HUNCHEST-II contributes to a shift to earlier-stage lung cancer detection: final results of a nationwide screening program.

OBJECTIVES: The introduction of low-dose CT (LDCT) altered the landscape of lung cancer (LC) screening and contributed to the reduction of mortality rates worldwide. Here we report the final results of HUNCHEST-II, the largest population-based LDCT screening program in Hungary, including the screening and diagnostic outcomes, and the characteristics of the LC cases. METHODS: A total of 4215 high-risk individuals aged between 50 and 75 years with a smoking history of at least 25 pack-years were assigned to undergo LDCT screening. Screening outcomes were determined based on the volume, growth, and volume doubling time of pulmonary nodules or masses. The clinical stage distribution of screen-detected cancers was compared with two independent practice-based databases consisting of unscreened LC patients. RESULTS: The percentage of negative and indeterminate tests at baseline were 74.2% and 21.7%, respectively, whereas the prevalence of positive LDCT results was 4.1%. Overall, 76 LC patients were diagnosed throughout the screening rounds (1.8% of total participants), out of which 62 (1.5%) patients were already identified in the first screening round. The overall positive predictive value of a positive test was 58%. Most screen-detected malignancies were stage I LCs (60.7%), and only 16.4% of all cases could be classified as stage IV disease. The percentage of early-stage malignancies was significantly higher among HUNCHEST-II screen-detected individuals than among the LC patients in the National Koranyi Institute of Pulmonology's archive or the Hungarian Cancer Registry (p < 0.001). CONCLUSIONS: HUNCHEST-II demonstrates that LDCT screening for LC facilitates early diagnosis, thus arguing in favor of introducing systematic LC screening in Hungary. CLINICAL RELEVANCE STATEMENT: HUNCHEST-II is the so-far largest population-based low-dose CT screening program in Hungary. A positive test's overall positive predictive value was 58%, and most screen-detected malignancies were early-stage lesions. These results pave the way for expansive systematic screening in the region. KEY POINTS: • Conducted in 18 medical facilities, HUNCHEST-II is the so far largest population-based low-dose CT screening program in Hungary. • The vast majority of screen-detected malignancies were early-stage lung cancers, and the overall positive predictive value of a positive test was 58%. • HUNCHEST-II facilitates early diagnosis, thus arguing in favor of introducing systematic lung cancer screening in Hungary.

The importance of chest CT severity score and lung CT patterns in risk assessment in COVID-19-associated pneumonia: a comparative study.

Introduction: Chest computed tomography (CT) is suitable to assess morphological changes in the lungs. Chest CT scoring systems (CCTS) have been developed and use in order to quantify the severity of pulmonary involvement in COVID-19. CCTS has also been correlated with clinical outcomes. Here we wished to use a validated, relatively simple CTSS to assess chest CT patterns and to correlate CTSS with clinical outcomes in COVID-19. Patients and methods: Altogether 227 COVID-19 cases underwent chest CT scanning using a 128 multi-detector CT scanner (SOMATOM Go Top, Siemens Healthineers, Germany). Specific pathological features, such as ground-glass opacity (GGO), crazy-paving pattern, consolidation, fibrosis, subpleural lines, pleural effusion, lymphadenopathy and pulmonary embolism were evaluated. CTSS developed by Pan et al. (CTSS-Pan) was applied. CTSS and specific pathologies were correlated with demographic, clinical and laboratory data, A-DROP scores, as well as outcome measures. We compared CTSS-Pan to two other CT scoring systems. Results: The mean CTSS-Pan in the 227 COVID-19 patients was 14.6 ± 6.7. The need for ICU admission (p < 0.001) and death (p < 0.001) were significantly associated with higher CTSS. With respect to chest CT patterns, crazy-paving pattern was significantly associated with ICU admission. Subpleural lines exerted significant inverse associations with ICU admission and ventilation. Lymphadenopathy was associated with all three outcome parameters. Pulmonary embolism led to ICU admission. In the ROC analysis, CTSS>18.5 significantly predicted admission to ICU (p = 0.026) and CTSS>19.5 was the cutoff for increased mortality (p < 0.001). CTSS-Pan and the two other CTSS systems exerted similar performance. With respect to clinical outcomes, CTSS-Pan might have the best performance. Conclusion: CTSS may be suitable to assess severity and prognosis of COVID-19-associated pneumonia. CTSS and specific chest CT patterns may predict the need for ventilation, as well as mortality in COVID-19. This can help the physician to guide treatment strategies in COVID-19, as well as other pulmonary infections.

Full Body Surface Coverage with Water-Equivalent Bolus as Novel Technique for Total Body Irradiation before Hematopoietic Stem Cell Transplantation in Pediatric Acute Lymphoid Leukemia.

BACKGROUND: Total body irradiation (TBI) 2 × 2 Gy for 3 consecutive days followed by chemotherapy for conditioning pediatric patients with acute lymphoid leukemia (ALL) before bone marrow transplantation is superior to chemo-conditioning alone. The globally used anterior-posterior/posterior-anterior (AP/PA) technique is the most referable method, but volumetric modulated arc therapy (VMAT) with modern linear accelerators is more precise in terms of ensuring better dose distribution, especially for skin, and higher protection of organs at risk, resulting in less side effects. METHOD: For TBI, a modern VMAT technique was used. Whole-body immobilization in the supine position was performed using a vacuum mattress with a full body coverage, with a water-equivalent bolus of 1 cm thickness. The design goal was to achieve dose inhomogeneity of less than ±10%. RESULTS: From 2020 to 2022, we performed TBI for five pediatric patients with ALL, with full body bolus and VMAT, who later received hematopoietic stem cell transplantation. No acute complications related to TBI were observed during the treatment period with a median follow-up of 1.27 (0.43-2.11) years. CONCLUSION: Using full body water-equivalent bolus with VMAT for TBI provides a safe method for children with a better organ sparing in the short term follow-up.

The Impact of COVID-19 on the Health and Experience of the Carers of Older Family Members Living with Dementia: An Italian-Hungarian Comparative Study.

This quantitative study (n = 370) compares the pandemic-related experiences of the family carers of older people living with dementia during the first wave of the pandemic, in two countries with different care regimes: Italy (Mediterranean) and Hungary (Eastern European). It aims at answering the following research questions: (1) How did the pandemic affect the subjective health of carers, and what were their experiences with care-related worries and workload? (2) What factors significantly predicted negative changes in these experiences? (3) What were carers' main difficulties during the first pandemic wave? Results have shown that carers in both samples reported a worsening in mental health (Italy/Hungary: M = 2.25/2.55, SD = 0.93/0.99), and Italian carers also in general health (M = 2.54, SD = 0.98) (on a scale of 1 to 5, with values under "3" representing deterioration). Carers in both samples experienced high worry levels (Italy/Hungary: M = 4.2/3.7, SD = 0.93/0.89) and feeling overwhelmed with care tasks (M = 3.2/3.7, SD = 1.3/1.3) (on a scale of 1 to 5, higher values representing higher worry/work overload). In regression models, all of the above negative experiences were predicted by a combination of factors. Two of these factors stood out in importance due to being a predictor of more than one type of negative experience: a decline in the carer-care receiver relationship, predicting work overload, as well as general and mental health deterioration and being the child of the care receiver, predicting both high worry and subjective work overload. The top five encountered problems were the unavailability of medical and social care, difficulties with shopping (medicine included), restricted freedom, isolation, and anxiety.

Treatment Algorithm for Cancerous Wounds: A Systematic Review.

BACKGROUND: In advanced cancer stage the incidence of cancerous wounds is about 5%, and the estimated life expectancy is not more than 6 to 12 months. Without interdisciplinary and individualized treatment strategy, symptoms progress, and adversely influence quality of life. METHODS: Authors collected different treatment algorithms for cancerous wound published by wide scale of medical expertise, and summarized surgical, oncological, radiation oncological, nursing and palliative care aspects based on radiological information. RESULTS: Interdisciplinary approach with continuous consultation between various specialists can solve or ease the hopeless cases. CONCLUSIONS: This distressing condition needs a comprehensive treatment solution to alleviate severe symptoms. Non-healing fungating wounds without effective therapy are severe socio-economic burden for all participants, including patients, caregivers, and health services. In this paper authors collected recommendations for further guideline that is essential in the near future.

Lumbar spine abnormalities in patients with obstructive sleep apnoea.

Previous studies suggested cervical spondylosis as a risk factor for development of obstructive sleep apnoea (OSA). We aimed to assess lumbar disc degeneration in patients with OSA and correlate the findings with symptoms and disease severity. Twenty-seven patients with OSA and 29 non-OSA controls underwent sleep studies and lumbar magnetic resonance imaging (MRI), and completed the Epworth Sleepiness Scale and the 24-item Roland-Morris Disability Questionnaire (RMDQ) questionnaires. Plasma klotho was determined with enzyme-linked immunosorbent assay. Patients with OSA had higher number of disc bulges (4.6 ± 3.7 vs. 1.7 ± 2.5, p < 0.01) and anterior spondylophytes (2.7 ± 4.2 vs. 0.8 ± 2.1, p < 0.01), increased disc degeneration (total Pfirrmann score 16.7 ± 4.7 vs. 13.2 ± 4.1, p < 0.01) and vertebral fatty degeneration (7.8 ± 4.7 vs. 3.8 ± 3.7, p < 0.01). There was no difference in the RMDQ score (0/0-3.5/ vs. 0/0-1/, p > 0.05). Markers of OSA severity, including the oxygen desaturation index and percentage of total sleep time spent with saturation < 90% as well as plasma levels of klotho were correlated with the number of disc bulges and anterior spondylophytes (all p < 0.05). OSA is associated with lumbar spondylosis. Our study highlights the importance of lumbar imaging in patients with OSA reporting lower back pain.

Are the Morphological Indices of the Vertebrobasilar System Heritable? A Twin Study Based on 3D Reconstructed Models.

Background and Objectives: The asymmetrical vertebral artery (VA) flow and diameter are common findings, which can result in an asymmetrical blood flow in the basilar artery (BA), leading to bending of the artery over time. This study investigated whether the variation of the different vertebrobasilar morphological indices that influence flow characteristics might be inherited. Materials and Methods: We analyzed 200 cerebral magnetic resonance imaging (MRI) scans of healthy Caucasian twins (100 pairs) who underwent time-of-flight MRI. From the scans, we reconstructed the 3D mesh of the posterior circulation from the start of the V4 segment to the basilar tip and subsequently analyzed the morphology of the vertebrobasilar system. The phenotypic covariances of the different morphological parameters were decomposed into heritability (A), shared (C), and unshared (E) environmental effects. Results: 39% of the twins had left dominant VA, while 32.5% had right dominant. In addition, 28.5% were classified as equal. The vertebral artery V4 segment diameter, curvature, and tortuosity were mainly influenced by shared (C) and unshared (E) environmental factors. A moderate heritability was found for the BA length (A: 63%; 95% CI: 45.7-75.2%; E: 37%; 95% CI: 24.8-54.3%) and volume (A: 60.1%; 95% CI: 42.4-73.2%; E: 39.9%; 95% CI: 26.8-57.6%), while the torsion of both arteries showed no heritability and were only influenced by the unshared environment. Conclusions: The length and volume of the BA show a moderate genetical influence. However, most of the measured morphological indices were influenced by shared and unshared factors, which highlight the role of the ever-changing hemodynamic influences shaping the geometry of the vertebrobasilar system.

Anomalies of coronary origin detected by cardiac CT / Coronariaeredési anomáliák kardio-CT-vizsgálatok során.

Összefoglaló. Bevezetés: Congenitalis coronariaanomáliának tekintik azokat a coronariamorfológiai rendellenességeket, melyek 1%-nál kisebb gyakorisággal fordulnak elo. Többségük nem jár tünettel, olykor azonban okozhatnak mellkasi fájdalmat, eszméletvesztést, és hirtelen halálhoz is vezethetnek. A coronariaanomáliák gyakoriságáról Magyarországon eddig csak invazív koronarográfiás adatok alapján jelent meg közlemény. Célkituzés: Jelen vizsgálatunkban a coronariák eredési rendellenességeinek gyakoriságát mértük fel intézetünk coronaria-komputertomográfiás angiográfián átesett betegeinél. Módszer: A coronaria-komputertomográfiás vizsgálatra került betegek felvételeinek értékelésekor rögzítettük a coronariaanomália jelenlétét. A vizsgálat indikációja általában mellkasi fájdalom volt. 128 szeletes berendezést használtunk, a vizsgálatok során részben retrospektív, részben prospektív EKG-kapuzást alkalmaztunk. Eredmények: 1751 beteg komputertomográfiás angiográfiás felvételeit elemeztük. A betegek között a férfiak aránya 38,4%, a vizsgálatra kerülok életkorának átlaga pedig 58,07 ± 11,07 év volt. Eredési anomáliát 1,83%-ban találtunk, ezen belül a leggyakoribb volt a körbefutó ág (ramus circumflexus) és az elülso leszálló ág különálló eredése a bal Valsalva-sinusból (1%). A további rendellenességek a következok voltak: a jobb coronaria eredése magasan az aortából (0,34%), ramus circumflexus a jobb sinusból vagy a jobb coronariából (0,34%), jobb coronaria a bal Valsalva-sinusból (0,057%), elülso leszálló ág részben a bal Valsalva-sinusból a circumflexustól külön, részben a jobb coronariából (kettos elülso leszálló ág, 0,057%). Következtetés: Mindössze 0,057%-ban fordult elo potenciálisan tünetet okozó coronariaeredési rendellenesség (a bal sinusból eredo jobb coronaria). A komputertomográfiás angiográfia segítségével a coronariaeredés helye pontosan megállapítható, tisztázható az ér lefutása és ennek során viszonya a környezo struktúrákhoz. Orv Hetil. 2020; 161(47): 1995-1999. INTRODUCTION: Congenital coronary artery anomaly is defined as a coronary morphology which occurs in less than 1% of the cases. Usually these anomalies do not result in symptoms but sometimes they can cause chest pain, syncope and sudden death. In Hungary, the prevalence of these abnormalities was published only from data of invasive coronary angiography. OBJECTIVE: In this study, we evaluated the prevalence of the anomalies of coronary origin in the patients of our institution undergoing coronary computed tomography. METHOD: While reading the computed tomography angiograms of our patients, we registered the presence of coronary anomalies. In most of the cases, the indication of the coronary computed tomography was chest pain. A scanner with 128 detectors was used, scans were performed partly with prospective, partly with retrospective ECG gating. RESULTS: We assessed 1751 patients. The ratio of males was 38.4%, while the average age of patients 58.07 ± 11.07 years. Anomaly of coronary origin was present in 1.83% of our patients, with the separate origin of left anterior descending and left circumflex artery being the most frequent (1%) among them. Other anomalies were as follows: high take-off of the right coronary artery from the ascending aorta (0.34%), left circumflex arising from the right sinus of Valsalva or from the right coronary (0.34%), right coronary artery from the left sinus of Valsalva (0.057%), left anterior descending arising partly from the left sinus of Valsalva, apart from the left circumflex, partly from the right coronary (dual left anterior descending artery, 0.057%). CONCLUSION: The prevalence of potentially symptomatic coronary anomalies was only 0.057% in our series (right coronary from the left sinus of Valsalva). The computed tomography angiography can precisely define the origin of the coronary artery, depict its run-off and its relationship to the neighbouring structures. Orv Hetil. 2020; 161(47): 1995-1999.

Correction to: Assessment of cervical spine involvement in rheumatoid arthritis patients in the era of biologics: a real-life, cross-sectional MRI study.

In the original article, the first author's given name and family name were interchanged as provided by the authors in the original manuscript.

Assessment of cervical spine involvement in rheumatoid arthritis patients in the era of biologics: a real-life, cross-sectional MRI study.

Cervical spine involvement may lead to severe complications in rheumatoid arthritis (RA). In the era of modern therapies, atlantoaxial subluxation (AAS) may be rare; however, it may still be detected in asymptomatic patients. The onset of myelopathy can occur at any time. Altogether 49 female RA patients were included. Among them, 15 were methotrexate treated, biologic free, while 34 patients received biologics. The patients had no cervical pain or any neurological symptoms. We assessed the first (C1) and second (C2) cervical vertebrae by 3 T magnetic resonance imaging (MRI). In addition to AAS, we also determined odontoid erosion or periodontal soft tissue thickening. We associated our MRI findings with clinical, laboratory parameters, and hand radiography. We detected anterior AAS and soft tissue thickening in one-quarter, while odontoid erosions in eight (16%) of RA patients. There were no significant differences among the therapeutic subgroups. No posterior or vertical AAS was seen. Anterior AAS was associated with higher degree of inflammation, soft tissue thickening was seen at younger age, while odontoid erosions were associated with van der Heijde-Sharp scores of the hand. None of the patients had any lesions requiring surgery. The presence of cervical involvement in RA patients with 10-11 years of disease duration is still an important and frequent phenomenon. Higher disease activity and erosive disease are associated with atlantoaxial involvement. 3 T MRI is a sensitive method to assess AAS, as well as soft tissue lesions and odontoid erosions.

Assessment of cognitive function in female rheumatoid arthritis patients: associations with cerebrovascular pathology, depression and anxiety.

We assessed cognitive function of female rheumatoid arthritis (RA) patients and analyze the determinants, with special focus on cerebrovascular morphology. Sixty methotrexate (MTX-) or biologic-treated RA patients and 39 healthy controls were included in a cross-sectional study. Smoking habits, alcohol intake and time spent in education were recorded. Standard measures were performed to assess cognitive function (Montreal Cognitive Assessment, MOCA; Trail Making Test, TMT; Victoria Stroop Test, VST; Wechsler Adult Intelligence Scale, WAIS; Benton Visual Retention test, BVRT), depression (Beck Depression Inventory, BDI), anxiety (State-Trait Anxiety Inventory, STAIT/S) and general health status (Short Form 36, SF-36). Mean disease activity (28-joint Disease Activity Score, mDAS28; erythrocyte sedimentation rate, mESR; C-reactive protein, mCRP) of the past 12 months was calculated; anti-cyclic citrullinated peptide (CCP) and rheumatoid factor (RF) were assessed. Cerebral vascular lesions and atrophy, carotid intima-media thickness (cIMT) and plaques, as well as median cerebral artery (MCA) circulatory reserve capacity (CRC) were assessed by brain magnetic resonance imaging (MRI), carotid ultrasound and transcranial Doppler, respectively. Cognitive function tests showed impairment in RA vs controls. Biologic- vs MTX-treated subgroups differed in TMT-A. Correlations were identified between cognitive function and depression/anxiety tests. WAIS, STAIS, STAIT and BDI correlated with most SF-36 domains. Numerous cognitive tests correlated with age and lower education. Some also correlated with disease duration, mESR and mDAS28. Regarding vascular pathophysiology, cerebral vascular lesions were associated with VST-A, carotid plaques with multiple cognitive parameters, while MCA and CRC with MOCA, BVRT and BDI. RA patients have significant cognitive impairment. Cognitive dysfunction may occur together with or independently of depression/anxiety. Older patients and those with lower education are at higher risk to develop cognitive impairment. Cognitive screening might be a useful tool to identify subgroups to be further investigated for cerebrovascular pathologies.

Are the Variants of the Circle of Willis Determined by Genetic or Environmental Factors? Results of a Twin Study and Review of the Literature.

BACKGROUND: Anatomic variants of the circle of Willis (CW) are commonly observed in healthy subjects. Genetic and environmental factors influencing these variants remain unclear. Our aim was to assess the genetic and environmental background affecting variant CW phenotypes. METHODS: A total of 122 adult healthy twins from the Hungarian Twin Registry (39 monozygotic (MZ) and 22 dizygotic (DZ) pairs, average age 49.7 ± 13.4 years) underwent Time-of-Flight magnetic resonance angiography and transcranial Doppler sonography. We investigated the anterior and posterior CW according to morphological categories. Prevalence and concordance rates of CW variants were calculated. MZ twins discordant for CW variants were analyzed for cardiovascular risk factors and altered blood flow. RESULTS: Complete CW (45.0%) and bilaterally absent posterior communicating artery (PCoA) (22.5%) were the most prevalent variants in the anterior and posterior CW, respectively. There was no significant difference regarding the prevalence of variants across zygosity except for bilaterally hypoplastic PCoA (p = .02). DZ concordance was higher compared to MZ twins regarding morphological categories of the CW. Cardiovascular risk factors were not significantly associated with variant CW in MZ twins discordant to CW morphology. Flow parameters did not differ significantly among MZ twins discordant to CW variants. CONCLUSION: CW variants may not be determined by substantial genetic effects and are not influenced by altered blood flow in healthy individuals. Further investigations are needed to identify potential environmental factors affecting these variants.

Increased frequency of temporal acoustic window failure in rheumatoid arthritis: a manifestation of altered bone metabolism?

Assessment of intracranial vessels includes transcranial Doppler (TCD). TCD performance requires intact temporal acoustic windows (TAW). Failure of TAW (TAWF) is present in 8-20% of people. There have been no reports on TAWF in rheumatoid arthritis (RA). Altogether, 62 female RA patients were included. Among them, 20 were MTX-treated and biologic-free, 20 received infliximab, and 22 tocilizumab. The controls included 60 non-RA women. TAWF, temporal bone thickness, and texture were determined by ultrasound and CT. BMD and T-scores of multiple bones were determined by DEXA. Several bone biomarkers were assessed by ELISA. In RA, 54.8% of the patients had TAWF on at least one side. Neither TAW could be identified in 34% of RA subjects. In contrast, only 20.0% of control subjects had TAWF on either or both sides (p < 0.001). In RA vs controls, 53.0 vs 2.9% of subjects exerted the trilayer, "sandwich-like" structure of TAW (p < 0.001). Finally, in RA vs controls, the mean temporal bone thickness values of the right TAW were 3.58 ± 1.43 vs 2.92 ± 1.22 mm (p = NS), while those of the left TAW were 4.16 ± 1.56 vs 2.90 ± 1.16 mm (p = 0.001). There was close association between TAWF, bone thickness, and texture (p < 0.05). These TAW parameters all correlated with age; however, TAW failure and texture also correlated with serum osteoprotegerin. TAW bone thickness inversely correlated with hip BMD (p < 0.05). TAWF, thicker, and heterogeneous temporal bones were associated with RA. These features have been associated with bone loss and OPG production. Bone loss seen in RA may result in OPG release and stimulation of bone formation around TAW.

Assessment of intracranial vessels in association with carotid atherosclerosis and brain vascular lesions in rheumatoid arthritis.

BACKGROUND: Stroke has been associated with rheumatoid arthritis (RA). We assessed patients with RA and healthy control subjects by transcranial Doppler (TCD), carotid ultrasonography and brain magnetic resonance imaging (MRI). METHODS: Altogether, 41 female patients with RA undergoing methotrexate (MTX) or biologic treatment and 60 age-matched control subjects underwent TCD assessment of the middle cerebral artery (MCA) and basilar artery. Pulsatility index (PI), resistivity (resistance) index (RI) and circulatory reserve capacity (CRC) were determined at rest (r) and after apnoea (a) and hyperventilation (h). The presence of carotid plaques and carotid intima-media thickness (cIMT) were also determined. Intracerebral vascular lesions were investigated by brain MRI. RESULTS: MCA PI and RI values at rest and after apnoea were significantly increased in the total and MTX-treated RA populations vs control subjects. MCA CRC was also impaired, and basilar artery PI was higher in RA. More patients with RA had carotid plaques and increased cIMT. Linear regression analysis revealed that left PI(r) and RI(r) correlated with disease duration and that left PI(r), RI(r), PI(a), PI(h) and basilar PI correlated with disease activity. Right CRC inversely correlated with 28-joint Disease Activity Score. Disease activity was an independent determinant of left PI(a) and right CRC. Compared with long-term MTX treatment alone, the use of biologics in combination with MTX was associated with less impaired cerebral circulation. Impaired cerebral circulation was also associated with measures of carotid atherosclerosis. CONCLUSIONS: To our knowledge, this is the first study to show increased distal MCA and basilar artery occlusion in RA as determined by TCD. Patients with RA also had CRC defects. We also confirmed increased carotid plaque formation and increased cIMT. Biologics may beneficially influence some parameters in the intracranial vessels.