Low-dose liver CT: image quality and diagnostic accuracy of deep learning image reconstruction algorithm

OBJECTIVES

To perform a comprehensive within-subject image quality analysis of abdominal CT examinations reconstructed with DLIR and to evaluate diagnostic accuracy compared to the routinely applied adaptive statistical iterative reconstruction (ASiR-V) algorithm.

MATERIALS AND METHODS

Oncologic patients were prospectively enrolled and underwent contrast-enhanced CT. Images were reconstructed with DLIR with three intensity levels of reconstruction (high, medium, and low) and ASiR-V at strength levels from 10 to 100% with a 10% interval. Three radiologists characterized the lesions and two readers assessed diagnostic accuracy and calculated signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), figure of merit (FOM), and subjective image quality, the latter with a 5-point Likert scale.

RESULTS

Fifty patients (mean age: 70 ± 10 years, 23 men) were enrolled and 130 liver lesions (105 benign lesions, 25 metastases) were identified. DLIR_H achieved the highest SNR and CNR, comparable to ASiR-V 100% (p ≥ .051). DLIR_M returned the highest subjective image quality (score: 5; IQR: 4-5; p ≤ .001) and significant median increase (29%) in FOM (p < .001). Differences in detection were identified only for lesions ≤ 0.5 cm: 32/33 lesions were detected with DLIR_M and 26 lesions were detected with ASiR-V 50% (p = .031). Lesion accuracy of was 93.8% (95% CI: 88.1, 97.3; 122 of 130 lesions) for DLIR and 87.7% (95% CI: 80.8, 92.8; 114 of 130 lesions) for ASiR-V 50%.

CONCLUSIONS

DLIR yields superior image quality and provides higher diagnostic accuracy compared to ASiR-V in the assessment of hypovascular liver lesions, in particular for lesions ≤ 0.5 cm.

CLINICAL RELEVANCE STATEMENT

Deep learning image reconstruction algorithm demonstrates higher diagnostic accuracy compared to iterative reconstruction in the identification of hypovascular liver lesions, especially for lesions ≤ 0.5 cm.

KEY POINTS

• Iterative reconstruction algorithm impacts image texture, with negative effects on diagnostic capabilities. • Medium-strength deep learning image reconstruction algorithm outperforms iterative reconstruction in the diagnostic accuracy of ≤ 0.5 cm hypovascular liver lesions (93.9% vs 78.8%), also granting higher objective and subjective image quality. • Deep learning image reconstruction algorithm can be safely implemented in routine abdominal CT protocols in place of iterative reconstruction.

Evaluating the Trend of VRE carriages in Health Facilities: A Retrospective Study from 2019-2022

Background

Healthcare-associated infections (HAIs) and multidrug resistance (MDR) are a growing public health threat and pose a risk to patient safety in healthcare facilities. Vancomycin-resistant Enterococci (VRE) are responsible for nosocomial infections and have intrinsic and acquired resistance to many antibiotics, including glycopeptides. VRE carriage can remain undetected, increasing the risk of contact transmission. Identifying colonized patients is crucial for the implementation of preventive measures.

Aims

The aims of this study were to evaluate the trend of VRE carriage based on rectal swab results between 2019 and February 2022 in a large Italian trust and the percentage of patients with VRE colonization at the time of hospitalization.

Methods

This was a retrospective observational study based on results of rectal swabs performed for screening on admission between January 2019 and February 2022 in four hospitals part of a single trust in Turin, North-Western Italy. The study collected data on the date of specimen collection, type of specimen, isolated pathogen and the date of hospital admission. Descriptive analysis of data was performed, and duplicate samples were not considered.

Results

From January 2019 to February 2022 we collected 5025 rectal swabs performed in hospitals of the trust, of which 3037 were performed in 2019 (60%), 741 in 2020 (15%), 611 in 2021 (12%) and 636 in the first two months of 2022 (13%). VRE positivity was found in 162 (3%) rectal swabs, of which 2 cases in both 2019 (0.1%) and 2020 (0.3%), 95 in 2021 (15.5%) and 63 in the first two months of 2022 (9.9%). Furthermore, 52% (84/162) of positive rectal swabs were performed at admission, whereas the remaining 48% (78/162) of positive rectal swabs were performed after 48h.

Conclusions

This study found an increasing trend of VRE carriage in the study population during the SARS-CoV-2 pandemic, highlighting the importance of screening patients for VRE carriage to prevent worsening clinical conditions, environmental contamination, and prolonged hospitalization.

Facilitators and barriers to attending postpartum screening in women with a recent pregnancy complicated by gestational diabetes mellitus: a qualitative study

OBJECTIVE

Pregnant women with gestational diabetes mellitus (GDM) are 50% more likely to develop type II diabetes (T2D) within 6 months to 2 years after giving birth. Therefore, international guidelines recommend it is best practice for women diagnosed with GDM to attend screening for T2D 6-12 weeks postpartum and every 1-3 years thereafter for life. However, uptake of postpartum screening is suboptimal. This study will explore the facilitators of and barriers to attending postpartum screening for T2D that women experience.

STUDY DESIGN

This was a prospective qualitative cohort study using thematic analysis.

METHODS

A total of 27 in-depth, semistructured interviews were conducted over the telephone with women who had recent GDM. Interviews were recorded and transcribed, and data were analysed using thematic analysis.

RESULTS

Facilitators of and barriers to attending postpartum screening were identified at three different levels: personal, intervention, and healthcare systems level. The most common facilitators identified were concern for their own health and having the importance of screening explained to them by a health professional. The most common barriers identified were confusion over the test and COVID-19.

CONCLUSION

This study identified several facilitators of and barriers to attending postpartum screening. These findings will help to inform research and interventions for improving rates of attendance at postpartum screening to reduce the subsequent risk of developing T2D.

Ureteral wall thickness and distal ureteral density in patients with residual fragments after Ho:YAG laser semi-rigid ureterolithotripsy

Recent data suggest that greater ureteral density distal to ureteral stones or increased ureteral wall thickness (UWT) can predict impacted stones. The aim of our study was to evaluate if patients with residual fragments present with greater ureteral density and larger UWT when compared to stone-free patients. From January onward, a consecutive series of patients undergoing semi rigid Ho:YAG laser ureterolithotripsy (ULT) for ureteral stones were enrolled. A non-contrast enhanced computed tomography (CT) scan was performed before the procedure to evaluate distal ureteral density (DUD) and wall ureteral thickness (UWT) at the site of ureteral stones. Patients with residual fragments were compared to stone-free patients using a matched-pair analysis (1:1 scenario). Cases were matched sequentially using the following criteria: age, gender, body mass index (BMI), stone length, hydronephrosis, location of stones, and mean Hounsfield unit (HU) of the stone. Overall, 160 patients were enrolled, mean age was 57.9 ± 14 years, mean BMI was 25.8 ± 4 kg/m2, mean length of the stone was 10.6 ± 4.9 mm, and mean UWT was 1.4 ± 1.6 mm. A total of 150/160 (94%) patients presented hydronephrosis; mean HU stone was 868 ± 327; mean DUD was 54 ± 17.8 HU. Ureteral distal density (51.7 vs 56.6; p = 0.535) and ureteral distal thickness (1.39 vs 1.54; p = 0.078) were similar in both groups of patients. In our study, the evaluation of distal ureteral density does not predict stone-free rate. Further studies should evaluate the role for preoperative computer tomography in predicting surgery outcome.

Covid-19 Hospitalization Costs Assessment in an Italian Covid Hospital

Introduction

Many consequences resulted from the breakout of the COVID-19 pandemic in Europe, which have disrupted our economic, social and medical world. This allowed us to measure and assess the hospitalisation costs regarding the COVID-19 disease at Martini Hospital in Turin, one of the hospitals entirely committed to the COVID-19 care, between January and June 2021.

Methods

In this single center retrospective study, we collected and analysed cost data on patients admitted at Martini Hospital in the time frame of January-June 2021 and compared the analysis with the same period in 2020, at a time when the hospital was not dedicated to Covid-19 patients. Cost data included full-time and temporary employees salaries, drugs, medical and non-medical supplies and equipment and facility utilities. We then estimated the cost per treated COVID-19 episode, in comparison with the cost per any desease including Covid-19.

Results

The first 6 months of 2021 registered 2,136 hospital discharges, while same period in 2020 counted 4376. The mean duration of the hospital stay was 7,67 days in 2020 and 12,83 in 2021. The average charge per treated episode doubled (+52,5%) from Euros 8997 in 2020 to Euros 19026 in 2021. The mean revenue increased of 35% from Euros 3280 in 2020 to Euros 5041 in 2021. This is due to the major complexity of care required for Covid patients. As it is, in 2021 the average complexity index of 2.13 while in 2020 it was 1.39.

Conclusions

Clinical management and treatment of COVID-19 economically strain the European health-care systems. The study of COVID-19 treatment costs, and their differences between 2020 and 2021 suggests an economic challenge for the entire Italian health system and emphasises the necessity to avoid the recurrence of such an economic impact by implementing effective infection prevention and control policies.

Key messages

• The Covid-19 pandemic has been straining both the European health and economic systems.

• Studying the Covid-19 expenditures allows to frame unexpected new challenges regarding health-care systems.

Gender medicine: a cross-sectional survey on knowledge and curriculum among Italian medical students

Introduction

Gender and sex are important predictors of many attitudes and behaviours that have an impact on health and disease. Gender medicine is then a fundamental approach for better quality of care in Europe. Few information is available on Italian medical students and their knowledge about gender medicine. Our study aimed to investigate knowledge about gender medicine in a sample of Italian medical students in order to identify specific knowledge gaps and improve Medicine degree curricula.

Methods

In 2020, an online cross-sectional survey was conducted on 430 medical students of the University of Turin, Italy. Participants filled out a questionnaire consisting of 29 items concerning the areas of knowledge and attitudes regarding gender medicine. Multivariable logistic regression model was performed to explore potential predictors of knowledge among students.

Results

More than 60% of the students knew the correct definition of gender medicine and around 90% of them knew the difference between sex and gender. In total, 58.16% of female students had a good level of knowledge, significantly more than male students (37,5%; p &lt; 0.001); female students also showed a higher mean score compared to male students (respectively 17.96±2.75 vs 16.59±3.20, p &lt; 0.001). Using a multivariate linear regression model, with level of knowledge about gender medicine used as a continuous variable, we found that being female was the only potential predictor of high consideration of gender medicine in patient management.

Conclusions

The results indicate that students have a good knowledge and high regard for gender medicine. Female students seem more aware of the importance of gender medicine and areas of improvement can be identified. Future European physicians must consider gender medicine in order to encourage a patient-tailored approach and to reduce gender gap still existent in current practice.

Key messages

Gender medicine is a fundamental approach to improve quality of care and to reduce gender gap among European patients. Medical students should be more aware and trained about gender and sex differences during clinical practice in order to encourage a patient-tailored medicine.

Postacute Sequelae of COVID-19 Pneumonia: 6-month Chest CT Follow-up

Background

The long-term post acute pulmonary sequelae of COVID-19 remain unknown.

Purpose

To evaluate lung injury in patients affected by COVID-19 pneumonia at six-month follow-up compared to baseline chest CT.

Methods

From March 19th,2020 to May 24th,2020, patients with moderate to severe COVID-19 pneumonia and baseline Chest CT were prospectively enrolled at six-months follow-up. CT qualitative findings, semi-quantitative Lungs Severity Score (LSS) and well-aerated lung quantitative Chest CT (QCCT) were analyzed. Baseline LSS and QCCT performances in predicting fibrotic-like changes (reticular pattern and/or honeycombing) at six-month follow-up Chest CT were tested with receiver operating characteristic curves. Univariable and multivariable logistic regression analysis were used to test clinical and radiological features predictive of fibrotic-like changes. The multivariable analysis was performed with clinical parameters alone (clinical model), radiological parameters alone (radiological model) and the combination of clinical and radiological parameters (combined model).

Results

One-hundred-eighteen patients, with both baseline and six-month follow-up Chest CT, were included in the study (62 female, mean age 65±12 years). At follow-up Chest CT, 85/118 (72%) patients showed fibrotic-like changes and 49/118 (42%) showed GGOs. Baseline LSS (>14), QCCT (≤3.75L and ≤80%) showed an excellent performance in predicting fibrotic-like changes at Chest CT follow-up. In the multivariable analysis, AUC was .89 (95%CI .77-.96) for the clinical model, .81 (95%CI .68-.9) for the radiological model and .92 (95%CI .81-.98)for the combined model.

Conclusion

At six-month follow-up Chest CT, 72% of patients showed late sequelae, in particular fibrotic-like changes. Baseline LSS and QCCT of well-aerated lung showed an excellent performance in predicting fibrotic-like changes at six-month Chest CT (AUC>.88). Male sex, cough, lymphocytosis and QCCT well-aerated lung were significant predictors of fibrotic-like changes at six-month with an inverse correlation (AUC .92).

See also the editorial by Wells and Devaraj.

Appropriateness of antibiotics for medical prophylaxis: evaluation of data from the Italian PPS-2

Background

Antibiotics (AB) are administered for medical prophylaxis (MP) to prevent infectious complications. The second national point prevalence survey (PPS) of healthcare-associated infections and AB use was conducted in Italy in 2016-2017. The survey found MP accounted for nearly 25% of all registered ABs, more than twice the EU/EEA proportion. The aim of this study was to evaluate how many ABs were administered for MP and how frequently general indications were followed.

Methods

Data from the PPS were used to evaluate the prevalence of indications for MP over the total number of ABs, the proportion - among these indications - of those justified by a motivation in the patients' charts, and the prevalence of ABs considered appropriate for MP. The evaluation was made in 12 hospitals out of 14 participating in the PPS in Piedmont, chosen on the basis of patient traceability. According to national guidelines, the indications for MP that were considered appropriate in this study were: Trimethoprim/sulfamethoxazole for P. carinii pneumonia, Rifaximin for diverticulitis, Penicillin for Streptococcal infections and for splenectomized patients, and Rifampin for TB infections.

Results

1844 AB prescriptions were registered among 1334 traceable inpatients in Piedmont. The prevalence of indications for MP was 16.2% and 253 ABs (84.6%) were prescribed with a motivation. Only 3% of ABs registered as MP were appropriate for this indication: Bactrim 2%, Rifaximin 0.3%, Penicillin 0.2% and Rifampin 0.4%.

Conclusions

This study found an extremely high rate of inappropriate ABs for MP, that will be further investigated through qualitative analysis of medical records to evaluate whether a misunderstanding of the PPS protocol occurred and empirical therapy was confused with MP. Nevertheless, this study highlighted the need for interventions to improve prescribing appropriateness for MP.

Key messages

This study found that only 2.98% of ABs registered as MP among traceable patients in Piedmont were appropriate for this indication. 15.38% of prescriptions for MP were not justified by a motivation. Interventions to improve prescribing appropriateness for MP could lead to a considerable reduction in inappropriate use of ABs, which is crucial in a country facing hyperendemic levels of AMR.

Typical and atypical COVID-19 computed tomography findings

In December 2019 a novel coronavirus, named severe acute respiratory syndrome coronavirus 2 was identified and the disease associated was named coronavirus disease 2019 (COVID-19). Fever, cough, myalgia, fatigue associated to dyspnea represent most common clinical symptoms of the disease. The reference standard for diagnosis of severe acute respiratory syndrome coronavirus 2 infection is real time reverse-transcription polymerase chain reaction test applied on respiratory tract specimens. Despite of lower specificity, chest computed tomography (CT), as reported in manifold scientific studies, showed high sensitivity, therefore it may help in the early detection, management and follow-up of COVID-19 pneumonia. Patients affected by COVID-19 pneumonia usually showed on chest CT some typical features, such as: Bilateral ground glass opacities characterized by multilobe involvement with posterior and peripheral distribution; parenchymal consolidations with or without air bronchogram; interlobular septal thickening; crazy paving pattern, represented by interlobular and intralobular septal thickening surrounded by ground-glass opacities; subsegmental pulmonary vessels enlargement (> 3 mm). Halo sign, reversed halo sign, cavitation and pleural or pericardial effusion represent some of atypical findings of COVID-19 pneumonia. On the other hand lymphadenopathy's and bronchiectasis' frequency is unclear, indeed conflicting data emerged in literature. Radiologists play a key role in recognition of high suspicious findings of COVID-19 on chest CT, both typical and atypical ones. Thus, the aim of this review is to illustrate typical and atypical CT findings of COVID-19.

External validation of Imamura nomogram as a tool to predict preoperatively laser semi-rigid ureterolithotripsy outcomes

BACKGROUND

We aimed to validate Imamura nomogram for prediction of stone free rate in patients undergoing ureterolithotripsy (ULT).

METHODS

From January 2013 to June 2016, patients undergoing laser semi-rigid ULT were prospectively enrolled at our center. All patients were preoperatively assessed with clinical history, blood samples, uranalysis and non-contrast enhanced computed tomography (CT). Treatment efficacy was assessed 1 month later by non-contrast enhanced CT. ROC curve was used to evaluate the performance characteristics of Imamura nomogram.

RESULTS

Overall, we enrolled 275 patients. Median age was 55 years (IQR: 46/64), median length of stone was 9.8 mm (IQR: 7.5/12). Pyuria was detected in 6/275 (2.1%) patients. Stones were located at ureteropelvic junction in 55/275 (19%) patients, proximal ureter in 74/275 (26%) patients, middle and distal ureter in 66/275 (24%) patients and 82/275 (30%) patients, respectively. At 1-month follow-up, 209/275 (76%) patients were stone free. Imamura nomogram presented an AUC of 0.67 (95% CI: 0.580-0.761) for the prediction of stone free rate. At the best cut-off value of 75%, sensitivity was 76%, specificity was 55%, positive predictive value (PPV) was 83% and negative predictive value was 45%.

CONCLUSIONS

We firstly validated Imamura nomogram in a European cohort study. It proved a reasonable accuracy (area under curve: 0.67) and a good PPV (83%). Further studies should confirm our results to support the routine clinical use of Imamura nomogram as a tool to predict ULT outcomes.

Effect of exercise modality on markers of insulin sensitivity and blood glucose control in pregnancies complicated with gestational diabetes mellitus: a systematic review

BACKGROUND/AIM

Exercise can be used as a strategy to attenuate hyperglycaemia experienced during gestational diabetes mellitus (GDM). To maximize its use for clinical management, the most effective modality should be identified. The purpose of this review is to elucidate the most effective modality of exercise on insulin sensitivity and blood glucose control in pregnant women with or at risk of GDM.

METHODS

A search was undertaken in MEDLINE, PubMed, Scopus, CINAHL, the Cochrane Library, Embase and the Maternity & Infant Healthcare Database. Studies that met inclusion criteria were randomized controlled trials and case-controlled studies, which compared exercise interventions with standard care during pregnancy in women with or at risk of GDM.

RESULTS

Two interventions using resistance training, eight using aerobic exercise and two using a combination of both modalities were included. The interventions showed consistently that requirements of insulin therapy, dosage, and latency to administration were improved in the exercise groups. Less consistent results were observed for capillary blood glucose measurements; however, both modalities and combination of modalities were effective at improving blood glucose control in already diagnosed patients and pregnant women with obesity. Discrepancies in the timing of intervention, GDM diagnostic criteria, and the different measures used to assess glucose metabolism make it difficult to draw clear recommendations.

CONCLUSION

Exercising three times per week for 40-60 min at 65-75% age-predicted heart rate maximum using cycling, walking or circuit training as a modality improved glycaemic control in GDM patients and reduced incidence of GDM in pregnant women with obesity. Further studies looking specifically at the effects of different modalities of exercise on glucose metabolism with combined strategies to enhance insulin sensitivity should be explored to maximize benefits for GDM pregnancies. Consistency in design and delivery of exercise-only interventions is required to make recommendations on a suitable exercise prescription in this population. In practice, adherence to consensus in diagnostic cut-offs for GDM diagnosis is fundamental for standardizing future research.

[Comparison of diagnostic quality in hysterosalpingography between iodinated non-ionic contrast media with low and high osmolarity]

PURPOSE

Comparison of diagnostic quality in hysterosalpingography between low and high-osmolality contrast media.

MATERIALS AND METHODS

We performed a retrospective evaluation of two cohorts of patients who underwent HSG using contrast media with different osmolarity: the first group ,47 patients, underwent hysterosalpingography in the period September 2011-December 2012 using Iopromide 370 mg/ml; the second group, 50 patients, underwent HSG from January 2013 to October 2013 using Iomeprol 400 mg/ml. Three radiologists, in consensus reading,, reviewed the radiographs by assessing the following four parameters: opacification of the uterine cavity, uterine profiles definition, Fallopian tubes visualization, contrast media spillage into peritoneum. A score-scale from 0 to 3 was assigned for each of the mentioned parameter (0 = minimum non-diagnostic exam, 1 = sufficient examination; 2 = good quality examination; maximum 3 = high quality images).

RESULTS

We documented a statistically significant higher quality in displaying Fallopian tubes among patients studied through high osmolarity contrast medium (Iopromide 370 mg/ml) than what obtained through lower osmolarity contrast medium (Iomeprol 400 mg/ml).

CONCLUSIONS

The use of high osmolarity contrast medium enabled better visualization of the tubes and a greater number of diagnoses of chronic aspecific salpigintis due to the increased osmolality and viscosity of Iomeprol 400 mg/ml. There were no significant differences between the two contrast agents in the evaluation of intra-uterine pathology and in the evaluation of the tubal patency.

Gamma-ray spectroscopy at MHz counting rates with a compact LaBr3 detector and silicon photomultipliers for fusion plasma applications

Gamma-ray spectroscopy measurements at MHz counting rates have been carried out, for the first time, with a compact spectrometer based on a LaBr₃ scintillator and silicon photomultipliers. The instrument, which is also insensitive to magnetic fields, has been developed in view of the upgrade of the gamma-ray camera diagnostic for α particle measurements in deuterium-tritium plasmas of the Joint European Torus. Spectra were measured up to 2.9 MHz with a projected energy resolution of 3%-4% in the 3-5 MeV range, of interest for fast ion physics studies in fusion plasmas. The results reported here pave the way to first time measurements of the confined α particle profile in high power plasmas of the next deuterium-tritium campaign at the Joint European Torus.

The role of contrast enhanced computed tomography in the diagnosis of necrotizing fasciitis and comparison with the laboratory risk indicator for necrotizing fasciitis (LRINEC)

PURPOSE

To evaluate the diagnostic efficacy of contrast enhanced computed tomography (CECT) in emergency departments for diagnosis of necrotizing fasciitis (NF) and for differential diagnosis of other musculoskeletal infections; to correlate radiological findings with the laboratory risk indicator for necrotizing fasciitis (LRINEC).

MATERIALS AND METHODS

7 radiological parameters to be analysed on CECT scans were established, exams of 36 patients with proven diagnosis of NF (n 12) and other musculoskeletal infections (n 24) were retrospectively reviewed; LRINEC score was calculated. Fisher's test and Spearman's and Kendall's coefficients of rank correlations were performed.

RESULTS

Two parameters were found to be strongly associated with the diagnosis of NF: involvement of the fascia (Spearman's ρ of 0.888, p < 0.001) and lack of fascial enhancement (Spearman's ρ of 0.672, p < 0.001). LRINEC score did not show strong association with the presence of fasciitis NF (Spearman's ρ of 0.490, p = 0.0024).

CONCLUSION

Computed tomography (CT) parameters, which are significantly associated with the diagnosis of NF, are the involvement of the fascia and its lack of enhancement; LRINEC score could be high (>5) also in other musculoskeletal infections. Final diagnosis of necrosis among the fascia is surgical. Presence of gas is not a specific sign of necrotizing fasciitis being present in other musculoskeletal infections. CT could easily discriminate NF from other musculoskeletal infections, adds an important value to clinical and laboratory tests in diagnosis of NF in an emergency context when magnetic resonance imaging, which is superior to CT in this discernment, could not be performed.

Imaging progression despite clinical remission in early rheumatoid arthritis patients after etanercept interruption

The aim of this preliminary study is to evaluate clinical and imaging response in twenty patients with early Rheumatoid Arthritits (eRA) treated with Etanercept (Etn) + Methotrexate (Mtx) and to investigate whether clinical and MRI remission may be maintained after biological therapy interruption. Assessment included: radiography, Visser score and anti-CCP antibodies at baseline; disease activity score in 44 joints (DAS44), rheumatoid factor (RF), Magnetic Resonance Imaging (MRI) of hands and wrists at baseline (T0), 12 (T1), and 24 months (T2). MRI was scored for synovitis, bone oedema and erosions (OMERACT study); patients who reached clinical and imaging remission at T1 were considered eligible for interrupting Etn. At T1 8/20 (40 percent) patients showed a total remission, DAS44 from 5 (T0) to 1.4 (T1); p<0.02, whereas the other 12/20 (60 percent) showed an improvement, without complete remission, DAS44 from 4.8 (T0) to 2.8 (T1); p<0.05. Etn was therefore interrupted in the first group of patients (group A), whereas it was continued in the other group (group B). At T2, group A maintained clinical remission and group B showed further not significant DAS44 reduction from T1. At T1, a significant reduction in synovitis, bone oedema and total score (p<0.01) was observed both in group A and in group B. At T2, group A showed an increase in all the MRI scores that was significant for the synovitis and total score, whereas group B exhibited a further not significant reduction. This preliminary study reports an excellent clinical and imaging response in eRA patients treated with Etn with total remission in 40 percent of them after a 1-year therapy period. However, it indicates that joint damage may progress, despite a sustained clinical remission, after Etn suspension.

MRI in the study of distal primary myopathopies and of muscular alterations due to peripheral neuropathies: possible diagnostic capacities of MR equipment with low intensity field (0.2 T) dedicated to peripheral limbs

The purpose of this work was to investigate whether or not an magnetic resonance imaging (MRI) equipment with a low field intensity (0.2 T) used in the study of muscular alterations can diagnose primary or secondary myopathies, due to peripheral neuropathies. In this study the peripheral areas of all patients were examined. A total of 40 patients (23 males and 17 females) were tested. Their age ranged from 10 to 78 years age (mean age 40.8, SD +/- 19,45 years). The group includes 23 patients: 18 with Stainert Myotonic Distrophy, 5 were myositic, and the remaining 17 had peropheral neuropathies. Every patient received a clinic examination, followed by EMG and MRI. The MRI study was done with a system dedicated to the study of limbs (Artoscan, Esaote Biomedica) that used a 0.2 T permanent magnet. Spin-echo T1, T2-weighted, multiple-echo, and STIR sequences were used. A good correspondence was found between clinical and MRI data. Specifically, in the group of 23 myopathies, Sperman's index was found to be 0.80 in its correlation between the clinical examination and MRI; in the group of 17 myopathies it was found to be 0.63. A discrepancy was found among clinical examination, EMG, and MRI in patients with neuropathies who were showing a lack of myelin and mixed ones. The T2-weighted and STIR sequences had great sensitivity in showing initial changes in the muscles. The SE T1-weighted sequence was especially useful in detecting degeneration in the fibrous adipose tissue. The STIR sequence because of its high sensitivity and greater speed of response could be used instead of the SE T2 weighted particularly in the study of patients, who were noted to tolerate a prolonge period of scanning. However, because these sequences have a low signal noise ratio, they must always be associated with a SE sequence, whenever there would be need of a precise determination of the structures under study. The MRI low field intensity was also found to be a useful technique in screening familial groups having a great number of myotonic distrophies. It can have a great clinical role in revealing muscular alterations, even in asymptomatic patients.

Ultrasound transmission velocity of the proximal phalanxes of the non-dominant hand in the study of osteoporosis

The aim of our study was to evaluate a quantitative ultrasound technique for measuring bone tissue at the proximal phalanxes of the non-dominant hand. We correlated the mean value of the amplitude-dependent speed of sound (AD-SoS) measured at the distal metaphysis of the last four proximal phalanxes with age, months since menopause and bone mineral density (BMD) of the lumbar spine in 264 women. We further assessed the ability of the AD-SoS to discriminate between normal and osteoporotic subjects with documented vertebral fractures. We found a positive correlation between the AD-SoS and the lumbar spine BMD, whereas the AD-SoS negatively correlated with age and months since menopause. The AD-SoS showed a higher correlation with age changes and months since menopause than BMD. The AD-SoS was significantly higher in healthy females than in osteoporotic ones (p < 0.001). Multiple logistic regression analysis showed for age-adjusted values that AD-SoS decrease is significantly associated to the presence of fracture. Our results suggest that AD-SoS is valuable in assessing age and menopause related bone loss and is useful for diagnosing osteoporosis.

[Myositis: diagnostic potential of a magnetic resonance unit with low intensity field (0.2 T)]

Magnetic Resonance Imaging (MRI) is a useful tool for demonstrating muscle changes in patients with inflammatory myopathies. We investigated the diagnostic capabilities of low field (0.2 T) MRI with a dedicated coil in a series of patients with an unquestionable clinical diagnosis of inflammatory myopathy. Infiltrating processes or muscle swelling are depicted as low-signal areas on T1-weighted SE images and as high-signal areas on T2-weighted SE and short time inversion recovery (STIR) images. Fatty infiltration appears as a high-signal area within muscles on T1-weighted SE images. T2-weighted SE and STIR sequences are highly sensitive in demonstrating infiltrating processes or muscle swelling. The signal-to-noise ratio was higher on T2-weighted SE than on STIR images; on the other hand, fast STIR sequences can effectively reduce scan times. To conclude, low field MRI is a useful tool in the study of inflammatory myopathies thanks to its noninvasiveness and to the good depiction of muscle inflammation provided by T2-weighted SE and STIR images.

[Early and systematic use of ultrasonography in emergency patients with renal colic: analysis of the actual diagnostic efficacy]

In this study, the diagnostic yield of ultrasonography (US) in the early phase of acute urinary obstruction was retrospectively assessed and compared with that of clinical examination. 351 patients were admitted to our emergency department because of suspected renal colic over an 11 months' period: urinary obstruction was subsequently confirmed with other examinations in 76 of them, who were all submitted to renal US within 2 hours of the onset of symptoms. Emergency US results were then retrospectively compared with clinical and laboratory data and the cost of each US exam was calculated. Thirty-nine of 76 patients had negative US findings (51.3%). In the extant 37 patients, US showed hydronephrosis (which was mild in 13 patients and moderate in 6) and renal stones (in 18 patients). Hydronephrosis was associated with renal stones or increased parenchymal echogenicity in 5 and 6 patients, respectively. Pain, which was always severe, was not a useful sign for diagnostic purposes. In contrast, all the 37 patients with abnormal US findings (hydronephrosis, renal stones and increased parenchymal echogenicity) exhibited specific clinical and laboratory abnormalities such as hematuria, ketonuria and marked blood pressure increase (diastolic pressure > 100 mmHg). The same abnormalities, although less severe (mild hematuria and ketonuria and increased diastolic pressure not exceeding 100 mmHg) were nevertheless present in all the 39 patients with negative US findings and yet having a renal colic. The cost of each emergency US exam (calculated on the basis of literature tables and reference cost) was approximately It. L. 104,000. The corresponding total cost for submitting to US all the 76 patients with renal colic was approximately It. L. 7,900,000. In the early phase of urinary obstruction, the association of hematuria, ketonuria and increased blood pressure was more reliable than US findings-the latter method yielding a 51.3% false-negative rate. The presence and severity of the above clinical and laboratory abnormalities might thus represent a criterion to select the patients who are less likely to have positive US findings. This should allow the cost of medical and non-medical staff, equipment and materials to be reduced. As for our personal series, It. L. 28,000,000 was the estimated additional cost of performing US routinely in all the remaining (275) patients with suspected renal colic.

Comparison of ultrasound transmission velocity with computed metacarpal radiogrammetry and dual-photon absorptiometry

The aim of our study was to evaluate the validity of a quantitative US technique for measuring the bone density of the proximal phalanges of the nondominant hand compared with computed metacarpal radiogrammetry and dual-photon absorptiometry (DPA) of the lumbar spine. Mean US bone velocity (UBV) correlated with mean metacarpal cortical index (MCI), with mean metacarpal bone density (MBD) and with bone mineral density (BMD) of the lumbar spine, whereas it was correlated negatively with age and menopause duration. The average UBV was significantly higher in premenopausal women than in postmenopausal women, and higher in normal lumbar DPA patients than in reduced lumbar DPA patients. We conclude that the US evaluation of the nondominant hand proximal phalanges may be a new alternative way for measuring bone mass in screening of osteoporosis.

[The role of magnetic resonance imaging with a low-intensity field (0.2 T) in assessing expansive lesions of the hand and wrist]

The diagnostic capabilities of a small-size low-field (0.2-T) MR unit with a dedicated coil were investigated in the study of expansive lesions of the hand and wrist. Twenty-five patients suffering from the following diseases were examined: synovial cyst (6 patients), ganglion cyst (4), acute suppurative tenosynovitis (3), stenosing tenosynovitis (2), arteriovenous fistula (1), lipoma (1), fibrolipoma (2), chondroma (1), glomus tumor (1), fibromatosis palmaris (3), villonodular synovitis (1). Spin Echo (SE) and Gradient Echo (GE) scans were performed on all patients. The MR findings were compared with US, surgical and pathologic results. In synovial and ganglion cysts, acute suppurative and stenosing tenosynovitis, fibromatosis palmaris, fibrolipoma and lipoma, MRI showed typical patterns. In arteriovenous fistula, chondroma, glomus tumor and villonodular tenosynovitis, an accurate diagnosis could not be made: in these cases US failed to yield unquestionable results and the lesions could be diagnosed only at pathology. MRI yielded very accurate information as to lesion site and relationship with the surrounding structures; this kind of information, which is extremely important for the surgical approach, is not always provided by US. Low-field MRI can be considered a valuable diagnostic tool in the study of some expansive lesions of the hand and wrist. In other lesions this method can play a major role for both their characterization and the surgical approach.

Interleukin 1 beta, hand and foot bone mineral content and the development of joint erosions in rheumatoid arthritis

OBJECTIVE

To assess the relationship between plasma levels of the cytokine interleukin-1 beta (IL-1 beta) and the progression of rheumatoid arthritis (RA).

METHODS

Two subgroups of patients, one with persistently raised ESR (>/= 50 mm/hour, n = 16, group A) and one with persistently low ESR (</= 28 mm/hour), n = 18, group I) were chosen to represent stable extremes of inflammatory activity from a prospective study of 106 patients with active RA studied over one year in a single centre. The change from baseline in hand, foot and calcaneal bone mineral content measured by single photon absorptiometry and radiographic score of joint damage was measured over 12 months, together with plasma IL-1 beta and erythrocyte sedimentation rate.

RESULTS

Significant progression of joint damage occurred in both subgroups over one year (p < 0.0001, paired t test) though progression was significantly less in the subgroup with low ESR (p < 0.05, ANOVA). Hand and foot bone mineral content decreased by almost 10% in the subgroup with raised ESR (p < 0.005, paired t test). Stepwise linear regression analysis revealed significant independent relationships between radiographic progression over one year and plasma IL-1 beta and ESR (multiple R 0.674, F = 11.64, p < 0.0002). No such relationships were observed for changes in bone mineral content parameters.

CONCLUSIONS

Plasma IL-1 beta levels correlate weakly with progression of joint damage though not with loss of peripheral bone density in RA. A significant reduction in peripheral bone mineral content occurs over one year in patients with active RA with persistently raised ESR.

The risk of alcohol

We have reviewed 156 papers which provided sufficient information to relate individual alcohol consumption to risk for a variety of physical damage. Overall, there was evidence for a dose-response relationship between level of alcohol consumption and risk of harm for liver cirrhosis, cancers of the oropharynx, larynx, oesophagus, rectum (beer only), liver and breast, and blood pressure and stroke. An increased risk of cardiac arrhythmias, cardiomyopathy and sudden coronary death was associated with heavy drinking. There was evidence for a protective effect of alcohol consumption against risk of coronary heart disease, which could be achieved at consumption levels of less than 10 g alcohol a day. The mortality of non-drinkers was higher than that of moderate drinkers in some studies. Level of alcohol consumption and total mortality were dose-related when non-drinkers were excluded. The finding of a dose-relationship between alcohol and harm suggested causality. It was not possible to define individual risk for all harms at a given level of alcohol consumption because of variations in methodology, but some idea of the order of magnitude of the increased risk can be obtained from calculating trends of pooled log-odds ratios. At levels of alcohol consumption of more than 20-30 g a day, all individuals are likely to accumulate risk of harm. Current guidelines on upper limits of lower risk drinking in different countries (168-280 g of alcohol a week for men and 84-140 g a week for women) reflect levels at which the risk of total mortality is not greatly increased above one.

How willing are general practitioners to manage narcotic misuse?

In 1989 a self-administered questionnaire concerning current management of, attitudes to, and knowledge of, narcotic misuse was completed by 206 Inner London general practitioners. Results showed that whilst over three quarters were prepared to offer patients supportive interviews, few were willing to prescribe for them, most preferring to refer to specialist facilities. Only 33 respondents had received adequate training in the management of narcotic misuse, but over a quarter expressed an interest in small group training to improve their skills. These findings are discussed in relation to Department of Health guidelines concerning the management of narcotic misuse.

Alcohol and death certification: influencing current practice and attitudes

Forty housemen were sent a letter informing them of changes to the coroner's rules and emphasizing the importance of recording alcohol abuse. All relevant death certificates signed by the housemen over the next 3 months were selected for case note review to check details of the alcohol history taken and the consequent accuracy of the death certificate. A questionnaire was also sent to the housemen covering reasons for not recording alcohol abuse and knowledge of the coroner's rules. Comparison of the results with those from an earlier group of housemen who received no informatory letter suggest that minimal educational intervention can effect housemens' attitudes and practice.

Mad drivers: psychiatric illness and driving performance

Road traffic accidents are a leading cause of mortality and morbidity. It has been estimated that over 25% of drivers involved in accidents had impaired driving due to alcohol, drugs, illness or emotional distress. This paper reviews the association between road traffic accidents and psychiatric illness including the effects of alcohol, drugs and psychotropic medication.

Safe limits of drinking: general practitioners' views

A survey was carried out by questionnaire of general practitioners' views on what the safe upper limits of alcohol consumption are for health education for men and women. The results showed lower limits than those suggested by "alcohol experts" in a previous survey.