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What information is used in treatment decision aids? A systematic review of the types of evidence populating health decision aids

Christopher A Miller

Josephine H Naish

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David Clark

Sha Zhao

Simon G Ray

Mark P Ainslie

Rahul Potluri

Geoffrey Parker

Matthias Schmitt

MODERATED POSTER PRESENTATION Open Access
Effect of contrast dose, post-contrast acquisition
time, myocardial regionality, cardiac cycle
and gender on dynamic-equilibrium CMR
measurement of myocardial extracellular
volume
Christopher A Miller1,2*, Josephine H Naish2, Glyn Coutts3, David Clark4, Sha Zhao2, Simon G Ray1, Mark P Ainslie1,2,
Rahul Potluri1,2, Geoffrey Parker2, Matthias Schmitt1,2
From 16th Annual SCMR Scientific Sessions
San Francisco, CA, USA. 31 January - 3 February 2013
Background
CMR techniques are increasingly being used to eval-
uate myocardial extracellular volume (ECV). In the
most commonly applied method, ECV is quantified using
haematocrit-adjusted myocardial and blood T1 values
measured before and after gadolinium bolus. The technique
is based on a two-compartment model, assuming contrast
kinetic effects to be negligible due to a dynamic equilibrium
between blood and myocardium (Dynamic-Equilibrium
CMR; DynEq-CMR). This study aimed to assess the effect
1North West Heart Centre, University Hospital of South Manchester,
Manchester, UK
Full list of author information is available at the end of the article
Table 1 Characteristics of healthy volunteers.
Overall (n=30) Group A (0.10 mmol/Kg) (n=10) Group B (0.15 mmol/Kg) (n=10) Group C (0.20 mmol/Kg) (n=10) p value
Male 15 5 5 5
Age 45±13 (22-65 44±14 (23-65) 45±14 (22-64) 46±13 (28-64) 0.98
Age Male 45±15 (22-65) 44±15 (27-65) 46±17 (22-64) 44±15 (30-60)
Age Female 45±12 (23-64) 45±15 (23-62) 44±12 (28-59) 47±12 (28-64)
Weight (Kg) 73.1±13.8 74.8±12.9 70.3±16.0 73.1±13.8 0.75
Height (m) 1.69±0.10 1.71±0.09 1.67±0.10 1.70±0.11 0.67
BSA (m2) 1.83±0.20 1.87±0.19 1.78±2.4 1.85±0.18 0.65
Systolic BP (mmHg) 114±11 116±11 114±11 112±12 0.63
Diastolic BP (mmHg) 67±11 71±11 65±13 66±7 0.41
eGFR (mL/min/m2) 95±17 94±11 100±20 91±19 0.50
Indexed EDV (mL/m2) 79±8 78±8 79±7 80±8 0.83
Indexed ESV (mL/m2) 26±5 27±5 27±5 26±5 0.78
EF (%) 67±5 66±4 66±4 68±5 0.45
Indexed Mass (g/m2) 45±8 44±9 43±8 47±7 0.46
HR (bpm) 68±9 67±9 70±11 66±8 0.67
Values are mean ± standard deviation. Age range is also given in brackets. BP indicates blood pressure, eGFR estimated glomerular filtration rate, EDV end
diastolic volume; ESV end-systolic volume; EF ejection fraction. ‘Indexed’ refers to indexed to body surface area.
Miller et al. Journal of Cardiovascular Magnetic
Resonance 2013, 15(Suppl 1):M3
http://www.jcmr-online.com/content/15/S1/M3
© 2013 Miller et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Figure 1 (A) Myocardial (Myo, dashed lines) and blood (continuous lines) T1 relaxation times plotted against time after contrast (Gd-DTPA)
administration. Group A (red) received 0.10mmol/kg contrast, Group B (blue) received 0.15mmol/kg and Group C (green) received 0.20mmol/kg.
Pre-contrast (Time 0) myocardial and blood T1 relaxation times were not significantly different between groups. Post-contrast T1 relaxation times
shortened significantly as contrast dose increased. (B) Myocardial and blood R1 (1/T1) values plotted against time after contrast administration.
Labeling as per A. (C) Dynamic-equilibrium CMR-measured myocardial extracellular volume fraction (ECV) plotted against time following contrast
administration. ECV was significantly higher in group A compared to group B and group C, but there was no significant difference between
groups B and C. ECV increased linearly over time in each group. Error bars represent ±1 SD.
Miller et al. Journal of Cardiovascular Magnetic
Resonance 2013, 15(Suppl 1):M3
http://www.jcmr-online.com/content/15/S1/M3
Page 2 of 3
of contrast dose, post-contrast acquisition time, myocardial
regionality, cardiac cycle and gender on DynEq-CMR ECV
measurement.
Methods
30 healthy volunteers (asymptomatic, no cardiovascular
risk factors, normal examination and ECG; also CMR con-
firmed normal global and regional function with no LGE
in all) were prospectively split into 3 age and sex-matched
groups: group A received 0.10mmol/kg Gd-DTPA, group
B 0.15mmol/kg and group C 0.20mmol/kg (Table 1). Mid-
ventricular short-axis modified look locker inversion
recovery (MOLLI) imaging was performed at 1.5T before,
and at 2min intervals between 2-20mins after, contrast
administration, with same-day hematocrit measurement.
MOLLI imaging was repeated in early systole (150ms after
R wave) pre- and at 10mins post-contrast. Resulting pixel-
wise T1 maps (MatLab) were used to calculate ECV.
(Phantom studies performed prior to patient scanning
determined T1 measurement accuracy and heart-rate cor-
rection algorithm).
Results
Pre-contrast myocardial (A 1051±49ms; B 1045±49ms;
C 1040±43ms; p=0.87) and blood (A 1678±98ms; B 1645
±118ms; C 1686±101ms; p=0.66) T1 times did not differ
significantly between groups. Mean myocardial (A 542
±65ms; B 465±69ms; C 407±55ms; p<0.001) and blood
(A 407±73ms; B 307±67ms; C 252±48ms; p<0.001) T1
averaged over all time points post-contrast shortened sig-
nificantly as contrast dose increased (Figure 1). Mean
ECV was significantly higher in group A compared to
groups B and C (A 27.7±3.7%; B 25.8±3.4%; C 25.8±2.8%;
p<0.001). The difference between groups B and C was
not significant. ECV increased linearly over time in each
group; between 2 and 20mins post-contrast, ECV
increased from 27.2±2.7% to 28.8±3.4%, p=0.020 in
group A; 25.3±2.8% to 26.5±3.2%, p=0.004 in group B;
and 25.2±1.7% to 26.2±2.1%, p=0.068 in group C. ECV
varied significantly between myocardial regions, being
highest in the septum and lowest in the lateral wall in
each group. ECV did not differ significantly between dia-
stole and systole. ECV was significantly higher in females
in each group (A female 29.6±3.0%, male 25.4±3.0%,
p<0.001; B female 27.4±2.7%, male 23.6±2.9%, p<0.001;
C female 26.1±2.8%, male 24.7±2.5%, p=0.027).
Conclusions
The small increase in ECV over time suggests that an
incomplete dynamic equilibrium between blood and myo-
cardium is achieved. DynEq-CMR-derived ECV varies
according to contrast dose, myocardial region and gender.
Funding
Christopher Miller is supported by a Doctoral Research
Fellowship from the National Institute for Health Research
(UK).
Author details
1North West Heart Centre, University Hospital of South Manchester,
Manchester, UK. 2Biomedical Imaging Institute, University of Manchester,
Manchester, UK. 3Christie Medical Physics and Engineering, The Christie
Hospital, Manchester, UK. 4Alliance Cardiac MRI Unit, University Hospital of
South Manchester, Manchester, UK.
Published: 30 January 2013
doi:10.1186/1532-429X-15-S1-M3
Cite this article as: Miller et al.: Effect of contrast dose, post-contrast
acquisition time, myocardial regionality, cardiac cycle and gender on
dynamic-equilibrium CMR measurement of myocardial
extracellularvolume. Journal of Cardiovascular Magnetic Resonance 2013
15(Suppl 1):M3.
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Miller et al. Journal of Cardiovascular Magnetic
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http://www.jcmr-online.com/content/15/S1/M3
Page 3 of 3


Effect of contrast dose, post-contrast acquisition time, myocardial regionality, cardiac cycle and gender on dynamic-equilibrium CMR measurement of myocardial extracellular volume

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Vol.:(0123456789) 
Arch Orthop Trauma Surg 
DOI 10.1007/s00402-017-2660-8
TRAUMA SURGERY
Total wrist arthrodesis for septic wrist arthritis and loss 
of the bony carpus following percutaneous pinning of the fifth 
carpometacarpal joint: a case report
C. Deml1  · S. A. Euler1 · G. Schmidle1 · S. Erhart1 · M. Gabl1 · R. Arora1 
Received: 3 February 2017 
© The Author(s) 2017. This article is published with open access at Springerlink.com
and had a closed comminuted fracture. The CMC was not 
dislocated and the axis of the metacarpal bone was dis-
placed palmary, 10°–15° in loss of extension. He suffers 
diabetes type 2. The orthopedic surgeon on call decided to 
surgically treat the injury using percutaneous pin fixation 
on the next day (Fig. 1). After the second postop X-ray at 
day 17, the patient developed some pain. Because of a fluc-
tuant swelling of the hand with erythema and signs of pin 
infection, the pin was removed without any surgical revi-
sion. The patient was then sent home with oral antibiotics 
(Cefuroxim) as a “standard treatment” and scheduled for 
a follow-up examination. 4  weeks following pin-removal, 
radiographs showed a continuous infection with osteomy-
elitis and bony erosions of the entire carpus, including the 
metacarpals and the distal forearm. Finally, the patient was 
transferred to our University hospital. The MRI showed 
osteomyelitis in all carpal bones, the bases of all metacar-
pal bones and the distal areas of radius and ulna (Fig. 2).
Initial blood tests revealed a glucose concentration of 
301  mg/dl, an  HbA1C of 10% and a CRP of 2.61  mg/dl. 
However, the white blood cell count (WBC) was found nor-
mal [8.3 (4.5–12.5) × 109/l].
Accordingly, the former pinhole and a fistula at the ulno-
metacarpal area were excised in a second revision surgery. 
A central approach was chosen, starting between the second 
and third metacarpal bones, continuing proximally towards 
the Lister tubercle of the radius. A second fistula was found 
in the middle dorsum of the wrist. The subcutaneous and 
peritendinous tissue was fully indurated, and diffuse cham-
bers of pus were found. The dorsal joint capsule was found 
to appear completely infiltrated and eroded by the infection. 
The wrist exhibited gross instability due to destruction of 
the intrinsic ligaments. Again, diffuse accumulations of pus 
were found in these areas. The cartilage of the carpal bones 
was partly destroyed, and the bony structure appeared soft 
Abstract We report on a patient who developed septic 
wrist arthritis with destruction of the entire carpus due to 
osteomyelitis following percutaneous pinning of a fifth 
metacarpal base fracture. Arthrodesis was performed using 
a 6 cm vascularized iliac bone graft. This case report may 
sharpen the surgeon’s awareness of risks in orthopedic sur-
geries, even though the procedure seems to be rather simple 
and the patient is young and seems to be healthy.
Keywords Septic arthritis · Wrist · Arthrodesis · Wrist-
fusion
Case report
Septic wrist arthritis (SWA) is defined as an infection of 
involving one or all of the radio-carpal, mid-carpal, distal 
radio-ulnar and carpo-metacarpal joints. In severe cases, 
the infection can extend into the carpal tunnel and the sur-
rounding subcutaneous tissues [1]. Several articles are pub-
lished, proposing potential pathways for the diagnosis and 
treatment of SWA [2]. We present a case of an end stage 
SWA with complete loss of the bony carpus following per-
cutaneous pinning of the fifth carpo-metacarpal (CMC) 
joint, resulting in a total wrist arthrodesis. The patient 
was asked for submission and publication of his data and 
agreed.
A 30-year-old man presented in a district hospital after a 
fall on ice. He injured the base of the fifth metacarpal bone 
 * C. Deml 
 Christian.Deml@tirol-kliniken.at
1 Department of Trauma Surgery, Medical University 
Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
 Arch Orthop Trauma Surg
1 3
and weak. All carpal bones except half of the trapezium, as 
well as the bases of the second to fifth metacarpal bones 
and the surfaces of radius and ulna had to be resected. 
Debridement and synovectomy of the flexor tendons were 
performed and the median nerve was inspected through the 
dorsal approach as well (Fig.  3). After meticulous irriga-
tion and installation of an external fixator, the defect and 
the wounds were covered using a VAC System. Postopera-
tively, a diabetic specialist followed the patient daily during 
his stay in the hospital to maintain low blood sugar levels. 
The bacteriologic tests of the tissue samples collected at 
multiple different areas during surgery showed multi-resist-
ant Staphylococcus aureus (ORSA) and Staphylococcus 
epidermidis. Antibiotic treatment using Linezolid and Fos-
fomycin was started immediately, according to the recom-
mendations of the consulted University department of med-
ical microbiology. 18 days after the initial revision surgery, 
followed by four revision procedures, the VAC System was 
finally removed, a Palacos cement spacer, saturated with 
Vancomyzin, was placed into the defect and the wound 
was closed. At this time, all collected tissue samples of 
the most recent revision surgery were found to be sterile 
and the patient was dismissed with continuous oral antibi-
otic therapy (Linezolid 1200 mg/d). 14 days later (32 days 
after initial revision), the definitive fusion of the wrist was 
performed, implanting a vascularized iliac bone auto graft 
(6 × 3 cm) connecting to the radial artery. Necrotic wound 
margins of 3 × 0.5 cm necessitated a visor flap from radial 
and split skin grafting. Bony healing was achieved after 
3 months, and acceptable mobility of the thumb and index 
finger were accomplished after 12 months (Fig. 4).
Discussion
We present a severe case of SWA, leading to a resec-
tion of the complete bony carpus and a total wrist 
arthrodesis following pin fixation of the CMC joint. 
Fig. 1  a Preoperative CT-scan 
revealing a metacarpal five frac-
ture. b Postoperative p/a radio-
graph following pin fixation
Fig. 2  a MRI and b p/a radio-
graph at initial presentation in 
our department. Vast erosions 
of the wrist bones due to osteo-
myelitis. The MRI shows septic 
arthritis beginning in the bases 
of the metacarpal bones con-
tinuing proximally to the distal 
parts of radius and ulna
Arch Orthop Trauma Surg 
1 3
Diagnosis of SWA may be difficult, even for expe-
rienced physicians. The incidence of confirmed and 
likely septic arthritis in Western Europe is 4–10 per 
100,000 patients per year [3, 10]. Risk factors for the 
development of SWA include rheumatoid arthritis, 
multiple drug abuse (psychotropic drugs), chronic alco-
hol abuse, previous intraarticular corticosteroid injec-
tions, cutaneous ulcers and insulin-dependent diabetes, as 
well as a low socio-economic status [5, 8, 11]. However, 
SWA may also occur following a surgical intervention. 
Our patient suffered severe insulin-dependent diabetes. 
There is hardly any evidence about the type and timing of 
the antibiotic treatment and clear guidelines are still miss-
ing [14]. The gold standard for the treatment of SWA is the 
initial needle aspiration. Examination of aspirated sample 
should include gram stain, culture, WBC and differential 
and microscopy for crystals. Finding gout or pseudo gout 
crystals does not exclude additional infection. As a second 
step, the surgical intervention as well as revision surgeries 
if needed are recommended [1, 6, 7]. Additional antibiotic 
treatments should be initiated according to the generated 
antibiogram using the collected tissue samples of the index 
surgical procedure. Studies showed that the most common 
bacteria detected were Staphylococcus aureus [9, 15]. The 
average duration of antibiotic treatment has been explained 
diversely in literature. The authors describe treatment peri-
ods between 5 and 180  days [7, 15]. There is hardly any 
evidence about the sequence, combination, or the superior-
ity of primary closed needle aspiration and surgical aspi-
ration with or without arthroscopy. In early stages, arthro-
scopic irrigation has shown likely better outcomes than 
the open revision with irrigation [12]. However, due to the 
severe grade of osteomyelitis within the carpal bones, this 
was not an option within our patient. Agreement exists that 
the key of treatment should include early removal of any 
Fig. 3  a Intraoperative fluoroscopy showing the complete carpal 
resection. b Surgical situs following carpectomy and meticulous soft 
tissue debridement
Fig. 4  a 12 months follow-up radiographs showing bony union of the arthrodesis. Acceptable and stable alignment of the first digital ray with-
out any further proximalization, resulting in a limited but satisfactory range of motion for the patient with the ability to perform a pinch grip (b)
 Arch Orthop Trauma Surg
1 3
infected material in combination with an individual and 
selective antibiotic treatment [2].
Negative WBC and negative or only slightly elevated 
CRP count have been described by other authors in com-
parable cases of septic arthritis before [9]. This may be a 
potential reason for the underestimation of the early stage 
pathology of a septic arthritis. Therefore, it seems to be 
important to precisely survey all anamnestic informa-
tion and to closely consider possible risk factors. The ini-
tial blood glucose level in our patient was over 300  mg/
dl and the  HbA1C test of 10% revealed a poorly regulated 
insulin-dependent diabetes. In combination with postop-
erative clinical signs of infection, including erythema and 
swelling, the treating doctor must be sensitized and aware 
of an infection. Care should be taken in cases with slightly 
spotted decalcification on the radiographs in combination 
with limited range of motion and pain, not to misdiagnose 
a chronic regional pain syndrome. Additional investiga-
tions like ultrasound or MRI might be helpful to further 
elucidate potential early stages of infection. In our case, 
the radiographs of the infected hand with osteomyelitis 
and erosions of the entire carpus were obvious signs of the 
ongoing infection.
The clinical outcome after SWA is poor and disappoint-
ing in the majority of the cases. In up to 73% of the cases, 
SWA results in a partially destroyed joint or may even 
result in amputation [4, 13, 15].
This case report may sharpen the surgeon’s awareness 
of risks in orthopedic surgeries, even though the proce-
dure seems to be rather simple and the patient is young and 
healthy.
Compliance with ethical standards 
Disclosure This article is in compliance with ethical standards.
Conflict of interest All named authors hereby declare that they have 
no conflicts of interest to disclose.
Funding This work received no specific grant from any funding 
agency in the public, commercial, or not-for-profit sectors.
Ethical approval This article does not contain any studies with 
human participants or animals performed by any of the authors. This 
article is a case report.
Informed consent Informed consent was obtained from the reported 
patient to present his medical data.
Open Access This article is distributed under the terms of the 
Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/), which permits unrestricted 
use, distribution, and reproduction in any medium, provided you give 
appropriate credit to the original author(s) and the source, provide a 
link to the Creative Commons license, and indicate if changes were 
made.
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Total wrist arthrodesis for septic wrist arthritis and loss of the bony carpus following percutaneous pinning of the fifth carpometacarpal joint: a case report

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