Publications by authors named "Stacy E Smith"

73 Publications

Association of markers of patellofemoral maltracking to cartilage damage and bone marrow lesions on MRI: Data from the 2016 Olympic Games of Rio De Janeiro.

Eur J Radiol Open 2021 4;8:100381. Epub 2021 Oct 4.

Department of Radiology, Boston University School of Medicine, Boston, MA, United States.

Background: Patellofemoral joint (PFJ) disease is a common ailment in elite athletes. Our aim is to report the frequency of superolateral Hoffa's fat pad (SHFP) edema, and PFJ cartilage damage and bone marrow lesions (BML), among Olympian athletes, and to study the association between measurements of trochlear morphology and vertical patellar position and a) PFJ cartilage damage or BML, and b) SHFP edema.

Methods: All knee MRI, performed in the Olympic Village and polyclinics, of participating athletes in the 2016 Olympic Games of Rio de Janeiro were included. MRI were scored for PFJ cartilage damage and BML, and SHFP edema. Trochlear morphology measurements included sulcus angle, trochlear angle, lateral trochlear inclination, and medial trochlear inclination. Insall-Salvati ratio was also assessed.

Results: One hundred twenty-one knee MRIs were included (62 female, 51.2 %). The highest frequencies of PFJ cartilage damage, combination of PFJ cartilage damage and BML, and SHFP edema were found among Beach Volleyball and Volleyball athletes. SHFP edema was more common among female compared to male Olympian athletes. We found no statistically significant associations between different measurements of trochlear morphology/vertical patellar position, and 1. SHFP edema, and 2. PFJ cartilage damage/BML.

Conclusion: SHFP edema and the combination of PFJ cartilage damage and BML are highly frequent among Olympic athletes especially those competing in Beach volleyball and Volleyball. SHFP edema is more common among female athletes. Further studies are needed to determine whether PFJ cartilage damage has a stronger association to sports disciplines rather than trochlear morphology.
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http://dx.doi.org/10.1016/j.ejro.2021.100381DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8502704PMC
October 2021

Sports with a Bat or Racket are Not Associated with Thumb-base Osteoarthritis.

J Athl Train 2021 Aug 17. Epub 2021 Aug 17.

Timothy E. McAlindon, MD, MPH, Chief, Division of Rheumatology, Allergy, & Immunology, Tufts Medical Center, Boston, MA, USA,

Context: Repetitive joint use is a risk factor for osteoarthritis, which is a leading cause of disability. Sports requiring a bat or racket to perform repetitive high-velocity impacts may increase the risk of thumb-base osteoarthritis. However, this hypothesis remains untested.

Objective: To determine if a history of participation in racket or bat sports is associated with the prevalence of thumb-base osteoarthritis.

Design: Descriptive epidemiology study.

Setting: Osteoarthritis Initiative. Four clinical sites in the United States.

Participants: We included men and women from the recruited from the community. Eligible participants had dominant hand radiographic readings, hand symptom assessments, and historical physical activity survey data.

Main Outcome Measures: A history of exposure to racket or bat sports (baseball/softball, racquetball/squash, badminton, table tennis, tennis [doubles/singles]) was based on self-reported recall data covering 3 age ranges (12-18 years, 19-34 years, 35-49 years). Prevalent radiographic thumb-base osteoarthritis was defined as someone with Kellgren-Lawrence grade≥2 in the first carpometacarpal joint or scaphotrapezoidal joint at the OAI baseline visit. Symptomatic thumb-base osteoarthritis was defined as the presence of radiographic osteoarthritis and hand/finger symptoms.

Results: In total, we included 2309 participants. Among 1049 men, 355 (34%) and 56 (5%) had radiographic or symptomatic thumb-base osteoarthritis, respectively; and among 1260 women, 535 (42%) and 170 (13%), respectively. After adjusting for age, race, and education level, we found no statistically significant associations between a history of any racket or bat sport participation and thumb-base osteoarthritis (radiographic or symptomatic; odds ratios range from 0.82 to 1.34).

Conclusions: Within a community-based cohort, a self-reported history of participation in racket or bat sports was not associated with an increased odds of having radiographic or symptomatic thumb-base osteoarthritis in the dominant hand.
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http://dx.doi.org/10.4085/1062-6050-0208.21DOI Listing
August 2021

Whole-body Computed Tomography Versus Dual Energy X‑ray Absorptiometry for Assessing Heterotopic Ossification in Fibrodysplasia Ossificans Progressiva.

Calcif Tissue Int 2021 12 31;109(6):615-625. Epub 2021 Jul 31.

Departments of Radiology, Medicine and Orthopaedic Surgery, University of California, San Francisco, CA, USA.

Fibrodysplasia ossificans progressiva (FOP) is an ultra-rare genetic disorder that leads to heterotopic ossification (HO), resulting in progressive restriction of physical function. In this study, low-dose, whole-body computed tomography (WBCT) and dual energy X-ray absorptiometry (DXA) were evaluated to determine the preferred method for assessing total body burden of HO in patients with FOP. This was a non-interventional, two-part natural history study in patients with FOP (NCT02322255; date of registration: December 2014). In Part A (described here), WBCT and DXA scans were individually assessed for HO presence and severity across 15 anatomical regions. All images were independently reviewed by an expert imaging panel. Ten adult patients were enrolled across four sites. The sensitivity to HO presence and severity varied considerably between the two imaging modalities, with WBCT demonstrating HO in more body regions than DXA (76/138 [55%] versus 47/113 [42%]) evaluable regions). Inability to evaluate HO presence, due to overlapping body regions (positional ambiguity), occurred less frequently by WBCT than by DXA (mean number of non-evaluable regions per scan 1.2 [standard deviation: 1.5] versus 2.4 [1.4]). Based on the increased sensitivity and decreased positional ambiguity of low-dose WBCT versus DXA in measuring HO in patients with FOP, low-dose WBCT was chosen as the preferred imaging for measuring HO. Therefore, low-dose WBCT was carried forward to Part B of the natural history study, which evaluated disease progression over 36 months in a larger population of patients with FOP.
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http://dx.doi.org/10.1007/s00223-021-00877-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8531122PMC
December 2021

Snapping Plantaris Tendon: A Rare Case in a Competitive Dancer.

J Am Acad Orthop Surg Glob Res Rev 2021 05 4;5(5):e21.00008. Epub 2021 May 4.

From the Foot and Ankle Center, Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (Greene and J. T. Smith); the Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S. E. Smith); and the STRATUS Center for Simulation in Medical Education, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (S. E. Smith).

Pathology associated with the plantaris includes rupture of the tendon and an association with mid-substance Achilles tendinopathy in some patients. There have only been two previous case reports in the literature in English language describing snapping of the plantaris tendon. We present a case report of a 15-year-old female competitive dancer who described pain and an audible popping at the medial margin of the Achilles tendon while squatting. Physical examination revealed visible and audible popping of the plantaris, and ultrasonography confirmed the diagnosis. After symptoms persisted despite nonsurgical treatment with physical therapy, the patient underwent an open plantaris tenotomy. By 8 weeks after surgery, she had resumed dancing. Twenty-three months after her operation, she reported an excellent outcome and full recovery with no limitations to her physical activity. She reported having no pain, a Foot and Ankle Ability Measure Activities of Daily Living Subscale score of 100, and a Foot and Ankle Ability Measure Sports Subscale score of 100. This case demonstrates a successful course of treatment for this uncommon pathology within the context of a competitive dancer.
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http://dx.doi.org/10.5435/JAAOSGlobal-D-21-00008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099407PMC
May 2021

Erosive Hand Osteoarthritis: Incidence and Predictive Characteristics Among Participants in the Osteoarthritis Initiative.

Arthritis Rheumatol 2021 11 28;73(11):2015-2024. Epub 2021 Sep 28.

Care New England Medical Group Family Care Center and Internal Medicine, Pawtucket, Rhode Island, and Brown University, Providence, Rhode Island.

Objective: To evaluate age, sex, race, osteoarthritis (OA) severity, metabolic factors, and bone health as risk factors for erosive hand OA at baseline and its incidence over a 48-month period.

Methods: This was a longitudinal cohort study that included participants from the Osteoarthritis Initiative (OAI) with complete hand radiographs from baseline and 48-month visits who were eligible at baseline for incident erosive hand OA (i.e., had or were at risk for knee OA [criterion for OAI inclusion] and did not currently have erosive hand OA). Individuals were classified as having erosive hand OA if the Kellgren/Lawrence (K/L) grade was ≥2 in at least 1 interphalangeal joint on 2 different fingers and central erosion was present in at least 1 joint.

Results: Of the 3,365 individuals without prevalent erosive hand OA at baseline, 86 (2.6%) developed erosive hand OA during the 48-month period. Risk factors included older age (relative risk [RR] per SD 1.63 [95% confidence interval 1.35-1.97]), female sex (RR 2.47 [95% confidence interval 1.52-4.02]), greater OA severity (sum K/L grade 13.9 versus 5.3; P < 0.001), and less cortical width (1.38 mm versus 1.52 mm; P < 0.001). After 48 months, subjects who had developed erosive hand OA were characterized by greater progression of radiographic OA (i.e., joint space narrowing, K/L grade progression [RR 1.35], and loss of cortical thickness [RR 1.23]), adjusted for age, sex, race, body mass index, and baseline OA severity (sum K/L grade).

Conclusion: These findings demonstrate that erosive hand OA is more common in older women and is strongly associated with severity of articular structural damage and its progression. Individuals who develop erosive hand OA have thinner bones prior to erosive hand OA development and as it progresses, suggesting that erosive hand OA is a disorder of skeletal frailty.
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http://dx.doi.org/10.1002/art.41757DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8505573PMC
November 2021

Prevalence of Undiagnosed Subchondral Insufficiency Fractures of the Knee in Middle Age Adults with Knee Pain and Suspected Meniscal Tear.

Osteoarthr Cartil Open 2020 Dec 19;2(4). Epub 2020 Aug 19.

Orthopedic and Arthritis Center for Outcomes Research, Brigham and Women's Hospital, Boston, MA.

Objective: Symptomatic knee osteoarthritis (OA) and meniscal tear are often treated with weight-bearing exercises and without ordering advanced imaging (e.g. MRI). This may lead to missed diagnoses of subchondral insufficiency fracture of the knee (SIFK). Failure to diagnose SIFK has treatment implications, as patients with SIFK are typically managed with a period of reduced weight-bearing. The primary objective of this study is to determine the prevalence of undiagnosed SIFK among persons treated non-operatively for knee pain and suspected meniscal tear(s).

Methods: The randomized controlled trial, TeMPO (Treatment of Meniscal Problems and Osteoarthritis), enrolls subjects whose clinicians suspect concomitant meniscal tear and knee OA. TeMPO participants undergo MRI ordered by the study to confirm meniscal tear. All study-ordered MRIs revealing a fracture were reviewed by two study radiologists who noted features of the fracture and joint. We report prevalence of SIFK and clinical and imaging features on these subjects with 95% confidence intervals.

Results: Ten of the 340 study-ordered MRIs had SIFK, resulting in an estimated prevalence of 2.94% (95% CI: 1.15%, 4.71%). Eight of the ten participants with SIFK had fractures located medially. The femur was involved in five of these participants, tibia in four, and both in one. Five of the ten participants did not have meniscal tears.

Conclusions: This is the only reported estimate of undiagnosed SIFK in adults with knee pain, to our knowledge. Approximately 3% of patients managed with weight-bearing exercise for suspected meniscal tear may have SIFK, a diagnosis typically treated with reduced weight-bearing approaches.
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http://dx.doi.org/10.1016/j.ocarto.2020.100089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771884PMC
December 2020

ACR Appropriateness Criteria® Acute Trauma to the Ankle.

J Am Coll Radiol 2020 Nov;17(11S):S355-S366

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute injuries to the ankle are frequently encountered in the setting of the emergency room, sport, and general practice. This ACR Appropriateness Criteria defines best practices for imaging evaluation for several variants of patients presenting with acute ankle trauma. The variants include scenarios when Ottawa Rules can be evaluated, when there are exclusionary criteria, when Ottawa Rules cannot be evaluated, as well as specific injuries. Clinical scenarios are followed by the imaging choices and their appropriateness with an accompanying narrative explanation to help physicians to order the most appropriate imaging test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.09.014DOI Listing
November 2020

Peroneal Sheath Volumes Are Greater in Patients With Peroneal Pathology Compared With Controls.

Foot Ankle Spec 2020 Aug 27:1938640020950897. Epub 2020 Aug 27.

Carl J. Shapiro Department of Orthopaedics, Division of Foot and Ankle Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (CPM).

Background: Peroneal tendon pathology is common. Several factors have been implicated, including low-lying muscles and accessory tendons. Studies have reported on the presence and length measurements of these structures. This study evaluates volume measurements within the sheath using magnetic resonance images for patients with operatively treated peroneal tendon pathology and control patients without peroneal disease.

Methods: Fifty-one patients with peroneal tendon pathology and 15 controls were included. The volumes of the peroneal sheath, peroneal tendons, peroneal muscle, and accessory peroneus tendons were measured. The distal extent of the peroneus brevis (PB) muscle was measured. Volume and length measurements were then compared.

Results: The mean PB muscle length from the tip of the fibula was 5.55 ± 2.5 mm (peroneal group) and 11.79 ± 4.07 mm (control) ( = .017). The mean peroneal sheath volume was 7.06 versus 5.12 mL, respectively ( = .001). The major contributors to this increased volume was the tenosynovitis (3.58 vs 2.56 mL, respectively; = .019), the peroneal tendons (2.17 vs 1.7 mL, = .004), and the accessory peroneus tendon + PB muscle (1.31 vs 0.86 mL, = .023).

Conclusion: The current study supports that the PB muscle belly is more distal in patients with peroneal tendon pathology. The study also demonstrates increased total volume within the peroneal sheath among the same patients. We propose that increased volume within the sheath, regardless of what structure is enlarged, is associated with peroneal tendon pathology. Further studies are needed to determine if debridement and decompression of the sheath will result in improved functional outcomes for these patients.

Levels Of Evidence: Level III: Case control imaging study.
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http://dx.doi.org/10.1177/1938640020950897DOI Listing
August 2020

Do non-weight-bearing knee radiographs for chronic knee pain result in increased follow-up imaging?

Skeletal Radiol 2021 Mar 20;50(3):515-519. Epub 2020 Aug 20.

Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.

Objective: While weight-bearing radiographs are considered the optimal method for evaluation of joint spaces in osteoarthritis, non-weight-bearing radiographs are often performed. The purpose of this study is to evaluate the rate of follow-up radiographs in patients receiving non-weight-bearing radiographs for chronic knee pain in the outpatient setting, compared with patients receiving weight-bearing radiographs.

Materials And Methods: Consecutive patients who received non-weight-bearing knee radiographs for chronic knee pain between January 1, 2018, and June 15, 2019, were included. Exclusion criteria included trauma, concern for infection or tumor, and post-surgical radiographs. An age- and sex-matched control group of 100 patients who received weight-bearing knee radiographs was compiled. The proportion of follow-up radiographs within 1 year was compared between the study and control groups with chi-squared tests.

Results: Four hundred non-weight-bearing knee radiographic examinations were included. There were 74/400 (18.5%) follow-up radiographs within 12 months. All follow-up radiographs were weight-bearing. In the control group, 4/100 (4%) had follow-up weight-bearing radiographs within 1 year (p < 0.001).

Conclusion: Outpatients who underwent non-weight-bearing knee radiographs for chronic pain had a higher frequency of repeat imaging than those who initially underwent weight-bearing knee radiographs. These results suggest that non-weight-bearing knee radiographs are of lower clinical utility compared with weight-bearing radiographs.
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http://dx.doi.org/10.1007/s00256-020-03585-8DOI Listing
March 2021

Use of Advanced Imaging for Radiographically Occult Hip Fracture in Elderly Patients: A Systematic Review and Meta-Analysis.

Radiology 2020 09 7;296(3):521-531. Epub 2020 Jul 7.

From the Russell H. Morgan Department of Radiology and Radiological Science, (A.H., J.E., P.T.J., S.D.) Department of Orthopaedic Surgery (A.S.L.), and High Value Practice Academic Alliance (A.H., A.S.R., P.T.J., S.D.), Johns Hopkins University School of Medicine, 601 N Caroline St, JHOC 3140D, Baltimore, MD 21287; Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass (R.K., S.E.S.); Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Mass (A.S.R.); and Library of Evidence, Harvard Medical School, Boston, Mass (R.K., A.S.R.).

Background The overall rate of hip fractures not identified on radiographs but that require surgery (ie, surgical hip fractures) remains unclear in elderly patients who are suspected to have such fractures based on clinical findings. Moreover, the importance of advanced imaging in these patients has not been comprehensively assessed. Purpose To estimate the frequency of radiographically occult hip fracture in elderly patients, to define the higher-risk subpopulation, and to determine the diagnostic performance of CT and bone scanning in the detection of occult fractures by using MRI as the reference standard. Materials and Methods A literature search was performed to identify English-language observational studies published from inception to September 27, 2018. Studies were included if patients were clinically suspected to have hip fracture but there was no radiographic evidence of surgical hip fracture (including absence of any definite fracture or only presence of isolated greater trochanter [GT] fracture). The rate of surgical hip fracture was reported in each study in which MRI was used as the reference standard. The pooled rate of occult fracture, diagnostic performance of CT and bone scanning, and strength of evidence (SOE) were assessed. Results Thirty-five studies were identified (2992 patients; mean age, 76.8 years ± 6.0 [standard deviation]; 66% female). The frequency of radiographically occult surgical hip fracture was 39% (1110 of 2835 patients; 95% confidence interval [CI]: 35%, 43%) in studies of patients with no definite radiographic fracture and 92% (134 of 157 patients; 95% CI: 83%, 98%) in studies of patients with radiographic evidence of isolated GT fracture (moderate SOE). The frequency of occult fracture was higher in patients aged at least 80 years (44%, 529 of 1184), those with an equivocal radiographic report (58%, 71 of 126), and those with a history of trauma (41%, 977 of 2370) (moderate SOE). CT and bone scanning yielded comparable diagnostic performance in the detection of radiographically occult hip fracture ( = .67), with a sensitivity of 79% and 87%, respectively (low SOE). Conclusion Elderly patients with acute hip pain and negative or equivocal findings at initial radiography have a high frequency of occult hip fractures. Therefore, the performance of advanced imaging (preferably MRI) may be clinically appropriate in all such patients. © RSNA, 2020
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http://dx.doi.org/10.1148/radiol.2020192167DOI Listing
September 2020

ACR Appropriateness Criteria® Acute Trauma to the Foot.

J Am Coll Radiol 2020 May;17(5S):S2-S11

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute injuries to the foot are frequently encountered in the emergency room and in general practice settings. This publication defines best practices for imaging evaluations for several variants of patients presenting with acute foot trauma. The variants include scenarios when the Ottawa rules can be evaluated, when there are exclusionary criteria, and when suspected pathology is in anatomic areas not addressed by the Ottawa rules. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.019DOI Listing
May 2020

ACR Appropriateness Criteria® Acute Trauma to the Knee.

J Am Coll Radiol 2020 May;17(5S):S12-S25

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute trauma to the knee is a common presentation seen in the emergency department. After a routine clinical examination, imaging is frequently performed to facilitate the diagnosis and almost always starts with radiographs. If clinically indicated, advanced cross-sectional imaging may then be performed for further evaluation. CT is often performed for preoperative planning of the complex tibial plateau and distal femur fractures. Currently, MRI is the study of choice for evaluation of bone marrow, internal derangements, and other soft-tissue injuries about the knee joint. In patients with knee dislocations, MR angiography may be performed simultaneously with MRI for evaluation of internal derangements and vascular injuries with less morbidity compared to conventional angiography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2020.01.041DOI Listing
May 2020

Bone Marrow Edema at Dual-Energy CT: A Game Changer in the Emergency Department.

Radiographics 2020 May-Jun;40(3):859-874

From the Departments of Radiology (B.G., J.C.M., J.W.U., S.E.S., A.D.S., B.K.) and Orthopedic Surgery (M.J.W.), Brigham and Women's Hospital Emergency Radiology Division, 75 Francis St, Boston, MA 02115.

Dual-energy CT is increasingly being used in the emergency department to help diagnose acute conditions. Its applications include demonstrating bone marrow edema (BME) seen in the setting of occult fractures and other acute conditions. Dual-energy CT acquires data with two different x-ray energy spectra and is able to help differentiate materials on the basis of their differential energy-dependent x-ray absorption behaviors. Virtual noncalcium (VNCa) techniques can be used to suppress the high attenuation of trabecular bone, thus enabling visualization of subtle changes in the underlying attenuation of the bone marrow. Visualization of BME can be used to identify occult or mildly displaced fractures, pathologic fractures, metastases, and some less commonly visualized conditions such as ligamentous injuries or inflammatory arthritis. The authors' major focus is use of dual-energy CT as a diagnostic modality in the setting of trauma and to depict subtle or occult fractures. The authors also provide some scenarios in which dual-energy CT is used to help diagnose other acute conditions. The causes and pathophysiology of BME are reviewed. Dual-energy CT image acquisition and VNCa postprocessing techniques are also discussed, along with their applications in emergency settings. The authors present potential pitfalls and limitations of these techniques and their possible solutions.RSNA, 2020.
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http://dx.doi.org/10.1148/rg.2020190173DOI Listing
April 2021

Parenting While in Training: A Comprehensive Needs Assessment of Residents and Fellows.

J Grad Med Educ 2020 Apr;12(2):162-167

Background: Parenting issues can affect physicians' choice of specialty or subspecialty, as well as their selection of individual training programs, because of the distinctive challenges facing residents and fellows with children. Specific information about how residents perceive these challenges is limited.

Objective: We sought to better understand the challenges associated with parenting during residency and fellowship training in order to inform policy and research.

Methods: In 2017, a voluntary online questionnaire was distributed to all 2214 Partners HealthCare graduate medical education trainees across 285 training programs. The survey queried attitudes of and about trainees with children and assessed needs and experiences related to parental leave, lactation, and childcare. Responses were compared between subgroups, including gender, surgical versus nonsurgical specialty, parental status, and whether the respondent was planning to become a parent.

Results: A total of 578 trainees (26%) responded to the questionnaire. Of these, 195 (34%) became parents during training. An additional 298 (52%) planned to become parents during training. Respondents overwhelmingly agreed that their institution should support trainees with children (95%) and that doing so is important for trainee wellness (98%). However, 25% felt that trainees with children burden trainees without children. Childcare access, affordability, and availability for sufficient hours were identified as key challenges, along with issues related to parental leave, lactation facilities, and effect on peers.

Conclusions: This survey highlights trainees' perspectives about parenting during their clinical training, signaling parental leave, lactation facilities, and childcare access and affordability as particular challenges and potential targets for future interventions.
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http://dx.doi.org/10.4300/JGME-D-19-00563.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161335PMC
April 2020

Temporomandibular joint imaging: current clinical applications, biochemical comparison with the intervertebral disc and knee meniscus, and opportunities for advancement.

Skeletal Radiol 2020 Aug 11;49(8):1183-1193. Epub 2020 Mar 11.

Division of Neuroradiology, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02135, USA.

Temporomandibular disorders encompass multiple pathologies of the temporomandibular joint that manifest as middle/inner ear symptoms, headache, and/or localized TMJ symptoms. There is an important although somewhat limited role of imaging in the diagnostic evaluation of temporomandibular disorders. In this manuscript, we provide a comprehensive review of TMJ anatomy, outline potentially important features of TMJ disc ultrastructure and biochemistry in comparison with the intervertebral disc and knee meniscus, and provide imaging examples of the TMJ abnormalities currently evaluable with MRI and CT. In addition, we provide an overview of emerging and investigational TMJ imaging techniques in order to encourage further imaging research based on the biomechanical alterations of the TMJ disc.
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http://dx.doi.org/10.1007/s00256-020-03412-0DOI Listing
August 2020

Women in Radiology: Obtaining Departmental Sponsorship and Building a Sustainable Organization Led by Residents.

J Am Coll Radiol 2020 Mar 13;17(3):441-443. Epub 2019 Dec 13.

Department of Radiology, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jacr.2019.11.011DOI Listing
March 2020

ACR Appropriateness Criteria Acute Hip Pain-Suspected Fracture.

J Am Coll Radiol 2019 May;16(5S):S18-S25

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Acute hip pain following a low-force trauma such as a ground-level fall is a common clinical problem. In the elderly osteoporotic population, this is frequently the result of fractures of the proximal femur or pelvis. As physical examination is often inconclusive, imaging is critical for diagnosis. Radiographs are the preferred first-line imaging modality, although their sensitivity is limited for nondisplaced fractures and further imaging may be necessary as discussed in this article and summarized in the recommendations. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2019.02.028DOI Listing
May 2019

Thinking beyond pannus: a review of retro-odontoid pseudotumor due to rheumatoid and non-rheumatoid etiologies.

Skeletal Radiol 2019 Oct 13;48(10):1511-1523. Epub 2019 Mar 13.

Department of Radiology, Division of Musculoskeletal Imaging and Intervention, Brigham and Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.

Retro-odontoid pseudotumor, or mass-like retro-odontoid soft tissue thickening, is an uncommon but important imaging finding that may be associated with rheumatoid arthritis, crystal deposition diseases, as well as non-inflammatory conditions such as cervical degenerative changes and mechanical alterations. Retro-odontoid pseudotumor is commonly associated with atlantoaxial microinstability or subluxation. MRI and CT have an important role in the detection and diagnosis of retro-odontoid pseudotumor. However, due to a wide range of imaging characteristics and ambiguous etiology, it is a frequently misunderstood entity. The purpose of this article is to review relevant anatomy of the craniocervical junction; describe various imaging appearances, pathophysiology and histology in both rheumatoid and non-rheumatoid etiologies; and discuss differential diagnosis of retro-odontoid pseudotumor in order to help guide clinical management.
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http://dx.doi.org/10.1007/s00256-019-03187-zDOI Listing
October 2019

Health Professional Training and Capacity Strengthening Through International Academic Partnerships: The First Five Years of the Human Resources for Health Program in Rwanda.

Int J Health Policy Manag 2018 11 1;7(11):1024-1039. Epub 2018 Nov 1.

Division of Hospital Medicine, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA.

Background: The Rwanda Human Resources for Health Program (HRH Program) is a 7-year (2012-2019) health professional training initiative led by the Government of Rwanda with the goals of training a large, diverse, and competent health workforce and strengthening the capacity of academic institutions in Rwanda.

Methods: The data for this organizational case study was collected through official reports from the Rwanda Ministry of Health (MoH) and 22 participating US academic institutions, databases from the MoH and the College of Medicine and Health Sciences (CMHS) in Rwanda, and surveys completed by the co-authors.

Results: In the first 5 years of the HRH Program, a consortium of US academic institutions has deployed an average of 99 visiting faculty per year to support 22 training programs, which are on track to graduate almost 4600 students by 2019. The HRH Program has also built capacity within the CMHS by promoting the recruitment of Rwandan faculty and the establishment of additional partnerships and collaborations with the US academic institutions.

Conclusion: The milestones achieved by the HRH Program have been substantial although some challenges persist. These challenges include adequately supporting the visiting faculty; pairing them with Rwandan faculty (twinning); ensuring strong communication and coordination among stakeholders; addressing mismatches in priorities between donors and implementers; the execution of a sustainability strategy; and the decision by one of the donors not to renew funding beyond March 2017. Over the next 2 academic years, it is critical for the sustainability of the 22 training programs supported by the HRH Program that the health-related Schools at the CMHS significantly scale up recruitment of new Rwandan faculty. The HRH Program can serve as a model for other training initiatives implemented in countries affected by a severe shortage of health professionals.
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http://dx.doi.org/10.15171/ijhpm.2018.61DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6326644PMC
November 2018

Acute Nontraumatic Back Pain: Infections and Mimics.

Radiographics 2019 Jan-Feb;39(1):287-288

From the Departments of Emergency Radiology (O.L., B.K.), Musculoskeletal Radiology (J.C.M., S.E.S.), and Neuroradiology (C.C.), Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; and Department of Radiology, Shields Health Care, Brockton, Mass (D.S.T.).

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http://dx.doi.org/10.1148/rg.2019180077DOI Listing
March 2020

Characteristics of Accelerated Hand Osteoarthritis: Data from the Osteoarthritis Initiative.

J Rheumatol 2019 04 1;46(4):422-428. Epub 2018 Dec 1.

From the Division of Rheumatology, Tufts Medical Center; Department of Radiology, Brigham and Women's Hospital and Harvard Medical School; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Center for Primary Care and Prevention, Alpert Medical School of Brown University, Pawtucket, Rhode Island, USA; Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway.

Objective: We aimed to determine whether hand joints develop an accelerated form of osteoarthritis (OA) and to characterize individuals who develop accelerated hand osteoarthritis (AHOA).

Methods: We evaluated 3519 participants in the Osteoarthritis Initiative with complete data for baseline and 48-month radiographic hand osteoarthritis (HOA). One reader scored posteroanterior radiographs of the dominant hand using a modified Kellgren-Lawrence (KL) scale and another reader scored the presence of central or marginal erosions. A third reader read images flagged for signs of diseases other than OA. We defined AHOA as ≥ 1 joints that progressed from a KL grade of 0 or 1 at baseline to KL grade 3 or 4 at 48 months.

Results: The definition of AHOA was met by 1% over 4 years: 37 hands had 1 joint affected and 1 hand had 2 joints affected. At baseline, adults who developed AHOA were more likely to have hand pain (37% vs 22%), radiographic HOA (71% vs 36%), as well as central (22% vs 7%) and marginal erosions (11% vs 2%) in other joints compared to those without AHOA. Adults with AHOA were more likely to develop new erosions over 48 months (central 35%, marginal 5%) than those without AHOA (central 5%, marginal 1%). The most common locations of accelerated OA were the second metacarpophalangeal and first carpometacarpal joint.

Conclusion: Accelerated OA can occur in the hand, especially among digits commonly used for pinching and fine motor skills.
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http://dx.doi.org/10.3899/jrheum.180240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6445673PMC
April 2019

"What program directors think IV": Results of the 2017 Annual Survey of the Association of Program Directors in Radiology.

Acad Radiol 2019 08 5;26(8):1102-1109. Epub 2018 Nov 5.

Department of Radiology, University of Washington, Seattle, Washington 98195-0001.

Rationale And Objectives: The Association of Program Directors in Radiology (APDR) regularly surveys its members to gather information regarding a broad range of topics related to radiology residency. The survey results provide insight into the opinions of residency program leadership across the country.

Materials And Methods: This is an observational cross-sectional study using a web-based survey posed to the APDR membership in the fall of 2017. The final survey consisted of 53 items, 48 multiple choice questions and five write-in comments. An invitation to complete the survey was sent to all 319 active APDR members.

Results: Deidentified responses were collected electronically, tallied utilizing Qualtrics software, and aggregated for the purposes of analysis and reporting at the 66th annual meeting of the Association of University Radiologists. The response rate was 36%.

Conclusion: Over the past 16 years, more PDs have assistant and APDs to administer growing residency programs, but the time allocation for these APDs has come from the PD's protected time. An overwhelming majority of PDs consider independent call beneficial to residents and most think a call assistant is desirable. The vast majority of PDs support a unified fellowship match and allow resident moonlighting. Most fourth year residents are actively or moderately involved in clinical work and teaching. The majority of PDs have lost or expect to lose DR training positions to the new IR/DR programs. In a competitive match, PDs do not rely on residency interviews in their selection process.
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http://dx.doi.org/10.1016/j.acra.2018.09.005DOI Listing
August 2019

ACR Appropriateness Criteria Chronic Knee Pain.

J Am Coll Radiol 2018 Nov;15(11S):S302-S312

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Chronic knee pain is a condition that is frequently encountered. Imaging often plays an important role in narrowing down the potential causes and determining the most effective next steps. The ACR Appropriateness Criteria for Chronic Knee Pain provides clinicians with the best practices for ordering imaging examinations. The following narrative and accompanying tables should serve as useful guides to any clinician. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.09.016DOI Listing
November 2018

Developing a Radiology Global Outreach Elective.

J Am Coll Radiol 2018 10 5;15(10):1471-1472. Epub 2018 May 5.

Department of Radiology, Division of Breast Imaging, Beth Israel Deaconess Medical Center, Boston, Massachusetts.

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http://dx.doi.org/10.1016/j.jacr.2018.02.019DOI Listing
October 2018

ACR Appropriateness Criteria Chronic Ankle Pain.

J Am Coll Radiol 2018 May;15(5S):S26-S38

Specialty Chair, Mayo Clinic, Phoenix, Arizona.

Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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http://dx.doi.org/10.1016/j.jacr.2018.03.016DOI Listing
May 2018

Transmembrane Domains of Highly Pathogenic Viral Fusion Proteins Exhibit Trimeric Association .

mSphere 2018 04 18;3(2). Epub 2018 Apr 18.

Department of Molecular and Cellular Biochemistry, University of Kentucky, Lexington, Kentucky, USA

Enveloped viruses require viral fusion proteins to promote fusion of the viral envelope with a target cell membrane. To drive fusion, these proteins undergo large conformational changes that must occur at the right place and at the right time. Understanding the elements which control the stability of the prefusion state and the initiation of conformational changes is key to understanding the function of these important proteins. The construction of mutations in the fusion protein transmembrane domains (TMDs) or the replacement of these domains with lipid anchors has implicated the TMD in the fusion process. However, the structural and molecular details of the role of the TMD in these fusion events remain unclear. Previously, we demonstrated that isolated paramyxovirus fusion protein TMDs associate in a monomer-trimer equilibrium, using sedimentation equilibrium analytical ultracentrifugation. Using a similar approach, the work presented here indicates that trimeric interactions also occur between the fusion protein TMDs of Ebola virus, influenza virus, severe acute respiratory syndrome coronavirus (SARS CoV), and rabies virus. Our results suggest that TM-TM interactions are important in the fusion protein function of diverse viral families. Many important human pathogens are enveloped viruses that utilize membrane-bound glycoproteins to mediate viral entry. Factors that contribute to the stability of these glycoproteins have been identified in the ectodomain of several viral fusion proteins, including residues within the soluble ectodomain. Although it is often thought to simply act as an anchor, the transmembrane domain of viral fusion proteins has been implicated in protein stability and function as well. Here, using a biophysical approach, we demonstrated that the fusion protein transmembrane domains of several deadly pathogens-Ebola virus, influenza virus, SARS CoV, and rabies virus-self-associate. This observation across various viral families suggests that transmembrane domain interactions may be broadly relevant and serve as a new target for therapeutic development.
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http://dx.doi.org/10.1128/mSphere.00047-18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5907656PMC
April 2018

Variability in the Use of Simulation for Procedural Training in Radiology Residency: Opportunities for Improvement.

Curr Probl Diagn Radiol 2019 May - Jun;48(3):241-246. Epub 2018 Mar 19.

Department of Radiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.

Objective: Increased attention to quality and safety has led to a re-evaluation of the classic apprenticeship model for procedural training. Many have proposed simulation as a supplementary teaching tool. The purpose of this study was to assess radiology resident exposure to procedural training and procedural simulation.

Materials And Methods: An IRB-exempt online survey was distributed to current radiology residents in the United States by e-mail. Survey results were summarized using frequency and percentages. Chi-square tests were used for statistical analysis where appropriate.

Results: A total of 353 current residents completed the survey. 37% (n = 129/353) of respondents had never used procedure simulation. Of the residents who had used simulation, most did not do so until after having already performed procedures on patients (59%, n = 132/223). The presence of a dedicated simulation center was reported by over half of residents (56%, n = 196/353) and was associated with prior simulation experience (P = 0.007). Residents who had not had procedural simulation were somewhat likely or highly likely (3 and 4 on a 4-point Likert-scale) to participate if it were available (81%, n = 104/129). Simulation training was associated with higher comfort levels in performing procedures (P < 0.001).

Conclusions: Although procedural simulation training is associated with higher comfort levels when performing procedures, there is variable use in radiology resident training and its use is not currently optimized. Given the increased emphasis on patient safety, these results suggest the need to increase procedural simulation use during residency, including an earlier introduction to simulation before patient exposure.
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http://dx.doi.org/10.1067/j.cpradiol.2018.02.008DOI Listing
August 2019

Factors Influencing Choice of Radiology and Relationship to Resident Job Satisfaction.

Curr Probl Diagn Radiol 2019 Jul - Aug;48(4):333-341. Epub 2018 Mar 20.

Department of Radiology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA.

Purpose: Identify when current radiology residents initially became interested in radiology, which factors influenced their decision to pursue a career in radiology, and which factors correlate with job satisfaction.

Methods: An online survey was distributed to United States radiology residents between December 7, 2016 and March 31, 2017. Respondents identified the most appealing aspects of radiology during medical school, identified experiences most influential in choosing radiology, and scored job satisfaction on visual analog scales. Relative importance was compared with descriptive statistics. Satisfaction scores were compared across factors with analysis of variance and post-hoc Tukey tests.

Results: 488 radiology residents responded (age 30.8 ± 3.2 years; 358 male, 129 female, 1 unknown; 144 PGY2, 123 PGY3, 103 PGY4, 118 PGY5). The most influential aspects in choosing radiology were the intellectual (n=187, 38%), imaging (n=100, 20%), and procedural (n=96, 20%) components and potential lifestyle (n=69, 14%). Radiology clerkship reading room shadowing (n=143, 29%), radiologist mentor (n=98, 20%), non-radiology clerkship imaging exposure (n=77, 16%), and radiology clerkship interventions exposure (n=75, 15%) were most influential. Choosing radiology because of potential lifestyle correlated with less job satisfaction than choosing radiology for intellectual (p=0.0004) and imaging (p=0.0003) components.

Conclusion: Recruitment of medical students into radiology may be most effective when radiology clerkships emphasize the intellectual and imaging components of radiology through reading room shadowing and exposure to interventions. Choosing radiology for lifestyle correlates with less job satisfaction, at least during residency.
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http://dx.doi.org/10.1067/j.cpradiol.2018.03.008DOI Listing
December 2019
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