Multicenter Evaluation of AI-generated DIR and PSIR for Cortical and Juxtacortical Multiple Sclerosis Lesion Detection.

Background Cortical multiple sclerosis lesions are clinically relevant but inconspicuous at conventional clinical MRI. Double inversion recovery (DIR) and phase-sensitive inversion recovery (PSIR) are more sensitive but often unavailable. In the past 2 years, artificial intelligence (AI) was used to generate DIR and PSIR from standard clinical sequences (eg, T1-weighted, T2-weighted, and fluid-attenuated inversion-recovery sequences), but multicenter validation is crucial for further implementation. Purpose To evaluate cortical and juxtacortical multiple sclerosis lesion detection for diagnostic and disease monitoring purposes on AI-generated DIR and PSIR images compared with MRI-acquired DIR and PSIR images in a multicenter setting. Materials and Methods Generative adversarial networks were used to generate AI-based DIR (n = 50) and PSIR (n = 43) images. The number of detected lesions between AI-generated images and MRI-acquired (reference) images was compared by randomized blinded scoring by seven readers (all with >10 years of experience in lesion assessment). Reliability was expressed as the intraclass correlation coefficient (ICC). Differences in lesion subtype were determined using Wilcoxon signed-rank tests. Results MRI scans of 202 patients with multiple sclerosis (mean age, 46 years ± 11 [SD]; 127 women) were retrospectively collected from seven centers (February 2020 to January 2021). In total, 1154 lesions were detected on AI-generated DIR images versus 855 on MRI-acquired DIR images (mean difference per reader, 35.0% ± 22.8; P < .001). On AI-generated PSIR images, 803 lesions were detected versus 814 on MRI-acquired PSIR images (98.9% ± 19.4; P = .87). Reliability was good for both DIR (ICC, 0.81) and PSIR (ICC, 0.75) across centers. Regionally, more juxtacortical lesions were detected on AI-generated DIR images than on MRI-acquired DIR images (495 [42.9%] vs 338 [39.5%]; P < .001). On AI-generated PSIR images, fewer juxtacortical lesions were detected than on MRI-acquired PSIR images (232 [28.9%] vs 282 [34.6%]; P = .02). Conclusion Artificial intelligence-generated double inversion-recovery and phase-sensitive inversion-recovery images performed well compared with their MRI-acquired counterparts and can be considered reliable in a multicenter setting, with good between-reader and between-center interpretative agreement. Published under a CC BY 4.0 license. Supplemental material is available for this article. See also the editorial by Zivadinov and Dwyer in this issue.

Diagnostic performance of computed tomography features in detecting oropharyngeal squamous cell carcinoma extranodal extension.

OBJECTIVES: Accurate pre-treatment imaging determination of extranodal extension (ENE) could facilitate the selection of appropriate initial therapy for HPV-positive oropharyngeal squamous cell carcinoma (HPV + OPSCC). Small studies have associated 7 CT features with ENE with varied results and agreement. This article seeks to determine the replicable diagnostic performance of these CT features for ENE. METHODS: Five expert academic head/neck neuroradiologists from 5 institutions evaluate a single academic cancer center cohort of 75 consecutive HPV + OPSCC patients. In a web-based virtual laboratory for imaging research and education, the experts performed training on 7 published CT features associated with ENE and then independently identified the "single most (if any) suspicious" lymph node and presence/absence of each of the features. Inter-rater agreement was assessed using percentage agreement, Gwet's AC1, and Fleiss' kappa. Sensitivity, specificity, and positive and negative predictive values were calculated for each CT feature based on histologic ENE. RESULTS: All 5 raters identified the same node in 52 cases (69%). In 15 cases (20%), at least one rater selected a node and at least one rater did not. In 8 cases (11%), all raters selected a node, but at least one rater selected a different node. Percentage agreement and Gwet's AC1 coefficients were > 0.80 for lesion identification, matted/conglomerated nodes, and central necrosis. Fleiss' kappa was always < 0.6. CT sensitivity for histologically confirmed ENE ranged 0.18-0.94, specificity 0.41-0.88, PPV 0.26-0.36, and NPV 0.78-0.96. CONCLUSIONS: Previously described CT features appear to have poor reproducibility among expert head/neck neuroradiologists and poor predictive value for histologic ENE. KEY POINTS: • Previously described CT imaging features appear to have poor reproducibility among expert head and neck subspecialized neuroradiologists as well as poor predictive value for histologic ENE. • Although it may still be appropriate to comment on the presence or absence of these CT features in imaging reports, the evidence indicates that caution is warranted when incorporating these features into clinical decision-making regarding the likelihood of ENE.

Microstructural Changes in the Left Mesocorticolimbic Pathway are Associated with the Comorbid Development of Fatigue and Depression in Multiple Sclerosis.

BACKGROUND AND PURPOSE: Lower reward responsiveness has been associated with fatigue in multiple sclerosis (MS). However, association of MS-related fatigue with damage to the mesocorticolimbic reward pathway (superolateral medial forebrain bundle [slMFB]) has not been assessed. We investigated the association of fatigue and depression with slMFB damage in MS patients stratified based on longitudinal fatigue patterns. METHODS: Patient stratification: 1. Sustained Fatigue (SF): latest two Modified Fatigue Impact Scale (MFIS) ≥ 38 (n = 26); 2. Reversible Fatigue (RF): latest MFIS < 38, and at least one previous MFIS ≥ 38 (n = 25); 3. Never Fatigued (NF): ≥ 5 consecutive MFIS < 38 (n = 42); 4. Healthy Controls (n = 6). Diffusion MRI-derived measures of fractional anisotropy (FA), axial (AD), mean (MD), and radial diffusivity (RD) of the slMFB were compared between the groups. Depression was assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D). RESULTS: Depressed (CES-D ≥ 16) SF patients showed significantly higher MD and RD than nondepressed SF and RF, and depressed RF patients, and significantly lower FA than nondepressed SF and depressed RF patients in their left slMFB. Depressed SF patients showed significantly higher left slMFB MD and AD than healthy controls. CONCLUSION: Microstructural changes to the left slMFB may play a role in the comorbid development of fatigue and depression in MS.

Identification and Characterization of Leptomeningeal Metastases Using SPINE, A Web-Based Collaborative Platform.

BACKGROUND AND PURPOSE: Leptomeningeal metastases (LMs) carry a poor prognosis. Existing LM scoring systems show limited reproducibility. We assessed the contribution of education level on the reproducibility of LM scoring using structured planning and implementation of new experiments (SPINE), a novel web-based platform. METHODS: Stringent radiological definitions of LM and a customized interactive scoring system were implemented in SPINE. Five patients with brain LM and 3 patients with spine, but no brain LM, were selected. Each patient's baseline post-contrast T1-weighted brain MRI was analyzed by three attending neuroradiologists, two neuroradiology fellows, and two radiology residents. Raters identified and characterized all LMs based on: (1) location (cerebrum, cerebellum, brainstem, ventricle, and/or cranial nerves); (2) shape (nodular and/or linear/curvilinear); (3) size (≥ or <5mm in two orthogonal diameters); (4) spatial extension (focal or diffuse). Inter-rater agreement and association of LM with patient survival were investigated. RESULTS: On average, 6.5 LMs per case were detected. Forty-nine percent of LMs were cerebral, 77.7% were nodular, 86.6% were focal, and 66% were <5 × 5 mm. Agreement on the total number of LMs and the above-mentioned common LM characteristics was higher between attendings (intra-class correlation [ICC] = 0.8-0.94) than fellows (ICC = 0.6-0.82) or residents (ICC = 0.43-0.73). Agreement on ventricular, cranial nerve, and nodular + linear LM was low even between attendings. The number of brainstem LMs showed significant correlation with survival. CONCLUSION: Structured education using SPINE may improve consistency in LM reporting. Future work should address the impact of the presented approach on the reproducibility of longitudinal analyses directly relevant to the assessment of treatment-response.

Microstructural fronto-striatal and temporo-insular alterations are associated with fatigue in patients with multiple sclerosis independent of white matter lesion load and depression.

BACKGROUND: Fatigue in multiple sclerosis (MS) has been inconsistently associated with disruption of specific brain circuitries. Temporal fluctuations of fatigue have not been considered. OBJECTIVE: The aim of this study was to investigate the association of fatigue with brain diffusion abnormalities, using robust criteria for patient stratification based on longitudinal patterns of fatigue. METHODS: Patient stratification: (1) sustained fatigue (SF, n = 26): latest two Modified Fatigue Impact Scale (MFIS) ⩾ 38; (2) reversible fatigue (RF, n = 25): latest MFIS < 38 and minimum one previous MFIS ⩾ 38; and (3) never fatigued (NF, n = 42): MFIS always < 38 (five assessments minimum). 3T brain magnetic resonance imaging (MRI) was used to perform voxel-wise comparison of fractional anisotropy (FA) between the groups controlling for age, sex, disease duration, physical disability, white matter lesion load (T2LV), and depression. RESULTS: SF and, to a lesser extent, RF patients showed lower FA in multiple brain regions compared to NF patients, independent of age, sex, disease duration, and physical disability. In cingulo-postcommissural-striato-thalamic regions, the differences in FA between SF and NF (but not between RF and NF or SF) patients were independent of T2LV, and in ventromedial prefronto-precommissuro-striatal and temporo-insular areas, independent of T2LV and depression. CONCLUSION: Damage to ventromedial prefronto-precommissuro-striatal and temporo-insular pathways appears to be a specific substrate of SF in MS.

Voxel-wise assessment of lung aeration changes on CT images using image registration: application to acute respiratory distress syndrome (ARDS).

PURPOSE: (1) To improve the accuracy of global and regional alveolar-recruitment quantification in CT scan pairs by accounting for lung-tissue displacements and deformation, (2) To propose a method for local-recruitment calculation. METHODS: Recruitment was calculated by subtracting the quantity of non-aerated lung tissues between expiration and inspiration. To assess global recruitment, lung boundaries were first interactively delineated at inspiration, and then they were warped based on automatic image registration to define the boundaries at expiration. To calculate regional recruitment, the lung mask defined at inspiration was cut into pieces, and these were also warped to encompass the same tissues at expiration. Local-recruitment map was calculated as follows: For each voxel at expiration, the matching location at inspiration was determined by image registration, non-aerated voxels were counted in the neighborhood of the respective locations, and the voxel count difference was normalized by the neighborhood size. The methods were evaluated on 120 image pairs of 12 pigs with experimental acute respiratory distress syndrome. RESULTS: The dispersion of global- and regional-recruitment values decreased when using image registration, compared to the conventional approach neglecting tissue motion. Local-recruitment maps overlaid onto the original images were visually consistent, and the sum of these values over the whole lungs was very close to the global-recruitment estimate, except four outliers. CONCLUSIONS: Image registration can compensate lung-tissue displacements and deformation, thus improving the quantification of alveolar recruitment. Local-recruitment calculation can also benefit from image registration, and its values can be overlaid onto the original image to display a local-recruitment map. They also can be integrated over arbitrarily shaped regions to assess regional or global recruitment.

¿Trombolisis o trombólisis? / Thrombolysis?

En medicina se emplean términos compuestos para describir fenómenos o accio-nes específicas, como "hemolisis", "trombolisis" y "fibrinolisis", en ocasiones de forma inadecuada y sin respetar su origen lingüístico. Aunque al usarlos en la práctica muchas veces se usa la acentuación llana antietimológica (probablemente por influencia del francés), el sufijo 'lisis' tiene una connotación particular.

Delirium y Delirio / Delirium and delusion

Aunque algunos utilizan los términos "delirium" para referirse al enfermo con síndrome mental orgánico caracterizado por confusión y desorientación, y "delirio" para hablar de la alteración psiquiátrica en la cual el individuo tiene una creencia firme pero errónea, en realidad no existe una diferencia semántica entre ellos sino que corresponden a la forma en español (delirio) y la raíz latina (delirium) del mismo vocablo, por lo que son intercambiables.

A tree-matching algorithm: Application to airways in CT images of subjects with the acute respiratory distress syndrome.

To match anatomical trees such as airways, we propose a graph-based strategy combined with an appropriate distance function. The strategy was devised to cope with topological and geometrical differences that may arise between trees corresponding to the same subject, but extracted from images acquired in different conditions. The proposed distance function, called father/family distance, combines topological and geometrical information in a single measure, by calculating a sum of path-to-path distances between sub-trees of limited extent. To use it successfully, the branches of these sub-trees need to be brought closer, which is obtained by successively translating the roots of these sub-trees prior to their actual matching. The work herein presented contributes to a study of the acute respiratory distress syndrome, where a series of pulmonary CT images from the same subject is acquired at varying settings (pressure and volume) of the mechanical ventilation. The method was evaluated on 45 combinations of synthetic trees, as well as on 15 pairs of real airway trees: nine corresponding to end-expiration and end-inspiration with the same pressure, and six corresponding to end-inspiration with significantly different pressures. It achieved a high rate of successful matches with respect to a hand-made reference containing a total of 2391 matches in real data: sensitivity of 94.3% and precision of 92.8%, when using the basic parameter settings of the algorithm.

Evaluación de las prescripciones autorizadas entre 2010 y 2011 por vía judicial en Bogotá, D.C., Colombia / Evaluation of prescriptions authorized between 2010 and 2011 through judicial protection in Bogotá

Resumen Introducción. La tutela es una herramienta legal empleada para garantizar el derecho a la salud en Colombia. Objetivo. Evaluar la racionalidad terapéutica de prescripciones de medicamentos autorizadas por tutela en pacientes afiliados al Sistema General de Seguridad Social en Salud. Materiales y métodos. Estudio descriptivo con recolección retrospectiva de información de bases de datos e historias clínicas de pacientes con medicamentos ordenados por acción judicial para tres aseguradoras en Bogotá, D.C. durante los años 2010 y 2011. Se consideraron la indicación, los consumos, las dosis, la duplicidad terapéutica, el riesgo de interacciones y los costos. Resultados. Se obtuvo información de 3 469 pacientes que solicitaron 2 419 medicamentos por tutela, siendo los más comunes antiepilépticos (10.7%), vitaminas (10%), hipoleipemiantes (5%)y antidiabéticos (4.8%). En el 75.5% de los casos el medicamento se correlacionó con el diagnóstico y el 66% de los pacientes estuvo expuesto a riesgos de interacciones farmacológicas. Se observó mayor duplicidad terapéutica en antiinflamatorios no esteroideos y antihipertensivos. El costo promedio de cada dispensación por tutela se estimó en COP 453 221 (USD 236.5). Conclusiones. Se evidencian problemas de racionalidad terapéutica en medicamentos ordenados por tutela, lo cual puede implicar mayores riesgos para la salud de los pacientes. Es recomendable un asesoramiento científico más riguroso con la finalidad de evitar posibles riesgos de interacciones y duplicidades terapéuticas.

Abstract Introduction: Judicial protection (tutela in Spanish) is a legal tool used to ensure the right to health in Colombia. Objective: To evaluate the therapeutic rationale of drug prescriptions authorized through judicial protection for patients enrolled in the General Social Security Health System. Materials and methods: Descriptive study with retrospective collection of information from databases and patient records associated with medications ordered by court action against three health insurers in Bogotá, D.C., during 2010 and 2011. Prescription, consumption, doses, therapeutic duplication, risk of interactions and costs were considered. Results: Information of 3 469 patients who requested 2 419 prescribed drugs through judicial protection was obtained; the most common drugs were anticonvulsants (10.7%), vitamins (10%), lipid-lowering medications (5%) and anti-diabetic drugs (4.8%). In 75.5% of cases the drug was correlated with the diagnosis and 66% of patients were exposed to drug interaction risks. Greater therapeutic duplication was observed in non-steroidal anti-inflammatory and antihypertensive drugs. The average cost of each dispensation per judicial protection issued was estimated at COP 453 221 (USD 236.5). Conclusions: Therapeutic rationality issues are evident in prescription drugs ordered by judicial protection, which may involve greater risks to the health of patients. A more rigorous scientific advice is recommended in order to avoid possible interactions and therapeutic duplications.

Hipoventilación / Hypoventilation

Es frecuente encontrar el mal uso del vocablo hipoventilación pretendiendo expresar el hallazgo clínico de la disminución de los ruidos respitatorios. Este uso es inaceptable, ya que este término no se refiere a un signo de la semiología pulmonar sino a un trastorno de la fisiología respiratoria en que diversas situaciones patológicas conducen a hipoventilación alveolar, la que se confirma mediante la gasimetría arterial (aumento de la PaCO2 y disminución de la PaO2.

La Asociación Colombiana de Medicina Interna y la recertificación en medicina interna en Colombia / The Colombian Association of Internal Medicine and recertification in internal medicine in Colombia

El ejercicio de la Medicina Interna se enfrenta a retos permanentes dado el entorno dinámico del cuidado de la salud, en el que los avances de las ciencias biomédicas deben integrarse racionalmente para proporcionar a la población una atención en salud coordinada y eficiente. Los numerosos desarrollos científicos y tecnológicos hacen de nuestra profesión médica una ciencia en cambio continuo, lo que exige al especialista la necesidad de mantenerse actualizado para procurar la mejor atención de sus pacientes. Los estudios demuestran que en general, con el paso del tiempo el conocimiento médico se deteriora, y que los hábitos y patrones de la práctica médica fallan en cambiar en respuesta a los avances científicos (1). Uno de ellos concluyó que el tiempo transcurrido desde la última certificación del médico, se correlaciona con la disminución en la calidad de la atención de sus pacientes con hipertensión arterial. También se ha demostrado que los médicos que renuevan frecuentemente sus conocimientos y habilidades mediante metodologías estructuradas de mejoramiento de la calidad, logran mejor cuidado de sus pacientes, por ejemplo, una mejor calidad de atención a los pacientes con infarto agudo de miocardio se relacionó con disminución de mortalidad del 15% (2-4). Análisis recientes indican que los médicos recertificados ofrecen a sus pacientes cuidados de salud de mayor calidad que quienes no lo están, y esto se correlaciona con mejor desempeño en un amplio rango de medidas de calidad, desenlaces favorables, atención más segura y mayores índices en actividades de prevención.

Bacteriemia / Bacteremia

Con frecuencia se utiliza equivocadamente la palabra bacteremia para referirse a la detección de bacterias en el torrente sanguíneo. Aunque en inglés esta expresión es adecuada, dada la adaptación en ese idioma del término francés bactériémie (acuñado por Vulpian en 1874), en nuestro idioma dicho vocablo debe conservar la raíz completa en el prefijo, por lo que la forma correcta es: Bacteriemia: (Del francés bactériémie, y éste del griego científico bakteri- 'bacteria' + -haimíã 'sangre'): 1. s.f. Presencia de bacterias en la sangre. 2. f. Med. Presencia de patógenos en la sangre circulante

Síndrome metabólico en trabajadores de un hospital de nivel III de atención Estudio SIMETRA / Metabolic syndrome in workers of a level III care hospital SIMETRA study

Introducción: el síndrome metabólico (SM) se caracteriza por obesidad, hiperglucemia o diabetes, hipertensión arterial y dislipidemia. La presencia de este síndrome incrementa el riesgo de enfermedades cardiovasculares, con el consecuente aumento de la mortalidad. Objetivo: determinar la frecuencia del SM y sus componentes en los trabajadores de un hospital de III nivel de atención, utilizando tanto los criterios de la Federación Internacional de Diabetes (IDF) como la definición unificada (armonizada). Metodología: estudio descriptivo transversal realizado en personal del Hospital Universitario de La Samaritana de Bogotá. Para 1.140 trabajadores, considerando prevalencia de 26% e IC 95%, se calculó una muestra de 235 sujetos, a quienes se les realizó encuesta personalizada, exámenes paraclínicos (perfil lipídico y glucemia) y toma de medidas antropométricas (peso, talla, perímetro de cintura y tensión arterial). Para el análisis, la muestra se distribuyó en dos grupos: Administrativo (sin formación específica en el área de salud) y Salud (con dicha formación), para determinar la posible relación entre prevalencia de SM y conocimiento previo sobre este síndrome. Resultados: se obtuvo información completa de 209 trabajadores: 83 (39.7%) en Administrativo y 126 (60.3%) en Salud; la mayoría (50.7%) con edad entre 35 y 50 años, y con predominio de mujeres (72.7%). La frecuencia de SM fue 28.7% por criterios unificados (armonizados) y 26.3% por IDF; utilizando los primeros la frecuencia fue 30.1% en el grupo Administrativo y 27.8% en el grupo Salud, diferencia sin significancia estadística. El SM fue más frecuente en mayores de 50 años (46.4%) y en los niveles educativos secundaria (42.9%) y técnico (32.5%). El análisis de frecuencia según conocimiento previo sobre SM y sus componentes no mostró diferencia estadísticamente significativa. Conclusiones: la frecuencia de SM en trabajadores de este hospital universitario es tan alta como la reportada para la población general. Los datos sugieren que aunque el personal de salud posee conocimiento básico sobre el SM no toma acciones eficaces para evitarlo.

Introduction: metabolic syndrome (MS) is characterized by obesity, hyperglycemia or diabetes, hypertension and dyslipidemia. The presence of this syndrome increases the risk of cardiovascular disease, with a consequent increase in mortality. Objective: to determine the frequency of MS and its components in workers of a tertiary level of care hospital, using both the criteria of the International Diabetes Federation (IDF) and the unified definition (harmonized). Methods: cross-sectional study made in staff of the University Hospital La Samaritana, in Bogota. For 1, 140 workers, considering a prevalence of 26% and CI 95%, a sample of 235 subjects who underwent personalized survey, laboratory tests (lipid profile and glucose) and taking of anthropometric measurements (weight, height, waist perimeter and blood pressure) was calculated. For analysis, the sample was divided into 2 groups: Administrative (without specific training in the area of health) and health (with health training) to determine the possible relationship between MS prevalence and prior knowledge about this syndrome. Results: complete information was obtained from 209 workers: 83 (39.7%) in Administrative and 126 (60.3%) in Health; the majority (50.7%) aged between 35 and 50 years and female predominance(72.7%). The frequency of MS was 28.7% for unified standards (harmonized) and 26.3% for IDF; using the first, the frequency was 30.1% in the Administrative group and 27.8% in the group Health, difference not statistically significant. MS was more frequent in patients over 50 years (46.4%) and in the educational levels Secondary (42.9%) and Technical (32.5%). The frequency analysis according to prior knowledge of MS and its components showed no statistically significant difference. Conclusions: the frequency of MS in this university hospital workers is as high as that reported for the general population. The data suggest that although health staff has basic knowledge of the MS, does not take effective action to prevent it.