An imaging-based artificial intelligence model for non-invasive grading of hepatic venous pressure gradient in cirrhotic portal hypertension

The hepatic venous pressure gradient (HVPG) is the gold standard for cirrhotic portal hypertension (PHT), but it is invasive and specialized. Alternative non-invasive techniques are needed to assess the hepatic venous pressure gradient (HVPG). Here, we develop an auto-machine-learning CT radiomics HVPG quantitative model (aHVPG), and then we validate the model in internal and external test datasets by the area under the receiver operating characteristic curves (AUCs) for HVPG stages (≥10, ≥12, ≥16, and ≥20 mm Hg) and compare the model with imaging- and serum-based tools. The final aHVPG model achieves AUCs over 0.80 and outperforms other non-invasive tools for assessing HVPG. The model shows performance improvement in identifying the severity of PHT, which may help non-invasive HVPG primary prophylaxis when transjugular HVPG measurements are not available.

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aHVPG is an automated HVPG quantitative estimation model based on CT

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aHVPG has the potential to assess HVPG and outperforms other non-invasive tools

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Non-invasive tools may help PHT monitoring when invasive HVPG is not available

Can Subclinical Atherosclerosis Be Assessed More Precisely in Behçet Syndrome Patients by Using a Particular Cutoff Value for Carotid Intima Media Thickness?

OBJECTIVE

Behçet syndrome (BS) is a multisystemic chronic vasculitic disease. Among previous studies, although there are some that showed increased risk of subclinical atherosclerosis in BS, there are also others that showed the opposite. The objective of this study is to evaluate subclinical atherosclerosis in BS by using the cutoff value for intima-media thickness in the 2013 European Society of Cardiology/European Society of Hypertension guideline.

METHODS

We conducted a cross-sectional analysis of 100 BS patients and 30 healthy volunteers at a single center in a 4-month period. All ultrasound scans were performed in a blind manner to the clinical assessment, and they were carried out by the same researcher by a B-mode ultrasonography.

RESULT

When we grouped the patients based on the presence of subclinical atherosclerosis, the frequency of subclinical atherosclerosis in the BS patients was found to be higher than that in the healthy controls (32% and 7%, respectively; p = 0.006). When a cutoff is used for carotid intima-media thickness, increased atherosclerosis risk is observed in BS patients with vascular involvement (p = 0.043).

CONCLUSIONS

Although higher inflammation and increased atherosclerosis in vascular BS patients were expected, this situation was not supported much in previous studies. We think that this may have been caused by mere comparison of numerical data, and usage of a cutoff value could be more significant in distinguishing what is normal and what is abnormal as in several medical parameters.

Noncontrast-enhanced MRI-based Noninvasive Score for Portal Hypertension (CHESS1802): An International Multicenter Study

BACKGROUND AND AIMS

This study aimed to determine the performance of the non-invasive score using noncontrast-enhanced MRI (CHESS-DIS score) for detecting portal hypertension in cirrhosis.

METHODS

In this international multicenter, diagnostic study (ClinicalTrials.gov, NCT03766880), patients with cirrhosis who had hepatic venous pressure gradient (HVPG) measurement and noncontrast-enhanced MRI were prospectively recruited from four university hospitals in China (n=4) and Turkey (n=1) between December 2018 and April 2019. A cohort of patients was retrospectively recruited from a university hospital in Italy between March 2015 and November 2017. After segmentation of the liver on fat-suppressed T1-weighted MRI maps, CHESS-DIS score was calculated automatically by an in-house developed code based on the quantification of liver surface nodularity.

RESULTS

A total of 149 patients were included, of which 124 were from four Chinese hospitals (training cohort) and 25 were from two international hospitals (validation cohort). A positive correlation between CHESS-DIS score and HVPG was found with the correlation coefficients of 0.36 (p<0.0001) and 0.55 (p<0.01) for the training and validation cohorts, respectively. The area under the receiver operating characteristic curve of CHESS-DIS score in detection of clinically significant portal hypertension (CSPH) was 0.81 and 0.9 in the training and validation cohorts, respectively. The intraclass correlation coefficients for assessing the inter- and intra-observer agreement were 0.846 and 0.841, respectively.

CONCLUSIONS

A non-invasive score using noncontrast-enhanced MRI was developed and proved to be significantly correlated with invasive HVPG. Besides, this score could be used to detect CSPH in patients with cirrhosis.

Deep Convolutional Neural Network-Aided Detection of Portal Hypertension in Patients With Cirrhosis

BACKGROUND & AIMS

Noninvasive and accurate methods are needed to identify patients with clinically significant portal hypertension (CSPH). We investigated the ability of deep convolutional neural network (CNN) analysis of computed tomography (CT) or magnetic resonance (MR) to identify patients with CSPH.

METHODS

We collected liver and spleen images from patients who underwent contrast-enhanced CT or MR analysis within 14 days of transjugular catheterization for hepatic venous pressure gradient measurement. The CT cohort comprised participants with cirrhosis in the CHESS1701 study, performed at 4 university hospitals in China from August 2016 through September 2017. The MR cohort comprised participants with cirrhosis in the CHESS1802 study, performed at 8 university hospitals in China and 1 in Turkey from December 2018 through April 2019. Patients with CSPH were identified as those with a hepatic venous pressure gradient of 10 mm Hg or higher. In total, we analyzed 10,014 liver images and 899 spleen images collected from 679 participants who underwent CT analysis, and 45,554 liver and spleen images from 271 participants who underwent MR analysis. For each cohort, participants were shuffled and then sampled randomly and equiprobably for 6 times into training, validation, and test data sets (ratio, 3:1:1). Therefore, a total of 6 deep CNN models for each cohort were developed for identification of CSPH.

RESULTS

The CT-based CNN analysis identified patients with CSPH with an area under the receiver operating characteristic curve (AUC) value of 0.998 in the training set (95% CI, 0.996-1.000), an AUC of 0.912 in the validation set (95% CI, 0.854-0.971), and an AUC of 0.933 (95% CI, 0.883-0.984) in the test data sets. The MR-based CNN analysis identified patients with CSPH with an AUC of 1.000 in the training set (95% CI, 0.999-1.000), an AUC of 0.924 in the validation set (95% CI, 0.833-1.000), and an AUC of 0.940 in the test data set (95% CI, 0.880-0.999). When the model development procedures were repeated 6 times, AUC values for all CNN analyses were 0.888 or greater, with no significant differences between rounds (P > .05).

CONCLUSIONS

We developed a deep CNN to analyze CT or MR images of liver and spleen from patients with cirrhosis that identifies patients with CSPH with an AUC value of 0.9. This provides a noninvasive and rapid method for detection of CSPH (ClincialTrials.gov numbers: NCT03138915 and NCT03766880).

Abdominal palpation and percussion maneuvers do not affect bowel sounds

Objectives

Medical textbooks suggest that the frequency of bowel sounds may be altered by performing auscultation after palpation or percussion. We hypothesize that the frequency of bowel sounds is not affected by the order of abdominal examination.

Material and Methods

Both healthy volunteers (n= 80) and patients (n= 100) were enrolled in this crossover randomized study. Two different examination orders, one as inspection, palpation, percussion, auscultation (IPPA) and the other order as inspection, auscultation, palpation, percussion (IAPP) were used by two observers, one of which was blinded to the order of the physical examination and only performed auscultation. Bowel motilities of 40 participants were analyzed with duplex Doppler USG by a radiologist. The effects of changing the order of abdominal examination and palpation-percussion maneuvers on the frequency of bowel sounds were evaluated.

Results

Gender distribution was similar between the healthy patients and controls, and mean age of the entire study population was 47 (18-60) years. Differences between the mean bowel sound frequencies for abdominal examinations in order IPPA-IAPP versus IAPP-IPPA were evaluated for both healthy subjects and the patients. There were no differences between the first and second listening, nor were there differences between examinations performed in either order. Duplex Doppler Ultrasonographic (USG) assessments were performed on 20 healthy subjects and 20 patients before and after palpation and percussion; there were no statistically significant differences between the two listenings (p= 0.694).

Conclusion

According to both abdominal examinations and Doppler USG, the order of auscultation, whether performed before or after palpation or percussion, did not change the frequency of bowel sounds in this subject population.

P1293WARFARIN INCREASES THE RISK OF VASCULAR CALCIFICATION IN HAEMODIALYSIS PATIENTS: A MULTICENTER CASE-CONTROL STUDY

Background and Aims

Vascular calcifications (VC) are highly prevalent in maintenance haemodialysis patients and it is a recognized risk factor for increased mortality. Previous experimental studies showed the relation between warfarin which has been prescribed frequently in dialysis patients and VC. The aim of this study is to investigate the association between VC and warfarin use in haemodialysis patients.

Method

This was a cross-sectional, observational, multicenter study. VC were assessed using Adragao (AS; pelvis and hands) and Kauppila (KS; lateral lumbar spine) scores in 76 haemodialysis patients from six centers. There were 32 patients (4.5%) being treated with warfarin for at least 1 year out of a total 711 haemodialysis patients and we included 44 control patients with matching parameters of age, sex and dialysis vintage to the study. Clinical characteristics, concomitant treatments, laboratory results were recorded and possible risk factors related to VC were analyzed.

Results

Of the patients, 47% were females, mean age was 65.8 ± 9 years, 23% were diabetics, their mean dialysis vintage was 68.39 ± 38.5 months and mean Kt/V 1.66 ± 0.27. No significant differences in clinical characteristics and basic laboratory results were found between control and warfarin group. In warfarin group, median Kauppila score was higher than control [11 vs 6.5, (25%-75% percentile, 5 vs 15), P=0.032] and percentages of Kauppila score &gt;6 patients were higher, as well (76,6% vs 50%; P=0.029). Median Adragao score was not significantly different between two groups [7 vs 6, (%25,%75 percentile 6 vs 8), P=0.177]. Logistic regression analysis revealed that warfarin treatment was independently associated with Kauppilla scores of &gt;6 (OR 3.28, 95% CI 1.17-9.22, P=0.024).

Conclusion

The results of this study showed that warfarin is a strong risk factor for vascular calcifications, especially in aorta of haemodialysis patients.

Stage I-laparoscopy partial ALPPS procedure for perihilar cholangiocarcinoma

The treatment for perihilar cholangiocarcinoma (PHC) is a challenge for the surgeon requiring complex resections with a reported perioperative mortality rate between 15% and 48%. In PHC patients with future liver remnant (FLR) less than 30%, it is advised that hepatectomy can be safely performed after the FLR is modified. Associating Liver Partition and Portal vein ligation for Staged Hepatectomy (ALPPS) procedure is criticized heavily due to its high morbidity and mortality rate in this setting. Hereby, we are reporting a modification of ALPPS procedure for PHC. Clinical presentation, preoperative work-up as well as operation and postoperative course of two cases were described in detail. Both patients were jaundiced preoperatively, stage 1 partial-ALPPS procedures were performed laparoscopically, there was sufficient remnant hypertrophy during the interval stage and there was no posthepatectomy liver failure after the second stage (Supporting Information Video). We have followed patients with a mean follow up of 35 months without any recurrence. Here we describe the key technical aspects of this approach that are discussed in three parts: minimally invasive first stage, biliary drainage of both FLR, and deportalized liver at first stage and biliary reconstruction at the second stage. This technique, in selected patients, can extend the indication of ALPPS procedure for PHC with preoperative jaundice.

Diagnostic accuracy and safety of CT-guided fine needle aspiration biopsy of pulmonary lesions with non-coaxial technique: a single center experience with 442 biopsies

PURPOSE

We aimed to evaluate the diagnostic accuracy and safety of computed tomography (CT)-guided biopsy of pulmonary lesions with fine needle aspiration (FNA) using non-coaxial technique.

METHODS

We analyzed 442 patients who underwent CT-guided lung biopsy with FNA and non-coaxial technique to determine the diagnostic outcomes, complication rates, and independent risk factors for diagnostic failure and pneumothorax.

RESULTS

Diagnostic accuracy, sensitivity, and specificity were 97.6%, 97.3%, and 100%, respectively. Age and >35 mm lesion size were significant risk factors for diagnostic failure. The rates of pneumothorax and chest tube placement were 19% and 2.9%, respectively. Middle and lower lobe location, lesion to pleura distance >7.5 mm, and >45° needle trajectory angle were significant risk factors for pneumothorax.

CONCLUSION

CT-guided FNA of pulmonary lesions with non-coaxial technique is a safe and reliable method with a relatively low pneumothorax rate and an acceptably high diagnostic accuracy.

Use of MRI to identify enlarged inferior gluteal and ischioanal lymph nodes and associated findings related to the primary disease

PURPOSE

We aimed to draw attention to the lymph nodes at the inferior gluteal and ischioanal regions and evaluate the lesions accompanying them using 3.0 T magnetic resonance imaging (MRI).

METHODS

In total, 22 patients (15 men, 7 women; mean age, 50±11.2 years; age range, 32-71 years) were included in this study. The patients' medical records were reviewed. MRI data were reviewed on a picture archiving and communication system workstation by two radiologists in consensus. Lymph node location, laterality, number, and size were documented.

RESULTS

The primary disorders causing the enlargement of inferior gluteal lymph nodes (n=16) were perianal fistula of cryptoglandular origin (n=5), perianal fistula associated with Crohn's disease (n=2), decubitus ulcers (n=2), presacral abscess (n=1), non-Hodgkin lymphoma (n=2), prostate cancer invading urethra and anorectal junction (n=1), endometrium cancer invading the urethra and vagina (n=1), and anal cancer (n=2). The pathologies causing the enlargement of ischioanal lymph nodes (n=6) were perianal fistula of cryptoglandular origin (n=4), subcutaneous inflammation of gluteal region related to Crohn's disease (n=1), and prostate cancer (n=1).

CONCLUSION

The infectious and neoplastic lesions involving the anal canal, distal rectum, gluteal region, prostate, and urethra are the possible causes of inferior gluteal and ischioanal lymph node enlargement. Lymphoproliferative diseases can also affect these node groups. MRI is an important method to identify enlarged inferior gluteal and ischioanal lymph nodes and define associated findings.

Diffuse Large B-Cell Lymphoma Presenting with Bilateral Renal Masses and Hematuria: A Case Report

Renal involvement is most often seen in conjunction with multisystemic, disseminated lymphoma either by direct extension from a retroperitoneal mass or via hematogenous spread. Primary lymphoma of the kidney is not a common entity and it is a controversial issue on account of the absence of lymphatic tissues in the normal kidney. In this case report, we describe a 19-year-old male with hematuria, acute kidney injury, and bilateral renal masses due to massive lymphomatous infiltration of the kidneys, which was diagnosed as diffuse large B-cell non-Hodgkin lymphoma by Tru-Cut biopsy.

Comparison of the effect of naproxen, etodolac and diclofenac on postoperative sequels following third molar surgery: a randomised, double-blind, crossover study

Objectives: To compare the three non-steroidal anti-inflammatory agents (NSAIDs) diclofenac potassium, etodolac and naproxen sodium in relation to pain, swelling and trismus following impacted third molar surgery. Study Design: The study was a randomized and a double-blinded study which included 42 healthy young individuals with impacted third molars and bone retention. Patients were randomly assigned to 3 groups (n: 14) to which diclofenac potassium, naproxen sodium and etodolac were administered orally an hour before the operation. Impacted third molars were surgically extracted with local anaesthesia. Visual analog scales (VAS) were used to assess the pain in the 6th, 12th hours and on the 1st, 2nd, 3rd, 5th, and 7th days postoperatively. Swelling was evaluated using ultrasound (US) and mouth opening (trismus) was measured with a composing stick pre and post operatively on the 2nd and 7th days respectively. Results: Regarding pain alleviation, diclofenac potassium was better than naproxen sodium and naproxen sodium was better than etodolac but these differences were not statistically significant. US measurements showed that the swelling on postoperative 2nd day was significantly lowest with diclofenac potassium as compared to others (p= 0.027) while naproxen sodium and etodolac acted similarly (p=0.747). No difference was noted regarding trismus in any of the groups. Conclusions: NSAIDs (diclofenac, naproxen and etodolac) are somehow similarly effective for controlling pain and trismus following extraction of mandibular third molars but diclofenac potassium surpasses others in reduction of swelling.

Key words:Diclofenac potassium, naproxen sodium, etodolac, impacted third molar surgery, pain, swelling, trismus.

Acute traumatic tear of latissimus dorsi muscle in an elite track athlete

Soft tissue injuries constitute 30-50% of all sports related injuries; however, injury to the latissimus dorsi muscle is quite rare with only a few cases reported in the literature. Herein, we describe an acute traumatic tear of the latissimus dorsi muscle in an elite track athlete, which has not been reported in the track and field sports before. The injury was caused by forceful resisted arm adduction that took place at hurdling and starting from the block. A pseudotumor appearance in the axillary region was misdiagnosed as a mass. The diagnosis was made by ultrasound alone and the patient was managed conservatively.

Common extensor tendon thickness measurements at the radiocapitellar region in diagnosis of lateral elbow tendinopathy

PURPOSE

The aim of this study was to determine the value of measuring common extensor tendon (CET) thickness at the radiocapitellar and capitellar regions with qualitative ultrasonographic findings in the diagnosis of lateral elbow tendinopathy.

MATERIALS AND METHODS

The study included 164 lateral elbow tendinopathy patients (84 bilateral, 80 unilateral) matched by age, gender, and body mass index with 80 normal subjects. CET was examined using gray-scale and Doppler ultrasonography for tendinopathy, and tendon thickness was measured at two landmark locations: capitellar and radiocapitellar.

RESULTS

In tendinopathy, tendon thickness including the dominant capitellar region, increased in every measured location. In the capitellar region of the dominant elbow, the cut-off thickness was 5.15 mm, and in the radiocapitellar region, this value was 4.05 mm. For the non-dominant elbow, the cut-off thickness was 4.61 mm, whereas in the radiocapitellar region, this value was 3.51 mm. The greatest risk of tendinopathy was at the radiocapitellar region on the dominant side. The overall sensitivity and specificity of gray-scale findings were 54% and 88%, respectively, and the addition of Doppler readings did not alter these values. When capitellar measurements were added, the values increased to 79% and 80% for sensitivity and specificity, respectively. These values further increased to 93% and 91%, respectively, when radiocapitellar measurements were included.

CONCLUSION

A second tendon thickness measurement at the radiocapitellar region of CET in addition to the capitellar region is recommended on the grounds that combined qualitative and quantitative evaluation of CET increases the diagnostic per- formance of ultrasonography in lateral elbow tendinopathy.