Association of imaging and pathological findings of breast cancer in very young women: Report of a twenty-year retrospective study

PURPOSE

In this study, we aimed to assess the new trends in characteristics, molecular subtypes, and imaging findings of breast cancer in very young women.

METHODS

We retrospectively reviewed the database of a primary breast cancer referral center in southern Iran in 342 cases of 30-year-old or younger women from 2001 to 2020. Pathologic data, including nuclear subtype and grade, tumor stage, presence of in situ cancer, imaging data including lesion type in mammogram and ultrasound, and treatment data were recorded. Descriptive statistics were applied. Differences between categorical values between groups were compared using Pearson's Chi-square test.

RESULTS

The mean age was 27.89 years. The tumor type was invasive ductal carcinoma in 82 % of cases. Fourteen patients (4.4 %) had only in situ cancer, and 170 patients had in situ components (49.7 %). Molecular subtypes were available in 278 patients, including 117 (42.1 %) Luminal A, 64 (23.0 %) Luminal B, 58 (20.9 %) triple negative, and 39 (14 %) HER2 Enriched. In those with mammograms available, 63 (30.1 %) had no findings, 53 (25.3 %) had mass, 27 (12.9 %) had asymmetry, whether focal or global, 21 (10 %) had microcalcifications solely, and 45 (21.5 %) had more than one finding. Microcalcifications were significantly more common in Luminal cancers than HER2 and triple-negative cancers (p = 0.041).

CONCLUSION

Our study shows the most common subtype to be Luminal A cancer, with 74 % of the tumors being larger than 2 cm at the time of diagnosis. Irregular masses with non-circumscribed margins were the most common imaging findings.

A Randomized Trial of Combination Therapy, Sitagliptin and Spironolactone, in Hospitalized Adult Patients with COVID-19

Context

COVID-19 may cause respiratory distress syndrome and death. Treatment of COVID-19 to prevent complications remains a priority.

Objective

Our investigation sought to determine whether combination of spironolactone and sitagliptin could reduce mortality for inpatients with SARS-CoV-2 infection.

Methods

This single-blind, 4-arm, prospective randomized clinical trial was conducted at Shiraz and Bushehr University of Medical Sciences hospitals between December 2020 and April 2021. We randomized hospitalized adult patients with COVID-19 pneumonia into 4 groups: control, combination therapy, sitagliptin add-on, or spironolactone add-on. The primary outcome was the clinical improvement of the patients in the hospital as measured on an 8-point numerical scale. The secondary outcomes included intubation, ICU admission, end organ damages, CT findings, and paraclinical information.

Results

A total of 263 admitted patients were randomly assigned to control group (87 patients), combination group (60 patients), sitagliptin group (66 patients), and spironolactone group (50 patients). There were no significant differences in baseline characteristics, except for higher age in control group. The intervention groups, especially combination therapy, had better clinical outcomes (clinical score on fifth day of admission: 3.11 ± 2.45 for controls, 1.33 ± 0.50 for combination, 1.68 ± 1.02 for sitagliptin, and 1.64 ± 0.81 for spironolactone; P = 0.004). However, the mortality rate was lower in patients who received spironolactone (21.84% control, 13.33% combination, 13.64% sitagliptin, 10.00% spironolactone; P = 0.275). Our intervention reduced lung infiltration but not the area of involvement in lungs.

Conclusion

Sitagliptin and spironolactone can potentially improve clinical outcomes of hospitalized COVID-19 patients.

Can shear wave elastography be utilized as an additional tool for the assessment of non-mass breast lesions?

INTRODUCTION

We aimed to describe shear wave elastography parameters of non-mass lesions of the breast and to assess the measures of diagnostic accuracy of shear wave elastography in the differentiation of non-mass lesions compared with conventional ultrasound, using histopathologic results as the reference standard.

METHODS

This retrospective study included breast ultrasound-detected non-mass lesions with a confirmed pathologic diagnosis during a two-year study period. B-mode ultrasound and shear wave elastography were performed for all lesions before biopsy. Ultrasound features, shear wave elastography parameters (mean elasticity and maximum stiffness color), as well as Breast Imaging-Reporting and Data System categories were recorded for each lesion. Measures of diagnostic accuracy of ultrasound and ultrasound + shear wave elastography were also assessed.

RESULTS

From a total of 567 breast lesions requiring core-needle biopsy, 49 (8.6%) were considered as non-mass lesions. Based on histopathologic reports, 32 patients (65.3%) had non-high-risk benign lesions, five (10.2%) had high-risk benign lesions, five (10.2%) had ductal carcinoma in situ, and seven (14.3%) had invasive carcinoma. There was no significant difference in patients' age and palpability between benign and malignant lesions (p = 0.16 and p = 0.12, respectively). Mean elasticity values and Breast Imaging-Reporting and Data System categories were significantly higher among malignant lesions compared with benign non-mass lesions (both p < 0.001). Furthermore, the addition of shear wave elastography to grayscale ultrasound increased the specificity, positive predictive value, and diagnostic accuracy.

CONCLUSION

The complementary use of shear wave elastography with conventional ultrasound might help in the differentiation of non-mass breast lesions and has the potential to decrease the frequency of unnecessary biopsies performed for benign non-mass lesions.

Differentiation of Chest CT Findings Between Influenza Pneumonia and COVID-19: Interobserver Agreement Between Radiologists

OBJECTIVES

To investigate the chest CT and clinical characteristics of COVID-19 pneumonia and H1N1 influenza, and explore the radiologist diagnosis differences between COVID-19 and influenza.

MATERIALS AND METHODS

This cross-sectional study included a total of 43 COVID-19-confirmed patients (24 men and 19 women, 49.90 ± 18.70 years) and 41 influenza-confirmed patients (17 men and 24 women, 61.53 ± 19.50 years). Afterwards, the chest CT findings were recorded and 3 radiologists recorded their diagnoses of COVID-19 or of H1N1 influenza based on the CT findings.

RESULTS

The most frequent clinical symptom in patients with COVID-19 and H1N1 pneumonia were dyspnea (96.6%) and cough (62.5%), respectively. The CT findings showed that the COVID-19 group was characterized by GGO (88.1%), while the influenza group had features such as GGO (68.4%) and consolidation (66.7%). Compared to the influenza group, the COVID-19 group was more likely to have GGO (88.1% vs. 68.4%, p = 0.032), subpleural sparing (69.0% vs. 7.7%, p <0.001) and subpleural band (50.0% vs. 20.5%, p = 0.006), but less likely to have pleural effusion (4.8% vs. 33.3%, p = 0.001). The agreement rate between the 3 radiologists was 65.8%.

CONCLUSION

Considering similarities of respiratory infections especially H1N1 and COVID-19, it is essential to introduce some clinical and para clinical modalities to help differentiating them. In our study we extracted some lung CT scan findings from patients suspected to COVID-19 as a newly diagnosed infection comparing with influenza pneumonia patients.

Challenges of diagnosis of COVID-19 in trauma patients: A case series

Background

Diagnosis of COVID-19 can be challenging in trauma patients, especially those with chest trauma and lung contusion.

Methods

We present a case series of patients from February and March 2020 who were admitted to our trauma center at Rajaee Hospital Trauma Center, in Shiraz, Iran and had positive SARS-CoV-2 PCR test or chest CT scan suggestive of COVID-19 and were admitted to the specific ICU for COVID-19.

Results

Eight COVID-19 patients (6 male) with mean age of 40 (SD = 16.3) years old, were presented. All patients were cases of trauma injuries, with multiple injuries including chest trauma and lung contusion, admitted to our trauma center for management of their injuries, but they were diagnosed with COVID-19 as well. Two of them had coinfection of influenza type-B and SARS-CoV-2. All patients were treated for COVID-19 and three of them died; the rest were discharged from hospital.

Conclusion

Since PCR for SARS-CoV-2 is not always sensitive enough to confirm the cause of pneumonia, chest CT manifestations can be helpful, though, they are not always differentiable from lung contusion. Therefore, both the CT scan and the clinical and paraclinical presentation and course of improvement can be beneficial in diagnosing COVID-19 in the trauma setting.

Evaluation of Chest CT Scan as a Screening and Diagnostic Tool in Trauma Patients with Coronavirus Disease 2019 (COVID-19): A Cross-Sectional Study

BACKGROUND

The lack of enough medical evidence about COVID-19 regarding optimal prevention, diagnosis, and treatment contributes negatively to the rapid increase in the number of cases globally. A chest computerized tomography (CT) scan has been introduced as the most sensitive diagnostic method. Therefore, this research aimed to examine and evaluate the chest CT  scan as a screening measure of COVID-19 in trauma patients.

METHODS

This cross-sectional study was conducted in Rajaee Hospital in Shiraz from February to May 2020. All patients underwent unenhanced CT with a 16-slice CT scanner. The CT scans were evaluated in a blinded manner, and the main CT scan features were described and classified into four groups according to RSNA recommendation. Subsequently, the first two Radiological Society of North America (RSNA) categories with the highest probability of COVID-19 pneumonia (i.e., typical and indeterminate) were merged into the "positive CT scan group" and those with radiologic features with the least probability of COVID-19 pneumonia into "negative CT scan group."

RESULTS

Chest CT scan had a sensitivity of 68%, specificity of 56%, positive predictive value of 34.8%, negative predictive value of 83.7%, and accuracy of 59.3% in detecting COVID-19 among trauma patients. Moreover, for the diagnosis of COVID-19 by CT scan in asymptomatic individuals, a sensitivity of 100%, specificity of 66.7%, and negative predictive value of 100% were obtained (p value: 0.05).

CONCLUSION

Findings of the study indicated that the CT scan's sensitivity and specificity is less effective in diagnosing trauma patients with COVID-19 compared with nontraumatic people.

Resuming Breast Imaging Services in the Aftermath of the COVID-19 Pandemic: Safety and Beyond

As the Coronavirus disease 2019 (COVID-19) epidemic begins to stabilize, different medical imaging facilities not directly involved in the COVID-19 epidemic face the dilemma of how to return to regular operation. We hereby discuss various fields of concern in resuming breast imaging services. We examine the concerns for resuming functions of breast imaging services in 2 broad categories, including safety aspects of operating a breast clinic and addressing potential modifications needed in managing common clinical scenarios in the COVID-19 aftermath. Using a stepwise approach in harmony with the relative states of the epidemic, health care system capacity, and the current state of performing breast surgeries (and in compliance with the recommended surgical guidelines) can ensure avoiding pointless procedures and ensure a smooth transition to a fully operational breast imaging facility.

Fetal MRI in Prenatal Diagnosis of Encephalocele

BACKGROUND

Encephalocele, a rare congenital brain malformation, is herniation of brain tissue with or without meninges through a cranial fossa defect. It is classified by location and is usually associated with other congenital anomalies.

CASE

A 29-year-old G2, P1, 36-week pregnant woman was referred for fetal ultrasound delivery planning. Sonographic abnormalities led to fetal magnetic resonance imaging, which revealed a large sac of cerebrospinal fluid herniating through the anterior cranial fossa defect with strands of neurogenic tissue in direct contact with the tongue in the absence of the palate. Agenesis of the corpus callosum and the classic "Viking helmet" appearance of the frontal horns of the lateral ventricles were clearly visible.

CONCLUSION

Prenatal diagnosis of encephalocele is rarely reported. Unfortunately, the infant in this case report died at 3 months of age despite intensive medical therapy.

Correlation of serum ferritin levels with hepatic MRI T2 and liver iron concentration in nontransfusion beta-thalassemia intermediate patients: A contemporary issue

BACKGROUND

Beta-thalassemia intermediate is a genetic disease that is milder than beta-thalassemia major. The T2^* magnetic resonance imaging (MRI) technique is currently the gold standard for iron load detection. However, it is expensive and needs an expert radiologist to report findings. Therefore, we conducted this study to determine an optimal cut-off value of ferritin in proportion to T2 MRI of liver and measurement of liver iron concentration for early detection of hepatic iron overload in Beta-thalassemia intermediate patients.

METHODS

This cross-sectional study was conducted on 108 patients with Beta-thalassemia intermediate who referred to tertiary hospital, Shiraz, Iran. Serum ferritin, hepatic T2 MRI, and liver iron concentration were assessed. Receiver operator characteristic was used to determine the sensitivity and specificity of cut-off value.

RESULTS

Serum ferritin levels showed a statistically significant negative correlation with T2 hepatic MRI (r = -0.290, p value =.003) and positive correlation with liver iron concentration (r = 0.426, p value <.001) in the patients with Beta-thalassemia intermediate. According to the receiver operator characteristic, the best cut-off value for ferritin to show early diagnosis of liver iron overload was 412 ng/mL. Calculated sensitivities and specificities were 0.78 and 0.82 for T2 MRI and 0.76 and 0.86 for liver iron concentration, respectively.

CONCLUSION

Serum ferritin levels of around 450 ng/mL might be considered as a cut-off point to evaluate hepatic iron overload before using expensive, not readily available T2 MRI. This level of serum ferritin could be considered for starting iron chelation therapy in patients with Beta-thalassemia intermediate in areas where T2 MRI is not available.

A Useful Gadget to Reduce the Radiation Dose of Interventionist's Hands

Increased demand for interventional radiology techniques has interventionists performing a large number of these procedures. Measurements and calculations have shown that the radiation doses received by these specialists can exceed the threshold of radiation-induced deterministic effects unless radiation protection procedures and devices are used. Proper usage of radiation protection devices can protect them from radiation-induced effects, even with a high workload. Occupational radiation protection entails proper training of interventionists to increase their awareness about available appropriate protection tools and equipment, and devices that can be used to minimize exposure, such as needle holders, tubing extensions, and injectors. This study introduces a device that can be used to fix the catheter to prevent the physician from holding the catheter by hand. The authors, also, discuss the importance of radiation protection training along with the training on new medical equipment, which can be applied to reduce the radiation dose.

Qualitative and quantitative analysis of diffusion-weighted imaging of gestational trophoblastic disease: Can it predict progression of molar pregnancy to persistent form of disease?

•

The incidence of GTD in Iran is significantly higher than America and Europe.

•

ADC value of GTD is (1.96 ± 0.32 × 10⁻³ mm²/s).

•

GTD in T1 and T2-weighted images shows heterogeneous “snow-storm” appearance.

•

Focal intratumoral hemorrhage is bright in DWI and low signal in the ADC map.

•

ADC value and DWI are not helpful to predict progression of HM to persistent disease.

Purpose

To describe the diffusion-weighted imaging (DWI) appearance of gestational trophoblastic disease (GTD) and to determine its apparent diffusion coefficient (ADC) values. To evaluate the feasibility of DWI to predict progression of hydatidiform mole (HM) to persistent disease.

Methods

During a period of 6 months, women with preliminary diagnosis of GTD, based on ultrasound and ßhCG levels, underwent 1.5T MRI (T2 high-resolution and DWI; b values 50, 400, 800; sagittal and perpendicular to the endometrium; and T1, T2 Turbo Spin Echo [TSE] axial images). Patients were followed for 6–12 months to monitor progression to persistent form of the disease. ADC values and image characteristics were compared between HM and persistent neoplasia and between GTD and non-molar pregnancy using Mann–Whitney U and Fisher’s exact tests, respectively.

Results

Among the 23 studied patients, 19 (83%) were classified as molar and 4 (17%) as non-molar, based on pathology reports. After 6–12 months of follow-up, 5 (26%) cases progressed to persistent disease and 14 (74%) cases were benign HM. There was no significant difference between ADC values for HM (1.93 ± 0.33 × 10⁻³ mm²/s) and persistent neoplasia (2.03 ± 0.28 × 10⁻³ mm²/s) (P = 0.69). The ADC of non-molar pregnancies was (0.96 ± 0.46 × 10⁻³ mm²/s), which was significantly different from GTD (1.96  ± 0.32 × 10⁻³ mm²/s) (P = 0.001). Heterogeneous snowstorm appearance, focal intratumoral hemorrhage, myometrial contraction, and prominent myometrial vascularity were more common in GTD compared to non-molar pregnancy (P < 0.05).

Conclusion

Heterogeneous snowstorm appearance, focal intratumoral hemorrhage, myometrial contraction, and prominent myometrial vascularity are among the imaging characteristics of GTD. We cannot use ADC values to predict progression to persistent disease.

Fetal Central Nervous System Anomalies Detected by Magnetic Resonance Imaging: A Two-Year Experience

BACKGROUND

Magnetic resonance imaging (MRI) is gradually becoming more common for thorough visualization of the fetus than ultrasound (US), especially for neurological anomalies, which are the most common indications for fetal MRI and are a matter of concern for both families and society.

OBJECTIVES

We investigated fetal MRIs carried out in our center for frequency of central nervous system anomalies. This is the first such report in southern Iran.

MATERIALS AND METHODS

One hundred and seven (107) pregnant women with suspicious fetal anomalies in prenatal ultrasound entered a cross-sectional retrospective study from 2011 to 2013. A 1.5 T Siemens Avanto scanner was employed for sequences, including T2 HASTE and Trufisp images in axial, coronal, and sagittal planes to mother's body, T2 HASTE and Trufisp relative to the specific fetal body part being evaluated, and T1 flash images in at least one plane based on clinical indication. We investigated any abnormality in the central nervous system and performed descriptive analysis to achieve index of frequency.

RESULTS

Mean gestational age ± standard deviation (SD) for fetuses was 25.54 ± 5.22 weeks, and mean maternal age ± SD was 28.38 ± 5.80 years Eighty out of 107 (74.7%) patients who were referred with initial impression of borderline ventriculomegaly. A total of 18 out of 107 (16.82%) patients were found to have fetuses with CNS anomalies and the remainder were neurologically normal. Detected anomalies were as follow: 3 (16.6%) fetuses each had the Dandy-Walker variant and Arnold-Chiari II (with myelomeningocele). Complete agenesis of corpus callosum, partial agenesis of corpus callosum, and aqueductal stenosis were each seen in 2 (11.1%) fetuses. Arnold-Chiari II without myelomeningocele, anterior spina bifida associated with neurenteric cyst, arachnoid cyst, lissencephaly, and isolated enlarged cisterna magna each presented in one (5.5%) fetus. One fetus had concomitant schizencephaly and complete agenesis of the corpus callosum.

CONCLUSIONS

MRI is superior to ultrasound and physical exam of live births in detection of CNS anomalies. In this investigation within a single referral center in southern Iran, anomalies included Dandy-Walker variant and Arnold-Chiari II as the most common findings. Other findings with lower incidence were complete and partial agenesis of corpus callosum, aqueductal stenosis, anterior spina bifida, schizencephaly, arachnoid cyst, lissencephaly, and isolated enlarged cisterna magna.

MRI-Arthroscopic Correlation in Rotator Cuff Tendon Pathologies; A Comparison between Various Centers

BACKGROUND

Magnetic resonance imaging (MRI) has long been considered a perfect imaging study for evaluation of shoulder pathologies despite occasional discrepancies between MR reports and arthroscopic findings. In this study we aim to evaluate impact of imaging center as an indicator of image quality on accuracy of MRI reports in diagnosis of rotator cuff tendon pathologies.

METHODS

We reviewed MR reports of 64 patients who underwent arthroscopy in university center hospital. MRIs were done in various centers including both university-affiliated and out-centers. All studies were reported by two radiologists in consensus unaware of the arthroscopic results or previous reports. An inter-observer agreement analysis using the kappa statistics was performed to determine consistency among imaging and surgical reports.

RESULTS

Kappa values for out-centers were as follows: 0.785 for biceps, 0.469 for suscapularis, 0.846 for supraspinatus and 0.785 for infraspinatus tendons. In university centers values were 0.799 for biceps, 0.802 for suscapularis, 0.789 for supraspinatus and 0.770 for infraspinatus tendons.

CONCLUSION

Image reporting in university centers with proficient sequences increased accuracy of diagnosis in 3/4 of evaluated features and showed subtle decreased inter-observer agreement in 1/4 of features. Uniformity of the scanners and protocols as well as evaluation on a workstation rather than hard copies cumulatively resulted in a meaningful increase in the accuracy of the same radiologists in diagnosis of rotator cuff tendon tear.

Objective Structured Clinical Examination (OSCE)-based Assessment of the Advanced Trauma Life Support (ATLS) Course in Iran

OBJECTIVE

To evaluate the effect of advance trauma life support (ATLS®) training on general surgery residents clinical reasoning skills using the national boards-style objective structured clinical examination (OSCE).

METHODS

This cross-sectional single-center study was conducted in Shiraz University of Medical Sciences including 51 surgery residents that participated in a mandatory national board style OSCE between May 2014 and May 2015. OSCE scores of two groups of general surgery residents including 23 ATLS® trained and 28 non-ATLS® trained were compared using Mann-Whitney U test. The exam was graded out of 20 points and the passing score was ≥14 including 40% trauma cases.

RESULTS

There were 8(15.7%) women and 43(84.3%) men among the participants with mean age of 31.12 ± 2.69 and 33.67 ± 4.39 years in women and men respectively. Overall 7 (87.5%) women and 34 (79.07%) men passed the OSCE. The trauma section OSCE score was significantly higher in the ATLS® trained participants when compared to non-ATLS®(7.79 ± 0.81vs.6.90 ± 1.00; p=0.001). In addition, the total score was also significantly higher in ATLS® trained residents (16.07 ± 1.41 vs. 14.60 ± 1.40; p=0.001). There was no association between gender and ATLS® score (p=0.245) or passing the OSCE (p=0.503).

CONCLUSION

ATLS® training is associated with improved overall OSCE scores of general surgery residents completing the board examinations suggesting a positive transfer of ATLS learned skills to management of simulated surgical patients including trauma cases.

Adherence of Academic Radiologists in a Non-English Speaking Imaging Center to the BI-RADS Standards of Reporting Breast MRI

Objectives:

To assess the adherence of academic radiologists in a university center to BI-RADS lexicon (BLA) and to evaluate the structural completeness of breast MRI reports.

Materials and Methods:

Breast MRI reports made during 2012 in a single academic center by six readers were scored for formal completeness (FS) including recording the MRI protocol, making relevant clinical correlation, and describing background enhancement; BLA including mass rather than lesion, describing lesion outline, enhancement characteristics, and dynamic curve; and also expressing the final conclusion using BLA, resulting in a maximal total score of 8. FS and BLA were correlated with reader characteristics including breast imaging background, years of academic experience, and number of breast MRIs reported yearly. Tests used for statistical analysis were the Mann–Whitney U test and analysis of variance (ANOVA).

Results:

Overall BLA was 38.9%. This percentage was 60.1% and 3.7% in radiologists with and without breast imaging background, respectively (P = 0.000). Mean FS among all readers was 3.81 ± 1.75. This score was 2.54 ± 1.1 for readers without breast imaging background and 4.6 ± 1.6 for the readers regularly involved in breast imaging (P = 0.000).

Conclusions:

Higher degree of BLA and higher mean FS were associated with radiologists regularly involved in breast imaging. No association was found with years of academic experience or number of breast MRIs interpreted yearly.

Assessment of Correlation Between MRI and Arthroscopic Pathologic Findings in the Shoulder Joint

BACKGROUND

The objective of this study was to determine the diagnostic value of magnetic resonance imaging for shoulder joint pathologies and then compare the results with arthroscopy, the standard for joint diagnosis.

METHODS

In this cross-sectional study, 80 patients with shoulder joint disorders, who underwent final arthroscopy, were studied. Based on patients' medical history and physical examinations, shoulder MRI was requested if paraclinical investigations were. If non-surgical therapies failed, arthroscopy of the affected shoulder was done and the same structures were inspected. Subsequently, sensitivity, specificity, and positive and negative predictive values (PPV) and (NPV) of MRI were determined by arthroscopy comparisons.

RESULTS

The highest sensitivity, specificity, PPV and NPV were found in MRI pathology reports that included: Hill-Sach lesion (0.910), infraspinatus tendon (0.985), supraspinatus tendon (0.930), and biceps tendon (0.954), respectively. Rotator interval (0.250), biceps labrum complex (0.805), subscapularis tendon (0.538) and anterior labrum lesions (0.604) had the lowest sensitivity, specificity, PPV and NPV, respectively.

CONCLUSION

The results showed that MRI can be a useful tool in ruling out possible abnormalities in the shoulder and to give clues to the most probable diagnosis. Although knowing some practical skills in order to successfully perform the procedure and experience of the radiologist with suitable feedback by surgeon is necessary.

Comparison of the Accuracy of DWI and Ultrasonography in Screening Hepatocellular Carcinoma in Patients With Chronic Liver Disease

Background:

Hepatocellular carcinoma (HCC) is a neoplasm usually arising in a cirrhotic liver by a multistep carcinogenesis process. Early detection of HCC and accurate assessment of tumor burden are crucial to successful treatment planning and long-term survival.

Objectives:

In this study, we compared the accuracy of diffusion weighted imaging (DWI) combined with limited sequence magnetic resonance imaging (MRI) set as a potentially quick and practical MR candidate with ultrasonography (US) for screening of HCC in patients with cirrhosis.

Patients and Methods:

Of 96 patients with cirrhosis, 30 who had concomitant HCC proved by pathology were selected. MRI, DWI, and US of the liver were performed for the patients. Sensitivity, specificity, and accuracy of DWI alone, limited sequences MRI alone, a combination of them, and US were calculated for the detection of HCC in these patients and then comparison between these modalities was performed.

Results:

Combination of limited sequences MRI and DWI had the highest accuracy (94.79%) followed by DWI alone followed by limited sequence MRI alone. The least accuracy was for US (78.12%) with a statistically significant difference.

Conclusion:

Due to the significant improvement in the treatment of early stage of HCC compared to the previous decade, we suggest a fast, non-invasive, more accurate, but more expensive method (HASTE, OP/IP T1W sequences MRI combined with DWI) rather than US for the screening of HCC in liver cirrhosis.

Comparing diagnostic accuracy of bedside ultrasound and radiography for bone fracture screening in multiple trauma patients at the ED

INTRODUCTION

Long bone fractures are currently diagnosed using radiography, but radiography has some disadvantages (radiation and being time consuming). The present study compared the diagnostic accuracy of bedside ultrasound and radiography in multiple trauma patients at the emergency department (ED).

METHOD

The study assessed 80 injured patients with multiple trauma from February 2011 to July 2012. The patients were older than 18 years and triaged to the cardiopulmonary resuscitation ward of the ED. Bedside ultrasound and radiography were conducted for them. The findings were separately and blindly assessed by 2 radiologists. Sensitivity, specificity, the positive and negative predictive value, and κ coefficient were measured to assess the accuracy and validity of ultrasound as compared with radiography.

RESULTS

The sensitivity of ultrasound for diagnosis of limb bone fractures was not high enough and ranged between 55% and 75% depending on the fracture site. The specificity of this diagnostic method had an acceptable range of 62% to 84%. Ultrasound negative prediction value was higher than other indices under study and ranged between 73% and 83%, but its positive prediction value varied between 33.3% and 71%. The κ coefficient for diagnosis of long bone fractures of upper limb (κ = 0.58) and upper limb joints (κ = 0.47) and long bones of lower limb (κ = 0.52) was within the medium range. However, the value for diagnosing fractures of lower limb joints (κ = 0.47) was relatively low.

CONCLUSION

Bedside ultrasound is not a reliable method for diagnosing fractures of upper and lower limb bones compared with radiography.

Chest Tube Removal Time in Trauma Patients on Positive Ventilation Pressure: A Randomized Clinical Trial

OBJECTIVE

To determine the removal time of the chest tube in ICU trauma patients under positive ventilation pressure (PVP).

METHODS

This was randomized clinical trial being performed in ICU department of Rajaei trauma hospital from March to December 2011. A total number of 92 trauma patients who were admitted in ICU and were under ventilation and had chest tube were randomly assigned into two groups. In case group, chest tube was clamped after 5-7 days. In the control group, chest tube was retained until the patients were under PVP. The chest tube was removed if there was no air leak or the drainage was less than 300 mL.

RESULTS

Complications observed in the case and control groups were 4.4% of 4.3% respectively (p=0.862). Among case group with hemothorax, 6.7% developed complication while this ratio for pneumothorax was 7.1% and zero in those with hemopneumothorax (p=0.561), whereas respective values for the control group were 11.1%, 8.3% and zero (p=0.262). Complications were noticed in 10.5% of those with more than 300 ml of pulmonary drainage. There were no complications in patients without air leak. In mild leak, 4.8% of subjects experienced complication, in moderate leak, no complication occurred and in severe ones, complication was visible in 7.7% of patients (p=0.842).

CONCLUSION

The present study showed that the removal of chest tube in patients under ventilation within 5-7 days after its insertion is safe without any complications.

Evaluation of intrapleural contrast-enhanced abdominal pelvic CT-scan in detecting diaphragm injury in stable patients with thoraco-abdominal stab wound: a preliminary study

BACKGROUND

Many of the patients with thoraco-abdominal stab wound remain asymptomatic; in this regard, previous studies reported that 7-48% of asymptomatic patients had diaphragm injury (DI). Thoracoscopy or multidetector computed tomography (MDCT) scan is the best method to detect DI. We aimed to evaluate the role of CT scan with intrapleural contrast to rule out DI in stable thoraco-abdominal stab wounds.

METHOD

In a prospective study, we evaluated all haemodynamically stable patients with thoraco-abdominal stab wound, from October 2009 to 2010. Exclusion criteria included patients who needed emergency thoracotomy or laparotomy, those who were haemodynamically unstable and those with blunt trauma or gunshot injury. In the CT-scan department, 500 cc of diluted meglumine diatrozate was transfused into the pleural space via a chest tube and the CT scan was performed from the dome of the diaphragm to the pelvic cavity. In the second step, all patients were taken for thoracoscopy within 24h after admission. The CT-scan slide was considered positive if one of the following signs was found: (1) the diaphragm was obviously injured as seen in CT-scan slides and (2) contrast agent was seen in the peritoneal cavity. Sensitivity and specificity were calculated for CT scan and thoracoscopy.

RESULTS

Four out of 40 patients had DI according to thoracoscopy. CT scan with intrapleural contrast predicted diaphragmatic injury correctly in all four patients. Considering thoracoscopy as the gold-standard method, the CT scan had two false-positive cases. The sensitivity of the intrapleural-contrast CT scan was 100% and its specificity was 94.4%.

CONCLUSION

Our study showed that CT scan with intrapleural contrast can be an acceptable approach to rule out DI and limit the use of thoracoscopy for final diagnosis and repair of DI in cases with suspicious or positive CT-scan results, especially in trauma centres with high load of trauma patients and little accessible equipment.

Primary glomus tumor of the liver: a rare case report and review of the literature

Glomus tumor is a rare neoplasm of the distal extremities. It occurs very rarely in the deep visceral organs such as stomach, lung, pancreas, ovary, and liver. Herein, we report a very rare case of glomus tumor of the liver in a 50-year-old woman presenting with abdominal mass which was diagnosed after surgery. The tumor was large and cystic; however, the morphology was similar to the ordinary soft-tissue glomus tumor. Tumor cells were reactive with CD34 and SMA. The patient's follow up failed to show any evidence of malignant behavior or tumor recurrence. This report is the third primary glomus tumor of the liver in the English literature.

Quantification of epicardial adipose tissue: correlation of surface area and volume measurements

OBJECTIVES

Epicardial adipose tissue (EAT) is an important structure both as an active secretor of hormones and cytokines that play a role in the development of atherosclerosis, as well as its potential as a cardiac risk marker. The purpose of this article was to determine an easy but accurate quantification of EAT for routine clinical use.

METHODS AND RESULTS

We randomly selected coronary computed tomography angiographies of 60 patients (20 lean, 20 overweight, and 20 obese) derived from a larger study. Systolic and diastolic surface areas (SAs) were measured at two axial levels: a) fat pocket (FP) between right atrium and right ventricular outflow tract at origin of right coronary artery (RCA-FP) and b) FP anterior to right ventricular free wall (RVFW-FP) at coronary sinus ostium level. Maximum RVFW-FP thickness and total diastolic EAT volume were measured. EAT SA and thickness measurements were correlated to EAT volume and compared. Both interobserver and intraobserver reliability were assessed for SA and thickness with the intraclass correlation coefficient (ICC) as well as mean relative difference ± standard deviation (SD). Differences between systolic and diastolic SA measurements were also evaluated. Diastolic RCA-FP showed the highest SA correlation with volume (ρ = 0.92) and compared to the correlation of EAT thickness with volume (ρ=0.59) demonstrated the largest difference in correlation (+ 0.33, P < .0001). Systolic RCA-FP, systolic RVFW-FP, and diastolic RVFW-FP correlations to volume were less than diastolic RCA-FP (ρ = 0.84, ρ = 0.82, ρ = 0.86 respectively), but all correlations were statistically significantly higher than EAT thickness with volume. Values of systolic SA were mildly higher than diastolic SA for the RCA-FP (relative difference ± SD = 1.8 ± 21%, P = .8), but significantly higher for the RVFW-FP (relative difference ± SD = 17 ± 35%, P < .0001). Both systolic and diastolic SA measurements showed excellent reproducibility (ICC >0.95). However, for EAT thickness, the inter-observer reliability was comparatively low (ICC = 0.66).

CONCLUSION

Diastolic RCA-FP SA is a quick, reproducible estimate of total EAT and compared to EAT thickness demonstrates a significantly better correlation with EAT volume.

Effect of intravenous extracellular gadolinium based contrast medium on renal diffusion weighted images

RATIONALE AND OBJECTIVES

The aim of this study was to compare precontrast and postcontrast renal diffusion-weighted images for signal intensity (SI), apparent diffusion coefficient (ADC), and lesion conspicuity.

MATERIALS AND METHODS

In 62 patients (mean age, 54 ± 29; 29 men, 33 women) precontrast and postcontrast (0.1 mmol/kg of extracellular gadolinium-based contrast medium; mean, 3.3 ± 0.9 minutes], diffusion-weighted images at b values of 50 and 400 s/mm² were compared (3 T). The SI, signal-to-noise ratio, and ADC of the renal cortex, medulla, and lesions were measured. Lesion contrast-to-noise ratios (against the medulla and cortex) were calculated.

RESULTS

Postcontrast medullary SI decreased by 50% and cortical SI decreased by 33% and 39% on images at b = 50 s/mm² and b = 400 s/mm², respectively (P < .0001). The SI and signal-to-noise ratio of lesions did not change significantly after contrast, but lesion-medullary contrast-to-noise ratio was increased by 50% at both b = 50 s/mm² and b = 400 s/mm² (P < .005 and P = .0005, respectively) following contrast. Qualitative postcontrast lesion conspicuity was improved, with average scores of 2.8 ± 0.9 for all lesions (κ = 0.7 ± 0.08) and 3.2 ± 0.9 for solid lesions (κ = 0.82 ± 0.1). The ADC of renal cortex decreased (P = .03), but the ADC of renal medulla or renal lesions did not significantly change.

CONCLUSION

Postcontrast diffusion-weighted imaging causes a significant decrease in renal parenchymal signal without a significant change in lesion signal, resulting in increased lesion conspicuity.

Retroesophageal aortic arch in a patient with pulmonary embolism

The authors report an interesting case of right retroesophageal aortic arch (REAA) with pulmonary embolism that presented like the dissection of the aortic aneurysm but eventually diagnosed by means of spiral CT. Right REAA should be considered as a rare cause of mediastinal widening in the patients in whom significant difference between the blood pressure and pulse intensity of both extremities is evident to prevent the erroneous diagnosis and treatment.

Inflammatory pseudotumor of the liver: two case reports and a review of the literature

Rare cases of inflammatory pseudotumor (IPT) in two adolescents are reported. Both of them presented with significant weight loss and were operated upon with the impression of liver abscess and malignant liver tumor. These two cases are reported to emphasize IPT of the liver as a differential diagnosis of hepatic masses in children because recognition of this condition before operation can avoid unnecessary surgery.

Bilateral renal lymphangiomatosis: sonographic findings

Renal lymphangiomatosis is an exceedingly rare disorder characterized by developmental malformation of the lymphatic system surrounding the kidneys. We report a case of bilateral renal lymphangiomatosis in a 21-year-old man who underwent abdominal sonographic examination that revealed numerous cystic areas of various sizes around both kidneys with extension along the renal hilum. Subsequent abdominal CT examination demonstrated bilateral, multilocular, fluid-filled cystic masses with thin walls in the perirenal and peripelvic region. MRI of the patient revealed bilaterally enlarged kidneys with multiple hyperintense lesions in both perirenal spaces and the peripelvic area on T2-weighted images. These cystic spaces appeared hypointense on T1-weighted images with no enhancement in postcontrast images. The diagnosis of renal lymphangiomatosis was made based on typical imaging findings.

Functioning adrenocortical oncocytoma: a case report and review of literature

Adrenocortical oncocytoma is very rare. Less than five functioning types of them are reported and most of the reported cases are incidentally found. We herein report a case of functioning adrenocortical oncocytoma of the left adrenal cortex in a young woman.

Comparison of metoclopramide oral tablets and solution in treatment of dysmotility-like dyspepsia

PURPOSE

The clinical effects of metoclopramide oral solution and tablets in patients with dysmotility-like dyspepsia (DLD) were compared.

METHODS

In a prospective study, 63 patients with DLD, selected according to Rome II criteria and randomly divided into three groups, received metoclopramide tablets 5 mg t.i.d., metoclopramide oral solution 2 mg t.i.d., or placebo for one week. Assessment was based on symptom score determined by interviews and on gastric emptying time measured by ultrasonography before and after drug consumption. Two antral and stomach body biopsies were taken to evaluate infection with Helicobacter pylori and the intensity of gastritis.

RESULTS

Symptom score and gastric emptying time were significantly reduced in both metoclopramide groups (p < 0.05) but not in the control group. Patients receiving the oral solution had a greater reduction in the symptom score than those receiving tablets (p < 0.05). The absence or presence of and intensity of gastritis or H. pylori infection had no correlation with the symptom scores or gastric emptying times.

CONCLUSION

Metoclopramide oral solution 2 mg t.i.d. was at least as effective as metoclopramide tablets 5 mg t.i.d. in reducing symptoms of DLD and gastric emptying time.

Sonographic measurement of the inferior vena cava as a predictor of shock in trauma patients

Detecting and monitoring blood loss is always a challenging dilemma in emergency settings. The diameter of the inferior vena cava (IVC) in trauma patients may be useful in this way. This has been classically done with computed tomography (CT); however, doing it with ultrasound as a bedside easily available modality is a relatively novel approach. Between January 2006 and March 2006, 88 injured patients referred to our center were investigated. The patients were divided in to two groups: a shock group (n = 11, 12.5%) and a control group (n = 77, 87.5%) who were trauma patients with normal blood pressure. The maximum anteroposteroir diameter of IVC was measured ultrasonographically both in inspiration (i) and expiration (e) by M-mode in the subxyphoid area. The difference between the diameters of IVCe and IVCi was regarded as collapsibility, and collapsibility index was defined as IVCe - IVCi/IVCe. Statistical analysis included Mann-Whitney U test and correlation analysis. The average diameters of IVCe and IVCi in the shock group at arrival were significantly smaller than in the control group (5.6 +/- 0.8 mm, 4.0 +/- 0.7 mm versus 11.9 +/- 2.2 mm, 9.6 +/- 2.0 mm; P < 0.0001). The maximum diameter of IVC in the shock group was in a 30-year-old male patient with an IVCe and IVCi of 7.0 and 5.3 mm, respectively. Correlation analysis revealed a negative correlation between the diameter of IVCe (r = 0.72) and IVCi (r = 0.73) and the presence of shock. Regarding the collapsibility index, the mean collapsibility index of IVC was significantly higher in the shock group compared to patients in the control group (27% versus 20%; P < 0.001). The diameter of IVC was found to correlate with shock in trauma patients. The measurement of the IVC may be an important addition to the ultrasonographic evaluation of trauma and other potentially volume-depleted patients and can be added to the focused assessment with sonography for trauma (FAST) of the trauma patient with minimum additional time.

Methanol poisoning: acute MR and CT findings in nine patients

INTRODUCTION

Methanol poisoning is an uncommon but potent central nervous system toxin. We describe here the CT and MR findings in nine patients following an outbreak of methanol poisoning.

METHODS

Five patients with a typical clinical presentation and elevated anion and osmolar gaps underwent conventional brain MRI with a 1.5-T Gyroscan Interna scanner. In addition nonenhanced CT was performed in another three patients with more severe toxicity.

RESULTS

Bilateral hemorrhagic or nonhemorrhagic necrosis of the putamina, diffuse white matter necrosis, and subarachnoid hemorrhage were among the radiological findings. Various patterns of enhancement of basal ganglial lesions were found including no enhancement, strong enhancement and rim enhancement.

CONCLUSION

A good knowledge of the radiological findings in methanol poisoning seems to be necessary for radiologists. The present study is unique in that it enables us to include in a single report most of the radiological findings that have been reported previously.