health, Örebro University, 701 85, Örebro, Sweden.

Objectives: Double reading in diagnostic radiology can find discrepancies in the original report, but a systematic program of double reading is resource consuming. There are conflicting opinions on the value of double reading. The purpose of the current study was to perform a systematic review on the value of double reading.

Methods: A systematic review was performed to find studies calculating the rate of misses and overcalls with the aim of establishing the added value of double reading by human observers.

Results: The literature search resulted in 1610 hits. After abstract and full-text reading, 46 articles were selected for analysis. The rate of discrepancy varied from 0.4 to 22% depending on study setting. Double reading by a sub-specialist, in general, led to high rates of changed reports.

Conclusions: The systematic review found rather low discrepancy rates. The benefit of double reading must be balanced by the considerable number of working hours a systematic double-reading scheme requires. A more profitable scheme might be to use systematic double reading for selected, high-risk examination types. A second conclusion is that there seems to be a value of sub-specialisation for increased report quality. A consequent implementation of this would have far-reaching organisational effects.

Key Points: • In double reading, two or more radiologists read the same images. • A systematic literature review was performed. • The discrepancy rates varied from 0.4 to 22% in various studies. • Double reading by sub-specialists found high discrepancy rates.
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http://dx.doi.org/10.1007/s13244-018-0599-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5990995PMC
June 2018

[Lumbar spine radiography – unreliable diagnostic accuracy and negligible value for the patients].

Lakartidningen 2017 11 14;114. Epub 2017 Nov 14.

Institutionen för translationell medicin - Divisionen för medicinsk radiologi Malmö, Sweden Institutionen för translationell medicin - Divisionen för medicinsk radiologi Malmö, Sweden.

Lumbar spine radiography - unreliable diagnostic accuracy and negligible value for the patients In 2016 140 000 lumbar spine radiographies were performed in Sweden (14 000 per million inhabitants) to a cost of about 85 million SEK (≈8.5 million Euro) and a negligible value for the patients with low back pain. In the work-up of low back pain, when imaging is indicated, lumbar spine radiography should be replaced by limited magnetic resonance imaging including a whole lower body coronal STIR sequence or computed tomography with radiation dose adapted to indication and patient age. Indication for imaging should be restricted to 1) low back pain with more than 3-4 weeks duration in combination with at least one »red flag«, 2) radicular pain without improvement on conservative treatment, or 3) low back pain with more than 8 weeks duration in combination with »yellow flags«.
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November 2017
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