A Multicenter Assessment of Interreader Reliability of LI-RADS Version 2018 for MRI and CT.

Background Various limitations have impacted research evaluating reader agreement for Liver Imaging Reporting and Data System (LI-RADS). Purpose To assess reader agreement of LI-RADS in an international multicenter multireader setting using scrollable images. Materials and Methods This retrospective study used deidentified clinical multiphase CT and MRI and reports with at least one untreated observation from six institutions and three countries; only qualifying examinations were submitted. Examination dates were October 2017 to August 2018 at the coordinating center. One untreated observation per examination was randomly selected using observation identifiers, and its clinically assigned features were extracted from the report. The corresponding LI-RADS version 2018 category was computed as a rescored clinical read. Each examination was randomly assigned to two of 43 research readers who independently scored the observation. Agreement for an ordinal modified four-category LI-RADS scale (LR-1, definitely benign; LR-2, probably benign; LR-3, intermediate probability of malignancy; LR-4, probably hepatocellular carcinoma [HCC]; LR-5, definitely HCC; LR-M, probably malignant but not HCC specific; and LR-TIV, tumor in vein) was computed using intraclass correlation coefficients (ICCs). Agreement was also computed for dichotomized malignancy (LR-4, LR-5, LR-M, and LR-TIV), LR-5, and LR-M. Agreement was compared between research-versus-research reads and research-versus-clinical reads. Results The study population consisted of 484 patients (mean age, 62 years ± 10 [SD]; 156 women; 93 CT examinations, 391 MRI examinations). ICCs for ordinal LI-RADS, dichotomized malignancy, LR-5, and LR-M were 0.68 (95% CI: 0.61, 0.73), 0.63 (95% CI: 0.55, 0.70), 0.58 (95% CI: 0.50, 0.66), and 0.46 (95% CI: 0.31, 0.61) respectively. Research-versus-research reader agreement was higher than research-versus-clinical agreement for modified four-category LI-RADS (ICC, 0.68 vs 0.62, respectively; P = .03) and for dichotomized malignancy (ICC, 0.63 vs 0.53, respectively; P = .005), but not for LR-5 (P = .14) or LR-M (P = .94). Conclusion There was moderate agreement for LI-RADS version 2018 overall. For some comparisons, research-versus-research reader agreement was higher than research-versus-clinical reader agreement, indicating differences between the clinical and research environments that warrant further study. © RSNA, 2023 Supplemental material is available for this article. See also the editorials by Johnson and Galgano and Smith in this issue.

Interreader Reliability of LI-RADS Version 2014 Algorithm and Imaging Features for Diagnosis of Hepatocellular Carcinoma: A Large International Multireader Study.

Purpose To determine in a large multicenter multireader setting the interreader reliability of Liver Imaging Reporting and Data System (LI-RADS) version 2014 categories, the major imaging features seen with computed tomography (CT) and magnetic resonance (MR) imaging, and the potential effect of reader demographics on agreement with a preselected nonconsecutive image set. Materials and Methods Institutional review board approval was obtained, and patient consent was waived for this retrospective study. Ten image sets, comprising 38-40 unique studies (equal number of CT and MR imaging studies, uniformly distributed LI-RADS categories), were randomly allocated to readers. Images were acquired in unenhanced and standard contrast material-enhanced phases, with observation diameter and growth data provided. Readers completed a demographic survey, assigned LI-RADS version 2014 categories, and assessed major features. Intraclass correlation coefficient (ICC) assessed with mixed-model regression analyses was the metric for interreader reliability of assigning categories and major features. Results A total of 113 readers evaluated 380 image sets. ICC of final LI-RADS category assignment was 0.67 (95% confidence interval [CI]: 0.61, 0.71) for CT and 0.73 (95% CI: 0.68, 0.77) for MR imaging. ICC was 0.87 (95% CI: 0.84, 0.90) for arterial phase hyperenhancement, 0.85 (95% CI: 0.81, 0.88) for washout appearance, and 0.84 (95% CI: 0.80, 0.87) for capsule appearance. ICC was not significantly affected by liver expertise, LI-RADS familiarity, or years of postresidency practice (ICC range, 0.69-0.70; ICC difference, 0.003-0.01 [95% CI: -0.003 to -0.01, 0.004-0.02]. ICC was borderline higher for private practice readers than for academic readers (ICC difference, 0.009; 95% CI: 0.000, 0.021). Conclusion ICC is good for final LI-RADS categorization and high for major feature characterization, with minimal reader demographic effect. Of note, our results using selected image sets from nonconsecutive examinations are not necessarily comparable with those of prior studies that used consecutive examination series. © RSNA, 2017.

A Pilot Comparative Study of Quantitative Ultrasound, Conventional Ultrasound, and MRI for Predicting Histology-Determined Steatosis Grade in Adult Nonalcoholic Fatty Liver Disease.

OBJECTIVE: The purpose of this study is to explore the diagnostic performance of two investigational quantitative ultrasound (QUS) parameters, attenuation coefficient and backscatter coefficient, in comparison with conventional ultrasound (CUS) and MRI-estimated proton density fat fraction (PDFF) for predicting histology-confirmed steatosis grade in adults with nonalcoholic fatty liver disease (NAFLD). SUBJECTS AND METHODS: In this prospectively designed pilot study, 61 adults with histology-confirmed NAFLD were enrolled from September 2012 to February 2014. Subjects underwent QUS, CUS, and MRI examinations within 100 days of clinical-care liver biopsy. QUS parameters (attenuation coefficient and backscatter coefficient) were estimated using a reference phantom technique by two analysts independently. Three-point ordinal CUS scores intended to predict steatosis grade (1, 2, or 3) were generated independently by two radiologists on the basis of QUS features. PDFF was estimated using an advanced chemical shift-based MRI technique. Using histologic examination as the reference standard, ROC analysis was performed. Optimal attenuation coefficient, backscatter coefficient, and PDFF cutoff thresholds were identified, and the accuracy of attenuation coefficient, backscatter coefficient, PDFF, and CUS to predict steatosis grade was determined. Interobserver agreement for attenuation coefficient, backscatter coefficient, and CUS was analyzed. RESULTS: CUS had 51.7% grading accuracy. The raw and cross-validated steatosis grading accuracies were 61.7% and 55.0%, respectively, for attenuation coefficient, 68.3% and 68.3% for backscatter coefficient, and 76.7% and 71.3% for MRI-estimated PDFF. Interobserver agreements were 53.3% for CUS (κ = 0.61), 90.0% for attenuation coefficient (κ = 0.87), and 71.7% for backscatter coefficient (κ = 0.82) (p < 0.0001 for all). CONCLUSION: Preliminary observations suggest that QUS parameters may be more accurate and provide higher interobserver agreement than CUS for predicting hepatic steatosis grade in patients with NAFLD.

Imaging Outcomes of Liver Imaging Reporting and Data System Version 2014 Category 2, 3, and 4 Observations Detected at CT and MR Imaging.

Purpose To determine the proportion of untreated Liver Imaging Reporting and Data System (LI-RADS) version 2014 category 2, 3, and 4 observations that progress, remain stable, or decrease in category and to compare the cumulative incidence of progression in category. Materials and Methods In this retrospective, longitudinal, single-center, HIPAA-compliant, institutional review board-approved study, 157 patients (86 men and 71 women; mean age ± standard deviation, 59.0 years ± 9.7) underwent two or more multiphasic computed tomographic (CT) or magnetic resonance (MR) imaging examinations for hepatocellular carcinoma surveillance, with the first examination in 2011 or 2012. One radiologist reviewed baseline and follow-up CT and MR images (mean follow-up, 614 days). LI-RADS categories issued in the clinical reports by using version 1.0 or version 2013 were converted to version 2014 retrospectively; category modifications were verified with another radiologist. For index category LR-2, LR-3, and LR-4 observations, the proportions that progressed, remained stable, or decreased in category were calculated. Cumulative incidence curves for progression were compared according to baseline LI-RADS category (by using log-rank tests). Results All 63 index LR-2 observations remained stable or decreased in category. Among 166 index LR-3 observations, seven (4%) progressed to LR-5, and eight (5%) progressed to LR-4. Among 52 index LR-4 observations, 20 (38%) progressed to a malignant category. The cumulative incidence of progression to a malignant category was higher for index LR-4 observations than for index LR-3 or LR-2 observations (each P < .001) but was not different between LR-3 and LR-2 observations (P = .155). The cumulative incidence of progression to at least category LR-4 was trend-level higher for index LR-3 observations than for LR-2 observations (P = .0502). Conclusion Observations classified according to LI-RADS version 2014 categories are associated with different imaging outcomes. (©) RSNA, 2016 Online supplemental material is available for this article.

Diagnostic Accuracy of Preoperative Gadoxetic Acid-enhanced 3-T MR Imaging for Malignant Liver Lesions by Using Ex Vivo MR Imaging-matched Pathologic Findings as the Reference Standard.

PURPOSE: To determine per-lesion sensitivity and positive predictive value (PPV) of gadoxetic acid-enhanced 3-T magnetic resonance (MR) imaging for the diagnosis of malignant lesions by using matched (spatially correlated) hepatectomy pathologic findings as the reference standard. Materials and METHODS: In this prospective, institutional review board-approved, HIPAA-compliant study, 20 patients (nine men, 11 women; mean age, 59 years) with malignant liver lesions who gave written informed consent underwent preoperative gadoxetic acid-enhanced 3-T MR imaging for surgical planning. Two image sets were independently analyzed by three readers to detect liver lesions (set 1 without and set 2 with hepatobiliary phase [HBP] images). Hepatectomy specimen ex vivo MR imaging assisted in matching gadoxetic acid-enhanced 3-T MR imaging findings with pathologic findings. Interreader agreement was assessed by using the Cohen κ coefficient. Per-lesion sensitivity and PPV were calculated. RESULTS: Cohen κ values were 0.64-0.76 and 0.57-0.84, and overall per-lesion sensitivity was 45% (42 of 94 lesions) to 56% (53 of 94 lesions) and 58% (55 of 94 lesions) to 64% (60 of 94 lesions) for sets 1 and 2, respectively. The addition of HBP imaging did not affect interreader agreement but significantly improved overall sensitivity for one reader (P < .05) and almost for another (P = .05). Sensitivity for 0.2-0.5-cm lesions was 0% (0 of 26 lesions) to 8% (two of 26 lesions) for set 1 and 4% (one of 26 lesions) to 12% (three of 26 lesions) for set 2. Sensitivity for 0.6-1.0-cm lesions was 28% (nine of 32 lesions) to 59% (19 of 32 lesions) for set 1 and 66% (21 of 32 lesions) to 69% (22 of 32 lesions) for set 2. Sensitivity for lesions at least 1.0 cm in diameter was at least 81% (13 of 16 lesions) for set 1 and was not improved for set 2. PPV was 98% (56 of 57 lesions) to 100% (60 of 60 lesions) for all readers without differences between image sets or lesion size. CONCLUSION: Gadoxetic acid-enhanced 3-T MR imaging provides high per-lesion sensitivity and PPV for preoperative malignant liver lesion detection overall, although sensitivity for 0.2-0.5-cm malignant lesions is poor.

Hepatobiliary agents and their role in LI-RADS.

The Liver Imaging Reporting and Data System (LI-RADS) was introduced with the goal of standardizing the diagnosis of hepatocellular carcinoma. The 2014 version of LI-RADS incorporates the use of hepatobiliary contrast agents (HBAs) into the diagnostic algorithm, including gadoxetate disodium and gadobenate dimeglumine. Three new ancillary features are introduced: hepatobiliary phase (HBP) hypointensity and HBP hypointense rim favor malignancy, while HBP isointensity favors benignity. HBP hyperintensity favors neither malignancy nor benignity. In this review, we describe how to use these new features as well as numerous pitfalls associated with the use ofHBAs, including hemangiomas, cholangiocarcinomas, and focal confluent fibrosis. Importantly, findings on the HBP are not included as major criteria and therefore the criteria for the diagnosis of LI-RADS 5 observations remain unchanged, and so congruence with the Organ Procurement Transplant Network system remains intact. Additionally, we review how the major features in LI-RADS, arterial phase hyperenhancement, threshold growth, and washout and capsule appearance, may be affected with HBAs. Notably with HBAs, hypointensity on the delayed phase, termed the transitional phase, does not qualify as washout appearance due to the possibility of early parenchymal enhancement. It is hoped that the incorporation of HBAs into LI-RADS will help create consistency when interpreting HBA enhanced MRIs.

Primary hepatic neuroendocrine tumor: A case report and literature review.

INTRODUCTION: Primary hepatic neuroendocrine tumors (PHNETs) are extremely rare, having less than 200 cases reported in the literature. PRESENTATION OF CASE: A 51-year-old woman presenting with mild intensity sharp pain in the upper abdomen that started 4 years ago. Preoperative Magnetic Resonance Imaging (MRI) suggested hepatocellular adenoma. Surgical exploration found a tumor occupying the whole segment IV of the liver, therefore a left hepatectomy was performed. Pathology and immunohistochemistry indicated to be a low-grade neuroendocrine tumor of the liver. The patient is enjoying a good quality of life, free of disease, presenting no signs of recurrence nor metastases 12 months after the procedure. CONCLUSION: The clinical presentation of PHNETs is non-specific and its radiologic features are intensely diversified, frequently leading to misdiagnosis of other hepatic neoplasms.

LI-RADS M (LR-M): definite or probable malignancy, not specific for hepatocellular carcinoma.

LI-RADS v2017 introduces major changes to the diagnostic criteria for LR-M observations to better guide radiologists in the use of this malignant category designation. LR-M is intended to preserve the specificity of the LI-RADS algorithm for diagnosis of HCC while not losing sensitivity for diagnosis of malignancy. The purpose of this paper is to provide a brief background on LR-M, discuss the diagnostic criteria new to v2017, special considerations for its application, and management implications.

Spironolactone Versus Clonidine as a Fourth-Drug Therapy for Resistant Hypertension: The ReHOT Randomized Study (Resistant Hypertension Optimal Treatment).

The aim of this study is to compare spironolactone versus clonidine as the fourth drug in patients with resistant hypertension in a multicenter, randomized trial. Medical therapy adherence was checked by pill counting. Patients with resistant hypertension (no office and ambulatory blood pressure [BP] monitoring control, despite treatment with 3 drugs, including a diuretic, for 12 weeks) were randomized to an additional 12-week treatment with spironolactone (12.5-50 mg QD) or clonidine (0.1-0.3 mg BID). The primary end point was BP control during office (<140/90 mm Hg) and 24-h ambulatory (<130/80 mm Hg) BP monitoring. Secondary end points included BP control from each method and absolute BP reduction. From 1597 patients recruited, 11.7% (187 patients) fulfilled the resistant hypertension criteria. Compared with the spironolactone group (n=95), the clonidine group (n=92) presented similar rates of achieving the primary end point (20.5% versus 20.8%, respectively; relative risk, 1.01 [0.55-1.88]; P=1.00). Secondary end point analysis showed similar office BP (33.3% versus 29.3%) and ambulatory BP monitoring (44% versus 46.2%) control for spironolactone and clonidine, respectively. However, spironolactone promoted greater decrease in 24-h systolic and diastolic BP and diastolic daytime ambulatory BP than clonidine. Per-protocol analysis (limited to patients with ≥80% adherence to spironolactone/clonidine treatment) showed similar results regarding the primary end point. In conclusion, clonidine was not superior to spironolactone in true resistant hypertensive patients, but the overall BP control was low (≈21%). Considering easier posology and greater decrease in secondary end points, spironolactone is preferable for the fourth-drug therapy. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01643434.

Lipid profile and cardiovascular risk in two Amazonian populations.

OBJECTIVE: To compare the lipid profiles and coronary heart disease risks of 2 Brazilian Amazonian populations as follows: a riverside population (village of Vigia) and an urban population (city of Bel m in the state of Par ). METHODS: Fifty individuals controlled for age and sex were assessed in each region, and the major risk factors for coronary heart disease were analyzed. RESULTS: According to the National Cholesterol Education Program (NCEP III) and using the Framingham score, both populations had the same absolute risk of events (Vigia = 5.4 +/- 1 vs Bel m = 5.7 +/- 1), although the population of Vigia had a lower consumption of saturated fat (P<0.0001), a greater consumption of mono- and polyunsaturated fat (P<0.03), in addition to lower values for body mass index (25.4 +/- 0.6 vs 27.6 +/- 0.7 kg/m , P<0.02), of biceps skin fold (18.6 1.1 vs 27.5 +/- 1.3 mm, P<0.0001), of triceps skin fold (28.7 +/- 1.2 vs 37.3 +/- 1.7 mm, P<0.002), and of total cholesterol (205 +/- 5 vs 223 +/- 6 mg/dL, P< 0.03) and triglycerides (119 +/- 9 vs 177 +/- 18 mg/dL, P<0.005). Both populations did not differ in regard to HDL-C (46 +/- 1 vs 46 +/- 1 mg/dL), LDL-C (135 +/- 4 vs 144 +/- 5 mg/dL) and blood pressure (SBP 124 +/- 3 vs 128 +/- 3 mmHg; DBP 80 +/- 2 vs 82 +/- 2 mmHg). CONCLUSION: The riverside and urban populations of Amazonia had similar cardiovascular risks. However, the marked difference in the variables studied suggests that different strategies of prevention should be applied.

Evaluation of the aggressive potential of marine chloride and sulfate salts on mortars applied as renders in the Metropolitan Region of Salvador--Bahia, Brazil.

In recent years, growing interest has focused on determining the performance of materials and evaluating the service life of structures exposed to various environmental forces. In this context, the determination of the aggressive potential of marine salts on mortars used as external renders is critical. The present study aimed to evaluate the spatial distribution of marine salts relative to distance from the sea. This was done by monitoring the deposition rate of chlorides and sulfates in wet candle sensors, located at nine stations scattered around the Metropolitan Region of Salvador, state of Bahia, Brazil. The study also determined the effectiveness of water-soluble salts at penetrating three different types of mortars of varying cement content via deposition and diffusion. The methodology employed enabled an evaluation of the efficiency of the monitoring sensors' measurement of the aggressiveness potential of local marine aerosol, and determination of the comparative performance of the three mortars tested, from the standpoint of resistance to salt penetration. The type and amount of salts captured both in solution and in powder samples extracted from the mortars were determined by ion chromatography. The analysis of the various types of mortars tested indicated which types are more resistant to the aggressive potential of the region's marine aerosol and the distance from the shore where local buildings are liable to be most strongly affected.

Association of lipoprotein lipase D9N polymorphism with myocardial infarction in type 2 diabetes: the genetics, outcomes, and lipids in type 2 diabetes (GOLD) study.

The association of polymorphisms affecting lipid metabolism with the risk of myocardial infarction (MI) in type 2 diabetes mellitus was investigated. The Genetics, Outcomes and Lipids in type 2 Diabetes (GOLD) Study is a prospective, multicenter study, conducted on 990 patients presenting diabetes and MI (n=386), or diabetes without previous manifestation of stroke, peripheral or coronary arterial disease (n=604), recruited from 27 institutions in Brazil. APO A1 (A/G -75 and C/T +83) and APO C3 (C/G 3'UTR) non-coding sequences, CETP (Taq 1B), LPL (D9N), APO E (epsilon2, epsilon3, epsilon4,), PON-1 (Q192R), and two LCAT variants Arg(147)-->Trp and Tyr(171)-->Stop were tested by PCR-RFLP. There was a higher prevalence of LPL DN genotype (19% vs.12%, p=0.03) and a higher frequency of the N allele (11% vs. 7%) among subjects with MI when compared to controls, with an odds ratio of MI for carriers of 9N allele of 2.46 (95% CI=1.79-3.39, p<0.0001). This association was present in men and women, in non-smokers and in hypertensive patients. A logistic regression model including gender, duration of diabetes, systolic blood pressure, HDL-C, left ventricle hypertrophy and D9N polymorphism showed that the latter still remained significantly associated with MI (OR=1.50, 95% CI=1.02-2.25, p=0.049). These findings suggest that D9N polymorphism can be a useful risk marker for myocardial infarction and that further potential candidate genes should be screened for exploratory analysis and for future therapeutic intervention in diabetes.

Sugestões para a implementação do Plano de ação para a redução dos riscos de transmissão da COVID-19 na escola

Texto disponibilizado no curso "Planejamento Escolar Local na Transpandemia" Ministrado pelo Programa de Pós graduação em Ensino de Biociências e Saúde do IOC/Fiocruz, disponibilizado no Campus Virtual da fiocruz

Vigilância escolar em saúde com participação comunitária

Texto elaborado para o curso "Planejamento Escolar Local na Transpandemia" - Minicurso 1- Oferecido pelo PGPGEBS/Fiocruz no Campus Virtual.

Sugestões para a implementação do Plano de Ação para a redução dos riscos de transmissão da COVID-19 na escola (1)

Sugestão de plano de reabertura de escolas na pandemia de COVID-19.

Vigilância em saúde escolar com participação comunitária (2)

Aborda a implementação da vigilância escolar em saúde com participação comunitária para o enfrentamento da da COVID-19 nas escolas, de maneira intersetorial, com ênfase no engajamento comunitário e na criação de comissões internas e constituição de uma "sala de situação escolar" para a microgestão local (na escola) da pandemia.