[Diagnostic imaging procedures and prescribing appropriateness: are administrative data a proper instrument? An experience from Piedmont Region (Northern Italy)]. / Diagnostica per immagini e appropriatezza prescrittiva: i dati amministrativi possono essere uno strumento informativo adeguato? Un'esperienza nella Regione Piemonte.

OBJECTIVES: to assess at population level if healthcare administrative data can be suitable to identify variability and determinants of the prescribing rates for some diagnostic imaging procedures at high-risk of inappropriateness. DESIGN: population-based observational study. SETTING AND PARTICIPANTS: Piedmont Region (Northern Italy) adult population (>20 years) in year 2013. The subjects included were 3,566,147, referring to 3,016 general practitioners (GPs), in 12 Local Health Authorities (LHAs). MAIN OUTCOME MEASURES: prescription rates of 4 diagnostic imaging procedures at high-risk of inappropriateness (vertebral and joint magnetic resonance - MR, vertebral computed tomography - CT, and bone densitometry). The following factors have been investigated: sociodemographic and clinical data of the subjects, prescribing GPs' characteristics, and organizational environment of the LHA for whom the GP is working. For each procedure, prescription rate determinants have been estimated by a logistic regression modelling of the probability of receiving at least one prescription during the year. Hierarchical data structure has been managed. The Intraclass Correlation Coefficient (ICC) and the Median Odds Ratio (MOR) were used as measures of variability due to GPs and LHAs. RESULTS: the degree of variability among LHAs and, within each LHA, among GPs was moderate (ICC for LHA: 0.009 and 0.004; ICC for GP: 0.015 and 0.014, respectively, for vertebral and joint MR). Prescribing probability was mainly explained by the demographic and clinical characteristics of the subjects. Most of the GPs' characteristics did not show any relevant association. Results suggest also a potential role of the private technology availability in the LHA where the GP is working. CONCLUSIONS: administrative healthcare data did not describe a relevant degree of variability in prescribing diagnostic imaging procedures in Piedmont Region, except for some GPs and LHAs with a different rate from the regional average. To explain differences in prescribing rates of some GPs or LHAs and to assess their appropriateness, outpatient databases should be enriched with clinical data (mainly, diagnosis or clinical suspicion) or different tools, such as clinical audit, should be used.

Aortic CT angiography dose reduction: investigation of optimal noise index and iterative algorithm strength in combination with low kV.

OBJECTIVE: The purpose of this study was to optimize an aorta angiographic CT protocol, by investigating the best combination of tube current modulation, iterative algorithm strength and kV reduction. MATERIALS AND METHODS: Anthropomorphic phantoms of three sizes were imaged by CT with different values of noise index, of iterative algorithm ASIR percentages and kV in the range 80-120. Quantitative noise and contrast noise ratios were evaluated at different phantom locations. Three radiologists assessed the subjective image quality by comparing the image series with the one acquired with the reference protocol (120 kV, slice thickness 0.625, noise index 28, ASIR 40 %). RESULTS: Although the highest CNR values were obtained for the 80 kV acquisitions, qualitative scores were higher for 100 and 120 kV at the same noise index. An optimized protocol was established with a NI of 39.2, ASIR 60%, 100 kV for small- and medium-sized patients and 120 kV for large-sized patients, with a dose reduction of 47%. CONCLUSION: When different dose reduction parameters are available, anthropomorphic phantoms of different sizes help to find the optimal combination. For aorta studies, 100 kV with relative high values of noise indexes and iterative levels provides the best balance between dose reduction and image quality.

Techniques for diagnosing osteoporosis: a systematic review of cost-effectiveness studies.

OBJECTIVES: The study question was whether dual-energy X-ray absorptiometry (DXA) alone is more cost-effective for identifying postmenopausal women with osteoporosis than a two-step procedure with quantitative ultrasound sonography (QUS) plus DXA. To answer this question, a systematic review was performed. METHODS: Electronic databases (PubMed, INAHTA, Health Evidence Network, NIHR, the Health Technology Assessment program, the NHS Economic Evaluation Database, Research Papers in Economics, Web of Science, Scopus, and EconLit) were searched for cost-effectiveness publications. Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Quality assessment of economic evaluations was undertaken using the Drummond checklist. RESULTS: Seven journal articles and four reports were reviewed. The cost per true positive case diagnosed by DXA was found to be higher than that for diagnosis by QUS+DXA in two articles. In one article it was found to be lower. In three studies, the results were not conclusive. These articles were characterized by the differences in the types of devices, parameters and thresholds on the QUS and DXA tests and the unit costs of the DXA and QUS tests as well as by variability in the sensitivity and specificity of the techniques and the prevalence of osteoporosis. CONCLUSIONS: The publications reviewed did not provide clear-cut evidence for drawing conclusions about which screening test may be more cost-effective for identifying postmenopausal women with osteoporosis.

Clinical performance of lung ultrasound in predicting ARDS morphology.

BACKGROUND: To assess diagnostic performance of lung ultrasound (LUS) in identifying ARDS morphology (focal vs non-focal), compared with the gold standard computed tomography. METHODS: Mechanically ventilated ARDS patients undergoing lung computed tomography and ultrasound were enrolled. Twelve fields, were evaluated. LUS score was graded from 0 (normal) to 3 (consolidation) according to B-lines extent. Total and regional LUS score as the sum of the four ventral (LUSV), intermediate (LUSI) or dorsal (LUSD) fields, were calculated. Based on lung CT, ARDS morphology was defined as (1) focal (loss of aeration with lobar distribution); (2) non-focal (widespread loss of aeration or segmental loss of aeration distribution associated with uneven lung attenuation areas), and diagnostic accuracy of LUS in discriminating ARDS morphology was determined by AU-ROC in training and validation set of patients. RESULTS: Forty-seven patients with ARDS (25 training set and 22 validation set) were enrolled. LUSTOT, LUSV and LUSI but not LUSD score were significantly lower in focal than in non-focal ARDS morphologies (p < .01). The AU-ROC curve of LUSTOT, LUSV, LUSI and LUSD for identification of non-focal ARDS morphology were 0.890, 0.958, 0.884 and 0.421, respectively. LUSV value ≥ 3 had the best predictive value (sensitivity = 0.95, specificity = 1.00) in identifying non-focal ARDS morphology. In the validation set, an LUSV score ≥ 3 confirmed to be highly predictive of non-focal ARDS morphology, with a sensitivity and a specificity of 94% and 100%. CONCLUSIONS: LUS had a valuable performance in distinguishing ARDS morphology.

Accuracy of cardiac magnetic resonance generated 3D models of the aortic annulus compared to cardiovascular computed tomography generated 3D models.

To evaluate the accuracy of 3D models of the aortic-root generated from non-contrast cardiac magnetic resonance (CMR). Data were retrospectively collected from 30 consecutive patients who underwent surgical aortic valve replacement and had available records of both intra-operative assessment and pre-surgery annulus assessment by cardiovascular computed tomography (CCT) and CMR. The 3D models were independently segmented, modelled and printed by two blinded "manufacturers". The measurements on the models were carried out by two cardiac surgeons with Hegar dilator. Data were analyzed with non-parametric tests. There was no significant intra- or inter-observer variability (p ≥ 0.13). The agreement between the diameter of the 3D model derived from CMR images and either the anatomical reference of the intraoperative measurement (p = 0.10, r = 0.97) or the radiological reference of the 3D model generated from CCT (p = 0.71, r = 0.92) was very good. The process of segmentation plus the post-processing was about 17 ± 2 min for a model created by CMR, significantly higher than a model created from CCT (7 ± 2 min; p < 0.001). The printing time for a single model did not differ between the two modalities (p = 0.61) and was less than 60 min. The cost for a single model was approximately 0.5 €. 3D models generated from non-contrast CMR performed well when compared to the anatomical reference standard and are comparable to the pair CCT derived models.

Usefulness of Cardiac Magnetic Resonance for Recurrent Pericarditis.

Cardiac magnetic resonance (CMR) offers the capability to objectively detect pericarditis by identifying pericardial thickening, edema/inflammation by Short-TI Inversion Recovery-T2 weighted (STIR-T2w) imaging, edema/inflammation or fibrosis by late gadolinium enhancement (LGE), and presence of pericardial effusion. This is especially helpful for the diagnosis of recurrent pericarditis. Aim of the present paper is to assess the diagnostic accuracy of CMR findings as well as their potential prognostic value for the diagnosis of recurrent pericarditis. Multicenter cohort study of consecutive patients with recurrent pericarditis evaluated by CMR. We included 128 consecutive cases (60 males, 47%; mean age 48 ± 14 years). CMR was performed at a mean time of 12 days (95% confidence interval 15 to 21) after the clinical diagnosis. We evaluated the diagnostic accuracy and areas under the receiver operating characteristic (ROC) curve for CMR diagnostic criteria and complications (additional recurrences, cardiac tamponade, and constrictive pericarditis). Areas under the ROC curve were respectively 64% for pericardial thickening, 84% for pericardial edema, 82% for pericardial LGE, and 71% for pericardial effusion. After a mean follow-up of 34 months, recurrences occurred in 52% of patients, tamponade in 6%, and constrictive pericarditis in 11%. Using a multivariable Cox model, elevation of CRP and presence of CMR pericardial thickening were predictors of adverse events, whereas the presence of CMR LGE was associated with a lower risk. The prognostic model for adverse events using gender, age, CRP level, and all CMR variables showed a C-index of 0.84. In conclusion, CMR findings show high diagnostic accuracy and may help identifying patients at higher risk of complications.

A comparative costs analysis of brachytherapy and radical retropubic prostatectomy therapies for clinically localized prostate cancer.

OBJECTIVES: The aim of this study is to perform a comparative costs analysis of brachytherapy (BT) and radical retropubic prostatectomy (RRP) for clinically localized prostate cancer and to shed light on the difficulties of comparing their relative economic effectiveness. METHODS: A systematic literature review of costing studies available in the Medline, Embase, DARE, and INAHTA databases. RESULTS: There is a lack of homogeneity among published studies in this field. Differences in the reported costs are related to different environments in which the two techniques (BT and RRP) are applied, and in particular due to the use of different methodology, cost items included, time frames, and different price levels in different settings. CONCLUSION: Published studies of costing data of BT and RRP do not provide clear-cut evidence for a conclusion about which treatment may be more effective from an economic point of view.

Prevalence and Prognostic Impact of Septal Late Gadolinium Enhancement in Acute Myocarditis With or Without Preserved Left Ventricular Function.

Recent data suggest that myocardial septal late gadolinium enhancement (LGE) may have an independent prognostic value in patients with acute myocarditis undergoing cardiac magnetic resonance (CMR). Aim of the present study is to evaluate its prevalence and prognostic implications in these patients with or without preserved LV function. Retrospective cohort study including all cases of clinically suspected acute myocarditis referred for CMR. A diagnosis of acute myocarditis was confirmed by CMR according to Lake Louise Criteria. Cardiovascular mortality, heart failure, heart transplantation, and sustained ventricular arrhythmias were considered adverse events at follow-up. Seventy-one patients were included in the present study (mean age 47 years 95% confidence intervals 42 to 51, 53 males; 75%). Left Ventricular Ejection Fraction (LVEF) was preserved in 45 cases (63%) and pericardial effusion was detected in 26 cases (38%). CMR was performed at a mean time of 11 days (95% confidence intervals 7.5 to 14.4) from symptoms onset. Myocardial hyperemia and edema were detected in 53 cases (75%), myocardial LGE in 66 cases (93%). Septal LGE was reported in 21 cases (30%). After a mean follow-up of 60.8 months, the mean LVEF increased from 51.6 ± 14.0% to 56.6 ± 10.9% (p = 0.021) and combined adverse events were only recorded in 4 patients (6%) with reduced basal LVEF. These patients had more commonly septal LGE (respectively 58% vs13%, p <0.0001). However, on multivariable analysis septal LGE had no additional predictive value over reduced basal LVEF. In conclusion, our study suggests that septal LGE is not uncommon in patients with acute myocarditis but has no added prognostic value over reduced LVEF at presentation.

Extradural motor cortex stimulation for advanced Parkinson disease. Report of two cases.

Motor cortex stimulation is a minimally invasive surgical procedure used for pain control. The authors report their results treating two patients with typical Parkinson disease. Unilateral motor cortex stimulation proved to be beneficial bilaterally. Motor cortex stimulation may represent a cost-effective alternative to deep brain stimulation.

Therapeutic extradural cortical stimulation for movement disorders: a review.

Extradural motor cortex stimulation was introduced in 1989 for control of central pain. In recent years this has been found useful in several patients with movement disorders. This paper attempts to bring together all the relevant literature, discuss mechanisms and lay out guidelines for future research and clinical applications.

Serum levels of heat shock protein 27 in patients with acute ischemic stroke.

Expression of intracellular heat shock protein 27 (Hsp27) rises in the brain of animal models of cerebral ischemia and stroke. Hsp27 is also released into the circulation and the aim of the present study was to investigated if serum Hsp27 (sHsp27) levels are altered in patients with acute ischemic stroke. sHsp27 was measured in 15 patients with acute ischemic stroke and in 14 control subjects comparable for age, sex, and cardiovascular risk factors. In patients, measurements were performed at admission and 1, 2, and 30 days thereafter. At admission, mean sHsp27 values were threefold higher in patients than in controls. In patients, sHsp27 values dropped after 24 h, rose again at 48 h, and markedly declined at 30 days, indicating the presence of a temporal trend of sHsp27 values following acute ischemic stroke.

Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome.

RATIONALE: Tidal volume and plateau pressure limitation decreases mortality in acute respiratory distress syndrome. Computed tomography demonstrated a small, normally aerated compartment on the top of poorly aerated and nonaerated compartments that may be hyperinflated by tidal inflation. OBJECTIVES: We hypothesized that despite tidal volume and plateau pressure limitation, patients with a larger nonaerated compartment are exposed to tidal hyperinflation of the normally aerated compartment. MEASUREMENTS AND MAIN RESULTS: Pulmonary computed tomography at end-expiration and end-inspiration was obtained in 30 patients ventilated with a low tidal volume (6 ml/kg predicted body weight). Cluster analysis identified 20 patients in whom tidal inflation occurred largely in the normally aerated compartment (69.9 +/- 6.9%; "more protected"), and 10 patients in whom tidal inflation occurred largely within the hyperinflated compartments (63.0 +/- 12.7%; "less protected"). The nonaerated compartment was smaller and the normally aerated compartment was larger in the more protected patients than in the less protected patients (p = 0.01). Pulmonary cytokines were lower in the more protected patients than in the less protected patients (p < 0.05). Ventilator-free days were 7 +/- 8 and 1 +/- 2 d in the more protected and less protected patients, respectively (p = 0.01). Plateau pressure ranged between 25 and 26 cm H(2)O in the more protected patients and between 28 and 30 cm H(2)O in the less protected patients (p = 0.006). CONCLUSIONS: Limiting tidal volume to 6 ml/kg predicted body weight and plateau pressure to 30 cm H(2)O may not be sufficient in patients characterized by a larger nonaerated compartment.

Dissection of cervicocephalic arteries: early diagnosis and follow-up with magnetic resonance imaging.

Evaluate Magnetic Resonance (MR) and Magnetic Resonance Angiography (MRA) sensibility in the diagnosis and follow-up of dissection of Internal Carotid and Vertebral Artery (ICA/VA). We revalued MR examination of 36 patients, 24 men, 12 women, aged 18-69 years. All patients underwent brain TC and MR (GE 1 Tesla); in 16 subjects 3D Time-of-Flight (TOF-3D) MRA was performed and in 20 subjects a Contrast-Enhanced MRA (CEMRA) of neck and head arteries. Thirty-one patients underwent a MRA follow-up. Dissection involved ICA in 30 and VA in 8. MR showed ischemic signs in 25 cases, wall hematoma in 19, and was normal in 11. MRA showed 25 vessels stenosis, 12 occlusions, and 9 aneurysm. Follow-up MRA showed 6 cases of complete resolution of stenosis, 17 partial resolution, 2 aneurysmal dissecanting, 6 luminal alteration unchanged, 1 aneurysma enlarged. MRA represented a non-invasive technique as investigation in suspected cervicocephalic arteries dissection.

Independent high-frequency oscillatory ventilation in the management of asymmetric acute lung injury.

We present a case of independent lung ventilation in an adult with asymmetric acute lung injury. We applied a conventional protective ventilatory strategy to the more homogeneously infiltrated lung and high-frequency oscillatory ventilation to the almost totally collapsed lung, because a conventional protective strategy exposed this lung to plateau pressure more than 30 cm H2O, whereas high-frequency oscillatory ventilation provided sufficient gas exchange at safer pressure levels. Analysis of a lung computed tomography scan was used to evaluate the efficacy of the ventilatory strategy.