Raffaele Masciangelo

Intraindividual Comparison of Gadoxetate Disodium–enhanced MR Imaging and 64-Section Multidetector CT in the Detection of Hepatocellular Carcinoma in Patients with Cirrhosis

PURPOSE To prospectively compare gadoxetate disodium-enhanced magnetic resonance (MR) imaging with multiphasic 64-section multidetector computed tomography (CT) in the detection of hepatocellular carcinoma (HCC) in patients with cirrhosis. MATERIALS AND METHODS Institutional review board approval and informed patient consent were obtained for this prospective study. Fifty-eight patients (39 men, 19 women; mean age, 63 years; age range, 35-84 years) underwent gadoxetate disodium-enhanced MR imaging and multiphasic 64-section multidetector CT. The imaging examinations were performed within 30 days of each other. The two sets of images were qualitatively analyzed in random order by three independent readers in a blinded and retrospective fashion. Using strict diagnostic criteria for HCC, readers classified all detected lesions with use of a four-point confidence scale. The reference standard was a combination of pathologic proof, conclusive imaging findings, and substantial tumor growth at follow-up CT or MR imaging (range of follow-up, 90-370 days). The diagnostic accuracy, sensitivity, and positive predictive value were compared between the two image sets. Interreader variability was assessed. The accuracy of each imaging method was determined by using an adjusted modified chi(2) test. RESULTS Eighty-seven HCCs (mean size +/- standard deviation, 1.8 cm +/- 1.5; range, 0.3-7.0 cm) were confirmed in 42 of the 58 patients. Regardless of lesion size, the average diagnostic accuracy and sensitivity for all readers were significantly greater with gadoxetate disodium-enhanced MR imaging (average diagnostic accuracy: 0.88, 95% confidence interval [CI]: 0.80, 0.97; average sensitivity: 0.85, 95% CI: 0.74, 0.96) than with multidetector CT (average diagnostic accuracy: 0.74, 95% CI: 0.65, 0.82; average sensitivity: 0.69, 95% CI: 0.59, 0.79) (P < .001 for each). No significant difference in positive predictive value was observed between the two image sets for each reader. Interreader agreement was good to excellent. CONCLUSION Compared with multiphasic 64-section multidetector CT, gadoxetate disodium-enhanced MR imaging yields significantly higher diagnostic accuracy and sensitivity in the detection of HCC in patients with cirrhosis.

Bacterial vaginosis and contraceptive methods

Objective: The aim of this study was to investigate if bacterial vaginosis is associated with the use of specific contraceptives. Methods: The study population consisted of 1314 women attending for periodical preventive examinations at our gynecology unit at the II Institute of Obstetrics and Gynecology of the University ‘La Sapienza’ in Rome. The patients history and any current genital symptom were recorded on a structured protocol. Current users of contraceptives were compared with non‐users. The χ2 test and the t‐test were used in the statistical analysis; a stepwise logistic regression analysis was performed to assess the simultaneous effect of more than one variable and to identify for possible confounding factors. Results: Both oral contraceptive and condom use showed a significant protective effect against bacterial vaginosis. Our results also showed a significant increase of BV among IUD users, either before or after adjustments. Conclusions: This study showed a significant negative association between BV and OC and condom use, respectively, and a significant positive association between BV and IUD use. Therefore, we suggest that it is advisable to carry out a systematic microscopic evaluation in order to identify BV for IUD users.

Hepatocellular Carcinoma in Patients with Cirrhosis: Qualitative Comparison of Gadobenate Dimeglumine–enhanced MR Imaging and Multiphasic 64-Section CT

PURPOSE To prospectively investigate whether combined interpretation of dynamic and hepatobiliary phase magnetic resonance (MR) images can improve the accuracy of gadobenate dimeglumine-enhanced MR imaging in the detection of hepatocellular carcinoma (HCC) compared with either dynamic MR or multiphasic multidetector computed tomographic (CT) images alone. MATERIALS AND METHODS Institutional review board approval and informed patient consent were obtained. Fifty-two patients (39 men, 13 women; mean age, 68 years; range, 38-81 years) suspected of having HCC underwent gadobenate dimeglumine-enhanced MR imaging and multiphasic 64-section multidetector CT. Images were qualitatively analyzed independently by three observers in three separate reading sessions. The alternating free-response receiver operating characteristic (AFROC) method was used to analyze the results. Differences in sensitivity and positive predictive values were calculated at a statistical significance of P < .05. RESULTS A total of 67 HCCs were detected in 36 patients. The mean area under the AFROC curve (A(z)) was significantly higher for either the combined interpretation of dynamic and hepatobiliary phase MR images (A(z) = 0.95) or dynamic MR images alone (0.91) than for CT images (0.77) (P = .01 for both comparisons). The mean sensitivity of combined interpretation of MR images (0.72) was significantly higher than those of dynamic MR images alone (0.63) and multidetector CT images (0.61) (P = .008 and .001, respectively). The mean positive predictive value was not significantly different among the three imaging sets. CONCLUSION The combined interpretation of dynamic and hepatobiliary phase MR images improves diagnostic accuracy of gadobenate dimeglumine-enhanced MR imaging for the detection of HCC compared with either dynamic MR or multiphasic multidetector CT images alone.

Prospective evaluation of multiparametric ultrasound and quantitative elastosonography in the differential diagnosis of benign and malignant thyroid nodules: Preliminary experience

PURPOSE To assess the clinical value of quantitative elastosonography compared with multiparametric ultrasound in differentiating the nature of thyroid nodules. METHODS AND MATERIALS Ninety-seven consecutive patients (32 males, 65 females, mean age, 54 years, range 20-81 years) with thyroid nodules previously detected at color-Doppler ultrasound (CDUS), were prospectively examined with elastosonography with dedicated quantitative software (Elasto-Q, Toshiba) before surgery. Ultrasound examination and elastosonography were evaluated by two investigators in consensus. US features, color-Doppler pattern, and strain ratio value were evaluated. Sensitivity and specificity of CDUS and sono-elastography were compared using X(2) test and ROC curves. RESULTS Sensitivity and specificity of hypoechogenicity, irregular margins or suspicious halo features, CDUS blood flow pattern, and strain ratio in the diagnosis of malignant nodules were 56.8%, 62.2%, 54.1% and 97.3% and 71.7%, 93.3%, 28.3%, and 91.7%, respectively. Elastosonography was more sensitive and specific than all ultrasonographic features in predicting malignancy of the thyroid nodules (p<0.0001). According to elastosonographic features the lesions characterized by strain ratio ≥ 2 were highly likely to be of malignant nature (p<0.0001, O.R. 396, 95%, CI: 44-3530). CONCLUSIONS The results of the present study suggest that elastosonography with Q system is a valuable tool in the characterization of thyroid nodules and it seems to be far more accurate than CDUS. These findings as well as those of previous studies support its use in selecting patients who are candidates for surgery.

Comparison of diagnostic methods in the diagnosis of dermatomycoses and onychomycoses

Direct microscopic examination of potassium hydroxide (KOH)‐prepared specimens is the simplest, cheapest method used for the diagnosis of mycotic infections of the skin. However, KOH preparations have been reported to have 5–15% of false‐negative results, possibly because of the low visibility of scant, scattered fungal material of the nail scrapings and because the detection of fungal elements depends on the skill of the observer [Arch Dermatol133 (1997) 1317; Clin Microbiol Rev8 (1995) 240]. We compared two different KOH‐based staining methods in order to obtain reliable results in shorter time than expected for cultures. A total of 124 patients with suspect diagnosis of dermatomycosis or onychomycosis were enrolled. Two scrapings from the same lesion of each patient were stained with KOH‐Chlorazole and KOH‐Acridine Orange (AO), respectively; cultural examination of the same specimen was considered as diagnostic gold standard. The two methods showed neither significantly different sensitivity nor specificity; however, for onychomycoses, we observed a slightly higher sensitivity for KOH‐Chlorazole and a higher specificity for KOH‐AO. We suggest the use of both techniques in order to improve detection of fungal infection, especially for onychomycoses.

Ultrasound evaluation of liver fibrosis: preliminary experience with acoustic structure quantification (ASQ) software.

PurposeThe aim of our study was to assess the diagnostic accuracy of acoustic structure quantification (ASQ) ultrasound software in estimating the degree of hepatic fibrosis compared to Fibroscan and liver biopsy.Materials and methodsSeventy-seven patients with chronic viral hepatitis B and C underwent standard ultrasound examination, ASQ, Fibroscan and liver biopsy. ASQ analysis was conducted by placing a single region of interest (ROI) on each image captured, and calculating mode, average and standard deviation. The sonographic technique was developed through a preliminary evaluation of 20 healthy volunteers.ResultsThe area under the receiver operating characteristic (AUROC) curve for the diagnosis of cirrhosis (F≥4) with ASQ was 0.77, whereas for the diagnosis of any degree of fibrosis (F≥1) it was 0.71. The AUROC for the diagnosis of cirrhosis (F≥4) with Fibroscan was 0.98, while for the diagnosis of any degree of fibrosis (F≥1) it was 0.94. The difference between the AUROC was statistically significant (p<0.05).ConclusionsASQ is a promising new ultrasound software programme which offers encouraging results in the diagnosis of both liver cirrhosis (F=4) and fibrosis (F≥1). However, to date it has not attained the same level of diagnostic performance as Fibroscan.RiassuntoObiettivoScopo del nostro studio è stato valutare l’accuratezza diagnostica del software ecografico acoustic structure quantification (ASQ) nella stima del grado di fibrosi epatica, ponendolo a confronto con Fibroscan e con la biopsia epatica.Materiali e metodiSono stati arruolati 77 pazienti affetti da epatite virale cronica B e C, che sono stati sottoposti ad esame ecografico standard, ASQ, Fibroscan e biopsia epatica. L’analisi ASQ è stata condotta posizionando una singola regione di interesse (ROI) per immagine, su tutte le immagini acquisite, calcolando moda, media e deviazione standard. La tecnica ecografica è stata messa a punto attraverso una valutazione preliminare su 20 volontari sani.RisultatiL’area sottesa alla curva receiver operating characteristic (AUROC) per diagnosi di cirrosi (F≥4) con ASQ è risultata 0,77 mentre per diagnosi di fibrosi di qualsiasi grado (F≥1) è stata 0,71. L’AUROC per la diagnosi di cirrosi (F≥4) con Fibroscan è risultata 0,98 mentre per la diagnosi di fibrosi di qualsiasi grado (F≥1) è stata 0,94. La differenza tra le due AUROC è risultata statisticamente significativa (p<0,05).ConclusioniL’ASQ è un nuovo e promettente software ecografico che presenta risultati incoraggianti sia nella diagnosi di cirrosi epatica (F=4) che nella diagnosi di fibrosi (F≥1). Attualmente tuttavia ancora non sono state raggiunte le performance diagnostiche del Fibroscan.

Intra-articular methotrexate in the treatment of rheumatoid arthritis and psoriatic arthritis: a clinical and sonographic study.

The aim of our study was to evaluate the effects of intra-articular methotrexate (MTX) in patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Twenty-three consecutive patients, 10 with RA and 13 with PsA, with prevalent or unique arthritic involvement of one knee, were treated with intra-articular injections of MTX 10 mg every 7 days for 8 weeks. Before the beginning of the treatment and after 9 and 17 weeks, the patients underwent a clinical evaluation measuring maximal knee flexion angle, visual analog scale (VAS) and erythrocyte sedimentation rate (ESR). On the same days, an ultrasonographic examination of the involved knee was performed by two independent experienced operators. Synovial thickness in the suprapatellar bursa and the presence of joint effusion and Baker’s cyst were assessed. An increase of the mean value of maximal knee flexion angle and a reduction of the mean values of ESR and VAS between TO, T9 and T17 were demonstrated. Ultrasonographic evaluation showed significant reduction of synovial thickness and joint effusion. No differences were detected for the presence of Baker’s cyst. We may conclude that repeated intra-articular injections of MTX resulted in a decrease of local as well as systemic inflammatory signs. As far as we know, this is the first study that explores the effects of intra-articular MTX in RA and PsA both clinically and by ultrasonography.

Relationship between global end-diastolic volume and cardiac output in critically ill infants and children

Objective:The objective of this study was to investigate possible correlations between the preload index global end-diastolic volume (GEDV) and the indexes of cardiac function, cardiac index, and stroke volume index in critically ill pediatric patients. The aim was to evaluate whether GEDV may help in the decision-making process concerning volume loading. Design:Prospective clinical study. Setting:Pediatric intensive care unit of the Bambino Gesù Children’s Research Hospital. Patients:Seventy patients, 40 male and 30 female, mean age 62 ± 41 months (range 5–156 months), divided into six groups: group A, hemorrhagic shock, ten cases; group B, head injury, 21 cases; group C, septic shock, ten cases; group D, encephalitis, ten cases; group E, respiratory failure, nine cases; group F, cardiogenic shock, ten cases. Interventions:All patients received volumetric hemodynamic monitoring following initial resuscitation and every 4 hrs thereafter or whenever a hemodynamic deterioration was suspected. During the cumulative in-hospital stay, a total 1,184 sets of measurements were done. Measurements and Main Results:Findings are consistent with a statistically significant linear correlation of GEDV with cardiac index and stroke volume index in hemorrhagic shock (group A) (R2 = .647, p < .0001; R2 = .738, p < .0001) and cardiogenic shock (group F) (R2 = .645, p < .0001; R2 = .841, p < .0001). Conclusions:GEDV may potentially be a useful guide to treatment in preload-dependent conditions, such as hemorrhagic and cardiogenic shock. In the other groups where there is little relationship between preload and cardiac function indexes, the influence of non-preload-dependent mechanisms on cardiac output is certainly more significant.

Computer-aided detection (CAD) in lung cancer screening at chest MDCT: ROC analysis of CAD versus radiologist performance.

To evaluate the performance of a computer-aided detection (CAD) algorithm in the detection of pulmonary nodules on high-resolution multidetector row computed tomography images in a large, homogeneous screening population, and to evaluate the effect of the system output on the performance of radiologists, using receiver operating characteristic analysis. Three radiologists with variable experience (1 to 7 y), independently read the 200 computed tomography scans and assigned each nodule candidate a confidence score (1-2-3: unlikely, probably, and definitely a nodule). CAD was applied to all scans; successively readers reevaluated all findings of the CAD, assigning, in consensus, a confidence score (1 to 3). The reference standard was established by the consensus of 2 experienced radiologists with 30 and 15 years of experience. Results were used to generate an free-response receiver operating characteristic analysis. The reference standard showed 125 nodules. Sensitivity for readers I-II-III was 57%, 68%, and 46%. A double reading resulted in an increase in sensitivity up to 75%. With CAD, sensitivity was increased to 94%, 96%, and 94% for readers I, II, and III. The area under the free-response receiver operating characteristic curve (Az) was 0.72, 0.82, 0.55, and 0.84 for readers I, II, III, and the CAD, when considering all nodules. Differences between readers I-II and CAD were not significant (P=0.9). There was a significant difference between reader III and the CAD. For nodules <6-mm Az was 0.40, 0.47, 0.14, and 0.72 for readers I, II, III, and the CAD. Differences between all readers and the CAD were significant (P<0.05). CAD can aid in daily radiologic routine detecting a substantial number of nodules unseen by radiologists. This is true for both board-certified radiologists and for less experienced readers especially in the detection of small nodules.

Correlation between posterior offset of femoral condyles and sagittal slope of the tibial plateau

The aim of this study was to address, in normal knees, the variability of posterior offset of femoral condyles and tibial slope, and the presence of any correlation between the two that might be needed to achieve an adequate joint motion in flexion. Magnetic resonance images of normal knees of 80 subjects, 45 males and 35 females, with a mean age of 38.9 years, were analysed. Measurements were performed by two independent observers using an imaging visualization software. The tibial slope averaged 8 and 7.7 °, on the medial and lateral sides, respectively (P = 0.2); the mean posterior offset of femoral condyles was 27.4 and 25.2 mm on the two sides, respectively (P = 0.0001). The variation coefficient of the condylar offset and tibial slope was 11.5 and 38%, respectively. In the medial compartment, a significant correlation was found between the femoral condylar offset and the tibial slope, while the same was not observed in the lateral compartment of the knee. Magnetic resonance imaging allows the assessment of tibial slope and femoral condylar offset in the medial and lateral side separately, taking into account any difference between the two compartments. The sagittal tibial slope exhibits a greater variability compared with the posterior offset of femoral condyles. The correlation found, in the medial compartment, between the tibial slope and femoral condylar offset suggests that the reconstitution of the proper morphology of the posterior part of the knee joint may be necessary to obtain a full range of motion in flexion after total knee replacement.