Efficacy and safety of shunt surgery in patients with idiopathic normal-pressure hydrocephalus: can we predict shunt response by preoperative magnetic resonance imaging (MRI)?

AIM

The aim of this study was to identify preoperative magnetic resonance imaging (MRI) findings that can predict the shunt responsiveness in idiopathic normal-pressure hydrocephalus (iNPH) patients and to investigate postoperative outcome and complications.

MATERIALS AND METHODS

A total of 192 patients with iNPH who underwent shunt at our hospital between 2000 and 2021 were included to investigate complications. Of these, after exclusion, 127 (1-month postoperative follow-up) and 77 (1-year postoperative follow-up) patients were evaluated. The preoperative MRI features (the presence of tightness of the high-convexity subarachnoid space, Sylvian fissure enlargement, Evans' index, and callosal angle) of the shunt-response and nonresponse groups were compared, and a systematic review was conducted to evaluate whether preoperative MRI findings could predict shunt response.

RESULTS

Postoperative complications within one month after surgery were observed in 6.8% (13/192), and the most common complication was hemorrhage. Changes in corpus callosum were observed in 4.2% (8/192). The shunt-response rates were 83.5% (106/127) in the 1-month follow-up group and 70.1% (54/77) in 1-year follow-up group. In the logistic regression analysis, only Evans' index measuring >0.4 had a significant negative relationship with shunt response at 1-month follow-up; however, no significant relationship was observed at 1-year follow-up. According to our systematic review, it is still controversial whether preoperative MRI findings could predict shunt response.

CONCLUSION

Evans' index measure of >0.4 had a significant relationship with the shunt response in the 1-month follow-up group. In systematic reviews, there is ongoing debate about whether preoperative MRI findings can accurately predict responses to shunt surgery. Postoperative corpus callosal change was observed in 4.2% of iNPH patients.

Improved diagnostic performance of susceptibility-weighted imaging with compressed sensing-sensitivity encoding and neuromelanin-sensitive MRI for Parkinson's disease and atypical Parkinsonism

AIM

To verify the diagnostic performance of the loss of nigrosome-1 on susceptibility-weighted imaging (SWI) with compressed sensing-sensitivity encoding (CS-SENSE) and neuromelanin on neuromelanin-sensitive (NM) magnetic resonance imaging (MRI) for the diagnosis of Parkinson's disease (PD) and atypical Parkinsonism.

MATERIALS AND METHODS

A total of 195 patients who underwent MRI between October 2019 and February 2020, including SWI, with or without CS-SENSE, and NM-MRI, were reviewed retrospectively. Two neuroradiologists assessed the loss of nigrosome-1 on SWI and neuromelanin on the NM-MRI. The result of N-3-fluoropropyl-2-beta-carbomethoxy-3-beta-(4-iodophenyl) nortropane positron-emission tomography (PET) was set as the reference standard.

RESULTS

When CS-SENSE was applied for nigrosome-1 imaging on SWI, the non-diagnostic scan rate was lowered significantly from 19.3% (17/88) to 5.6% (6/107; p=0.004). Diagnosis of PD and atypical Parkinsonism based on the loss of nigrosome-1 on SWI and based on NM-MRI showed good diagnostic value (area under the curve [AUC] 0.821, 95% confidence interval [CI] = 0.755-0.875: AUC 0.832, 95% CI = 0.771-0.882, respectively) with a substantial inter-reader agreement (κ = 0.791 and 0.681, respectively). Combined SWI and neuromelanin had a similar discriminatory ability (AUC 0.830, 95% CI = 0.770-0.880). Similarly, the diagnosis of PD was excellent.

CONCLUSIONS

CS-SENSE may add value to the diagnostic capability of nigrosome-1 on SWI to reduce the nondiagnostic scan rates. Furthermore, loss of nigrosome-1 on SWI or volume loss of neuromelanin on NM-MRI may be helpful for diagnosing PD.

Image findings of anti-neutrophil cytoplasmic antibody-associated vasculitis involving the skull base

AIM

To investigate computed tomography (CT) and magnetic resonance imaging (MRI) features of skull bases involving anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV).

MATERIALS AND METHODS

A retrospective review was undertaken to identify an institutional historical cohort of 17 patients with confirmed AAV who underwent CT or MRI and had skull base involvement between 2002 and 2021. Two radiologists reviewed the extent and features of the lesions, bone changes, and other MRI findings.

RESULTS

A total of 17 patients (12 men; mean age ± standard deviation, 46.5 ± 17.1 years) were selected. AAV presented as infiltrative lesions with involvement at various sites. Most cases involved the paranasal sinuses (PNS; 88%, 15/17), nasopharynx (88%, 15/17), pterygopalatine fossa (82%, 14/17), and parapharyngeal space (82%, 14/17), frequently accompanied by mucosal irregularity of the PNS and nasopharynx (71%, 12/17). Central skull base and temporal bone involvement were seen in 53% (9/17) and 38% (6/16) of cases, respectively. On T1-weighted imaging (WI) and T2WI MRI, all lesions (15/15) showed predominant signal iso-intensity to grey matter.

CONCLUSIONS

Although radiological findings of AAV are non-specific and skull base involvement is less common, AAV may be considered if infiltrative lesions predominantly involving the PNS, nasopharynx, pterygopalatine fossa, and parapharyngeal space with combined bone changes of skull base are seen.

Detection rate of MR myelography without intrathecal gadolinium in patients with newly diagnosed spontaneous intracranial hypotension

AIM

To evaluate the detection rate of magnetic resonance (MR) myelography without intrathecal gadolinium for cerebrospinal fluid (CSF) leakage in patients with newly diagnosed spontaneous intracranial hypotension (SIH) and to validate a published scoring system for predicting CSF leakage.

MATERIALS AND METHODS

This retrospective, observational, single-institution study included patients with newly diagnosed SIH between March 2015 and April 2021. Patients were included if they (a) had newly diagnosed SIH and (b) underwent initial brain MR imaging and preprocedural MR myelography with two- and three-dimensional turbo spin-echo sequences. Patients who underwent spine surgery or procedures including epidural injection and acupuncture were excluded. The detection rate was defined as the proportion of patients with a true-positive MR myelography result among all patients with confirmed CSF leakage. The interobserver agreement for the MR myelography results between two radiologists was analysed using weighted kappa statistics.

RESULTS

A total of 136 patients (mean age, 48 years; 70 women) with suspected SIH were included. Of these patients, 120 (88%, 120/136) were confirmed to have CSF leakage. Of the patients with confirmed CSF leakage, 90 (75%, 90/120) had epidural fluid collection. The detection rate of MR myelography for CSF leakage was 88% (105/120). The interobserver agreement between the two readers for detecting CSF leakage (κ = 0.76) or epidural fluid collection (κ = 0.76) on MR myelography was high. Among 24 patients with normal brain MR imaging results, 16 had CSF leakage (67%, 16/24).

CONCLUSIONS

Non-invasive MR myelography without intrathecal gadolinium should be considered to detect CSF leakage in patients with suspected SIH.

Carotid Plaque Composition Assessed by CT Predicts Subsequent Cardiovascular Events among Subjects with Carotid Stenosis

BACKGROUND AND PURPOSE

Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis.

MATERIALS AND METHODS

This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed.

RESULTS

During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04).

CONCLUSIONS

Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.

Prognostic Utility of Disproportionately Enlarged Subarachnoid Space Hydrocephalus in Idiopathic Normal Pressure Hydrocephalus Treated with Ventriculoperitoneal Shunt Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Disproportionately enlarged subarachnoid space hydrocephalus is a specific radiologic marker for idiopathic normal pressure hydrocephalus. However, controversy exists regarding the prognostic utility of disproportionately enlarged subarachnoid space hydrocephalus.

PURPOSE

Our aim was to evaluate the prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and its predictive utility regarding prognosis in patients treated with ventriculoperitoneal shunt surgery.

DATA SOURCES

We used MEDLINE and EMBASE databases.

STUDY SELECTION

We searched for studies that reported the prevalence or the diagnostic performance of disproportionately enlarged subarachnoid space hydrocephalus in predicting treatment response.

DATA ANALYSIS

The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was obtained. Pooled sensitivity, specificity, and area under the curve of disproportionately enlarged subarachnoid space hydrocephalus to predict treatment response were obtained. Subgroup and sensitivity analyses were performed to explain heterogeneity among the studies.

DATA SYNTHESIS

Ten articles with 812 patients were included. The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus was 44% (95% CI, 34%-54%). The pooled prevalence of disproportionately enlarged subarachnoid space hydrocephalus was higher in the studies using the second edition of the Japanese Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus compared with the studies using the international guidelines without statistical significance (52% versus 43%, P = .38). The pooled sensitivity and specificity of disproportionately enlarged subarachnoid space hydrocephalus for prediction of treatment response were 59% (95% CI, 38%-77%) and 66% (95% CI, 57%-74%), respectively, with an area under the curve of 0.67 (95% CI, 0.63-0.71).

LIMITATIONS

The lack of an established method for assessing disproportionately enlarged subarachnoid space hydrocephalus using brain MR imaging served as an important cause of the heterogeneity.

CONCLUSIONS

Our meta-analysis demonstrated a relatively low prevalence of disproportionately enlarged subarachnoid space hydrocephalus in idiopathic normal pressure hydrocephalus and a poor diagnostic performance for treatment response.

Development and Validation of a Deep Learning-Based Automatic Brain Segmentation and Classification Algorithm for Alzheimer Disease Using 3D T1-Weighted Volumetric Images

BACKGROUND AND PURPOSE

Limited evidence has suggested that a deep learning automatic brain segmentation and classification method, based on T1-weighted brain MR images, can predict Alzheimer disease. Our aim was to develop and validate a deep learning-based automatic brain segmentation and classification algorithm for the diagnosis of Alzheimer disease using 3D T1-weighted brain MR images.

MATERIALS AND METHODS

A deep learning-based algorithm was developed using a dataset of T1-weighted brain MR images in consecutive patients with Alzheimer disease and mild cognitive impairment. We developed a 2-step algorithm using a convolutional neural network to perform brain parcellation followed by 3 classifier techniques including XGBoost for disease prediction. All classification experiments were performed using 5-fold cross-validation. The diagnostic performance of the XGBoost method was compared with logistic regression and a linear Support Vector Machine by calculating their areas under the curve for differentiating Alzheimer disease from mild cognitive impairment and mild cognitive impairment from healthy controls.

RESULTS

In a total of 4 datasets, 1099, 212, 711, and 705 eligible patients were included. Compared with the linear Support Vector Machine and logistic regression, XGBoost significantly improved the prediction of Alzheimer disease (P < .001). In terms of differentiating Alzheimer disease from mild cognitive impairment, the 3 algorithms resulted in areas under the curve of 0.758-0.825. XGBoost had a sensitivity of 68% and a specificity of 70%. In terms of differentiating mild cognitive impairment from the healthy control group, the 3 algorithms resulted in areas under the curve of 0.668-0.870. XGBoost had a sensitivity of 79% and a specificity of 80%.

CONCLUSIONS

The deep learning-based automatic brain segmentation and classification algorithm allowed an accurate diagnosis of Alzheimer disease using T1-weighted brain MR images. The widespread availability of T1-weighted brain MR imaging suggests that this algorithm is a promising and widely applicable method for predicting Alzheimer disease.

Diagnostic Accuracy of MRI-Based Morphometric Parameters for Detecting Olfactory Nerve Dysfunction

BACKGROUND AND PURPOSE

Although olfactory dysfunction is a common cranial nerve disorder, there are no simple objective morphometric criteria to assess olfactory dysfunction. The aim of this study was to evaluate the diagnostic performance of MR imaging morphometric parameters for detecting olfactory dysfunction.

MATERIALS AND METHODS

This prospective study enrolled patients from those presenting with olfactory symptoms who underwent both an olfactory function test and MR imaging. Controls without olfactory dysfunction were recruited during the preoperative work-up for pituitary adenoma. Two independent neuroradiologists measured the olfactory bulb in 3D and assessed olfactory bulb concavity on MR imaging while blinded to the clinical data. Diagnostic performance was assessed using receiver operating characteristic curve analysis.

RESULTS

Sixty-four patients and 34 controls were enrolled. The patients were significantly older than the controls (mean age, 57.8 ± 11.9 years versus 47.1 ± 12.1 years; P < .001). Before age adjustment, the olfactory bulb height was the only olfactory bulb parameter showing a significant difference between patients and controls (1.6 ± 0.3 mm versus 2.0 ± 0.3 mm, P < .001). After age adjustment, all parameters and olfactory bulb concavity showed significant intergroup differences, with the olfactory bulb height having the highest area under the curve (0.85). Olfactory bulb height was confirmed to be the only significant parameter showing a difference in the detection of olfactory dysfunction in 22 pairs after matching for age and sex (area under the curve = 0.87, P < .001). Intraclass correlation coefficients revealed moderate-to-excellent degrees of inter- and intrareader agreement.

CONCLUSIONS

MR imaging morphometric analysis can differentiate patients with olfactory dysfunction, with the olfactory bulb height having the highest diagnostic performance for detecting olfactory dysfunction irrespective of age.

Diagnostic performance of MRI to detect metastatic cervical lymph nodes in patients with thyroid cancer: a systematic review and meta-analysis

AIM

To evaluate the diagnostic performance of magnetic resonance imaging (MRI) in the diagnosis of metastatic cervical lymph nodes.

MATERIALS AND METHODS

Ovid-MEDLINE and EMBASE databases were searched up until 12 June 2018. Eleven articles were included in the qualitative systematic review and nine of the 11 in the quantitative analysis. Two radiologists independently performed data extraction and methodological quality assessment using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A qualitative systematic review and quantitative analysis were performed, followed by a meta-regression analysis to determine factors causing heterogeneity.

RESULTS

The pooled sensitivity and specificity in the diagnosis of metastatic cervical lymph nodes were 80% (95% confidence interval [CI]: 68-88%) and 85% (95% CI: 63-95%), respectively. The sensitivity and false-positive rate (correlation coefficient, 0.655) showed a positive correlation due to a threshold effect, which was responsible for heterogeneity across the studies, as indicated by a Q-test (p<0.01) and Higgins I² statistic (sensitivity, I²=90.11%; specificity, I²=92.49%). In the meta-regression analysis, fat-suppressed imaging, and the analysis method were significant factors influencing the heterogeneity in diagnostic performance.

CONCLUSIONS

MRI shows moderate diagnostic performance in the diagnosis of metastatic lymph nodes in patients with thyroid cancer in the neck. MRI may be an optional or complementary imaging method to ultrasound or computed tomography (CT) in thyroid cancer patients.

CT and MRI Findings of Glomangiopericytoma in the Head and Neck: Case Series Study and Systematic Review

Glomangiopericytoma is a rare sinonasal mesenchymal tumor of borderline or low malignant potential. We reviewed the CT and MR imaging findings of head and neck glomangiopericytoma via a retrospective case series study and systematic review. Our study revealed that glomangiopericytoma is a well-defined lobulated avidly enhancing soft-tissue mass with erosive bony remodeling that is most commonly found in the sinonasal cavity. Typically, it is hyperintense on T2-weighted images with vascular signal voids, has a high mean ADC value, and a wash-in and washout pattern on dynamic contrast-enhanced MR imaging. Although the CT findings are nonspecific, typical MR imaging findings, including those on the ADC map and dynamic contrast-enhanced MR imaging, may be helpful for differentiating glomangiopericytomas from other hypervascular tumors in the head and neck.

The Diagnostic Value of Diffusion-Weighted Imaging in Differentiating Metastatic Lymph Nodes of Head and Neck Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis

BACKGROUND

Accurate lymph node staging is crucial for proper treatment planning for metastasis in patients with head and neck squamous cell carcinoma.

PURPOSE

Our aim was to evaluate the diagnostic performance of DWI for differentiating metastatic cervical lymph nodes from benign cervical lymph nodes in patients with head and neck squamous cell carcinoma and to identify optimal cutoff values for ADC.

DATA SOURCES

A computerized literature search was performed to identify relevant original articles in Ovid MEDLINE and EMBASE.

STUDY SELECTION

Studies evaluating the diagnostic performance of DWI for differentiating metastatic cervical lymph nodes from benign cervical lymph nodes were selected.

DATA ANALYSIS

Diagnostic meta-analysis was conducted with a bivariate random-effects model, and a hierarchical summary receiver operating characteristic curve was obtained. Meta-regression was also performed.

DATA SYNTHESIS

Nine studies with 337 patients were included. In all studies, ADC values derived from metastatic lymph nodes were significantly lower than ADC values derived from benign lymph nodes. The median ADC cutoff value was 0.965 × 10^-3 mm²/s. The pooled sensitivity and specificity for the diagnostic performance of DWI in differentiating metastatic lymph nodes from benign lymph nodes were 90% (95% CI, 84%-94%) and 88% (95% CI, 80%-93%), respectively. In the meta-regression, sensitivity was significantly higher in the studies using a 3-mm slice thickness (93% [95% CI, 88%-98%]) than in studies using a slice thickness of >3 mm (86% [95% CI, 77%-95%], P < .01).

LIMITATIONS

A small number of studies were included in our meta-analysis.

CONCLUSIONS

DWI demonstrated high diagnostic performance for differentiating metastatic lymph nodes from benign lymph nodes in patients with head and neck squamous cell carcinoma, and the median ADC cutoff value was 0.965 × 10^-3 mm²/s. A 3-mm DWI slice thickness can provide a slight improvement in sensitivity.

MRI Findings in Tumefactive Demyelinating Lesions: A Systematic Review and Meta-Analysis

BACKGROUND

Accurate diagnosis of tumefactive demyelinating lesions is clinically important to avoid unnecessary invasive biopsy or inappropriate treatment.

PURPOSE

We aimed to evaluate conventional and advanced MR imaging findings of tumefactive demyelinating lesions and determine the diagnostic performance of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor.

DATA SOURCES

A systematic search of Ovid MEDLINE and EMBASE up to December 6, 2017, was conducted.

STUDY SELECTION

Original articles describing MR imaging findings in patients with tumefactive demyelinating lesions were selected.

DATA ANALYSIS

The pooled incidences of conventional MR imaging findings of tumefactive demyelinating lesions were obtained with the DerSimonian and Liard random-effects model. The pooled sensitivity and specificity of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor were obtained using the bivariate random-effects model.

DATA SYNTHESIS

Nineteen eligible studies with 476 patients with tumefactive demyelinating lesions were included. The pooled incidence of open ring or incomplete rim enhancement was 35% (95% CI, 24%-47%), which was significantly higher than the incidence of closed ring or complete rim enhancement (18% [95% CI, 11%-29%]; P = .0281). The pooled incidences of T2 hypointense rim, absent or mild mass effect, and absent or mild perilesional edema were 48%, 67%, and 57%, respectively. On advanced MR imaging, tumefactive demyelinating lesions showed a high apparent diffusion coefficient, peripheral restricted diffusion, and low cerebral blood volume. The pooled sensitivity and specificity of MR imaging for differentiating tumefactive demyelinating lesions from primary brain tumor were 89% (95% CI, 82%-93%) and 94% (95% CI, 89%-97%), respectively.

LIMITATIONS

Seventeen of 19 studies were retrospective studies.

CONCLUSIONS

Conventional MR imaging findings may help differentiate tumefactive demyelinating lesions from primary brain tumor, though further study is needed to determine the added value of advanced MR imaging.

Clinically Relevant Imaging Features for MGMT Promoter Methylation in Multiple Glioblastoma Studies: A Systematic Review and Meta-Analysis

BACKGROUND

O6-methylguanine methyltransferase (MGMT) promoter methylation status has been reported as a prognostic biomarker in clinical trials.

PURPOSE

Our aim was to systematically evaluate imaging features of MGMT promoter methylated glioblastoma and to determine the diagnostic performance of MR imaging for prediction of MGMT promoter methylation in patients with newly diagnosed glioblastoma.

DATA SOURCES

A computerized search of Ovid MEDLINE and EMBASE up to February 27, 2018, was conducted.

STUDY SELECTION

We selected studies evaluating imaging features of MGMT promoter methylated glioblastoma and the diagnostic performance of MR imaging for prediction of MGMT promoter methylation.

DATA ANALYSIS

Pooled estimates of sensitivity and specificity were calculated using a hierarchic logistic regression model. Meta-regression and sensitivity analysis were performed.

DATA SYNTHESIS

Twenty-two articles including 2199 patients were included. MGMT promoter methylated glioblastoma is likely to show less edema, high ADC, and low perfusion. Ten articles including 753 patients were included in the meta-analysis. The summary sensitivity was 79% (95% CI, 72%-85%), and the summary specificity was 78% (95% CI, 71%-84%). In the meta-regression, MGMT promoter methylation and mean age were associated with heterogeneity. Sensitivity analysis excluding 1 study resolved the heterogeneity.

LIMITATIONS

Included studies used a variety of different MR imaging techniques to predict MGMT promoter methylation.

CONCLUSIONS

MGMT promotor methylated glioblastoma is likely to show less aggressive imaging features than MGMT promotor unmethylated glioblastoma. Despite the variety of different MR imaging techniques used, MR imaging in patients with newly diagnosed glioblastoma was shown to have the potential to predict MGMT promoter methylation noninvasively.

Diffusion-Weighted Imaging and Diffusion Tensor Imaging for Differentiating High-Grade Glioma from Solitary Brain Metastasis: A Systematic Review and Meta-Analysis

BACKGROUND

Accurate diagnosis of high-grade glioma and solitary brain metastasis is clinically important because it affects the patient's outcome and alters patient management.

PURPOSE

To evaluate the diagnostic performance of DWI and DTI for differentiating high-grade glioma from solitary brain metastasis.

DATA SOURCES

A literature search of Ovid MEDLINE and EMBASE was conducted up to November 10, 2017.

STUDY SELECTION

Studies evaluating the diagnostic performance of DWI and DTI for differentiating high-grade glioma from solitary brain metastasis were selected.

DATA ANALYSIS

Summary sensitivity and specificity were established by hierarchic logistic regression modeling. Multiple subgroup analyses were also performed.

DATA SYNTHESIS

Fourteen studies with 1143 patients were included. The individual sensitivities and specificities of the 14 included studies showed a wide variation, ranging from 46.2% to 96.0% for sensitivity and 40.0% to 100.0% for specificity. The pooled sensitivity of both DWI and DTI was 79.8% (95% CI, 70.9%-86.4%), and the pooled specificity was 80.9% (95% CI, 75.1%-85.5%). The area under the hierarchical summary receiver operating characteristic curve was 0.87 (95% CI, 0.84-0.89). The multiple subgroup analyses also demonstrated similar diagnostic performances (sensitivities of 76.8%-84.7% and specificities of 79.7%-84.0%). There was some level of heterogeneity across the included studies (I² = 36%); however, it did not reach a level of concern.

LIMITATIONS

The included studies used various DWI and DTI parameters.

CONCLUSIONS

DWI and DTI demonstrated a moderate diagnostic performance for differentiation of high-grade glioma from solitary brain metastasis.

Polyamine patterns in plasma of patients with systemic lupus erythematosus and fever

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease with various clinical manifestations and serologic markers. In this study, we analyzed nine polyamine (PA) profiles of plasma from patients with SLE and healthy controls (HCs), and the relationship between the PA profiles and disease activity. PA alterations in plasma of 44 patients with SLE and fever were investigated using gas chromatography mass spectrometry (GC-MS) in selected ion monitoring mode using N-ethoxycarbonyl/ N-pentafluoropropionyl derivatives, and compared with those of 43 HCs. Patients with SLE and HCs showed differences in five of nine PA profiles. Among five changed PA levels, four PAs, namely N¹-acetylcadaverine, spermidine, N¹-acetylspermidine, and spermine, were dramatically decreased. However, the level of cadaverine was increased in patients with SLE. In the partial correlation with PA profiles and disease activity markers of SLE, several disease activity markers and nutritional markers were correlated with cadaverine, spermidine, and N ⁸-acetylspermidine. Thus, our results provide a comprehensive understanding of the relationship between PA metabolomics and disease activity markers in patients with SLE.

The Role of Core Needle Biopsy for Thyroid Nodules with Initially Indeterminate Results on Previous Fine-Needle Aspiration: A Systematic Review and Meta-Analysis

BACKGROUND

Sonography-guided fine-needle aspiration leads to relatively frequent cases of indeterminate cytology for the diagnosis of thyroid nodules.

PURPOSE

Our aim was to evaluate the efficacy and safety of core needle biopsy for the examination of thyroid nodules with initially indeterminate results on fine-needle aspiration.

DATA SOURCES

A computerized search of the MEDLINE and Embase databases was performed to identify relevant original articles.

STUDY SELECTION

Studies investigating the use of core needle biopsy for thyroid nodules with initially indeterminate results on previous fine-needle aspiration were eligible for inclusion.

DATA ANALYSIS

The pooled proportions for nondiagnostic results, inconclusive results, malignancy on core needle biopsy, the ability of core needle biopsy to diagnose malignancy, and the related complications of the procedure were analyzed.

DATA SYNTHESIS

The meta-analytic pooling was based on a random-effects model. Nine eligible studies, involving 2240 patients with 2245 thyroid nodules, were included. The pooled proportion for nondiagnostic results was 1.8% (95% CI, 0.4%-3.2%), and the pooled proportion for inconclusive results was 25.1% (95% CI, 15.4%-34.9%). The pooled proportion for malignancy was 18.9% (95% CI, 8.4%-29.5%). With regard to the diagnostic performance for malignancy, the sensitivity of core needle biopsy varied, ranging from 44.7% to 85.0%, but the specificity was 100% in all cases. No major complications of core needle biopsy were observed.

LIMITATIONS

The relatively small number of included studies and retrospective nature were limitations.

CONCLUSIONS

Core needle biopsy has low nondiagnostic result rates and high specificity for the diagnosis of malignancy. It is a safe diagnostic technique with a higher diagnostic yield, especially when molecular testing is not available or fine-needle aspiration did not yield enough cells for molecular testing.

Performance of CT in the Preoperative Diagnosis of Cervical Lymph Node Metastasis in Patients with Papillary Thyroid Cancer: A Systematic Review and Meta-Analysis

BACKGROUND AND PURPOSE

Ultrasound has become widely accepted as the first imaging technique used for the assessment of cervical lymph node metastasis in patients with papillary thyroid cancer. In this systematic review and meta-analysis, we evaluate the performance of CT for the preoperative diagnosis of cervical lymph node metastasis in patients with papillary thyroid cancer compared with ultrasound.

MATERIALS AND METHODS

Ovid-MEDLINE and EMBASE data bases were searched for studies regarding the use of CT to diagnose cervical lymph node metastasis. The diagnostic performance of CT, ultrasound, and combined CT/ultrasound was assessed by using level-by-level and patient-based analyses. We also performed meta-analyses on the basis of the central and lateral neck levels.

RESULTS

Nine eligible studies, including a total sample size of 1691 patients, were included. CT showed a summary sensitivity of 62% (95% CI, 52%-70%) and specificity of 87% (95% CI, 80%-92%) for diagnosing cervical lymph node metastasis when using level-by-level analysis. There was a positive correlation between the sensitivity and the false-positive rate (correlation coefficient, 0.807) because of the threshold effect. The summary sensitivity of combined CT/ultrasound (69%; 95% CI, 61%-77%) was significantly higher than ultrasound (51%; 95% CI, 42%-60%), though the summary specificity did not differ.

CONCLUSIONS

The diagnostic performances of CT and ultrasound are similar, though CT and ultrasound combined are superior to ultrasound only. CT may be used as a complementary diagnostic method in addition to ultrasound for diagnosing cervical lymph node metastasis in patients with papillary thyroid cancer.

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam-based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up

OBJECTIVE

To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)-based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

METHODS

A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan- Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child-Pugh classification) were analysed by univariate logistic regression.

RESULTS

HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21-21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83-66.29) during 10 sessions and 68.0% (95% CI, 67.62-88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors.

CONCLUSION

In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE.

ADVANCES IN KNOWLEDGE

In patients who underwent three or more sessions of cisplatin and Gelfoam-based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.

A phase I/IIa study on intra-articular injection of holmium-166-chitosan complex for the treatment of knee synovitis of rheumatoid arthritis

Previous animal studies have established that the intra-articular injection of holmium-166-chitosan complex (DW-166HC) causes effective necrosis of the inflamed synovium with litle leakage of radioactivity from the injected joint. Based on these findings, we conducted a phase I/IIa study to examine the biodistribution of DW-166HC and to assess the safety of DW-166HC for the treatment of knee synovitis in patients with rheumatoid arthritis (RA). A total of 16 patients [1 man, 15 women; median age 49 (range 36-65) years] who had RA knee synovitis refractory to disease-modifying anti-rheumatic drug treatments of > 3 months' duration were randomly assigned to three treatment groups with different radiation doses of DW-166HC: 370 MBq (n = 6), 555 MBq (n = 5) and 740 MBq (n = 5). In each treatment group, blood and urine radioactivity were analysed by beta counter and biodistribution of the injected DW-166HC was evaluated using a gamma scan camera. Clinical assessment was done according to three variables (evaluation method): knee joint pain (visual analogue scale), range of motion (goniometry) and joint swelling (circumference of knee joint). The duration of follow-up observation was 3 months. Following the intra-articular injection of DW-166HC, the blood radioactivity was little changed from the baseline measurement and the accumulated radioactivity excreted in urine was minimal. Gamma scan study indicated that most of the injected radiochemical was localized within the injected joint cavity, and the extra-articular leakage was negligible at 24 h after the injection: brain, 0.3%; lung, 0.6%; abdomen, 0.7%; and pelvis, 0.8%. Major adverse events were transient post-injection knee joint pain and swelling. These results suggest that DW-166HC might be a safe agent for radiation synovectomy, particularly for the treatment of knee synovitis of RA, and further trials in a larger patient population are warranted to evaluate the therapeutic efficacy of DW-166HC.

Prediction of pseudoprogression in patients with glioblastomas using the initial and final area under the curves ratio derived from dynamic contrast-enhanced T1-weighted perfusion MR imaging

BACKGROUND AND PURPOSE

Dynamic contrast-enhanced T1-weighted perfusion MR imaging is much less susceptible to artifacts, and its high spatial resolution allows accurate characterization of the vascular microenvironment of the lesion. The purpose of this study was to test the predictive value of the initial and final area under the time signal-intensity curves ratio derived from dynamic contrast-enhanced perfusion MR imaging to differentiate pseudoprogression from early tumor progression in patients with glioblastomas.

MATERIALS AND METHODS

Seventy-nine consecutive patients who showed new or enlarged, contrast-enhancing lesions within the radiation field after concurrent chemoradiotherapy were assessed by use of conventional and dynamic contrast-enhanced perfusion MR imaging. The bimodal histogram parameters of the area under the time signal-intensity curves ratio, which included the mean area under the time signal-intensity curves ratio at a higher curve (mAUCRH), 3 cumulative histogram parameters (AUCR50, AUCR75, and AUCR90), and the area under the time signal-intensity curves ratio at mode (AUCRmode), were calculated and correlated with the final pathologic or clinical diagnosis. The best predictor for differentiation of pseudoprogression from early tumor progression was determined by receiver operating characteristic curve analyses.

RESULTS

Seventy-nine study patients were subsequently classified as having pseudoprogression (n=37, 46.8%) or early tumor progression (n=42, 53.2%). There were statistically significant differences of mAUCRH, AUCR50, AUCR75, AUCR90, and AUCRmode between the 2 groups (P < .0001, each). Receiver operating characteristic curve analyses showed the mAUCRH to be the best single predictor of pseudoprogression, with a sensitivity of 90.1% and a specificity of 82.9%. AUCR50 was found to be the most specific predictor of pseudoprogression, with a sensitivity of 87.2% and a specificity of 83.1%.

CONCLUSIONS

A bimodal histogram analysis of the area under the time signal-intensity curves ratio derived from dynamic contrast-enhanced perfusion MR imaging can be a potential, noninvasive imaging biomarker for monitoring early treatment response in patients with glioblastomas.

Histogram analysis of intravoxel incoherent motion for differentiating recurrent tumor from treatment effect in patients with glioblastoma: initial clinical experience

BACKGROUND AND PURPOSE

Intravoxel incoherent motion can simultaneously measure diffusion and perfusion characteristics. Our aim was to determine whether the perfusion and diffusion parameters derived from intravoxel incoherent motion could act as imaging biomarkers for distinguishing recurrent tumor from treatment effect in patients with glioblastoma.

MATERIALS AND METHODS

Fifty-one patients with pathologically confirmed recurrent tumor (n = 31) or treatment effect (n = 20) were assessed by means of intravoxel incoherent motion MR imaging. The histogram cutoffs of the 90th percentiles for perfusion and normalized CBV and the 10th percentiles for diffusion and ADC were calculated and correlated with the final pathology results. A leave-one-out cross-validation was used to evaluate the diagnostic performance of our classifiers.

RESULTS

The mean 90th percentile for perfusion was significantly higher in the recurrent tumor group (0.084 ± 0.020) than in the treatment effect group (0.040 ± 0.010) (P < .001). The 90th percentile for perfusion provided a smaller number of patients within an overlap zone in which misclassifications can occur, compared with the 90th percentile for normalized CBV. The mean 10th percentile for diffusion was significantly lower in the recurrent tumor group than in the treatment effect group (P = .006). Receiver operating characteristic curve analyses showed the 90th percentile for perfusion to be a significant predictor for differentiation, with a sensitivity of 87.1% and a specificity of 95.0%. There was a significant positive correlation between the 90th percentiles for perfusion and normalized CBV (r = 0.674; P < .001).

CONCLUSIONS

A histogram analysis of intravoxel incoherent motion parameters can be used as a noninvasive imaging biomarker for differentiating recurrent tumor from treatment effect in patients with glioblastoma.

Association of TNF-alpha promoter polymorphisms with aspirin-induced urticaria

OBJECTIVE

Although the pathogenesis of aspirin-induced urticaria (AIU) is not fully understood, mast cell activation has been noted in patients with AIU. Tumour necrosis factor (TNF)-alpha, a potent pro-inflammatory cytokine, is released by human skin mast cells and other inflammatory cells in patients with urticaria. To investigate the role of TNF-alpha promoter polymorphisms in the development of AIU, we performed an association study of TNF-alpha promoter polymorphisms with AIU phenotype.

METHODS

Two hundred thirty-nine patients with AIU consisting of 120 patients with aspirin intolerant chronic urticaria (AICU) and 119 with aspirin-intolerant acute urticaria (AIAU), and 524 normal controls were enrolled. AIU was confirmed by oral aspirin challenge test. Five SNPs in the TNF-alpha gene (-1031T>C, -863C>A, -857C>T, -308G>A, -238G>A) were genotyped by a single-base extension method. Haplotype analyses were done.

RESULTS

The genotype frequencies of TNF-1031T>C and TNF-863C>A were significantly higher in the AIU patients than in the normal controls in both co-dominant (P = 0.014, P = 0.007) and dominant (P = 0.007, P = 0.004) models. The frequency of TNF-ht2[CACGG] containing a genotype in the AIU group was significantly higher in the normal controls with both co-dominant (P = 0.004, Pc = 0.02) and dominant models (P = 0.002, Pc = 0.01).

CONCLUSIONS

These findings suggest that the two promoter polymorphisms of TNF-alpha at -1031T>C and -863C>A may contribute to the development of AIU.

Specific immunoglobulin E for staphylococcal enterotoxins in nasal polyps from patients with aspirin-intolerant asthma

BACKGROUND

Nasal polyps infiltrated with eosinophils are commonly found in chronic asthmatic patients, more frequently in those with aspirin-intolerant asthma (AIA) than aspirin-tolerant asthma (ATA). Some studies have suggested a contribution of superantigens derived from Staphylococcus sp to nasal polyposis and eosinophilia, but their relative importance in AIA and ATA subjects is unknown.

OBJECTIVE

We investigated whether local production of specific IgE to staphylococcal enterotoxins A and B (SEA and SEB) and relationships with markers of eosinophilic inflammation differ in the nasal polyps of AIA and ATA subjects.

METHODS

Fifteen AIA subjects with positive responses to lysine-aspirin bronchoprovocation and 15 ATA subjects underwent polypectomy. Immunoassays were used to quantify eosinophil cationic protein (ECP), IL-5, mast cell tryptase, soluble IL-2 receptors (sIL-2R), total IgE, and specific IgE for SEA and SEB.

RESULTS

ECP levels in nasal polyp homogenates were higher in AIA subjects than in ATA subjects (P < 0.02), with no significant differences in tryptase, IL-5 or sIL-2R. Total IgE, and specific IgE to both SEA and SEB, were detectable in some nasal polyps from both subject groups, but median levels were markedly higher in AIA subjects than in ATA subjects (P = 0.04, 0.01, 0.05, respectively). Levels of specific IgE to SEA and SEB correlated significantly with levels of ECP and IL-5, but not those of tryptase or sIL-2R.

CONCLUSION

These findings suggest that staphylococcal superantigens may drive local eosinophilic inflammation in nasal polyp tissue, and that this is exacerbated in subjects with AIA.

Gallbladder carcinoma and chronic cholecystitis: differentiation with two-phase spiral CT

The objective of the present study was to determine whether an analysis of two-phase spiral computed tomographic (CT) features provides a sound basis for the differential diagnosis between gallbladder carcinoma and chronic cholecystitis. Eighty-two patients, 35 with gallbladder carcinoma and 47 with chronic cholecystitis, underwent two-phase spiral CT. We reviewed the two-phase spiral CT features of thickness and enhancement pattern of the gallbladder wall seen during the arterial and venous phases. Mean wall thicknesses were 12.6 mm in the gallbladder carcinoma group and 6.9 mm in the chronic cholecystitis group. The common enhancement patterns seen in gallbladder carcinoma were (a) a highly enhanced thick inner wall layer during the arterial phase that showed isoattenuation with the adjacent hepatic parenchyma during the venous phase (16 of 35, 45.7%) and (b) a highly enhanced thick inner wall layer during both phases (eight of 35, 22.9%). The most common enhancement pattern of chronic cholecystitis was isoattenuation of the thin inner wall layer during both phases (42 of 47, 89.4%). In conclusion, awareness of the wall thickening and enhancement patterns in gallbladder carcinoma and chronic cholecystitis on two-phase spiral CT appears to be valuable in differentiating these two different disease entities.

The effects of anti-idiotypic antibody on antibody production and apoptosis of anti-dsDNA antibody producing cells

OBJECTIVE

Systemic lupus erythematosus is an autoimmune disease characterized by the production of anti-dsDNA antibody. Because the titer of anti-dsDNA antibody is correlated with disease severity, especially in lupus nephritis, controlling anti-dsDNA antibody production is important in the treatment of SLE. There are many regulatory mechanisms of autoantibody production; one of these is the interaction between idiotype and anti-idiotype antibody (anti-Id). The purpose of the present study was to assess the effect of anti-Id on anti-dsDNA antibody production and apoptosis and to study the mechanism of anti-Id induced apoptosis.

METHODS

After anti-dsDNA antibody producing hybridomas were treated with anti-Id, we checked the amount of anti-dsDNA antibody production, the rate of transcription, cellular proliferation, and apoptosis. Also, after treatment with anti-oxidant (N-acetyl-Lcysteine), phorbol esters with calcium ionophore and corticosteroids, we compared their effect on apoptosis with anti-Id.

RESULTS

Two types of anti-dsDNA antibody producing hybridomas (G1-2, gamma and kappa chains; M2-10, mu and kappa chains) were treated with anti-Id and it was found that: (1) the amount of anti-dsDNA antibody production decreased; (2) the rate of transcription and cellular proliferation did not decrease; and (3) the level of apoptosis increased. The two cells expressed Fas and Fas-ligand, and the Fas of G1-2 was functional but that of M2-10 was not. The treatment of these cells with anti-Id resulted in no change in Fas-ligand and Bax expression, but the expression of Bcl-2 was decreased. In addition, treatment with antioxidant (N-acetyl-L-cysteine) inhibited anti-Id-induced apoptosis in G1-2 and M2-10. Phorbol esters with calcium ionophore also inhibited anti-Id induced apoptosis in M2-10. Corticosteroids induced apoptosis in both cells and showed similar results with anti-Id induced apoptosis.

CONCLUSION

The anti-Id suppressed the production of anti-dsDNA antibody in two cells by inducing apoptosis, as did prednisolone. Furthermore, Bcl-2, oxygen-free radicals and protein kinase C might be involved in the induction of apoptosis by anti-Id.

Evaluation of stress patterns generated by reduction forceps within a photoelastic mandibular model

INTRODUCTION

Little attention has been paid to the mechanical effects of fracture reduction forceps.

AIM

This study aims to evaluate the stress patterns within the fractured mandible generated by reduction forceps.

MATERIAL AND METHODS

Thirty-six mandibular models were fabricated using a photoelastic resin. Each of the three sets of mandibular models was osteotomized according to one of three different fracture types. After reducing the cut segments, reduction forceps were placed into different engagement holes to compress the segments. Photoelastic stress analysis was used to visualize the stress patterns within the fractured mandibular models as generated by the reduction forceps.

RESULTS

In the case of symphyseal or parasymphyseal fractures, an optimum distribution of stresses over the fracture site was achieved when placing the reduction forceps more than 12mm away from either side of the fracture line, between the midway level of the mandibular height (bisecting the mandible) and 5mm below this level. In the case of body fractures, optimum stress distribution was achieved when the reduction forceps were placed more than 16mm from the fracture line at the midway level.

CONCLUSION

Correct use of the reduction forceps helps to provide a precise three-dimensional reduction for mandibular fractures.

An effective technique for open reduction of mandibular angle fractures using new reduction forceps: technical innovations

We demonstrate a new technique that is useful for precompressing and holding mandibular angle fractures by means of new reduction forceps. The forceps were designed for application in the mandibular angle area via a transoral approach.

Chronic hepatitis: in vivo proton MR spectroscopic evaluation of the liver and correlation with histopathologic findings

PURPOSE

To correlate the in vivo hydrogen 1 ((1)H) magnetic resonance (MR) spectroscopic features of the chronic hepatitis-involved liver with the histopathologic stages of fibrosis.

MATERIALS AND METHODS

Seventy-five patients with chronic hepatitis were examined with (1)H MR spectroscopy, which was performed in the right hepatic lobe. The peak areas of glutamine and glutamate complex (Glx), phosphomonoesters (PME), glycogen and glucose complex (Glyu), and lipid were measured on the liver spectra. The histopathologic features were correlated with the in vivo (1)H MR spectroscopic findings at each stage of chronic hepatitis. Fifteen healthy volunteers also were included as a control group.

RESULTS

(1)H MR spectroscopy depicted Glx, PME, Glyu, and lipid in all livers. In the normal livers, the calculated mean (+/- SD) relative metabolite-to-lipid ratios of Glx, PME, and Glyu were 0.14 +/- 0.04, 0.03 +/- 0.01, and 0.21 +/- 0.04, respectively. The mean value of each metabolite-to-lipid ratio was significantly different between all stages of chronic hepatitis, and with the exception of the mean ratio at the interval between stages 0 and 1 (P > .05), the mean value increased significantly with increasing stage (P < .05). A pronounced peak was demonstrated at 3.9-4.1 ppm at (1)H MR spectroscopy of all stages of chronic hepatitis except stage 0.

CONCLUSION

The increased Glx, PME, and Glyu levels relative to the lipid content with chronic hepatitis indicated the severity of fibrosis and thus were concordant with the histopathologic stages. In vivo (1)H MR spectroscopy might be a substitute for liver biopsy in the diagnosis and staging of chronic hepatitis.

Oligoclonal B lymphocyte expansion in the synovium of a patient with Behçet's disease

OBJECTIVE

Plasma cell infiltration is observed in recurrent arthritis associated with Behçet's disease (BD). The immune mechanism underlying B lymphocyte proliferation in the synovium is unclear. One hypothesis involves nonspecific polyclonal activation and another involves antigen-driven activation. The present study was undertaken to test both hypotheses and identify immunoglobulin genes that are clonally expanded in the synovium.

METHODS

Peripheral blood lymphocytes (PBL) and synovial cells from a patient with BD and PBL from a healthy control subject were obtained. Complementarity-determining region 3 (CDR3) fingerprinting analysis and nucleotide sequence analysis of Ig transcripts derived from clonally expanded B lymphocytes were performed in parallel.

RESULTS

Of 44 mu heavy chain clones of the VH4 family identified in the synovial tissue from the BD patient, 8 clones showed identical nucleotide sequences, and therefore, 18.2% were clonally expanded. For y heavy chain, 4 of 50 clones of the VH3 family showed nearly identical sequences; therefore, 4-8% were clonally expanded. The kappa light chain did not show a dominant band, but a clone with a 12-amino acid CDR3 showed 3% clonal expansion. Somatic mutations were frequently observed, with a high ratio of replacement to silent mutations in the CDRs compared with the framework regions. Three Ig genes expressed in the clonally expanded B lymphocytes were derived from germline gene segments reported to be involved in the production of autoantibodies.

CONCLUSION

These results support the hypothesis that antigen-driven clonal B lymphocyte proliferation occurs in the synovium in BD. Immunoglobulin transcripts clonally expanded in the synovium were identified.

Risk factors for infection and role of C-reactive protein in Korean patients with systemic lupus erythematosus

To evaluate risk factors for infection and the role of C-reactive protein (CRP) in the diagnosis of infection, a retrospective case control study was performed among Korean systemic lupus erythematosus patients. Of 120 proven infections, 31 episodes (25.8%) occurred in patients taking no corticosteroids (CS). The risk of infection was lower in patients taking low-dose CS (< 300 mg prednisolone/month) than no CS (odds ratio (OR) 0.36). In patients receiving high-dose CS (> 1000 mg prednisolone/month), however, the risk increased (OR 2.9). In patients taking no CS, disease activity manifested as increased SLEDAI, anemia and active urinary sediment, was associated with infection. The CRP was higher in the patients with infection than controls and the CRP levels over 50 mg/l were observed only in infection. These results suggest that CS have a bimodal influence on infection depending on dose. Disease activity is an important risk factor for infection in patients taking no CS. Finally, CRP levels greater than 50 mg/l suggest the presence of infection.

Proliferating trichilemmal tumors: CT and MR imaging findings in two cases, one with malignant transformation

We report the imaging findings in two patients with proliferating trichilemmal tumors. In the first patient, the tumor arose on the lower lip, a very unusual location for this type of tumor, and showed malignant transformation with metastasis to a regional lymph node. It was seen as a poorly marginated soft-tissue mass with isointense signal on T1-weighted MR images and hyperintense signal on T2-weighted images. Large areas of high signal intensity caused by necrosis were also found within the tumor on T2-weighted images. After i.v. administration of contrast material, the mass showed significant enhancement, with considerable portions remaining unenhanced. In the second patient, the tumor originated from a preexisting trichilemmal cyst and occurred in the hair-bearing area of the posterior part of the neck. CT scans showed a well-encapsulated cystic mass that contained multiple speckled calcifications in a wall of variable thickness. There were several foci of smooth soft-tissue elevations from the inner wall of the mass, which corresponded histologically to proliferating portions of trichilemmal cyst.

Aggressive epithelial odontogenic ghost cell tumor in the mandible: CT and MR imaging findings

We report a case of aggressive epithelial odontogenic ghost cell tumor arising from the mandible in a 32-year-old man. On CT and MR studies, the tumor was seen as a large, heterogeneous soft-tissue mass that caused marked destruction of the mandible and invaded the mouth floor and tongue base. The tumor displayed a variety of densities and signal intensities on CT and MR images, which correlated well with the degree of cellularity of epithelial islands, abundance of ghost cells and eosinophilic materials, calcification, and cystic areas on histologic sections. Owing to the unpredictable biological behavior of this type of tumor, careful, long-term follow-up is highly recommended.

Helical CT angiography and three-dimensional reconstruction of total anomalous pulmonary venous connections in neonates and infants

OBJECTIVE

The objective of this study was to investigate the usefulness of helical CT angiography in the evaluation of total anomalous pulmonary venous connections.

MATERIALS AND METHODS

Fourteen patients with total anomalous pulmonary venous connections underwent helical CT angiography and subsequent three-dimensional (3D) reconstruction. They ranged in age from 3 days to 8 months (median age, 2.3 months) and in weight from 2.3 to 7.1 kg (median weight, 4.3 kg). The types of total anomalous pulmonary venous connections and the number of pulmonary veins were evaluated on axial and 3D images. Qualitative evaluations were performed for extent of pulmonary vascular enhancement and contrast- or motion-induced artifacts.

RESULTS

In all patients, helical CT angiography correctly depicted total anomalous pulmonary venous connections. Seven cases were the supracardiac type, four cases were the cardiac type, one case was the infracardiac type, and two cases were the mixed type. The detection rate of the pulmonary vein in 3D reconstruction images (95-98%) was slightly lower than that of the pulmonary vein in the axial images (100%), but the difference between axial and 3D reconstruction images was not statistically significant (p > 0.1). No statistically significant differences were noted among 3D reconstruction images in the detection rates of the pulmonary vein (p > 0.1). The extent of contrast enhancement of the pulmonary vein was good or excellent in all patients. In five patients, there were contrast-induced artifacts that made some surrounding vascular distortion but did not interfere with the pulmonary vein analysis, except in one patient. Motion-induced artifacts were observed in nine patients. One of them had an obstacle in pulmonary vein analysis.

CONCLUSION

The combination of axial and 3D images in helical CT angiography is helpful in the assessment of a total anomalous pulmonary venous connection containing the individual pulmonary vein, and this combination can be a good diagnostic tool in preoperative evaluation of neonates and infants with a total anomalous pulmonary venous connection.

Systemic lupus erythematosus: brain MR imaging and single-voxel hydrogen 1 MR spectroscopy

PURPOSE

To evaluate the usefulness of magnetic resonance (MR) imaging and hydrogen 1 MR spectroscopy in the detection of brain involvement in patients with systemic lupus erythematosus (SLE) with or without neuropsychiatric symptoms.

MATERIALS AND METHODS

Twenty-six patients who had SLE with (n = 17) or without (n = 9) neuropsychiatric symptoms were examined at MR imaging and (1)H MR spectroscopy. The voxel was placed in the basal ganglia and peritrigonal white matter. Eight healthy volunteers were included.

RESULTS

Five of nine patients with major neuropsychiatric symptoms and one of eight patients with minor neuropsychiatric symptoms had abnormal MR imaging findings. (1)H MR spectroscopy showed a significantly decreased N:-acetylaspartate-creatine (Cr) ratio in the basal ganglia and an increased choline-Cr ratio in the peritrigonal white matter in patients with major symptoms compared with those with minor symptoms, those without symptoms, and healthy control subjects. Among patients with major symptoms, there was no difference in metabolite ratios between those with and those without abnormal MR imaging findings. Among patients with normal MR imaging findings, abnormal spectral changes were observed only in those with major neuropsychiatric symptoms. In patients without neuropsychiatric symptoms, results of (1)H MR spectroscopy and MR imaging were normal.

CONCLUSION

In patients with SLE, (1)H MR spectroscopic findings seem to reflect the cerebral metabolic disturbance related to the severity of the neuropsychiatric symptoms and are not related to the presence of abnormal MR imaging findings.

Malignant fibrous histiocytoma: an ultrastructural perspective

Malignant fibrous histiocytoma is a frequent diagnosis, but the relationship of the tumors to histologically similar soft tissue neoplasms is controversial. In this study, 157 examples representing the 4 main subtypes were reviewed by light microscopy and each tumor was studied with the electron microscope. Immunohistochemical stains were performed on 77 tumors. Electron micrographs on 100 fibrosarcomas were reviewed for comparison. Malignant fibrous histiocytomas often closely resemble fibrosarcomas at the ultrastructural level and differences between the two are generally of degree only. Evidence for true histiocytic differentiation was not found. The immunohistochemical results did not contradict the authors' impression from electron microscopy that malignant fibrous histiocytoma forms part of the histologic spectrum of tumors of fibroblasts.

Clinical manifestations of Korean female gouty patients

In an endeavor to analyse the clinical characteristics of female gout, we reviewed 36 women with gout. Twenty-seven (75%) developed the first symptomatic episode of gout after the onset of the menopause. The mean age at onset of gout was 54.3 years (range 15-87 years). Twenty-two patients (61%) had hypertension, 17 (47%) had renal insufficiency, 13 (36%) used diuretics and 10 (28%) were taking cyclosporine for a renal allograft. Tophaceous gout occurred in 10 patients (27%) and polyarticular involvement was seen in 16 (44%) at initial presentation. Five of nine premenopausal patients were taking cyclosporine and four had renal insufficiency. A comparison with a control group of 72 randomly selected male patients with gout showed that the female patients were frequently receiving diuretics at the time of the attack and had significantly lower mean uric acid excretion, whereas significantly more male patients showed heavy alcohol consumption and precipitating events for an acute attack compared with the female patients. There were no significant differences between the sexes for onset age, hypertension, renal insufficiency, distribution of joint involvement, tophi and mean serum uric acid concentration. The female patients in this study had a lower mean age at onset of gout than in previous studies, which was attributed to the inclusion of renal transplantation patients. Transplantation gout patients receiving cyclosporine lower the mean age at onset of female gout and this is an emerging problem in female gout.

Pilomatricoma in the head and neck: CT findings in three patients

We report three cases of pilomatricoma, one in the infrahyoid neck and the others in the preauricular area. In all cases, CT showed well marginated soft tissue masses that were located mainly in the subcutaneous fat, partly attaching to the overlying skin. There was no evidence of infiltration to deeper structures. Substantial amounts of calcification were found in one tumor. Pilomatricoma should be included in diagnostic consideration when CT shows a well marginated subcutaneous soft tissue mass adherent to the skin with or without visible calcification in the head and neck region.

Lipid profiles in untreated patients with rheumatoid arthritis

OBJECTIVE

To investigate lipid profiles in patients with untreated active rheumatoid arthritis (RA) and to assess the relationship of the inflammatory condition of RA with lipid profiles.

METHODS

Forty-two patients with RA and 42 age and sex matched healthy controls were studied. Patients with RA had not been treated with corticosteroid or disease modifying antirheumatic drugs prior to the study. Total cholesterol, triglyceride, HDL-cholesterol, LDL-cholesterol, apolipoprotein A1 (apo A1), apolipoprotein B (apo B), lipoprotein(a) [Lp(a)], and C-reactive protein (CRP) were measured in both groups.

RESULTS

The levels of apo A1 and HDL-cholesterol were significantly lower in patients than in controls (128.5 vs. 151.8 mg/dl, 41.2 vs. 54.9 mg/dl, respectively). The level of Lp(a) was significantly higher in patients than in controls (27.1 vs. 18.0 mg/dl). The ratios of apo B/apo A1, total cholesterol/HDL-cholesterol, and LDL-cholesterol/HDL-cholesterol were significantly higher in patients than in controls (0.82 vs. 0.67, 4.4 vs. 3.4, 2.8 vs. 1.9, respectively). CRP showed a significant correlation with apo A1 (r = -0.44, p<0.01) and HDL-cholesterol (r = -0.35, p<0.05).

CONCLUSION

Our study suggests that patients with untreated active RA have altered lipoprotein and apolipoprotein patterns that may possibly expose them to higher risk of atherosclerosis. The inflammatory condition of RA may affect the metabolism of HDL-cholesterol and apo A1.

Elevated serum interleukin-15 levels in systemic lupus erythematosus

Interleukin-15 (IL-15) has multiple biological properties, including the induction of other cytokine production and the inhibition of T cell apoptosis. Recently, IL-15 was reported to have a major role in synovial inflammation of rheumatoid arthritis, and that it provokes and amplifies the inflammatory process through the activation of TNF-alpha production. In systemic lupus erythematosus (SLE), the dysregulation of apoptosis and various cytokine production were observed and have been implicated in the pathogenesis of SLE. Thus, we tried to determine serum IL-15 levels in SLE patients and to assess the relationship among IL-15 levels, TNF-alpha levels and disease activity of SLE. Twenty SLE patients and 10 controls were studied. Paired serum samples were collected from all SLE patients at the time of presentation with active disease and at 4 weeks after institution of treatment. IL-15 levels were determined by ELISA and compared with the disease activity indices in SLE. The disease activity of SLE was measured using the SLE Disease Activity Index (SLEDAI) and laboratory parameters such as circulating immune complex (CIC), C3, C4, anti-DNA antibody, IgG, IgM, and IgA. The IL-15 levels in SLE patients were significantly higher than those of controls (5.38 +/- 4.89 vs. 1.04 +/- 1.26 pg/ml). However, elevated IL-15 levels did not correlate with the SLEDAI, nor did they correlate with other laboratory activity indices. The changes in serum IL-15 levels did not correlate with the changes in serum TNF-alpha in the disease course of SLE patients, whereas TNF-alpha reflected the changes in disease activity of SLE. Serum levels of IL-15 are elevated in SLE patients, but IL-15 did not correlate with the disease activity of SLE. TNF-alpha production in SLE patients was unlikely to be related with IL-15.

Presence of specific IgG antibody to grain dust does not go with respiratory symptoms

A high prevalence of work-related symptoms in relation to grain dust exposure has been reported in grain dust workers, but the role of the specific IgG antibody is unknown. To study the possible role of specific IgG (sIgG) and specific IgG4 (sIgG4) in the development of work-related symptoms, sIgG and sIgG4 subclass antibodies against grain dust antigens were determined by ELISA in sera from 43 workers and 27 non-exposed controls. They were compared with results of specific IgE antibodies, exposure intensity and the presence of respiratory symptoms. SIgG and sIgG4 antibodies were detectable in almost all sera of exposed workers, and the prevalence were significantly higher than those of controls (p<0.05). Higher sIgG4 was noted in workers with specific IgE (p<0.05). The correlation between sIgG and exposure duration was significant (p<0.05). There was no association between the prevalence of sIgG and sIgG4 and the presence of respiratory symptoms, or work stations. In conclusion, these results suggest that the existence of sIgG and sIgG4 might represent a response to grain dust exposure and may unlikely play a role in the etiology of respiratory symptoms.

Ileal obstruction caused by idiopathic sclerosing encapsulating peritonitis

A 26-year-old woman presented with epigastric pain, vomiting, and a palpable mass in the right lower abdomen. Ultrasonography showed a high echogenic mass associated with a small amount of ascites in the right lower abdomen. Computed tomography demonstrated entrapped ileal loops within a thin-walled fibrous capsule. A thin fibrous sac encasing the terminal ileum was detected on laparotomy and confirmed as idiopathic sclerosing encapsulating peritonitis.

A case of small cell carcinoma arising in a mature cystic teratoma of the ovary

Malignant transformation of ovarian mature cystic teratomas is reported to occur in about 1% of cases. The most common malignant evolution is that of squamous cell carcinoma and one of the least common is that of small cell carcinoma. We report a case of distant metastasis from a small cell carcinoma arising in a mature cystic teratoma. A 28-year-old nulliparous female presented with signs of supraclavicular lymph node metastasis. This is the first known case report of lymph node metastasis as an initial sign of cancer developing in a pre-existing mature cystic teratoma. Histologically, the tumor cells had microscopic features similar to those of pulmonary small cell carcinoma. This report gives a literature review, and the histological, immunohistochemical, flow cytometric and ultrastructural features are described.

Giant hidradenocarcinoma: a report of malignant transformation from nodular hidradenoma

A giant hidradenocarcinoma presented by a 75-year-old female is reported. The patient had a malignant transformation within a nodular hidradenoma involving the right postauricular area, which was treated by mass removal and a right radical neck dissection with a free-flap covering. Malignant hidradenocarcinoma is the least common adnexal tumor of uncertain origin. They are usually malignant from their inception, but some develop from a benign counterpart. To the authors' knowledge, only three cases have been reported previously. Two histologically distinct components were seen in this tumor: (i) typical nodular hidradenoma, which constituted a small part of the tumor; and (ii) carcinoma with areas of transition. The secretory cells of hidradenocarcinoma showed decapitation secretion on light and electron microscopic observations, which is evidence of apocrine differentiation. Histologically, this case was concluded as a hidradenocarcinoma arising from a long-standing nodular hidradenoma. A literature review is presented and the histological, immunohistochemical and ultrastructural features are described.

Oilseed rape allergy presented as occupational asthma in the grain industry

BACKGROUND

There have been several reports on respiratory allergic symptoms induced by pollen of oilseed rape. To the best of our knowledge, this is the first report dealing with oilseed rape dust mainly composed of seeds, as an occupational allergen in the grain industry. In this paper, we present a case of occupational asthma caused by oilseed rape dust from the Animal Feed Industry, which proved to be induced by an IgE-mediated reaction.

METHODS AND RESULTS

The patient displayed positive responses to Dermatophagoides farinae as well as oilseed rape dust extract. The bronchoprovocation test showed an early asthmatic response to oilseed rape dust extract. Serum specific IgE antibody to oilseed rape antigen was detected by enzyme-linked immunosorbent assay (ELISA). ELISA inhibition test showed significant inhibitions with addition of oilseed rape antigen. In order to further identify the allergenic components of extract, sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) and immunoblot analysis were performed. Fourteen IgE-binding components ranging from 10 to 160kDa were detected within the oilseed rape extract.

CONCLUSION

These results suggest that the inhalation of oilseed rape dust, not pollen, can cause IgE mediated bronchoconstriction in an exposed worker of the grain industry.

Role of specific IgE, IgG and IgG4 antibodies to corn dust in exposed workers

BACKGROUND AND METHODS

To evaluate the role of specific antibodies to corn dust (CD) and their relationship to respiratory dysfunction, we detected serum specific IgE(slgE) and IgG4(slgG4) antibodies by ELISA in 42 employees working in the animal feed industry and 27 unexposed controls.

RESULTS

Our survey revealed that 15 (34.9%) subjects had work-related respiratory dysfunction associated with or without nasal symptoms. Among these subjects, eight had airway hyper-responsiveness to methacholine. Significant differences were noted in slgE and slgG4 between exposed and unexposed groups (p = 0.04, p = 0.00 respectively), but no difference was noted in slgG (p = 0.1). Although there was no significant differences in the prevalence of specific IgE antibody between symptomatic (29%) and asymptomatic groups (19%, p = 0.55), the specific IgE levels were significantly higher in symptomatic workers than in asymptomatic workers (p = 0.03). Specific IgG antibody was detected in 1 (6%) symptomatic and 4 (15%) asymptomatic workers (p = 0.46). Specific IgG4 antibody was detected in 11 (73%) of symptomatic and 21 (78%) of asymptomatic workers (p = 0.90). The higher prevalence of slgG4 antibody was noted in workers with slgE antibody (p = 0.001). The correlation between slgG and exposure duration was significant (r = 0.36, p = 0.02). There was no association between the prevalence of slgE, slgG, and slgG4 to exposure intensity, smoking or atopic status.

CONCLUSION

These results suggested that the existence of slgG and slgG4 might represent a response to CD exposure, and that some unexposed subjects had slgG to CD. Specific IgE might play a role in the development of respiratory symptoms.