Andrea Puchnick

Prevalence of incidental pancreatic cysts on 3 tesla magnetic resonance.

Objectives To ascertain the prevalence of pancreatic cysts detected incidentally on 3-Tesla magnetic resonance imaging (MRI) of the abdomen and correlate this prevalence with patient age and gender; assess the number, location, and size of these lesions, as well as features suspicious for malignancy; and determine the prevalence of incidentally detected dilatation of the main pancreatic duct (MPD). Methods Retrospective analysis of 2,678 reports of patients who underwent abdominal MRI between January 2012 and June 2013. Patients with a known history of pancreatic conditions or surgery were excluded, and the remaining 2,583 reports were examined for the presence of pancreatic cysts, which was then correlated with patient age and gender. We also assessed whether cysts were solitary or multiple, as well as their location within the pancreatic parenchyma, size, and features suspicious for malignancy. Finally, we calculated the prevalence of incidental MPD dilatation, defined as MPD diameter ≥ 2.5 mm. Results Pancreatic cysts were detected incidentally in 9.3% of patients (239/2,583). The prevalence of pancreatic cysts increased significantly with age (p<0.0001). There were no significant differences in prevalence between men and women (p=0.588). Most cysts were multiple (57.3%), distributed diffusely throughout the pancreas (41.8%), and 5 mm or larger (81.6%). In 12.1% of cases, cysts exhibited features suspicious for malignancy. Overall, 2.7% of subjects exhibited incidental MPD dilatation. Conclusions In this sample, the prevalence of pancreatic cysts detected incidentally on 3T MRI of the abdomen was 9.3%. Prevalence increased with age and was not associated with gender. The majority of cysts were multiple, diffusely distributed through the pancreatic parenchyma, and ≥ 5 mm in size; 12.1% were suspicious for malignancy. An estimated 2.7% of subjects had a dilated MPD.

Whole-body diffusion-weighted magnetic resonance imaging versus FDG-PET/CT for initial lymphoma staging: systematic review on diagnostic test accuracy studies

CONTEXT AND OBJECTIVE Positron emission tomography with [18]F-fluoro-2-deoxyglucose (FDG-PET/CT) has been advocated as the method of choice for lymphoma staging, since it enables whole-body analysis with high sensitivity for detection of affected areas and because it combines capacities for anatomical and functional assessment. With technological advances, magnetic resonance imaging (MRI) has emerged as an alternative to FDG-PET/CT. This systematic review with meta-analysis aimed to compare whole-body diffusion-weighted MRI (WB-MRI) with FDG-PET/CT for lymphoma staging. DESIGN AND SETTING Systematic review on diagnostic test accuracy studies conducted at a public university. METHODS The Medline, Scopus, Embase and Lilacs databases were searched for studies published up to September 2013 that compared WB-MRI and FDG-PET/CT for lymphoma staging. The reference lists of included studies were checked for any relevant additional citations. RESULTS Six studies that evaluated the initial lymphoma staging in 116 patients were included. WB-MRI and FDG-PET/CT agreed in 90.5% of the cases (κ = 0.871; P < 0.0001). In most of the studies, when there was disagreement between the methods, WB-MRI overstaged in relation to FDG-PET/CT. The sensitivity of WB-MRI and FDG-PET/CT, in comparison with the clinical-radiological standard, ranged from 59 to 100% and from 63 to 100% respectively. CONCLUSION WB-MRI is a highly sensitive method for initial lymphoma staging. It has excellent agreement with FDG-PET/CT and is a great alternative for managing lymphoma patients, without using ionizing radiation or an intravenous contrast agent.

Avaliação do conhecimento de médicos não radiologistas sobre aspectos relacionados à radiação ionizante em exames de imagem

Objetivo:Avaliar o conhecimento dos medicos nao radiologistas sobre a utilizacao da radiacao ionizante em exames de imagem.Materiais e Metodos:Estudo transversal, utilizando questionario anonimo, aplicado a medicos de especialidades clinicas e cirurgicas, dividido em duas partes: uma com questoes sobre as caracteristicas dos medicos, frequencia de solicitacao de exames e de participacao em eventos de atualizacao profissional, e outra com questoes de multipla escolha, abordando conhecimentos gerais sobre radiacao, principios de otimizacao e radioprotecao.Resultados:De 309 questionarios distribuidos, 120 (38,8%) foram respondidos, 50% por medicos de especialidades cirurgicas e 50% clinicas; 45% e 2,5% dos medicos responderam, respectivamente, que a ressonância magnetica e a ultrassonografia utilizam radiacao ionizante. No geral, a media das notas foi maior nas especialidades cirurgicas, sem diferencas significativas, exceto na questao sobre exposicao em gravidas (p = 0,047). Os medicos que se atualizam profissionalmente mostraram conhecimento sobre radiacao ionizante estatisticamente superior aos demais, principalmente os que frequentam reunioes clinicas (p = 0,050) e participam de atividades de ensino (p = 0,047).Conclusao:O conhecimento dos medicos nao radiologistas sobre radiacao ionizante e heterogeneo e em alguns pontos precisa ser melhorado. Reunioes clinicas multidisciplinares e atividades de ensino sao importantes formas de disseminar informacoes sobre o tema.

A sonographic technique to evaluate the anterior bundle of the ulnar collateral ligament of the elbow: imaging features and anatomic correlation.

The aim of this study was to test a sonographic technique used to view the anterior bundle of the ulnar collateral ligament (UCL), describe its sonographic characteristics in healthy volunteers, and verify these characteristics by determining interobserver variability and their correlations in cadavers.

Remarks about systematic reviews of diagnostic tests.

century, the evolution of medicine was seen to be accelerating, and the new millennium began with a fast pace. Doctors and other health pro-fessionals cannot survive unless they are up to date with the constant changes imposed by tech -nology, especially in big cities.Over the last few decades, the avalanche of new drugs and modern methods of treatment has encouraged doctors to look for faster ways to follow these changes, as well as ways to verify the true efficacy of these new interventions. All of these changes led to evidence-based medi-cine, which has subsequently become known as evidence-based healthcare, when other health-care professionals are included in this.Evidence consists of nothing more than the results of assessments through scientific studies with reproducible methodological quality (for all the data described in the work). This is pos-sible in intervention studies on high-prevalence diseases because they present large numbers of participants. However, in cases of low-prevalence diseases, the results give rise to doubts. This has led to the use of systematic reviews, since these are able to fulfill the need to evaluate inter-vention studies. However, this is only possible when studies are designed to have similar objec-tives and interventions and their methodological quality can be assessed. In a systematic review, it is desirable and often feasible to obtain the sum of statistical data from several studies, which is called meta-analysis.More recently, the same need has arisen in the field of diagnostics. The evolution of diagnos -tic equipment and the emergence of new laboratory kits with promises of faster, more accurate and less invasive diagnostic methods has been widely broadcasted in the media. This directly influences patients’ opinions, and affects the people responsible for doing the examinations and governments. Patients obviously want to have access to the best examination that there is, while professionals and governments want to make sure that these new tests really are superior to the existing ones, so that the possibly high financial investment can be justified. Therefore, system-atic reviews on diagnostic accuracy studies are considered to be of great relevance.Given the lack of consensus on the most appropriate way of conducting the systematic review method, the Cochrane Collaboration, a pioneer in implementing systematic reviews on intervention studies, decided to disseminate and encourage the development of systematic reviews on accuracy studies by creating a section aimed only at reviews on diagnostic accu-racy studies. This new section forms part of the RevMan (Review Manager) software, which the Cochrane Collaboration maintains in order to guide the elaboration of reviews and enable pro -duction of meta-analysis whenever possible. This brilliant initiative has caught the attention of many researchers and has encouraged them to work in this field, but just as in any other move-ment in its initial phase, several unresolved issues still hinder the work.The tools for assessing the quality of individual diagnostic accuracy studies are different from those applied in intervention studies. This has generated great confusion among research -ers and among editorial boards evaluating such studies. There are several published system-atic reviews on accuracy studies that are full of inappropriate terms and were methodologically designed as if they were intervention studies. Furthermore, there is a lack of significant accuracy values, such as sensitivity, specificity and predictive values.

Pediatric minor head trauma: do cranial CT scans change the therapeutic approach?

OBJECTIVES: 1) To verify clinical signs correlated with appropriate cranial computed tomography scan indications and changes in the therapeutic approach in pediatric minor head trauma scenarios. 2) To estimate the radiation exposure of computed tomography scans with low dose protocols in the context of trauma and the additional associated risk. METHODS: Investigators reviewed the medical records of all children with minor head trauma, which was defined as a Glasgow coma scale ≥13 at the time of admission to the emergency room, who underwent computed tomography scans during the years of 2013 and 2014. A change in the therapeutic approach was defined as a neurosurgical intervention performed within 30 days, hospitalization, >12 hours of observation, or neuro-specialist evaluation. RESULTS: Of the 1006 children evaluated, 101 showed some abnormality on head computed tomography scans, including 49 who were hospitalized, 16 who remained under observation and 36 who were dismissed. No patient underwent neurosurgery. No statistically significant relationship was observed between patient age, time between trauma and admission, or signs/symptoms related to trauma and abnormal imaging results. A statistically significant relationship between abnormal image results and a fall higher than 1.0 meter was observed (p=0.044). The mean effective dose was 2.0 mSv (0.1 to 6.8 mSv), corresponding to an estimated additional cancer risk of 0.05%. CONCLUSION: A computed tomography scan after minor head injury in pediatric patients did not show clinically relevant abnormalities that could lead to neurosurgical indications. Patients who fell more than 1.0 m were more likely to have changes in imaging tests, although these changes did not require neurosurgical intervention; therefore, the use of computed tomography scans may be questioned in this group. The results support the trend of more careful indications for cranial computed tomography scans for children with minor head trauma.

Can ultrasound of plantar plate have normal appearance with a positive drawer test

OBJECTIVES The aims of this study were (1) to evaluate the reliability of ultrasound (US) examination in the identification and measurement of the metatarsophalangeal plantar plate (MTP-PP) in asymptomatic subjects and (2) to establish the correlation of US findings with those of physical examination and magnetic resonance imaging (MRI), once it is an important tool in the evaluation of the instability syndrome of the second and third rays. MATERIALS AND METHODS US examinations of the second and third MTP-PPs were performed in eight asymptomatic volunteers, totaling 32 MTP joints, by three examiners with different levels of experience in musculoskeletal US. Plantar plate dimensions, integrity and echogenicity, the presence of ruptures, and confidence level in terms of structure identification were determined using conventional US. Vascular flow was assessed using power Doppler. US data were correlated with data from physical examination and MRI. RESULTS MTP-PPs were ultrasonographically identified in 100% of cases, always showing homogeneous hyperechoic features and no detectable vascular flow on power Doppler, with 100% certainty in identification for all examiners. There was excellent US inter-observer agreement for longitudinal measures of second and third toe MTP-PPs and for transverse measures of the second toe MTP-PP. The MTP drawer test was positive for grade 1 MTP instability in 34.4% of joints with normal US results. Transverse MTP-PP measures were significantly higher in individuals with positive MTP drawer test. US measures and characteristics of MPT-PPs were positively correlated with those of MRI. CONCLUSIONS US is efficient in identifying and measuring MPT-PPs and may complement physical examination. A grade 1 positive MTP drawer test may be found in asymptomatic individuals with normal MPT-PPs, as assessed by imaging.

Avaliação de um sistema de segunda opinião em radiologia

OBJETIVO: A segunda opiniao medica pode auxiliar no processo de investigacao do problema de saude de um paciente e na definicao da conduta terapeutica. Este trabalho tem por objetivo demonstrar um processo de segunda opiniao medica por meio de um sistema web multiespecialidades adaptado para a radiologia. MATERIAIS E METODOS: O sistema foi utilizado por 49 medicos residentes da Universidade Federal de Sao Paulo, os quais responderam a 52 solicitacoes de segunda opiniao. Como instrumentos de avaliacao foram utilizados questionarios. RESULTADOS: Foram avaliadas 1.704 respostas de segunda opiniao. Deste total, 514 (29,1%) foram definidas como satisfatorias. Em 64,4% as respostas dos questionarios indicaram que a qualidade das imagens nao comprometeu o diagnostico. O tempo medio para emitir a segunda opiniao remota foi de 6 minutos e 26 segundos. CONCLUSAO: O processo de segunda opiniao medica realizado por intermedio de um sistema web multiespecialidades ajustado para a radiologia pode ser uma excelente ferramenta para o manejo das condutas medicas.

Mycetoma Involving the Heart

A 59-year-old female farm worker developed a dark-centered cutaneous lesion in her right leg, associated with progressive swelling for the past 35 years. During the past 4 years, she also had dry cough and dyspnea, which became more intense for the past 6 months. She complained of asthenia and weight loss of 10 kg in the previous year. The patient had diabetes mellitus and hypertension. On physical examination, she had crackling rale at the base of the lungs, edema of the distal right lower limb, with several sinuses and ulcerated lesions of ≈1 cm with purulent discharge (Figure 1). Figure 1. Right lower foot with several ulcerated lesions with purulent discharge. Radiographic studies showed lytic foci of destruction in the medullary cavity with bone expansion, reactive sclerosis, and thickening of the cortex in right tibia and in bones of the right foot. Metatarsal bones also had cortical scalloping (Figure 2A and 2B). T1-weighted magnetic resonance image of the right foot with fat suppression after intravenous gadolinium demonstrate numerous round lesions containing small low-signal foci, also known as dot-in-circle sign, representing granulation tissue surrounded …

Reproducibility of a quantitative system for assessing the quality of diagnostic ultrasound

Objective To present a quantitative system for assessing the quality of ultrasound examinations-SQUALUS-and to determine its reproducibility, taking into consideration the images on file, as well as the consistency between the images obtained and the final report. Materials and Methods The system includes questions related to the number of images; the appropriateness of images in relation to the protocol established; focus adjustment; depth; gain; and appropriateness of the measurements for B-mode examinations. For Doppler examinations, the system includes questions related to the appropriateness of color images, the spectral analysis, and correction of the insonation angle. To assess the quality of the report, the system includes questions related to the consistency between the images obtained and the contents of the report. An overall numerical score was assigned by averaging the scores for image quality and for the contents of the report. Two independent examiners, each blinded to the evaluation of the other, assessed 30 different types of ultrasound examinations. Results There was statistically significant agreement between the two examiners for 8 of the 10 questions related to image quality. For the questions related to the quality of the reports, the interexaminer agreement was almost perfect. Conclusion The proposed quantitative system for assessing the quality of ultrasound examinations is a reproducible tool that can be used in audits and accreditation programs.