Contrast-Enhanced Ultrasound Algorithms (CEUS-LIRADS/ESCULAP) for the Noninvasive Diagnosis of Hepatocellular Carcinoma - A Prospective Multicenter DEGUM Study

BACKGROUND

 This prospective multicenter study funded by the DEGUM assesses the diagnostic accuracy of standardized contrast-enhanced ultrasound (CEUS) for the noninvasive diagnosis of hepatocellular carcinoma (HCC) in high-risk patients.

METHODS

 Patients at high risk for HCC with a histologically proven focal liver lesion on B-mode ultrasound were recruited prospectively in a multicenter approach. Clinical and imaging data were entered via online entry forms. The diagnostic accuracies for the noninvasive diagnosis of HCC were compared for the conventional interpretation of standardized CEUS at the time of the examination (= CEUS on-site) and the two CEUS algorithms ESCULAP (Erlanger Synopsis for Contrast-enhanced Ultrasound for Liver lesion Assessment in Patients at risk) and CEUS LI-RADS (Contrast-Enhanced UltraSound Liver Imaging Reporting and Data System).

RESULTS

 321 patients were recruited in 43 centers; 299 (93.1 %) had liver cirrhosis. The diagnosis according to histology was HCC in 256 cases, and intrahepatic cholangiocarcinoma (iCCA) in 23 cases. In the subgroup of cirrhotic patients (n = 299), the highest sensitivity for the diagnosis of HCC was achieved with the CEUS algorithm ESCULAP (94.2 %) and CEUS on-site (90.9 %). The lowest sensitivity was reached with the CEUS LI-RADS algorithm (64 %; p < 0.001). However, the specificity of CEUS LI-RADS (78.9 %) was superior to that of ESCULAP (50.9 %) and CEUS on-site (64.9 %; p < 0.001). At the same time, the negative predictive value (NPV) of CEUS LI-RADS was significantly inferior to that of ESCULAP (34.1 % vs. 67.4 %; p < 0.001) and CEUS on-site (62.7 %; p < 0.001). The positive predictive values of all modalities were high (around 90 %), with the best results seen for CEUS LI-RADS and CEUS on-site.

CONCLUSION

 This is the first multicenter, prospective comparison of standardized CEUS and the recently developed CEUS-based algorithms in histologically proven liver lesions in cirrhotic patients. Our results reaffirm the excellent diagnostic accuracy of CEUS for the noninvasive diagnosis of HCC in high-risk patients. However, on-site diagnosis by an experienced examiner achieves an almost equal diagnostic accuracy compared to CEUS-based diagnostic algorithms.

Influence of age, sex, body mass index, alcohol, and smoking on shear wave velocity (p-SWE) of the pancreas

Purpose

A variety of elastographic techniques have been developed to facilitate the non-invasive assessment of tissue properties. The goal of the study was to examine the influence of gender, age, BMI, alcohol consumption, and smoking in healthy volunteers.

Methods

Of the 263 participants who met all the study inclusion criteria, 234 had successful measurements. The examination was performed with the Siemens Acuson S3000 (Siemens Healthcare, Erlangen, Germany), using the 6C1 curved array transducer with the virtual touch tissue quantification (VTQ) method.

Results

The values determined with the curved array in the head of the pancreas were 1.44 ± 0.39 m/s for women and 1.19 ± 0.29 m/s for men; in the body, the results were 1.49 ± 0.37 m/s for women and 1.26 ± 0.30  m/s for men; in the tail, the corresponding values were 1.29 ± 0.36 m/s for women and 1.05 ± 0.30 m/s for men. Comparison of gender showed that men have significantly lower mean values than women. There were significantly higher values in all parts of the organ with the increasing age of the participants (p < 0.0001). For BMI, there was a significant correlation with the values only when considering the BMI in continuous form. Alcohol consumption and smoking did not have any significant effects.

Conclusions

ARFI-VTQ is qualified for use on pancreatic tissue. Further studies are required to examine the influence of other factors in larger populations.

Proposal of a computed tomography classification for hepatic alveolar echinococcosis

AIM: To establish a computed tomography (CT)-morphological classification for hepatic alveolar echinococcosis was the aim of the study.

METHODS: The CT morphology of hepatic lesions in 228 patients with confirmed alveolar echinococcosis (AE) drawn from the Echinococcus Databank of the University Hospital of Ulm was reviewed retrospectively. For this reason, CT datasets of combined positron emission tomography (PET)-CT examinations were evaluated. The diagnosis of AE was made in patients with unequivocal seropositivity; positive histological findings following diagnostic puncture or partial resection of the liver; and/or findings typical for AE at either ultrasonography, CT, magnetic resonance imaging or PET-CT. The CT-morphological findings were grouped into the new classification scheme.

RESULTS: Within the classification a lesion was dedicated to one out of five “primary morphologies” as well as to one out of six “patterns of calcification”. “primary morphology” and “pattern of calcification” are primarily focussed on separately from each other and combined, whereas the “primary morphology” V is not further characterized by a “pattern of calcification”. Based on the five primary morphologies, further descriptive sub-criteria were appended to types I-III. An analysis of the calcification pattern in relation to the primary morphology revealed the exclusive association of the central calcification with type IV primary morphology. Similarly, certain calcification patterns exhibited a clear predominance for other primary morphologies, which underscores the delimitation of the individual primary morphological types from each other. These relationships in terms of calcification patterns extend into the primary morphological sub-criteria, demonstrating the clear subordination of those criteria.

CONCLUSION: The proposed CT-morphological classification (EMUC-CT) is intended to facilitate the recognition and interpretation of lesions in hepatic alveolar echinococcosis. This could help to interpret different clinical courses better and shall assist in the context of scientific studies to improve the comparability of CT findings.

Comparison of Two High-End Ultrasound Systems for Contrast-Enhanced Ultrasound Quantification of Mural Microvascularity in Crohn's Disease

PURPOSE

To verify the reproducibility of contrast-enhanced ultrasound (CEUS) quantification results of two different high-end ultrasound systems and to evaluate the clinical utility of the method in patients with Crohn's disease (CD).

MATERIALS AND METHODS

18 patients with histologically confirmed CD (36.8 % women, 63.2 % men; mean age 43.7 ± 14.1 years) and wall segments thicker than 5 mm were recruited. CEUS quantification and conventional ultrasound investigation were performed under standardized settings using Toshiba Aplio500 and Siemens Acuson S3000 high-end ultrasound systems. CEUS was performed at a low mechanical index of 0.1 after bolus application of 4.8 ml of SonoVue(®) contrast medium. The recorded DICOM clips were quantified using VueBox(®) (version 4.3) calculating 11 quantitative parameters. Subsequently, CEUS quantification and conventional ultrasound results were analyzed.

RESULTS

Correlation of quantitative parameters between the Aplio500 and AcusonS3000 systems for peak enhancement (PE), rise time (RT), wash-in-rate (WiR) and quality of fit (QOF) yielded significance levels of p < 0.05 and p < 0.0001 for wash-in-wash-out area under the curve (WiWoAUC). Spearman rank test showed moderate levels of correlation for PE, RT, WiR and QOF (r = 0.5, 0.49, 0.49 and 0.5 respectively), and high correlation for WiWoAUC (r = 0.89) between the two ultrasound systems.

CONCLUSION

Due to multiple uncontrollable affecting factors, the method of CEUS quantification by VueBox in the intestine cannot be recommended for device-independent multicenter studies. Therefore we suggest to use identical ultrasound systems and probes as well as to establish adequate reference ROIS, like a AIF-ROI.

Comparison of Acoustic Structure Quantification (ASQ), shearwave elastography and histology in patients with diffuse hepatopathies

Background

Objective of the study was to evaluate the diagnostic value of novel ultrasonographic modalities in comparison with simultaneously performed liver biopsy.

Methods

The results of simultaneously performed examinations using Acoustic Structure Quantification (ASQ), Virtual Touch Imaging and Quantification (VTIQ) and Virtual Touch Tissue Quantification (VTTQ) were compared with the findings of liver biopsy in patients with a wide variety of diffuse hepatopathies (n = 51). The histologically determined fibrosis stage according to Desmet and Scheuer was compared with quantitative measurements returned by the ultrasonographic imaging modalities.

Results

No statistically significant correlation with histologically determined fibrosis stage could be identified for any measurements returned using ASQ. Increasing severity of hepatic steatosis, however, was associated with a reduction in the focal disturbance (FD) ratio (r = −0.55; p < 0.0001). The shearwave velocities measured using VTTQ satisfyingly correlated with fibrosis stage (r = 0.56; p > 0.0001). Fibrosis stages > F2 were associated with an area under the curve (AUC) of 0.94 (95 %-CI:0.84–0.99). A cut-off value for shearwave velocity of 1.66 m/s was determined with a sensitivity of 100 % and a specificity of 84 %. VTIQ showed a less pronounced but acceptable correlation with fibrosis stage (r = 0.35; p = 0.0154). For fibrosis stages > F2 analysis showed an AUC of 0.84 (95 %-CI:0.70–0.93). The cut-off value was 1.82 m/s with a sensitivity of 100 % and a specificity of 58 %.

Conclusion

While ASQ showed no diagnostic advantage in our patient collective, VTTQ showed high reliability for determining severe liver fibrosis in a group of patients with diffuse liver diseases of different etiology.

Subclinical and clinical hypothyroidism and non-alcoholic fatty liver disease: a cross-sectional study of a random population sample aged 18 to 65 years

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) is one of the most common disorders of the liver worldwide. Recently, a correlation between thyroid dysfunction and NAFLD has been discussed. Objective of the present study was to investigate the association between thyroid dysfunction and hepatic steatosis.

METHODS

Data from 2,445 subjects (51.7% females) aged 18 to 65 years participating in a population-based cross-sectional study were assessed based on a standardized questionnaire and documentation of physical, biochemical and ultrasonographic findings. After application of exclusion criteria, a total of 1,276 subjects were included in the study collective. The influence of potential factors on the development of hepatic steatosis was assessed using multivariate logistic regression.

RESULTS

The prevalence of hepatic steatosis in the study collective was 27.4% (n = 349). The serum thyroxin (TT4) concentration in subjects with hepatic steatosis was reduced (p =0.0004). Adjusting for age, or BMI, there was an increased prevalence of hepatic steatosis in subjects with reduced TT4 concentrations (p = 0.0143; p = < .0001).

CONCLUSIONS

The findings of the present study confirm an association between both subclinical and clinical hypothyroidism and hepatic steatosis.

Influence of plasma cortisol and other laboratory parameters on nonalcoholic Fatty liver disease

The objective of the present study was to analyse the association between the plasma cortisol concentration and nonalcoholic fatty liver disease (NAFLD). A total of 1 326 subjects (age 18-65 years) were examined in the context of an epidemiological study of a population-based random sample. Medical history and anthropometric data of 662 women and 664 men were documented. In addition, laboratory examinations were performed and the fat concentration of the liver was estimated by ultrasound examination. Mean cortisol concentration in plasma was 260.4±156.8 nmol/l for women and 295.8±161.2 nmol/l for men. NAFLD was identified in 17.7% in women and 35.1% in men. Plasma cortisol concentration showed no association with the existence of NAFLD. NAFLD correlated positive with age, body-mass index (BMI), waist-to-hip-ratio (WHR), alanine aminotransferase (ALT), and triglycerides. The present study failed to establish any association of plasma cortisol concentrations and NAFLD.

Hepatobiliary complications of alveolar echinococcosis: A long-term follow-up study

AIM: To determine the long-term hepatobiliary complications of alveolar echinococcosis (AE) and treatment options using interventional methods.

METHODS: Included in the study were 35 patients with AE enrolled in the Echinococcus Multilocularis Data Bank of the University Hospital of Ulm. Patients underwent endoscopic intervention for treatment of hepatobiliary complications between 1979 and 2012. Patients’ epidemiologic data, clinical symptoms, and indications for the intervention, the type of intervention and any additional procedures, hepatic laboratory parameters (pre- and post-intervention), medication and surgical treatment (pre- and post-intervention), as well as complications associated with the intervention and patients‘ subsequent clinical courses were analyzed. In order to compare patients with AE with and without history of intervention, data from an additional 322 patients with AE who had not experienced hepatobiliary complications and had not undergone endoscopic intervention were retrieved and analyzed.

RESULTS: Included in the study were 22 male and 13 female patients whose average age at first diagnosis was 48.1 years and 52.7 years at the time of intervention. The average time elapsed between first diagnosis and onset of hepatobiliary complications was 3.7 years. The most common symptoms were jaundice, abdominal pains, and weight loss. The number of interventions per patient ranged from one to ten. Endoscopic retrograde cholangiopancreatography (ERCP) was most frequently performed in combination with stent placement (82.9%), followed by percutaneous transhepatic cholangiodrainage (31.4%) and ERCP without stent placement (22.9%). In 14.3% of cases, magnetic resonance cholangiopancreatography was performed. A total of eight patients received a biliary stent. A comparison of biochemical hepatic function parameters at first diagnosis between patients who had or had not undergone intervention revealed that these were significantly elevated in six patients who had undergone intervention. Complications (cholangitis, pancreatitis) occurred in six patients during and in 12 patients following the intervention. The average survival following onset of hepatobiliary complications was 8.8 years.

CONCLUSION: Hepatobiliary complications occur in about 10% of patients. A significant increase in hepatic transaminase concentrations facilitates the diagnosis. Interventional methods represent viable management options.

Assessment of liver size by ultrasonography

BACKGROUND

To determine liver span sonographically in a randomly selected population sample and identify factors that affect liver size.

METHODS

A total of 1,789 subjects (963 females, 826 males; mean age 41.8 ± 12.8 years) underwent sonographic examination of the liver in the midclavicular line to determine liver span. Subjects underwent physical examination and blood tests and completed a standardized interview questionnaire.

RESULTS

The average liver span in the midclavicular line for the overall collective was 15.0 ± 1.5 cm; the average for females was 14.9 ± 1.6 cm and 15.1 ± 1.5 cm for males. Liver span exceeded 16 cm in 24.3% of subjects. Results of the multivariate analysis showed that, of the factors potentially influencing liver span, gender, age, body mass index, body height, fatty liver (p < 0.0001), waist-to-hip ratio (p = 0.015), and metabolic syndrome (p = 0.032) are significant. By contrast, diabetes mellitus, alcohol consumption, tobacco consumption, physical activity, and laboratory findings showed no influence.

CONCLUSIONS

Sonographic measurement of liver span in the midclavicular line is a simple method for routine clinical use. Gender, age, body mass index, waist-to-hip ratio, body height, hepatic steatosis, and metabolic syndrome are factors associated with liver span.

Acoustic structure quantification (ASQ): a new tool in sonographic examination of liver lesions in hepatic alveolar echinococcosis

PURPOSE

Qualitative and quantitative acoustic structure quantification (ASQ) is a new, noninvasive sonographic imaging method based on B-mode. This prospective clinical pilot study aims to answer the question whether delineation and measurement of liver lesions in hepatic alveolar echinococcosis (HAE) can be improved by ASQ. Furthermore, this is the first pilot study to explore how ASQ parameters in HAE lesions develop.

METHODS

A total of 24 patients (male = 13/female = 11, mean age = 52 years (16-85), mean disease duration = 68 months (1-334)) with HAE were examined with ASQ using a Toshiba Aplio 500 unit. ASQ parameters were measured in HAE liver lesions and in adjacent non-tumor parenchyma. Quantitative analysis was performed offline using ASQ quantification software.

RESULTS

Subjectively parasitic tumors in HAE appear more prominent in color-coded ASQ imaging, but the size of lesions measured in ASQ mode does not differ from size measurements in B-mode. Median focal disturbance ratio (FD ratio) in lesions was 3 (0.1-3), compared with 0.5 (0.1-1.8) in surrounding liver parenchyma (p < 0.0001). Statistical comparison of other ASQ parameters (mode, average, standard deviation) shows results that are similarly significant with p values between p < 0.0001 and p < 0.0018.

CONCLUSION

ASQ is a promising sonographic method for examination and quantification of structural changes of liver parenchyma in HAE lesions.

Associations of fatty liver disease and other factors affecting serum SHBG concentrations: a population based study on 1657 subjects

Sex hormone binding globulin (SHBG) is a glycoprotein expressed predominantly in the hepatocytes. It regulates the transport of sex steroid hormones in the blood stream to their target tissues. The expression of the SHBG gene is subject to multifactorial regulation including hormonal, metabolic, and nutritional aspects. Against this background, we investigated the effect of fatty liver and metabolic syndrome, together with other parameters, on serum SHBG concentrations in a population-based cohort in Germany. This cross-sectional study included 870 women and 787 men (average age 42.3±12.8 years), who underwent ultrasound screening for fatty liver in addition to providing a complete medical history and undergoing physical and laboratory examination. Fatty liver was diagnosed on ultrasound criteria in 159 women (18.3%) and 287 men (36.5%). Fatty liver was shown to exert a significant influence on serum SHBG concentrations in men and in premenopausal women. Men with grade 1 fatty liver had a 1.96-fold increased risk (95%-confidence interval=1.28-3.02; p=0.0022) and postmenopausal women with grade 1 fatty liver a 2.4-fold risk (95%-confidence interval=1.11-5.27; p=0.0267) for low SHBG concentrations. Among metabolic parameters, HDL-C represented as affecting factor in men (p=0.0058) and premenopausal women (p=0.0002), while cholesterol only showed an association in premenopausal women (p=0.0439) and triglyceride in postmenopausal women (p=0.0436). No association of concentrations of SHBG and metabolic syndrome was observed. Age, BMI and waist-to-hip ratio also influence the SHBG concentration. Based on these findings, we conclude that fat accumulation in the liver influences SHBG concentrations in men and premenopausal women.

Fasting time and lipid parameters: association with hepatic steatosis--data from a random population sample

Background

Current guidelines recommend measuring plasma lipids in fasting patients. Recent studies, however, suggest that variation in plasma lipid concentrations secondary to fasting time may be minimal. Objective of the present study was to investigate the impact of fasting time on plasma lipid concentrations (total cholesterol, HDL and LDL cholesterol, triglycerides). A second objective was to determine the effect of non-alcoholic fatty liver disease exerted on the above-mentioned lipid levels.

Method

Subjects participating in a population-based cross-sectional study (2,445 subjects; 51.7% females) were questioned at time of phlebotomy regarding duration of pre-phlebotomy fasting. Total cholesterol, LDL and HDL cholesterol, and triglycerides were determined and correlated with length of fasting. An upper abdominal ultrasonographic examination was performed and body-mass index (BMI) and waist-to-hip ratio (WHR) were calculated. Subjects were divided into three groups based on their reported fasting periods of 1–4 h, 4–8 h and > 8 h. After application of the exclusion criteria, a total of 1,195 subjects (52.4% females) were included in the study collective. The Kruskal-Wallis test was used for continuous variables and the chi-square test for categorical variables. The effects of age, BMI, WHR, alcohol consumption, fasting time and hepatic steatosis on the respective lipid variables were analyzed using multivariate logistic regression.

Results

At multivariate analysis, fasting time was associated with elevated triglycerides (p = 0.0047 for 1–4 h and p = 0.0147 for 4–8 h among females; p < 0.0001 for 1–4 h and p = 0.0002 for 4–8 h among males) and reduced LDL cholesterol levels (p = 0.0003 for 1–4 h and p = 0.0327 for 4–8 h among males). Among males, hepatic steatosis represents an independent factor affecting elevated total cholesterol (p = 0.0278) and triglyceride concentrations (p = 0.0002).

Conclusion

Total and HDL cholesterol concentrations are subject to slight variations in relation to the duration of the pre-phlebotomy fasting period. LDL cholesterol and triglycerides exhibit highly significant variability; the greatest impact is seen with the triglycerides. Fasting time represents an independent factor for reduced LDL cholesterol and elevated triglyceride concentrations. There is a close association between elevated lipids and hepatic steatosis.

Association of proinsulin and hepatic steatosis in a random, population-based sample

OBJECTIVE

Proinsulin may represent a predictive marker for assessing insulin resistance and reduced β-cell function. The objective of this study was to investigate the association between hepatic steatosis, proinsulin and other parameters in a random, population-based sample.

DESIGN

Cross-sectional study, conducted in south-western Germany.

METHODS

Upper abdominal ultrasound examinations were performed in 343 subjects (147 females, 196 males; average age 40.0±11.5 years). Proinsulin, the proinsulin-to-insulin ratio and other laboratory parameters were determined, and the BMI, waist-to-hip ratio (WHR) and other anthropometric data were documented.

RESULTS

HEPATIC STEATOSIS WAS OBSERVED IN 80 SUBJECTS (23.3%: 29.6%, males; 15.0%, females). Multivariate analysis showed an association with hepatic steatosis for male gender (P=0.0212), advancing age (P=0.0241), elevated BMI (P<0.0001), elevated WHR (P=0.0024), alanine aminotransferase (P=0.0046), proinsulin (P=0.0403) and proinsulin-to-insulin ratio (P=0.0116).

CONCLUSIONS

There is an association between elevated proinsulin concentrations and hepatic steatosis.

Sonographically guided puncture of the pancreas: incidence of complications, and risk factors

PURPOSE

Data yielded by transabdominal ultrasound-guided puncture techniques are valuable for determining the malignancy of inoperable mass lesions of the pancreas. In this study we analyzed the incidence of complications and the risk factors.

METHODS

A total of 430 punctures of the pancreas were performed for 281 patients. Risk factors were prospectively assessed and complications were recorded. All punctures were sonographically guided.

RESULTS

The 281 patients underwent a total of 351 puncture procedures including 430 punctures and 901 passes. The maximum diameter of the pancreatic mass lesion was documented; the mean diameter was 48.3 ± 29.1 mm. 75.8 % of punctures were performed with a needle diameter of 0.7-0.95 mm, and 23.0 % of punctures were performed as cutting biopsies producing a tissue sample 1.2 or 1.6 mm in diameter. In 77.8 % of punctures, one puncture was performed, and in 21.9 %, two punctures were performed. Three punctures were performed for one patient (0.3 %) only. The incidence of major complications was 0.3 %. None of the assessed risk factors was associated with an elevated incidence of complications.

CONCLUSION

Our findings demonstrate the safety of transabdominal percutaneous puncture of the pancreas but do not enable conclusions to be drawn with regard to individual risk factors.

Percutaneous ultrasonographically guided liver punctures: an analysis of 1961 patients over a period of ten years

Background

Ultrasonographically guided punctures of the liver represent a decisive tool in the diagnosis of many diseases of the liver. Objective of the study was to determine the extent to which the complication rate for ultrasonographically guided punctures of the liver is affected by less comprehensively studied risk factors.

Methods

A total of 2,229 liver biopsies were performed in 1,961 patients (55.5% males; 44.5% females). We recorded actual complications and assessed the following risk factors: needle gauge, puncture technique, examiner experience, coagulation status, puncture target (focal lesion versus parenchyma), lesion size, patient sex and age.

Results

he rate of complications stood at 1.2% (n = 27), of which 0.5% (n = 12) were major and 0.7% (n = 15) minor complications. A significant increase in complications involving bleeding was observed with larger-gauge needles compared with smaller-gauge needles and for cutting biopsy punctures compared with aspiration biopsies (Menghini technique). In the bivariate analysis complications were 2.7 times more frequent in procedures performed by experienced examiners compared with those with comparatively less experience. Lower values for Quick’s test and higher partial thromboplastin times were associated with a higher rate of bleeding. Neither the puncture target, lesion size or patient sex exerted any measurable influence on the puncture risk. Advanced patient age was associated with a higher rate of complications involving bleeding.

Conclusions

Our study helps to establish the importance of potential and less comprehensively studied risk factors and may contribute to further reduction in complications rates in routine clinical practice.

Physical exercise in southern Germany: a cross-sectional study of an urban population

OBJECTIVES

The aim of this study was to investigate the degree of physical exercise and self-assessment of physical fitness (PF) and their relationship to health- and behaviour-specific factors in a randomly selected sample of an urban population in southern Germany.

DESIGN

Cross-sectional study.

SETTING

In the southern German city of Leutkirch.

PARTICIPANTS

2187 subjects randomly selected from the registry of inhabitants. Of the selected group, aged 18-65 years, 52.1% were women and 47.9% men.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked how many hours per week they spent on physical exercise and sports. They were also asked to rate their own performance and/or PF.

RESULTS

Overall, 38.9% of the participants reported no physical exercise. Men reported a higher level of physical exercise than did women. Less exercise was reported by subjects with diabetes, high body mass index and waist-to-hip ratio and by those who were underweight. Alcohol consumption, smoker status and higher educational level showed a positive association with physical exercise. A negative trend with respect to moderate physical exercise was observed for those with metabolic syndrome, diabetes, hypertension and hepatic steatosis, but this was statistically significant only for subjects with diabetes. In both men and women, there was a relationship between self-assessed 'good' PF and high physical exercise.

CONCLUSIONS

The data show that a large proportion of the study population is not physically active; specific risk groups (overweight subjects, older subjects, smokers or subjects with low educational level) are even less active. The data suggest that there is a great potential for measures promoting physical exercise in these groups.

Benefit of early abdominal ultrasonography in non-surgical patients admitted to the emergency department: a pilot study

PURPOSE

Ultrasonography plays a decisive role in emergency patients. The primary aim of this study is to assess whether early emergency ultrasonography alters the length of stay.

METHODS

In a prospective study, patients admitted to the emergency department were divided into two groups. The first group underwent early abdominal ultrasonography (within 24 h after admission), and the second group underwent ultrasonography after more than 24 h. The two groups were compared in terms of length of stay, age, admission diagnosis, and number of further imaging techniques used. A subgroup analysis was carried out for admission diagnosis. One hundred and forty-five patients were included in the study.

RESULTS

In terms of length of stay, no difference was seen between the first group (11.7 ± 11.4 days) and the second group (13.6 ± 11.0 days) (p = 0.1196). In the subgroups "abdominal pain" (p = 0.0333) and "cardiopulmonary disorders" (p = 0.0207), a shorter length of stay was associated with early ultrasonography, while in the subgroup "infectious disease/fever," the early ultrasonography group was associated with a prolonged length of stay (p = 0.0211).

CONCLUSION

Early ultrasonography in our setting of emergency patients with a variety of different admission diagnoses did not shorten the length of stay, but the subgroups of patients with "abdominal pain" and "cardiopulmonary disorders" might have benefited from early ultrasonography.

A single dose of intravenous zoledronate prevents glucocorticoid therapy-associated bone loss in acute flare of Crohn's disease, a randomized controlled trial

OBJECTIVES

To assess the effectiveness and safety of zoledronate (ZOL) in preventing glucocorticoid therapy-associated bone loss in patients with acute flare of Crohn's disease (CD) in a randomized, double-blind, placebo-controlled trial.

METHODS

Forty CD patients starting a glucocorticoid therapy (60 mg prednisolone per day) for acute flare (CD activity index (CDAI) >220) were randomized to compare the effect of ZOL (4 mg intravenous, n=20) or placebo (n=20) on change in lumbar bone mineral density (BMD). All patients received calcium citrate (800 mg) and colecalciferol (1,000 IU) daily. Dual energy X-ray absorptiometry (DXA) of the lumbar spine (L1-L4) was performed at baseline and day 90. Follow-up examinations at day 1/7/14/30 and 90 included laboratory tests and adverse event/serious adverse events reports.

RESULTS

Thirty-six patients were available for per-protocol analysis. With placebo (n=18), a decrease in BMD was seen (T-score: -0.98 ± 0.8, day 0 and -1.25 ± 0.77, day 90, P=0.06), with ZOL (n=18) BMD increased (-1.15 ± 1.02, day 0 and -0.74 ± 1.09, day 90, P=0.03). The change in BMD under placebo (-0.26 ± 0.21) vs. ZOL (+0.41 ± 0.19) was highly significant (P=0.006). In all, 14 out of 18 patients with ZOL had an increase in BMD (+0.64 ± 0.48), 12 of 18 with placebo a decrease (-0.50 ± 0.39). Changes of clinical findings and laboratory results of inflammation (leukocytes, platelets, and C-reactive protein) were the same in- and between-groups throughout the study. With ZOL, serum bone degradation marker β-Cross-Laps decreased. Study medication was safe and well tolerated.

CONCLUSIONS

ZOL is effective in preventing glucocorticoid therapy-induced bone loss in patients with acute flare of CD and should be considered whenever a glucocorticoid therapy is started in CD patients.

[Gallbladder polyps: prevalence and risk factors]

PURPOSE

The objective of the present study was to investigate the prevalence of gallbladder polyps and possible risk factors in a random population sample of an urban population.

MATERIAL AND METHODS

A total of 2099 subjects (1072 women, 1027 men; aged 19 - 65 years, mean age 42.1 (SD ± 12.8 years) were prospectively examined using ultrasound, a standardized questionnaire and laboratory studies.

RESULTS

Gallbladder polyps were identified in 6.1 % (128 / 2099) of all subjects (women: 6.1 % [63 / 1027]); men: 6.1 % [65 / 1072]). Solitary polyps were found in 52.4 % (65 / 124), two polyps in 16.1 % (20 / 124), three polyps in 6.5 % (8 / 124), several polyps in 22.6 % (28 / 124) and multiple polyps in 2.4 % (3 / 124) of subjects. The mean polyp diameter was 4.7 mm (SD ± 2.2; range 2 - 20 mm). The polyp diameter was ≤ 7 mm in 94.5 % of subjects. The polyps were described as pedunculate in 82.3 % (102 / 124). The polyps were broad-based in 11.3 % of subjects (14 / 124; men: 18 % women: 4.8 %). The polyps were homogeneously echogenic in 100 % of cases and with irregular contours in only one male subject. Multiple logistic regression failed to demonstrate an influence on the increased occurrence of gallbladder polyps for the risk factors of male sex, age, body-mass index (BMI), alcohol, nicotine or caffeine consumption or diabetes mellitus.

CONCLUSION

The prevalence of gallbladder polyps reported in the present study (6.1 %) is higher than figures previously published for populations in Germany or Europe. The majority of polyps were pedunculate and solitary. A typical risk factor profile for gallbladder polyps could not be identified in the present population sample.

Comparison of panorama ultrasonography, conventional B-mode ultrasonography, and computed tomography for measuring liver size

PURPOSE

The objective of the present study is to compare the utility of extended field-of-view ultrasonography and conventional B-mode ultrasonography for determining liver size.

MATERIALS AND METHODS

The liver size in the medioclavicular line (MCL) was determined in 104 inpatients (females: n = 47; males: n = 57) using both ultrasound methods (Philips HDI 5000). The liver size measured in computed tomography (CT; MX 8000 IDT, Philips) served as the gold standard. The body mass index (BMI), ultrasound scanning conditions, and hepatomegaly identified by CT were evaluated as possible factors affecting the measurement accuracy of the sonographic methods.

RESULTS

The standard deviation of the differences between the measured pairs of values shows less dispersion in B-mode ultrasonography (18.7 mm) than panorama ultrasonography (20.8 mm). The mean value of differences between the measured pairs (bias) in the ultrasonographic methods compared to CT is considerably higher in panorama sonography (15.3 mm; SD = 20.8) than in B-mode ultrasonography (0.27 mm; SD = 18.7). A paired t-test of the mean values shows a significant difference between the ultrasonographic methods (p < 0.0001). In diagnosing or excluding hepatomegaly, B-mode sonography is consistent with CT findings in 84 (80.8 %) of 104 patients and panorama ultrasonography is consistent with CT findings in 77 (74.0 %) of 104 patients. Ultrasonographic methods show moderate agreement with each other (Kappa = 0.4265). Higher BMI and limited scanning conditions lead to an increase in the mean difference of measured pairs of values (bias) as well as to an increase in standard deviation of the differences (dispersion).

CONCLUSION

The determination of liver size in the medioclavicular line using panorama ultrasonography often leads to the false-positive diagnosis of hepatomegaly. Therefore, the method should not be recommended for routine diagnostic scans. In cases of significant hepatomegaly, however, panorama ultrasonography offers superior visualization compared to conventional B-mode ultrasonography.

Prevalence and risk factors of focal sparing in hepatic steatosis

PURPOSE

The prevalence, localization and potential risk factors for focal sparing were prospectively assessed in subjects with sonographically detectable hepatic steatosis as part of a population-based cross-sectional study.

MATERIALS AND METHODS

A total of 1,624 persons (n = 906 women; n = 718 men) were evaluated using ultrasonography, laboratory testing and a standardized questionnaire. The following were excluded from the analysis: subjects with reported alcohol consumption > 40 g/day (males) or > 20 g/day (females), those with known chronic hepatitis B or C infection, elevated serum transaminases (AST: m > 44 U/l, f > 33 U/l; ALT: m > 45 U/l, f > 35 U/l) and prior right nephrectomy.

RESULTS

The prevalence of focal sparing in patients with hepatic steatosis (grade I) was 25.6 % for men and 13.0 % for women. In patients with grade II/III disease, the prevalence was 70.9 % for men and 77.6 % for women. The most common site of focal sparing was in segment IV. The average diameter was 22.3 mm (range 7 - 84 mm). No correlation was found for postulated risk "age" (p = 0.09) or "status post cholecystectomy" (p = 0.09). Male sex (p = 0.02) and metabolic syndrome (odds ratio, 2.1; 95 % confidence interval, 1.1 - 4.1; p = 0.02) were confirmed as risk factors.

CONCLUSION

Sonographic evidence of focal sparing in subjects with hepatic steatosis is associated with an increased risk for metabolic syndrome and may be an easily obtained diagnostic criterion in routine clinical settings.

Prevalence of gallbladder stone disease in obese children and adolescents: influence of the degree of obesity, sex, and pubertal development

OBJECTIVES

The objective of the present study was to investigate the prevalence of gallbladder stone disease (GD) in a collective of obese children and adolescents and to assess the role of potential influencing factors such as the degree of obesity, sex, age, and pubertal development.

METHODS

Four hundred ninety-three obese children and adolescents (body mass index standard deviation score [BMI-SDS] > 2.0p) aged 8 to 19 years (218 males, 275 females) were included in the study and underwent ultrasound for detection of GD.

RESULTS

Gallbladder stones were detected in 10 of 493 (2.0%; 8 girls, 2 boys) subjects studied. None of the 95 prepubertal children examined were found to suffer from GD. Patients with GD were more severely obese (BMI-SDS 3.4 +/- 0.5 vs. 2.7 +/- 0.4; P < 0.001) and older (16.1 +/- 1.5 vs.13.9 +/- 2.0 years; P < 0.008) than children and adolescents without GD.

CONCLUSIONS

Compared with published data for unselected children an adolescents, the prevalence of GD (2.0%) in obese children and adolescents, previously treated with diet for obesity, is high. Obesity and female sex appear even in children and adolescents to be risk factors for the development of GD. The occurrence of prepubertal GD is rare.

Pregnancy is not a risk factor for gallstone disease: Results of a randomly selected population sample

AIM: To investigate the prevalence, risk factors, and selection of the study population for cholecystolithiasis in an urban population in Germany, in relation to our own findings and to the results in the international literature.

METHODS: A total of 2 147 persons (1 111 females, age 42.8 ± 12.7 years; 1 036 males, age 42.3 ± 13.1 years) participating in an investigation on the prevalence of Echinococcus multilocularis were studied for risk factors and prevalence of gallbladder stone disease. Risk factors were assessed by means of a standardized interview and calculation of body mass index (BMI). A diagnostic ultrasound examination of the gallbladder was performed. Data were analyzed by multiple logistic regression, using the SAS statistical software package.

RESULTS: Gallbladder stones were detected in 171 study participants (8.0%, n = 2 147). Risk factors for the development of gallbladder stone disease included age, sex, BMI, and positive family history. In a separate analysis of female study participants, pregnancy (yes/no) and number of pregnancies did not exert any influence.

CONCLUSION: Findings of the present study confirm that age, female sex, BMI, and positive family history are risk factors for the development of gallbladder stone disease. Pregnancy and the number of pregnancies, however, could not be shown to be risk factors. There seem to be no differences in the respective prevalence for gallbladder stone disease in urban and rural populations.

Comparison of contrast-enhanced power Doppler ultrasound (Levovist) and computed tomography in alveolar echinococcosis

BACKGROUND

To date, no study has compared unenhanced and contrast-enhanced (Levovist) power Doppler ultrasound with three-phase helical computed tomography (CT) for the analysis of the vascularization of hepatic lesions in patients who have alveolar echinococcosis.

METHODS

Fifteen patients (11 female and four male; average age, 45.8 years) with confirmed Echinococcus multilocularis infection underwent unenhanced and contrast-enhanced (Levovist) power Doppler ultrasound (2- to 5-MHz transducer head) and three-phase helical CT. The largest identified lesion in each patient was studied.

RESULTS

CT visualized vascularization peripheral or central to the largest echinococcal lesions in 11 of 15 patients. Vascularization in the area of the echinococcal lesions was not visualized by unenhanced or contrast-enhanced power Doppler ultrasound in any of the 15 patients studied.

CONCLUSION

Three-phase helical CT visualizes the vascularization associated with Echinococcus multilocularis lesions in the liver. Neither unenhanced nor contrast-enhanced ultrasound in power mode is suitable for this application.

[Intestinal wall vascularisation in Crohn's disease]

BACKGROUND AND AIMS

In a pilot study the semi-quantitative classification of intestinal wall vascularisation as proposed by Limberg was evaluated.

PATIENTS AND METHODS

20 patients with confirmed Crohn's disease and clinical activity (10 male, 10 female, mean age 30.0 +/- 7.72 years, range 21 - 49 years, mean time since onset of disease 4.6 years, range 0 - 15 years) were included. CDAI, CRP, ESR, and the blood count were evaluated. Two and six weeks after inclusion into the study these examinations were repeated. All patients were treated with anti-inflammatory drugs. The intestinal wall thickness was measured with ultrasound. The vascularisation following the Limberg classification and the number of blood vessels per square centimetre were assessed in the power-Doppler mode.

RESULTS

The mean length of bowel segments with increased wall thickness (> 3 mm) at the beginning of the study was 20.3 cm (range 5 - 50 cm), the mean intestinal wall diameter 5.9 mm (range 4 - 9 mm). The mean density of blood vessels in the power-Doppler mode was 3.8 vessels/cm (2) (range 0 - 8 vessels/cm (2)), the median of Limberg levels was 2 (range 1 - 4). The density of blood vessels per cm (2) well correlated with the Limberg classification throughout the study (r = 0.2 at start; r = 0.94 at 1st follow-up; r = 0.91 at 2nd follow-up).

CONCLUSION

The classification for measuring intestinal wall vascularisation semi-quantitatively (as proposed by Limberg) proved to be easily applicable in routine sonography. Besides the measurement of intestinal wall thickness, activity indices, clinical and laboratory parameters, it may constitute an additional means for evaluation of disease activity.