The adoption of LI-RADS: a survey of non-academic radiologists.

PURPOSE: To understand the practice and determinants of non-academic radiologists regarding LI-RADS and the four current LI-RADS algorithms: CT/MRI, contrast-enhanced ultrasound (CEUS), ultrasound (US), and CT/MRI Treatment Response. MATERIALS AND METHODS: Seven themes were covered in this international survey, as follows: (1) demographics of participants and sub-specialty, (2) HCC practice and interpretation, (3) reporting practice, (4) screening and surveillance, (5) HCC imaging diagnosis, (6) treatment response, and (7) CT and MRI technique. RESULTS: Of the 232 participants, 69.4% were from the United States, 25.0% from Canada, and 5.6% from other countries and 45.9% were abdominal/body imagers. During their radiology training or fellowship, no formal HCC diagnostic system was used by 48.7% and LI-RADS was used by 44.4% of participants. In their current practice, 73.6% used LI-RADS, 24.7% no formal system, 6.5% UNOS-OPTN, and 1.3% AASLD. Barriers to LI-RADS adoption included lack of familiarity (25.1%), not used by referring clinicians (21.6%), perceived complexity (14.5%), and personal preference (5.3%). The US LI-RADS algorithm was used routinely by 9.9% of respondents and CEUS LI-RADS was used by 3.9% of the respondents. The LI-RADS treatment response algorithm was used by 43.5% of the respondents. 60.9% of respondents thought that webinars/workshops on LI-RADS Technical Recommendations would help them implement these recommendations in their practice. CONCLUSION: A majority of the non-academic radiologists surveyed use the LI-RADS CT/MR algorithm for HCC diagnosis, while nearly half use the LI-RADS TR algorithm for assessment of treatment response. Less than 10% of the participants routinely use the LI-RADS US and CEUS algorithms.

Contrast-Enhanced Ultrasound (CEUS) in the Evaluation of Hemoperitoneum in Patients With Cirrhosis.

Hemoperitoneum in cirrhosis is a life-threatening condition that requires emergent evaluation. Contrast-enhanced ultrasound (CEUS) permits multiple dynamic characterizations of abdominal structures through all vascular phases, and contrast extravasation or the presence of microbubbles in the ascites could be a sensitive tool. We reviewed 13 patients with cirrhosis that underwent CEUS due to high suspicion for intra-abdominal bleeding. In 10 cases, CEUS demonstrated extravasation of contrast, including 2 instances where CEUS detected active bleeding despite negative computed tomography. These data support further study of CEUS in direct comparison to other imaging modalities in this clinical context.

Dots, lines, contours, and ends: An image-based review of esophageal pathology.

Esophageal pathologies encountered on fluoroscopic examination may pose a diagnostic challenge to the interpreting Radiologist. Understanding the varied imaging appearances of esophageal pathology requires a thorough understanding of barium esophagography. This article reviews the various fluoroscopic imaging findings of different esophageal pathologies by describing an approach to image interpretation centered on dots, lines, contours, and ends. By utilizing this approach, the Radiologist will be better positioned to reconcile seemingly disparate pathologies into a cogent and succinct differential diagnosis.

Risk of nephrogenic systemic fibrosis is low in patients with chronic liver disease exposed to gadolinium-based contrast agents.

PURPOSE: To determine the risk of nephrogenic systemic fibrosis (NSF) in a cohort of patients with chronic liver disease. MATERIALS AND METHODS: This retrospective, Institutional Review Board (IRB)-approved, Health Insurance Portability and Accountability Act (HIPAA)-compliant study was performed at a single tertiary liver center. The study cohort comprised 1167 patients with chronic liver disease followed in a liver clinic and exposed to gadolinium-based contrast agents (GBCAs) between February 2004 and October 2007. A retrospective review of medical records was performed. For each patient, data were collected on demographics, history of GBCA exposure, presence of purported risk factors for NSF, and histopathological evidence of NSF. RESULTS: Of the 1167 patients with chronic liver disease, 58% (n = 678) had cirrhosis. The patients had a total of 2421 separate GBCA exposures. Fifty-five percent (n = 646) had a single exposure, 19% (n = 218) had two exposures, and 26% (n = 303) had three or more exposures. Seventy-two percent (n = 843) of patients had renal insufficiency, 25 patients (2.1%) had hepatorenal syndrome, 80 patients (6.8%) were in the perioperative liver transplant period, and 49 patients (4.2%) had one or more additional risk factors for NSF. None of the 1167 patients developed NSF. CONCLUSION: Chronic liver disease does not appear to be a significant risk factor for NSF.

Effect of flip angle on the accuracy and repeatability of hepatic proton density fat fraction estimation by complex data-based, T1-independent, T2*-corrected, spectrum-modeled MRI.

PURPOSE: To evaluate the effect of flip angle (FA) on accuracy and within-examination repeatability of hepatic proton-density fat fraction (PDFF) estimation with complex data-based magnetic resonance imaging (MRI). MATERIALS AND METHODS: PDFF was estimated at 3T in 30 subjects using two sets of five MRI sequences with FA from 1° to 5° in each set. One set used 7 msec repetition time and acquired 6 echoes (TR7/E6); the other used 14 msec and acquired 12 echoes (TR14/E12). For each FA in both sets the accuracy of MRI-PDFF was assessed relative to MR spectroscopy (MRS)-PDFF using four regression parameters (slope, intercept, average bias, R(2) ). Each subject had four random sequences repeated; within-examination repeatability of MRI-PDFF for each FA was assessed with intraclass correlation coefficient (ICC). Pairwise comparisons were made using bootstrap-based tests. RESULTS: Most FAs provided high MRI-PDFF estimation accuracy (intercept range -1.25 to 0.84, slope 0.89-1.06, average bias 0.24-1.65, R(2) 0.85-0.97). Most comparisons of regression parameters between FAs were not significant. Informally, in the TR7/E6 set, FAs of 2° and 3° provided the highest accuracy, while FAs of 1° and 5° provided the lowest. In the TR14/E12 set, accuracy parameters did not differ consistently between FAs. FAs in both sets provided high within-examination repeatability (ICC range 0.981-0.998). CONCLUSION: MRI-PDFF was repeatable and, for most FAs, accurate in both sequence sets. In the TR7/E6 sequence set, FAs of 2° and 3° informally provided the highest accuracy. In the TR14/E12 sequence set, all FAs provided similar accuracy.

Evaluation of MRI fat fraction in the liver and spine pre and post SPIO infusion.

This study evaluates the robustness of a magnetic resonance (MR) fat quantification method to changes in R2* caused by an intravenous infusion of superparamagnetic iron oxide (SPIO) contrast agent. The R2* and proton density fat fraction (PDFF) were measured in liver and spine in 14 subjects using an investigational sequence (IDEAL IQ) provided by the MR scanner vendor. Measurements were made before and after SPIO infusion. Results showed SPIO significantly increased R2* in both liver (p=8.8×10(-8)) and spine (p=1.3×10(-2)) but PDFFs were not significantly different in either the liver (p=5.5×10(-1)) or the spine (p=5.6×10(-1)). These results confirm that the IDEAL IQ method of fat quantification is robust to changes in R2*.

Reproducibility of MRI-determined proton density fat fraction across two different MR scanner platforms.

PURPOSE: To evaluate magnetic resonance imaging (MRI)-determined proton density fat fraction (PDFF) reproducibility across two MR scanner platforms and, using MR spectroscopy (MRS)-determined PDFF as reference standard, to confirm MRI-determined PDFF estimation accuracy. MATERIALS AND METHODS: This prospective, cross-sectional, crossover, observational pilot study was approved by an Institutional Review Board. Twenty-one subjects gave written informed consent and underwent liver MRI and MRS at both 1.5T (Siemens Symphony scanner) and 3T (GE Signa Excite HD scanner). MRI-determined PDFF was estimated using an axial 2D spoiled gradient-recalled echo sequence with low flip-angle to minimize T1 bias and six echo-times to permit correction of T2* and fat-water signal interference effects. MRS-determined PDFF was estimated using a stimulated-echo acquisition mode sequence with long repetition time to minimize T1 bias and five echo times to permit T2 correction. Interscanner reproducibility of MRI determined PDFF was assessed by correlation analysis; accuracy was assessed separately at each field strength by linear regression analysis using MRS-determined PDFF as reference standard. RESULTS: 1.5T and 3T MRI-determined PDFF estimates were highly correlated (r = 0.992). MRI-determined PDFF estimates were accurate at both 1.5T (regression slope/intercept = 0.958/-0.48) and 3T (slope/intercept = 1.020/0.925) against the MRS-determined PDFF reference. CONCLUSION: MRI-determined PDFF estimation is reproducible and, using MRS-determined PDFF as reference standard, accurate across two MR scanner platforms at 1.5T and 3T.

Estimation of hepatic proton-density fat fraction by using MR imaging at 3.0 T.

PURPOSE: To compare the accuracy of several magnetic resonance (MR) imaging-based methods for hepatic proton-density fat fraction (FF) estimation at 3.0 T, with spectroscopy as the reference technique. MATERIALS AND METHODS: This prospective study was institutional review board approved and HIPAA compliant. Informed consent was obtained. One hundred sixty-three subjects (39 with known hepatic steatosis, 110 with steatosis risk factors, 14 without risk factors) underwent proton MR spectroscopy and non-T1-weighted gradient-echo MR imaging of the liver. At spectroscopy, the reference FF was determined from frequency-selective measurements of fat and water proton densities. At imaging, FF was calculated by using two-, three-, or six-echo methods, with single-frequency and multifrequency fat signal modeling. The three- and six-echo methods corrected for T2*; the two-echo methods did not. For each imaging method, the fat estimation accuracy was assessed by using linear regression between the imaging FF and spectroscopic FF. Binary classification accuracy of imaging was assessed at four reference spectroscopic thresholds (0.04, 0.06, 0.08, and 0.10 FF). RESULTS: Regression intercept of two-, three-, and six-echo methods were -0.0211, 0.0087, and -0.0062 (P <.001 for all three) without multifrequency modeling and -0.0237 (P <.001), 0.0022, and -0.0007 with multifrequency modeling, respectively. Regression slope of two-, three-, and six-echo methods were 0.8522, 0.8528, and 0.7544 (P <.001 for all three) without multifrequency modeling and 0.9994, 0.9775, and 0.9821 with multifrequency modeling, respectively. Significant deviation of intercept and slope from 0 and 1, respectively, indicated systematic error. Classification accuracy was 82.2%-90.1%, 93.9%-96.3%, and 83.4%-89.6% for two-, three-, and six-echo methods without multifrequency modeling and 88.3%-92.0%, 95.1%-96.3%, and 94.5%-96.3% with multifrequency modeling, respectively, depending on the FF threshold. T2*-corrected (three- and six-echo) multifrequency imaging methods had the overall highest FF estimation and classification accuracy. Among methods without multifrequency modeling, the T2-corrected three-echo method had the highest accuracy. CONCLUSION: Non-T1-weighted MR imaging with T2 correction and multifrequency modeling helps accurately estimate hepatic proton-density FF at 3.0 T.

Indeterminate orbital masses: restricted diffusion at MR imaging with echo-planar diffusion-weighted imaging predicts malignancy.

PURPOSE: To determine whether magnetic resonance (MR) imaging with diffusion-weighted (DW) imaging can help discriminate between radiologically indeterminate benign and malignant orbital masses and to identify optimal apparent diffusion coefficient (ADC) thresholds for such discrimination. MATERIALS AND METHODS: Informed consent was waived for this HIPAA-compliant institutional review board-approved retrospective study. Forty-seven orbital masses imaged with echo-planar DW imaging were identified in 47 patients (25 female patients, 22 male patients; average age, 35 years). A fellowship-trained orbital surgeon determined reference-standard diagnoses on the basis of chart review, and a neuroradiology fellow and senior neuroradiologist who were blinded to the diagnoses selected a region of interest for each lesion by consensus. ADC was calculated from signal intensity on DW images obtained with b = 1000 and b = 0 sec/mm(2). Lesion ADC was also compared with that of normal-appearing white matter (ADC ratio). The Student t test was used to compare groups. Receiver operating characteristic analysis was performed. Intraobserver agreement was assessed with a repeat data collection. RESULTS: Malignant lesions had lower ADCs than benign lesions, irrespective of patient age (P < .02) and in adults specifically (P < .05). Lymphomas had lower ADCs than pseudotumors (P < .001). An ADC of less than 1.0 x 10(-3) mm(2)/sec and an ADC ratio of less than 1.2 were optimal for predicting malignancy (sensitivity, 63% for both; specificity, 84% and 90%, respectively; and accuracy, 77% and 81%, respectively). Lymphoma was differentiated from pseudotumor with 100% accuracy (in 16 of 16 cases) by using these values. Infiltrative lesions that were hypointense on T2-weighted images were better characterized with DW imaging than lesions that were hyperintense or well defined. CONCLUSION: Echo-planar DW MR imaging can help characterize indeterminate orbital masses.

Apparent diffusion coefficient of fibrosis and regenerative nodules in the cirrhotic liver at MRI.

OBJECTIVE: The purpose of this article is to compare the apparent diffusion coefficient (ADC) of fibrosis and regenerative nodules in the cirrhotic liver at MRI, both in vivo and ex vivo. SUBJECTS AND METHODS: A prospective ex vivo and in vivo study was performed at a tertiary liver center. To characterize the diffusion properties of cirrhotic liver, 63 human liver specimens obtained anonymously from 23 freshly explanted cirrhotic livers underwent T1-, T2-, and diffusion-weighted MRI ex vivo. ADC values of fibrotic bridges and regenerative nodules were calculated. In vivo conventional and diffusion-weighted MRI was performed for 17 cirrhotic patients (12 men and five women; mean age, 54 years; range, 34-77 years) with focal areas of confluent fibrosis. ADC values of confluent fibrosis and background cirrhotic liver parenchyma were calculated. Log-transformed ADC values of fibrosis and regenerative nodules were compared between ex vivo and in vivo images. RESULTS: Ex vivo, the mean ADC of fibrotic bridges (0.55 +/- 0.24 mm(2)/s [SD]) was greater than that of regenerative nodules (0.36 +/- 0.18 x 10(-3) mm(2)/s) (p < 0.0001). In vivo, the mean ADC value of confluent fibrosis (2.07 +/- 0.39 x 10(-3) mm(2)/s) was greater than that of background cirrhotic liver parenchyma (1.53 +/- 0.35 x 10(-3) mm(2)/s) (p < 0.0001). CONCLUSION: The mean ADC of fibrosis is significantly greater than that of regenerative nodules both in vivo and ex vivo. The prevailing paradigm that fibrosis causes the reduced liver ADC observed in cirrhosis may need modification.

Assessment of liver fat quantification in the presence of iron.

This study assesses the stability of magnetic resonance liver fat measurements against changes in T2* due to the presence of iron, which is a confound for accurate quantification. The liver T2* was experimentally shortened by intravenous infusion of a super paramagnetic iron oxide contrast agent. Low flip angle multiecho gradient echo sequences were performed before, during and after infusion. The liver fat fraction (FF) was calculated in co-localized regions-of-interest using T2* models that assumed no decay, monoexponential decay and biexponential decay. Results show that, when T2* was neglected, there was a strong underestimation of FF and with monoexponential decay there was a weak overestimation of FF. Curve-fitting using the biexponential decay was found to be problematic. The overestimation of FF may be due to remaining deficiencies in the model, although is unlikely to be important for clinical diagnosis of steatosis.

Proximal tibial osteophytes and their relationship with the height of the tibial spines of the intercondylar eminence: paleopathological study.

OBJECTIVE: Tibial spiking (i.e., spurring of tibial spines), eburnation, and osteophytes are considered features of osteoarthritis. This investigation employed direct inspection of the medial and lateral tibial plateaus in paleopathological specimens to analyze the frequency and morphological features of osteoarthritis and to define any relationship between the size of osteophytes and that of the intercondylar tibial spines. MATERIALS AND METHODS: A total of 35 tibial bone specimens were evaluated for the degree of osteoarthritis and presence of eburnation. Each plateau was also divided into four quadrants and the presence and size of bone outgrowths were recorded in each quadrant. The "medial/lateral tibial intercondylar spine index" for each specimen was calculated as follows: (medial/lateral intercondylar tibial spine height)/(anteroposterior width of the superior tibial surface). The relationships between medial and lateral tibial height indexes with the degree of osteoarthritis were then tested. RESULTS: Osteophytes were observed more frequently in the anterior quadrants of both tibial plateaus than in the posterior quadrants (29 vs 16 for the medial tibial plateau [p = 0.01] and 28 vs 20 for the lateral tibial plateau [p = 0.04]). Eburnation was seen more frequently in the posterior regions of both tibial plateaus than in the anterior regions (17 vs 5, p < 0.01). In specimens with no signs of osteoarthritis the lateral intercondylar tibial index was significantly lower than that in specimens with some degree of osteoarthritis (p = 0.02). The medial intercondylar tibial index of the specimens with no signs of osteoarthritis was not significantly different from that of the specimens with some degree of osteoarthritis (p = 0.45). There was a positive correlation between the lateral spine height index and the overall grading of osteoarthritis, (r = 0.6, p < 0.01). In the anteromedial and posteromedial quadrants of the lateral tibial plateau, the association between the lateral intercondylar tibial spine index and the grade of osteophytes was 0.5 (p < 0.01) and 0.7 (p < 0.01) respectively. CONCLUSION: Spiking of the lateral tibial intercondylar spine is associated with osteophyte formation and osteoarthritis. Eburnation occurs mainly in the posterior parts of the tibial plateaus while osteophytes arise mainly in the anterior parts. These findings suggest that stresses occurring in the flexed knee may contribute to many of the morphological abnormalities of osteoarthritis.

MR imaging of liver fibrosis: current state of the art.

Chronic liver disease is a major public health problem worldwide. Liver fibrosis, a common feature of almost all causes of chronic liver disease, involves the accumulation of collagen, proteoglycans, and other macromolecules within the extracellular matrix. Fibrosis tends to progress, leading to hepatic dysfunction, portal hypertension, and ultimately cirrhosis. Liver biopsy, the standard of reference for diagnosing liver fibrosis, is invasive, costly, and subject to complications and sampling variability. These limitations make it unsuitable for diagnosis and longitudinal monitoring in the general population. Thus, development of a noninvasive, accurate, and reproducible test for diagnosis and monitoring of liver fibrosis would be of great value. Conventional cross-sectional imaging techniques have limited capability to demonstrate liver fibrosis. In clinical practice, imaging studies are usually reserved for evaluation of the presence of portal hypertension or hepatocellular carcinoma in cases that have progressed to cirrhosis. In response to the rising prevalence of chronic liver diseases in Western nations, a number of imaging-based methods including ultrasonography-based transient elastography, computed tomography-based texture analysis, and diverse magnetic resonance (MR) imaging-based techniques have been proposed for noninvasive diagnosis and grading of hepatic fibrosis across its entire spectrum of severity. State-of-the-art MR imaging-based techniques in current practice and in development for noninvasive assessment of liver fibrosis include conventional contrast material-enhanced MR imaging, double contrast-enhanced MR imaging, MR elastography, diffusion-weighted imaging, and MR perfusion imaging.

Nephrogenic systemic fibrosis in liver disease: a systematic review.

Nephrogenic systemic fibrosis (NSF) may develop in patients with liver disease, a fact highlighted by Food and Drug Administration (FDA) announcements cautioning against the use of gadolinium-based contrast agents (GBCAs) in select liver disease patients. The purpose of this systematic literature review is to characterize the risk of NSF in patients with liver disease. All published articles on NSF from September 2000 through August 2008, were identified via PubMed searches and examination of articles' reference lists. Two reviewers independently read each article and identified unique patients with biopsy-proven or suspected NSF. Data on demographics, liver status, renal status, and GBCA exposure were collected. A total of 324 articles were reviewed, with 108 articles containing case descriptions of 335 unique NSF patients. After excluding the 95/335 (28%) patients in whom the presence or absence of liver disease was uncertain, liver disease was confirmed present in 41/239 (17%) patients. Renal insufficiency could be assessed in 35 of the liver disease patients; severe renal insufficiency, defined as a glomerular filtration rate (GFR) or estimated GFR (eGFR) <30 mL/min/1.73 m(2) or dialysis requirement, was present in 34/35 (97%) patients. The lone patient who developed NSF with mild/moderate renal insufficiency was atypical and received a total gadodiamide load of 0.76 mmol/kg over a 10-week period periliver transplantation. The published medical literature demonstrates that patients with liver disease who develop NSF also have severe renal insufficiency, suggesting that liver disease does not confer a risk for NSF beyond that of the underlying renal insufficiency. J. Magn. Reson. Imaging 2009;30:1313-1322. (c) 2009 Wiley-Liss, Inc.

Effect of shot number on the calculated apparent diffusion coefficient in phantoms and in human liver in diffusion-weighted echo-planar imaging.

PURPOSE: To show the signal intensity varies with shot number in diffusion-weighted (DW) echo-planar imaging (EPI) and affects apparent diffusion coefficient (ADC) calculation. MATERIALS AND METHODS: This prospective study was performed on 35 adult patients and 20 volunteers. Measurements were made on a 3T scanner using a breathhold DW spin-echo EPI (SE EPI) sequence. Three protocols were used: A) eight consecutive shots at a fixed b-value of 0 seconds/mm(2) with TR = 1000 and 3000 msec; B) seven consecutive shots at b-values = 0, 1000, 750, 500, 250, 100, 0 seconds/mm(2) (in that order) with TR = 3500 msec; and C) seven consecutive shots (as in B) with TR = 1000, 1750, and 7000 msec. RESULTS: For protocol A, signal intensity decreased significantly from the first to second shot (P<0.0001) and thereafter remained constant. For protocol B, the ADC depended on which b = 0 seconds/mm(2) image was used. Using the first b = 0 seconds/mm(2), the mean ADC was 15% higher than using the second b = 0 seconds/mm(2) (P<0.0001). For protocol C, the difference between ADC using the first b = 0 seconds/mm(2) and the second b = 0 seconds/mm(2) decreased as the TR increased. CONCLUSION: The signal intensity can vary with shot number in SE EPI. For TR > or = 3000 msec, steady-state is attained after one shot. Using data acquired prior to steady-state confounds the calculation of ADC values.

Heritability of nonalcoholic fatty liver disease.

BACKGROUND & AIMS: Nonalcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in the United States. The etiology is believed to be multifactorial with a substantial genetic component; however, the heritability of NAFLD is undetermined. Therefore, a familial aggregation study was performed to test the hypothesis that NAFLD is highly heritable. METHODS: Overweight children with biopsy-proven NAFLD and overweight children without NAFLD served as probands. Family members were studied, including the use of magnetic resonance imaging to quantify liver fat fraction. Fatty liver was defined as a liver fat fraction of 5% or higher. Etiologies for fatty liver other than NAFLD were excluded. Narrow-sense heritability estimates for fatty liver (dichotomous) and fat fraction (continuous) were calculated using variance components analysis adjusted for covariate effects. RESULTS: Fatty liver was present in 17% of siblings and 37% of parents of overweight children without NAFLD. Fatty liver was significantly more common in siblings (59%) and parents (78%) of children with NAFLD. Liver fat fraction was correlated with body mass index, although the correlation was significantly stronger for families of children with NAFLD than those without NAFLD. Adjusted for age, sex, race, and body mass index, the heritability of fatty liver was 1.000 and of liver fat fraction was 0.386. CONCLUSIONS: Family members of children with NAFLD should be considered at high risk for NAFLD. These data suggest that familial factors are a major determinant of whether an individual has NAFLD. Studies examining the complex relations between genes and environment in the development and progression of NAFLD are warranted.

Noninvasive assessment of hepatic steatosis.

Hepatic steatosis, the accumulation of lipids within hepatocytes, is a common condition. The prevalence of its most frequent manifestation, nonalcoholic fatty liver disease (NAFLD), has been estimated to be as high as 35% in some populations. Currently, liver biopsy is the gold standard for the diagnosis and assessment of severity of hepatic steatosis, staging of fibrosis, and is the only modality able to differentiate bland steatosis from steatohepatitis. However, its invasiveness, significant side effect profile, and susceptibility to sampling error ultimately make it a suboptimal tool. Accordingly, focus has been placed on noninvasive radiologic techniques for hepatic fat detection and quantification. The rationale, performance characteristics, and limitations of traditional noninvasive measures, including ultrasound, computed tomography, and magnetic resonance (MR) spectroscopy and imaging, are reviewed. A novel MR method, the spectrally modeled relaxation-invariant technique, overcomes the inherent weaknesses of conventional MR to diagnose and quantify hepatic steatosis over its entire range of severity. Noninvasive radiologic techniques, particularly MR, can be applied broadly, including in the diagnosis of NAFLD in asymptomatic patients with elevated serum aminotransferase levels, longitudinal monitoring of disease progression or response to treatment, population-based epidemiologic or observational studies, and drug discovery.

H pylori seroprevalence in patients with lung cancer.

AIM: To assess H pylori seroprevalence in lung cancer and determine whether there is a potential association between lung cancer and H pylori infection. METHODS: The study was conducted on forty consecutive patients with lung cancer, confirmed by pathology (32 men, 8 women; mean age 55.50+/-11.91 years, range 16-77 years). Forty healthy subjects (25 men, 15 women; mean age 43.08+/-12.60 years, range 20-79 years) from the patients' family members were matched to each case subject on the basis of age and socioeconomic status. H pylori infection was detected with a commercially available immunoglobulin G (IgG) enzyme-linked immunosorbent assay (Trinity kit, Biotech co., USA), previously validated in adults (86% sensitivity, 96% specificity) against a gold standard of culture and histology. RESULTS: H pylori seropositivity was present in 52.5% of patients with lung cancer in comparison to 45.0% of healthy control subjects. Although H pylori seropositivity was more frequent in lung cancer patients than in controls, the difference did not reach statistical significance (OR=1.35, 95% CI=0.56-3.25; P=0.65). In addition, there was no significant difference between cases and controls in terms of gastrointestinal symptoms. CONCLUSION: The earlier described association between H pylori infection and lung cancer was not supported in this study. Further studies with larger sample sizes should be undertaken to assess the frequency of H pylori infection in patients with lung cancer and their potential association.

A randomised, double-blind, placebo-controlled study to evaluate the role of formoterol in the management of acute asthma.

AIM: To evaluate the efficacy and tolerability of formoterol delivered by Aerolizer in the emergency department. METHODS: A single-centre, double-blind, randomised, placebo-controlled, parallel group study was conducted in patients seeking emergent care for an acute exacerbation of asthma. Patients were randomly assigned to one of two groups: group 1 (salbutamol), receiving a total dose of 600 microg salbutamol (200+200+200) delivered by a meter-dose inhaler into a spacer device as two puffs at 20 min intervals; and group 2 (formoterol), receiving formoterol 24 microg (12+12) as two dry powder capsules each containing 12 microg of formoterol via Aerolizer at 20 min intervals. The peak expiratory flow rate (PEFR) was measured at baseline and 5 min after the second and third doses. RESULTS: 60 subjects receiving salbutamol (n = 28) or formoterol (n = 32) completed the study. Age, gender, baseline PEFR, duration of asthma and previous medication were balanced between the two groups. Mean PEFR increased significantly over baseline values in both the salbutamol and formoterol groups (63% in the salbutamol group, p = 0.001, and 55% in the formoterol group, p = 0.001). No significant difference was observed in the increase in PEFR between the groups (p = 0.99, 95% CI -29.62 to 29.59). The proportion of patients reporting adverse events was similar in the two groups. CONCLUSION: Formoterol was found to be well tolerated and as effective as salbutamol in the management of acute asthma. Further studies are needed to follow the patients after discharge from the emergency room to compare the long-term effect of formoterol on patients' stability.