The American College of Radiology (ACR) has issued Appropriateness Criteria to guide radiologists in deciding on radiologic imaging and treatment for children with developmental dysplasia of the hip (DDH), according to an article in the August issue of the Journal of the American College of Radiology.

"These criteria can improve patient care by emphasizing standardization of the screening process and the appropriate use of imaging to decrease late detection of DDH," lead author Boaz K. Karmazyn, MD, from Riley Hospital for Children, Indiana University in Indianapolis, said in a news release. "Late detection could lead to early degenerative changes in adulthood — possibly resulting in the need for joint replacement. Hopefully, the appropriate use of imaging set forth in these criteria will help decrease the number of late DDH diagnoses."
Formerly known as congenital dislocation of the hip, DDH encompasses a variety of hip joint abnormalities including abnormal acetabular shape (dysplasia) and unstable positioning or displacement from the femoral head. Malposition of the femoral head can range from dislocatable hip and mild subluxation to fixed dislocation.

Early Detection of DDH Reduces Complications

Incidence of DDH is approximately 2 to 4 per 1000 live births, with prevalence rates of 1.5 in 1000 in whites and somewhat lower in blacks. Risk factors include female sex (4- to 8-fold increased risk), family history of DDH, firstborn status, large infant size, and history of oligohydramnios. Because of the normal left occiput anterior position in utero, which places the left hip against the mother's spine and limits its abduction, DDH is 3 times more common in the left hip than in the right.

When detected early, DDH is usually treated with a harness, with low risk for complications. However, diagnosis of DDH later in childhood usually requires surgical intervention, with higher attendant risk for complications. When DDH is not diagnosed until adulthood, outcomes may include debilitating, end-stage, degenerative hip joint disease.

To reduce the incidence of late diagnosis, screening for DDH is therefore important. Until the age of 12 months, children should be clinically evaluated for DDH at each well-baby visit (typically performed at 1 – 2 weeks and at 2, 4, 6, 9, and 12 months of age). In addition to historical risk factors, examination findings indicating DDH include positive Ortolani or Barlow test results for ligamentous or capsular laxity, asymmetric skin folds, and shortening of the thigh on the dislocated side.

In the Ortolani test, the clinician abducts and gently lifts the flexed thigh and pushes the greater trochanter anteriorly. When the femoral head of the dislocated hip slips into the acetabulum, there is an audible or palpable "clunk." In the Barlow maneuver, the clinician places the thumb of one hand over the femoral neck and the fingers over the greater trochanter to try to gently adduct the thigh and dislocate the femoral head posteriorly, and then gently lift the thigh upward while abducting the leg with the fingers over the greater trochanter, attempting to relocate the femoral head in its socket.

These tests are less likely to be positive in children older than 3 months of age. Once children with DDH begin walking, there is a characteristic limp, often with toe-walking on the affected side. Dislocation of both hips may present with increased lumbar lordosis, prominent buttocks, and a waddling gait. Physical findings may include a stable "clicking" hip.

No Consensus on Optimal Screening Method

At present, there is no consensus opinion regarding optimal imaging screening for DDH. Screening with ultrasound offers the benefits of early diagnosis of DDH, but these benefits must be balanced against increased treatment and cost factors.

In addition, randomized trials evaluating the merits of primary screening with ultrasound have not demonstrated a significant reduction in late diagnosis of DDH. Typical practice in the United States is to selectively perform hip ultrasound in infants with risk factors such as family history of DDH, breech presentation, and inconclusive findings on physical examination.

A North American standard for hip ultrasound was agreed upon in 1993, consisting of a coronal view in the Graf format and a transverse view with the hip flexed, with and without modified Barlow stress maneuver.

Ultrasound for DDH should not be done until after 2 weeks of age, because laxity often occurs after birth and may be transient, with spontaneous resolution.

There is no established role for the use of radiography for generalized screening for DDH. Pelvic radiography should optimally be delayed until after 4 months of age, when ossification centers of the femoral heads have developed in most infants.

Computed tomography in DDH is primarily used for follow-up rather than for initial diagnosis. Either computed tomography or magnetic resonance imaging may be used to evaluate outcomes of surgery or of attempted closed reduction. Magnetic resonance imaging also may be useful to evaluate complex dislocations and suspected avascular necrosis.

The main use of arthrography is during surgery, to allow the orthopedic surgeon to evaluate lateral displacement of the femoral head and congruity after closed reduction of the hip and to look for labral infolding that could hinder proper hip reduction.

"The criteria we have developed follow the American Academy of Pediatrics guidelines for selective use of ultrasound in the screening of DDH. The hope is that the criteria will send out the message that ultrasound is the screening modality of choice for evaluation of DDH in children younger than four months," Dr. Karmazyn said.

Article written by staff at medscape.com and adapted for the purposes of this newsletter.

Rather than feeling for a broken bone or swollen abdomen or merely listening to the heart, Fox has trained UC Irvine Medical Center's emergency department clinicians to use the latest in lightweight, high-resolution ultrasound scanners, allowing them to diagnose in minutes — and with striking precision — life-threatening conditions requiring immediate intervention.

The emergency-medicine doctor became an evangelist for ultrasound when a young woman with breathing problems was rushed to the Chicago hospital where he was learning to use the device. She seemed to be having an asthma attack, but her lungs were clear, so Fox moved the sound-wave probe lower and saw that her abdomen had filled with blood, which he quickly traced to a fetus developing outside her uterus. She was rushed into surgery.

"Without the ultrasound scanner, she would have died from a ruptured ectopic pregnancy," said Fox, co-author and editor of Clinical Emergency Radiology, a new textbook on the use of ultrasound in the ER. "We knew immediately what we needed to do."

Ultrasound has long been a staple of obstetrics. The technology has developed rapidly in recent years, allowing cardiologists, urologists and others to peer inside the body with a clarity that makes minimally invasive surgical techniques, such as heart catheterization and clot removal, safer and more effective. Some scanners, which work by emitting sound waves to plot images on a computer screen, can produce three-dimensional results.

With portable devices that weigh less than 7 pounds and fire up in 15 seconds, trained clinicians can identify 44 medical conditions with a high degree of accuracy in two minutes. They can detect collapsed lungs, gallstones, blood clots, heart problems and blockages in the stomach, intestines and kidneys.

When a 40-year-old car crash victim was wheeled into UC Irvine's emergency room recently, his pulse stopped, suggesting heart failure. But by moving the ultrasound probe over the man's chest, Fox saw that blood had flooded the sac surrounding his heart, constricting its ability to pump.

"We cracked his chest open right there and found the cause of the bleeding, which was a hole in the right ventricle," Fox said. "We temporarily closed it, stabilized the patient for more definitive care in the operating room — and he survived." The scans minimize "the shotgun approach we have had to take in emergency medicine," said Fox, UC Irvine's director of emergency ultrasound and an associate clinical professor who has written 20 peer-reviewed articles and an earlier textbook on the subject.

"We now have the ability to look through the skin, right at the organs we're interested in," he added. "We can see tears in tissue, in muscles and tendons. Not since the stethoscope have we been able to find out what's going on inside the body without something more invasive, like X-rays. With ultrasound, there's no radiation, just sound waves."

U.S. military medics already have battery-operated ultrasound machines on the battlefield. NASA astronauts have them on the space shuttle. And researchers at remote Antarctic stations are being trained to use them.

Yet only a few hospital emergency rooms in Orange County — indeed, in Southern California — use ultrasound for diagnosis, Fox says.
He credits UC Irvine's director of emergency medicine, Dr. Mark Langdorf, with the foresight to send him almost a decade ago to the Chicago ultrasound program, where Fox became the nation's third ER physician to specialize in emergency radiology. Today there are 44 emergency radiology fellowship programs, including UC Irvine's.

When not in the ER or teaching, Fox is spreading the word about diagnostic ultrasound. He has given lectures in seven countries, 47 states and throughout Southern California.

Fox won't be satisfied until ambulances carry ultrasound scanners. "The next step," he said, "is to push this equipment out into the field, with the paramedics, pre-hospital."

View the article online.

Article written by staff at physorg.com and adapted for the purposes of this newsletter.

Limiting detailed second-trimester ultrasound exams to patients with risk factors may result in many fetal anomalies going undetected -- and current U.S. reimbursement policy may need updating to reflect this finding, according to research published in the August issue of the Journal of Ultrasound in Medicine (JUM).

A research team led by Dr. Stephen Chasen of Weill Cornell Medical College in New York City found that more-detailed ultrasound scans usually reserved for at-risk women found 40% of fetal abnormalities in normal women that would not have been detected on more basic scans (JUM, August 2009, Vol. 28:8, pp. 1015-1018). U.S. reimbursement policy that restricts the more-detailed scans to at-risk women may need to be revised to cover more women.

"It is clear that a policy limiting the structures to be examined in all pregnant women will lead to a substantial proportion of major anomalies going undetected," Chasen said.

The basic scan

Under current clinical practice, women with no risk factors for abnormal pregnancy receive a basic second-trimester ultrasound examination (current procedural terminology [CPT] code 76805), consisting of a survey of intracranial, spinal, and abdominal anatomy; evaluation of the heart; and assessment of the umbilical cord insertion site.

More-detailed scans have been reserved for at-risk women under CPT code 76811, which was introduced in 2003. This study includes the same components of the basic scan, as well as a detailed anatomic evaluation of the fetal brain, ventricles, face, heart, outflow tracts, chest anatomy, and specific abdominal organ anatomy, along with the number, length, and architecture of limbs, according to the authors.

Seeking to evaluate the effects of restricted versus routine use of detailed second-trimester sonography, the Cornell researchers reviewed the records of singleton pregnancies undergoing evaluation at their institution after 14 weeks' gestation from 2004 to 2008. A detailed examination (CPT code 76811) was routinely performed on all patients.

Major structural abnormalities were categorized based on whether the structure would be included in a basic examination (CPT code 76805). In addition, the researchers identified risk factors for anomalies. Of the 22,335 patients in the study, 218 (1%) had major anomalies. Seventy-five patients (34.4%) elected to have an abortion following the diagnosis.

"There were no significant differences in maternal age, the proportion of pregnancies with risk factors for structural anomalies, or the rate of abortion based on whether the abnormalities involved structures included in the basic examination," the authors wrote.

In 88 patients (40.4%), the abnormal structures would not have been included in a basic examination. These anomalies included 35 clubfoot deformities, 14 cardiac outflow tract anomalies, 10 cleft lip and/or palate cases, seven cases with multiple abnormalities, six arthrogryposis cases, six with limb reduction defect, three with ambiguous genitalia, three with facial teratoma, three skeletal dysplasia cases, and one case of fetal warfarin syndrome.

Sixty-two patients (28.4%) among the 218 with major anomalies were noted to have risk factors for structural anomalies. In 20 of these patients, however, the risk factors were only identified by reviewing medical records and were unknown at the time of the sonographic examinations, according to the study team.

Restricting evaluation of fetal anatomy to those structures included in the basic examination would have prevented detection of a substantial proportion of anomalies, according to the researchers.

"Although these include anomalies that are usually associated with good outcomes, such as clubfoot deformity, anomalies associated with major morbidity, such as cardiac outflow abnormalities, skeletal dysplasia, and arthrogryposis, would also go undetected," the authors wrote.

If a detailed scan had been performed only on the 62 patients with risk factors, and anomalies of structures not included in the basic scan were missed in the remaining patients, 71.6% of anomalies would have been identified with routine use of detailed sonography, according to the authors. Also, if only the 42 patients with known risk factors at the time of the study had received a detailed scan, 66.5% of anomalies would have been identified with routine use of detailed sonography.

View the article online.

Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.

Is it groundbreaking public policy or a case of the law outpacing the clinical evidence? Either way, the eyes of Texas are following the potential impact of new legislation that will take effect on September 1 requiring insurers to pay for CT and ultrasound scans for atherosclerosis screening.

The Texas Heart Attack Prevention Bill (HB 1290) mandates that all health benefit providers in the state provide a minimum of $200 per individual every five years to cover the cost of CT coronary artery calcium (CAC) scans or carotid ultrasound studies. The coverage must be offered to men between the ages of 45 and 76 and women between the ages 55 to 76, as well as anyone else who has diabetes or is deemed to be at intermediate risk or higher for developing coronary artery disease per the Framingham risk score.

The controversial bill (click here for complete text in PDF file) was signed into law by Gov. Rick Perry on June 23. The first of its kind in the U.S., it was passed in early June by both houses in the Texas Legislature after being introduced twice and withdrawn once. Filed by Rep. René Oliveira (R-Brownsville) on his first day back at work from coronary artery bypass surgery, the legislation was modeled on the Screening for Heart Attack Prevention and Education (SHAPE) task force guidelines published in 2006, in which the Society for Heart Attack Prevention and Eradication (also SHAPE) of Houston recommended screening of all individuals at risk of a heart attack.

Despite the bill's passage, it remains controversial for several reasons. First, the law mandates coverage of broad-based screening, requiring the use of radiation in the case of CAC scans (although such tests are now commonly performed using less than 1 mSv of radiation).

There are also concerns that the yield of positive results per capita -- in terms of individuals identified through screening who would then have an opportunity to undergo treatment or make lifestyle modifications -- remains insufficient to justify the expenditure. Finally, critics of the new law are concerned that a large influx of new patients showing up for screening could overburden the healthcare system, and that downstream testing of incidental findings could add substantially to both risks and the cost of care.

A hot potato?

Perhaps because of these issues, support for the nascent law is something of a hot potato, to the point where some individuals contacted were unwilling to comment. The American Heart Association (AHA), the American College of Cardiology, the American College of Radiology, and the Texas Radiological Society all take no official position on the legislation. A prominent Texas radiologist declined to speak on the record, saying only that expressing either support or opposition to the law would be too controversial.
The Texas Medical Association said that it "monitored" the bill in the Texas Legislature without taking a position. Helen Kent Davis, director of governmental affairs with the Austin-based association, said the organization rarely supports preventive care with a few exceptions. As for the new bill, the physicians on the scientific committee felt that mandatory screening was "too expensive for widespread use."

The American Heart Association's vice president of advocacy, Joel Romo, said that the lack of an endorsement now doesn't mean one won't eventually be produced, merely that the process is slow. All of the AHA's policy positions involve a painstaking, collaborative process "based on hard science and the unanimous approval among policy committees made up of our volunteers across the country," Romo stated. "For this particular issue, we just didn't have anything from the AHA that could give us a conclusive position whether it was for or against."

Shaping legislation

On the other hand, the Society for Heart Attack Prevention and Eradication has been a major proponent of the legislation throughout its ups and downs in the Texas Legislature, stating on its Web site that the results of the group's analysis found that proper screening of the asymptomatic men and women of screening age could:

• Prevent more than 4,300 deaths from cardiovascular disease each year in the state (more than 90,000 deaths in the U.S.).
• Reduce the Texas population with a history of heart attack -- currently estimated to be 550,000 -- by as much as 25%.
• Save approximately $1.6 billion annually (more than $21 billion in the U.S.).

Dr. Matthew Budoff, a SHAPE task force panel member and an assistant professor of cardiology at Harbor-UCLA Medical Center in Los Angeles, defended the organization's support of the law, said that the data are "overwhelming that calcium scoring is the best current known predictor of future cardiovascular events in asymptomatic persons" and support the Texas law.

Although the AHA may not endorse it, the organization does support the use of calcium scoring for intermediate-risk patients, per its 2006 statement on cardiac CT, wrote Budoff, first author of the 2006 AHA report, in an e-mail.

The Multi-Ethnic Study of Atherosclerosis (MESA) (New England Journal of Medicine, March 27, 2008, Vol. 358:13, pp. 1336-1345), a 6,814-person National Institutes of Health-funded study showed that calcium scoring was the best predictor of cardiac events, better than C-reactive protein, intimal-medial thickness (IMT), and traditional risk factors, Budoff wrote. Finally, new five-year follow-up results of the Heinz Nixdorf Recall Study presented at the 2009 American College of Cardiology meeting "also strongly show that calcium scoring was a better predictor of events than risk factors, and strongly support the law," he wrote.

SHAPE chairman Dr. Morteza Naghavi last year responded to criticism that the science was not yet sufficient to support population-wide atherosclerosis screening -- and that any false-positive results could actually be dangerous if they led to unnecessary additional tests -- by arguing that CAC scoring would be useful in identifying more individuals at risk of heart attack.

"Most initial myocardial infarctions occur in asymptomatic individuals with unrecognized atherosclerosis who are classified by the Framingham risk score as low or intermediate risk," Naghavi and colleagues wrote in a letter to the Journal of the American Medical Association. "Thus, when screening is based on risk factors alone, most individuals destined for a near-term myocardial infarction are not identified and, consequently, not offered adequate preventive treatment" (JAMA, May 14, 2008, Vol. 299:18, pp. 2147-2148).
Dr. Pamela Bowe Morris, director of the Seinsheimer Cardiovascular Health Program and co-director of the Women's Heart Care Program at the Medical University of South Carolina in Charleston, said that she also strongly supports the new law. The evidence favoring both CAC scoring and carotid artery sonography is compelling, and the need for increased screening is real, she wrote in an e-mail.

"There is a strong multiethnic evidence base in men and women that both assessment of coronary artery calcification (calcium scoring) and measurement of carotid intima media thickness (carotid IMT) can improve our ability to identify individuals with subclinical atherosclerosis who are at risk for future cardiovascular events," Bowe Morris stated. "Current guidelines recommend initial risk stratification based on risk scoring algorithms such as the Framingham risk score. However, many individuals fall into an 'intermediate risk' range, and the need to pursue aggressive preventive therapies may be uncertain. It is in just such patients that noninvasive imaging for the presence of already-present subclinical disease can greatly aid physicians as they design a preventive regimen and determine the intensity of treatment."

Until now these simple and noninvasive tests have been available only to more financially advantaged patients who can afford to pay for the tests out of pocket, Bowe Morris wrote. "With the great groundbreaking decision of the Texas Legislature, all insured appropriate individuals in the great state will now be able to benefit from this advanced technology and improved cardiovascular risk prediction," she stated. The decision "shows great appreciation for the devastating morbidity and mortality that is caused by cardiovascular disease ... and the need to be more aggressive in identifying persons at risk and implementing aggressive preventive strategies."
Dr. Raymond Stainback, a supporter of the bill and a councilor with the Texas chapter of the American College of Cardiology, spoke to Heartwire about the act in June. The law's provisions are generally considered reasonable, he told the publication, and the tests are already in common use today -- but purchased entirely at the patient's expense.

"In some cases, the doctor may feel that an additional piece of concrete imaging screening data would be helpful for encouraging aggressive and sometimes expensive-for-the-patient preventive measures, such as statin therapy, with requisite follow-up over many years," Stainback said. "When a dramatic plaque burden is demonstrated, it seems to make sense that doctors and patients may take this more seriously than the theoretical risk. The somewhat-contentious remaining issue is that asymptomatic at-risk patients would presumably already have aggressive prevention measures in place, regardless of these additional imaging studies."
Dr. Lincoln Berland, vice chairman for quality improvement and patient safety at the University of Alabama at Birmingham, said that, while he did not specialize in cardiac imaging, general caveats about the risks of screening too many individuals are certainly applicable to the new law.

"Cardiac disease kills more people than anything else in the U.S., so naturally there is great interest in trying to decrease cardiac deaths," Berland wrote. "One problem with screening that is particularly troublesome here is the huge numbers of people who would be candidates for scanning. Usually, scanning only becomes cost-effective when at least a moderate-risk population is selected."
Incidental findings are quite common in any screening program, leading "to a substantial number of extra tests, primarily for what turns out to be benign disease," he added. "This is one of the factors that makes screening less cost-effective," Berland stated.
The relationship between better healthcare and cost is widely misunderstood, Berland wrote. While screening may save lives by increasing quality-adjusted life years (QALY), the effort is almost always accompanied by higher costs. In the new law, these costs are likely to be significant because of the large number of people who are candidates. Preventive strategies such as diet and medication may or may not increase costs.

"The Texas law mandating [screening] is bold, but it may prove expensive, with an uncertain effect on outcomes, Berland wrote."Hopefully, if this is implemented, it can be scientifically studied to help answer the important questions about its cost-effectiveness."

View the article online.

Article written by staff at auntminnie.com and adapted for the purposes of this newsletter.