Appropriateness and imaging outcomes of ultrasound, CT, and MR in the emergency department: a retrospective analysis from an urban academic center.

PURPOSE: To evaluate the appropriateness and outcomes of ultrasound (US), computed tomography (CT), and magnetic resonance (MR) orders in the ED. METHODS: We retrospectively reviewed consecutive US, CT, and MR orders for adult ED patients at a tertiary care urban academic center from January to March 2019. The American College of Radiology Appropriateness Criteria (ACRAC) guidelines were primarily used to classify imaging orders as "appropriate" or "inappropriate". Two radiologists in consensus judged specific clinical scenarios that were unavailable in the ACRAC. Final imaging reports were compared with the initial clinical suspicion for imaging and categorized into "normal", "compatible with initial diagnosis", "alternative diagnosis", or "inconclusive". The sample was powered to show a prevalence of inappropriate orders of 30% with a margin of error of 5%. RESULTS: The rate of inappropriate orders was 59.4% for US, 29.1% for CT, and 33.3% for MR. The most commonly imaged systems for each modality were neuro (130/330) and gastrointestinal (95/330) for CT, genitourinary (132/330) and gastrointestinal (121/330) for US, neuro (273/330) and gastrointestinal (37/330) for MR. Compared to inappropriately ordered tests, the final reports of appropriate orders were nearly three times more likely to demonstrate findings compatible with the initial diagnosis for all modalities: US (45.5 vs. 14.3%, p < 0.001), CT (46.6 vs. 14.6%, p < 0.001), and MR (56.3 vs. 21.8%, p < 0.001). Inappropriate orders were more likely to show no abnormalities compared to appropriate orders: US (65.8 vs. 38.8%, p < 0.001), CT (62.5 vs. 34.2%, p < 0.001), and MR (61.8 vs. 38.7%, p < 0.001). CONCLUSION: The prevalence of inappropriate imaging orders in the ED was 59.4% for US, 29.1% for CT, and 33.3% for MR. Appropriately ordered imaging was three times more likely to yield findings compatible with the initial diagnosis across all modalities.

MRI with DWI improves detection of liver metastasis and selection of surgical candidates with pancreatic cancer: a systematic review and meta-analysis.

OBJECTIVE: To perform a systematic review and meta-analysis to evaluate if magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) adds value compared to contrast-enhanced computed tomography (CECT) alone in the preoperative evaluation of pancreatic cancer. METHODS: MEDLINE, EMBASE, and Cochrane databases were searched for relevant published studies through October 2022. Studies met eligibility criteria if they evaluated the per-patient diagnostic performance of MRI with DWI in the preoperative evaluation of newly diagnosed pancreatic cancer compared to CECT. Our primary outcome was the number needed to treat (NNT) to prevent one futile surgery using MRI with DWI, defined as those in which CECT was negative and MRI with DWI was positive for liver metastasis (i.e., surgical intervention in metastatic disease missed by CECT). The secondary outcomes were to determine the diagnostic performance and the NNT of MRI with DWI to change management in pancreatic cancer. RESULTS: Nine studies met the inclusion criteria with a total of 1121 patients, of whom 172 had liver metastasis (15.3%). The proportion of futile surgeries reduced by MRI with DWI was 6.0% (95% CI, 3.0-11.6%), yielding an NNT of 16.6. The proportion of cases that MRI with DWI changed management was 18.1% (95% CI, 9.9-30.7), corresponding to an NNT of 5.5. The per-patient sensitivity and specificity of MRI were 92.4% (95% CI, 87.4-95.6%) and 97.3% (95% CI, 96.0-98.1). CONCLUSION: MRI with DWI may prevent futile surgeries in pancreatic cancer by improving the detection of occult liver metastasis on preoperative CECT with an NNT of 16.6. CLINICAL RELEVANCE STATEMENT: MRI with DWI complements the standard preoperative CECT evaluation for liver metastasis in pancreatic cancer, improving the selection of surgical candidates and preventing unnecessary surgeries. KEY POINTS: • The NNT of MRI with DWI to prevent potential futile surgeries due to occult liver metastasis on CECT, defined as those in which CECT was negative and MRI with DWI was positive for liver metastasis, in patients with pancreatic cancer was 16.6. • The higher performance of MRI with DWI to detect liver metastasis occult on CECT can be attributed to an increased detection of subcentimeter liver metastasis.

Detection of Liver Lesions in Colorectal Cancer Patients Using 18F-FDG PET/CT Dual-Time-Point Scan Imaging.

OBJECTIVE: The aim of this study was to evaluate the diagnostic performance of dual-time-point fluorine-18-fluorodeoxyglucose positron emission computed tomography/computed tomography (18F-FDG PET/CT) compared to conventional early imaging for detecting colorectal liver metastases (CRLM) in colorectal cancer (CRC) patients. METHODS: One hundred twenty-four consecutive CRC patients underwent dual-time-point imaging scans on a retrospective basis. Histopathological confirmation and/or clinical follow-up were accepted as the gold standard. Standard uptake values (SUV), signal-to-noise ratio (SNR), retention index (RI), tumor-to-normal liver ratio (TNR), and lesion sizes were measured for early and delayed PET scans. The diagnostic performance of early and delayed images was calculated on a per-patient basis and compared using McNemar's test. RESULTS: Among the 124 patients, 57 (46%) had CRLM, 6 (4.8%) had benign lesions, and 61 (49.2%) had no concerning lesions detected. Smaller CRLM lesions (<5 cm3) showed significantly higher uptake in the delayed scans relative to early imaging (p < 0.001). The SUV and TNR increased significantly in delayed imaging of all metastatic lesions (p < 0.001). The retention index of all CRLM was high (40.8%), especially for small lesions (54.8%). A total of 177 lesions in delayed images and 124 in standard early images were identified. In a per-patient analysis, delayed imaging had significantly higher sensitivity (100% vs. 87.7%) and specificity (91.0% vs. 94.0%) compared to early imaging (p-value = 0.04). CONCLUSIONS: The detection of liver lesions using dual-time-point PET/CT scan improves the sensitivity and specificity for the detection of colorectal liver metastasis.

Core Needle Biopsy Accuracy for Androgen Receptor Expression in Invasive Breast Cancer.

OBJECTIVE: Breast cancer (BC) biomarkers, such as hormone receptors expression, are crucial to guide therapy in BC patients. Antiandrogens have been studied in BC; however, limited data are available on androgen receptor (AR) expression test methodology. We aim to report the core needle biopsy (CNB) accuracy for AR expression in BC. METHODS: Patients diagnosed with stage I-III invasive BC from a single institution were included. Androgen receptor expression was evaluated by immunohistochemistry (IHC) using 1 and 10% cutoff and the AR expression in surgical specimens (SS) was the gold standard. Kappa coefficients were used to evaluate the intraprocedural agreement. RESULTS: A total of 72 patients were included, with a mean age of 61 years old and 84% were Luminal A or B tumors. The prevalence of AR expression in all BC samples was 87.5% using a cutoff ≥ 10% in SS. With a cutoff value ≥ 1%, CNB had an accuracy of 95.8% (Kappa value = 0.645; 95% confidence interval [CI]: 0.272-1.000; p < 0.001) and 86.1% (Kappa value = 0.365; 95% CI: 0.052-0.679; p < 0.001) when ≥ 10% cutoff was used for AR positivity. Androgen receptor expression in CNB (cutoff ≥ 1%) had a sensitivity of 98.5%, specificity of 60%, positive predictive value of 97.0%, and a negative predictive value of 76.9% in the detection of AR expression in SS. CONCLUSION: Core needle biopsy has good accuracy in evaluating AR expression in BC. The accuracy of CNB decreases with higher cutoff values for AR positivity.

OBJETIVO: Biomarcadores, como a expressão de receptores hormonais, são cruciais para guiar a terapia de pacientes com câncer de mama. Apesar de ter sido estudado, poucos dados estão disponíveis sobre o método de testagem. Buscamos avaliar a precisão da biópsia com agulha de grande calibre (CNB, na sigla em inglês) para a expressão de receptores androgênicos (AR, na sigla em inglês) no câncer de mama. MéTODOS: Foram incluídos pacientes de uma única instituição diagnosticados com câncer de mama invasivo estágio I-III. A expressão de AR foi avaliada por imunohistoquímica, com valores de cutoff de 1 e 10%. A expressão de AR em espécimes cirúrgicos foi o padrão ouro. O coeficiente Kappa foi usado para avaliar a concordância entre procedimentos. RESULTADOS: Foi incluído um total de 72 pacientes, com idade média de 61 anos; 84% eram tumores luminais A ou B. A prevalência da expressão de AR em todas as amostras foi de 87.5%, com cutoff ≥ 10%. Com um valor de cutoff ≥ 1%, a CNB teve precisão de 95.8% (Kappa = 0.64; intervalo de confiança [IC] 95%: 0.272­1.000; p < 0.001) e 86.1% (Kappa = 0.365; CI95%: 0.052­0.679]; p < 0.001) quando um cutoff ≥ 10% foi usado para AR positivo. A expressão de AR na CNB (cutoff ≥ 1%) teve a sensibilidade de 98.5%, especificidade de 60%, valor preditivo positivo de 97.0% e valor preditivo negativo de 76.9% na detecção. CONCLUSãO: |Biópsia com agulha de grande calibre tem uma boa precisão em avaliar a expressão de AR no câncer de mama. A precisão do método cai com valores elevados de cutoff para AR positivo.

Machine learning for malignant versus benign focal liver lesions on US and CEUS: a meta-analysis.

OBJECTIVES: To perform a meta-analysis of the diagnostic performance of learning (ML) algorithms (conventional and deep learning algorithms) for the classification of malignant versus benign focal liver lesions (FLLs) on US and CEUS. METHODS: Available databases were searched for relevant published studies through September 2022. Studies met eligibility criteria if they evaluate the diagnostic performance of ML for the classification of malignant and benign focal liver lesions on US and CEUS. The pooled per-lesion sensitivities and specificities for each modality with 95% confidence intervals were calculated. RESULTS: A total of 8 studies on US, 11 on CEUS, and 1 study evaluating both methods met the inclusion criteria with a total of 34,245 FLLs evaluated. The pooled sensitivity and specificity of ML for the malignancy classification of FLLs were 81.7% (95% CI, 77.2-85.4%) and 84.8% (95% CI, 76.0-90.8%) for US, compared to 87.1% (95% CI, 81.8-91.0%) and 87.0% (95% CI, 83.1-90.1%) for CEUS. In the subgroup analysis of studies that evaluated deep learning algorithms, the sensitivity and specificity of CEUS (n = 4) increased to 92.4% (95% CI, 88.5-95.0%) and 88.2% (95% CI, 81.1-92.9%). CONCLUSIONS: The diagnostic performance of ML algorithms for the malignant classification of FLLs was high for both US and CEUS with overall similar sensitivity and specificity. The similar performance of US may be related to the higher prevalence of DL models in that group.

Risk assessment validation in patients with pulmonary arterial hypertension: Data from a Southern Brazil registry (RESPHIRAR study).

Pulmonary arterial hypertension (PAH) is a severe and progressive disease characterized by increased pulmonary vascular resistance, ultimately leading to right heart failure and death. Registries are a valuable tool in the research of rare conditions such as PAH. Moreover, the risk assessment strategy has been validated in European and North American registries and has been reported to provide an accurate prediction of mortality and the clinical advantage of reaching low-risk status. However, there is no available data from Brazil. Thus, the aim of the present study was to describe the characteristics of a sample of PAH from Southern Brazil and to retrospectively validate the risk assessment at our population. The RESPHIRAR is a retrospective and multicentric registry on pulmonary hypertension. With a join collaboration from nine centers in Southern Brazil, demographics, clinical presentation, and hemodynamics data of PAH were collected between 2007 and 2017. Moreover, the REVEAL 2.0 and REVEAL 2.0 Lite risk assessments were validated in our population. Overall, 370 PAH patients were included in the present study. Patients were predominantly female (78.5%) and had a mean age of 41.8 ± 18.8 years. Most patients (33.4%) had idiopathic PAH, 30.2% had PAH associated with congenital heart disease, and 23.5% had PAH associated with connective tissue disease. The low-risk group showed significantly lower mortality than the intermediated- or high-risk group at diagnosis (p < 0.05). In conclusion, our data suggest that REVEAL 2.0 and REVEAL 2.0 Lite risk assessments can predict mortality risk in PAH patients in Southern Brazil.

Ambulatory oxygen therapy in lung transplantation candidates with idiopathic pulmonary fibrosis referred for pulmonary rehabilitation.

OBJECTIVE: To determine independent factors related to the use of oxygen and the oxygen flow rate in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and undergoing pulmonary rehabilitation (PR). METHODS: This was a retrospective quasi-experimental study presenting functional capacity and health-related quality of life (HRQoL) data from lung transplant candidates with IPF referred for PR and receiving ambulatory oxygen therapy. The patients were divided into three groups on the basis of the oxygen flow rate: 0 L/min (the control group), 1-3 L/min, and 4-5 L/min. Data on functional capacity were collected by means of the six-minute walk test, and data on HRQoL were collected by means of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), being collected before and after 36 sessions of PR including aerobic and strength exercises. RESULTS: The six-minute walk distance improved in all three groups (0 L/min: Δ 61 m, p < 0.001; 1-3 L/min: Δ 58 m, p = 0.014; and 4-5 L/min: Δ 35 m, p = 0.031). Regarding HRQoL, SF-36 physical functioning domain scores improved in all three groups, and the groups of patients receiving ambulatory oxygen therapy had improvements in other SF-36 domains, including role-physical (1-3 L/min: p = 0.016; 4-5 L/min: p = 0.040), general health (4-5 L/min: p = 0.013), social functioning (1-3 L/min: p = 0.044), and mental health (1-3 L/min: p = 0.046). CONCLUSIONS: The use of ambulatory oxygen therapy during PR in lung transplant candidates with IPF and significant hypoxemia on exertion appears to improve functional capacity and HRQoL.

Diagnostic accuracy of magnetic resonance elastography and point-shear wave elastography for significant hepatic fibrosis screening: Systematic review and meta-analysis.

The hepatic diseases are extremely common in clinical practice. The correct classification of liver fibrosis is extremely important, as it influences therapy and predicts disease outcomes. The purpose of this study is to compare the diagnostic performance of point-shear wave elastography (pSWE) and magnetic resonance elastography (MRE) in the hepatic fibrosis diagnostic. A meta-analysis was carried out based on articles published until October 2020. The articles are available at following databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scientific Electronic Library Online, LILACS, Scopus, and CINAHL. Diagnostic performances were analyzed per METAVIR F2, using 3.5kPa as target fibrosis. Assessment of the methodological quality of the incorporated papers by the QUADAS-2 tool for pSWE and MRE. A total 2,153 studies articles were evaluated and 44 studies, comprising 6,081 patients with individual data, were included in the meta-analysis: 28 studies for pSWE and 16 studies for MRE. The pooled sensitivity and specificity were 0.86 (95%CI 0.80-0.90) and 0.88 (95%CI 0.85-0.91), respectively, for pSWE, compared with 0.94 (95%CI 0.89-0.97) and 0.95 (95%CI 0.89-0.98) respectively, for MRE. The pooled SROC curve for pSWE shows in the area under the curve (AUC) of 0.93 (95%CI 0.90-0.95), whereas the AUC for MRE was 0.98 (95%CI 0.96-0.99). The diagnostic odds ratio for pSWE and MRE were 41 (95%CI 24-72) and 293 (95%CI 86-1000), respectively. There was statistically significant heterogeneity for pSWE sensitivity (I² = 85.26, P<0.001) and specificity (I² = 89.46, P<0.001). The heterogeneity for MRE also was significant for sensitivity (I² = 73.28, P<0.001) and specificity (I² = 87.24, P<0.001). Therefore, both pSWE and MRE are suitable modalities for assessing liver fibrosis. In addition, MRE is a more accurate imaging technique than pSWE and can be used as alternative to invasive biopsy.

Antifibrotic therapy in idiopathic pulmonary fibrosis candidates for lung transplantation undergoing pulmonary rehabilitation.

OBJECTIVE: To investigate the impact of pulmonary rehabilitation (PR) on functional outcomes and health-related quality of life (HRQoL) in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and receiving antifibrotic therapy (AFT). METHODS: This was a retrospective observational study of consecutive IPF patients receiving AFT with either pirfenidone or nintedanib (the AFT group) and undergoing PR between January of 2018 and March of 2020. The AFT group and the control group (i.e., IPF patients not receiving AFT) participated in a 12-week PR program consisting of 36 sessions. After having completed the program, the study participants were evaluated for the six-minute walk distance (6MWD) and HRQoL. Pre- and post-PR 6MWD and HRQoL were compared within groups and between groups. RESULTS: There was no significant difference between the AFT and control groups regarding baseline characteristics, including age, airflow limitation, comorbidities, and oxygen requirement. The AFT group had a significant increase in the 6MWD after 12 weeks of PR (effect size, 0.77; p < 0.05), this increase being significant in the between-group comparison as well (effect size, 0.55; p < 0.05). The AFT group showed a significant improvement in the physical component of HRQoL at 12 weeks (effect size, 0.30; p < 0.05). CONCLUSIONS: Among IPF patients undergoing PR, those receiving AFT appear to have greater improvements in the 6MWD and the physical component of HRQoL than do those not receiving AFT.

Antifibrotic therapy in idiopathic pulmonary fibrosis candidates for lung transplantation undergoing pulmonary rehabilitation / Antifibróticos em pacientes com fibrose pulmonar idiopática candidatos a transplante de pulmão e submetidos a reabilitação pulmonar

ABSTRACT Objective: To investigate the impact of pulmonary rehabilitation (PR) on functional outcomes and health-related quality of life (HRQoL) in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and receiving antifibrotic therapy (AFT). Methods: This was a retrospective observational study of consecutive IPF patients receiving AFT with either pirfenidone or nintedanib (the AFT group) and undergoing PR between January of 2018 and March of 2020. The AFT group and the control group (i.e., IPF patients not receiving AFT) participated in a 12-week PR program consisting of 36 sessions. After having completed the program, the study participants were evaluated for the six-minute walk distance (6MWD) and HRQoL. Pre- and post-PR 6MWD and HRQoL were compared within groups and between groups. Results: There was no significant difference between the AFT and control groups regarding baseline characteristics, including age, airflow limitation, comorbidities, and oxygen requirement. The AFT group had a significant increase in the 6MWD after 12 weeks of PR (effect size, 0.77; p < 0.05), this increase being significant in the between-group comparison as well (effect size, 0.55; p < 0.05). The AFT group showed a significant improvement in the physical component of HRQoL at 12 weeks (effect size, 0.30; p < 0.05). Conclusions: Among IPF patients undergoing PR, those receiving AFT appear to have greater improvements in the 6MWD and the physical component of HRQoL than do those not receiving AFT.

RESUMO Objetivo: Investigar o impacto da reabilitação pulmonar (RP) em desfechos funcionais e na qualidade de vida relacionada à saúde (QVRS) em pacientes com fibrose pulmonar idiopática (FPI) em lista de espera para transplante de pulmão e em tratamento com antifibróticos (AF). Métodos: Estudo observacional retrospectivo com pacientes consecutivos com FPI em tratamento com pirfenidona ou nintedanibe (grupo AF) submetidos a RP entre janeiro de 2018 e março de 2020. O grupo AF e o grupo controle (pacientes com FPI que não estavam em tratamento com AF) participaram de um programa de RP com 36 sessões ao longo de 12 semanas. Após o término do programa, os participantes foram avaliados quanto à distância percorrida no teste de caminhada de seis minutos (DTC6) e à QVRS. A DTC6 e a QVRS pré e pós-RP foram comparadas intra e intergrupos. Resultados: Não houve diferença significativa entre os grupos AF e controle quanto às características basais, incluindo idade, limitação do fluxo aéreo, comorbidades e necessidade de oxigênio. O grupo AF apresentou um aumento significativo da DTC6 após 12 semanas de RP (tamanho do efeito: 0,77; p < 0,05); esse aumento também foi significativo na comparação intergrupos (tamanho do efeito: 0,55; p < 0,05). O grupo AF apresentou melhora significativa no componente físico da QVRS após 12 semanas (tamanho do efeito: 0,30; p < 0,05). Conclusões: Em pacientes com FPI submetidos a RP, a melhora na DTC6 e no componente físico da QVRS parece ser maior naqueles que estejam recebendo tratamento com AF do que naqueles que não o estejam.

Ambulatory oxygen therapy in lung transplantation candidates with idiopathic pulmonary fibrosis referred for pulmonary rehabilitation / Oxigenoterapia ambulatorial em candidatos a transplante de pulmão com fibrose pulmonar idiopática encaminhados para reabilitação pulmonar

ABSTRACT Objective: To determine independent factors related to the use of oxygen and the oxygen flow rate in idiopathic pulmonary fibrosis (IPF) patients placed on a lung transplant waitlist and undergoing pulmonary rehabilitation (PR). Methods: This was a retrospective quasi-experimental study presenting functional capacity and health-related quality of life (HRQoL) data from lung transplant candidates with IPF referred for PR and receiving ambulatory oxygen therapy. The patients were divided into three groups on the basis of the oxygen flow rate: 0 L/min (the control group), 1-3 L/min, and 4-5 L/min. Data on functional capacity were collected by means of the six-minute walk test, and data on HRQoL were collected by means of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), being collected before and after 36 sessions of PR including aerobic and strength exercises. Results: The six-minute walk distance improved in all three groups (0 L/min: Δ 61 m, p < 0.001; 1-3 L/min: Δ 58 m, p = 0.014; and 4-5 L/min: Δ 35 m, p = 0.031). Regarding HRQoL, SF-36 physical functioning domain scores improved in all three groups, and the groups of patients receiving ambulatory oxygen therapy had improvements in other SF-36 domains, including role-physical (1-3 L/min: p = 0.016; 4-5 L/min: p = 0.040), general health (4-5 L/min: p = 0.013), social functioning (1-3 L/min: p = 0.044), and mental health (1-3 L/min: p = 0.046). Conclusions: The use of ambulatory oxygen therapy during PR in lung transplant candidates with IPF and significant hypoxemia on exertion appears to improve functional capacity and HRQoL.

RESUMO Objetivo: Determinar fatores independentes relacionados ao uso de oxigênio e ao fluxo de oxigênio em pacientes com fibrose pulmonar idiopática (FPI) em lista de espera para transplante de pulmão e em reabilitação pulmonar (RP). Métodos: Estudo quase experimental retrospectivo no qual são apresentados dados referentes à capacidade funcional e qualidade de vida relacionada à saúde (QVRS) de pacientes com FPI candidatos a transplante de pulmão e encaminhados para RP em oxigenoterapia ambulatorial. Os pacientes foram divididos em três grupos com base no fluxo de oxigênio: 0 L/min (grupo controle), 1-3 L/min e 4-5 L/min. Os dados referentes à capacidade funcional foram coletados por meio do teste de caminhada de seis minutos, e os dados referentes à QVRS foram coletados por meio do Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), sendo coletados antes e depois de 36 sessões de RP com exercícios aeróbicos e de força. Resultados: A distância percorrida no teste de caminhada de seis minutos melhorou nos três grupos (0 L/min: Δ 61 m, p < 0,001; 1-3 L/min: Δ 58 m, p = 0,014; 4-5 L/min: Δ 35 m, p = 0,031). No tocante à QVRS, a pontuação obtida no domínio "capacidade funcional" do SF-36 melhorou nos três grupos, e os pacientes que receberam oxigenoterapia ambulatorial apresentaram melhora em outros domínios do SF-36: função física (1-3 L/min: p = 0,016; 4-5 L/min: p = 0,040), estado geral de saúde (4-5 L/min: p = 0,013), aspectos sociais (1-3 L/min: p = 0,044) e saúde mental (1-3 L /min: p = 0,046). Conclusões: O uso de oxigenoterapia ambulatorial durante a RP em candidatos a transplante de pulmão com FPI e hipoxemia significativa aos esforços parece melhorar a capacidade funcional e a QVRS.

Core Needle Biopsy Accuracy for Androgen Receptor Expression in Invasive Breast Cancer / Precisão da biópsia com agulha de grande calibre para expressão de receptores androgênicos no câncer de mama invasivo

Abstract Objective Breast cancer (BC) biomarkers, such as hormone receptors expression, are crucial to guide therapy in BC patients. Antiandrogens have been studied in BC; however, limited data are available on androgen receptor (AR) expression test methodology. We aim to report the core needle biopsy (CNB) accuracy for AR expression in BC. Methods Patients diagnosed with stage I-III invasive BC from a single institution were included. Androgen receptor expression was evaluated by immunohistochemistry (IHC) using 1 and 10% cutoff and the AR expression in surgical specimens (SS) was the gold standard. Kappa coefficients were used to evaluate the intraprocedural agreement. Results A total of 72 patients were included, with a mean age of 61 years old and 84% were Luminal A or B tumors. The prevalence of AR expression in all BC samples was 87.5% using a cutoff ≥ 10% in SS. With a cutoff value ≥ 1%, CNB had an accuracy of 95.8% (Kappa value = 0.645; 95% confidence interval [CI]: 0.272-1.000; p< 0.001) and 86.1% (Kappa value = 0.365; 95% CI: 0.052-0.679; p< 0.001) when ≥ 10% cutoff was used for AR positivity. Androgen receptor expression in CNB (cutoff ≥ 1%) had a sensitivity of 98.5%, specificity of 60%, positive predictive value of 97.0%, and a negative predictive value of 76.9% in the detection of AR expression in SS. Conclusion Core needle biopsy has good accuracy in evaluating AR expression in BC. The accuracy of CNB decreases with higher cutoff values for AR positivity.

Resumo Objetivo Biomarcadores, como a expressão de receptores hormonais, são cruciais para guiar a terapia de pacientes com câncer de mama. Apesar de ter sido estudado, poucos dados estão disponíveis sobre o método de testagem. Buscamos avaliar a precisão da biópsia com agulha de grande calibre (CNB, na sigla em inglês) para a expressão de receptores androgênicos (AR, na sigla em inglês) no câncer de mama. Métodos Foram incluídos pacientes de uma única instituição diagnosticados com câncer de mama invasivo estágio I-III. A expressão de AR foi avaliada por imunohistoquímica, com valores de cutoff de 1 e 10%. A expressão de AR em espécimes cirúrgicos foi o padrão ouro. O coeficiente Kappa foi usado para avaliar a concordância entre procedimentos. Resultados Foi incluído um total de 72 pacientes, com idade média de 61 anos; 84% eram tumores luminais A ou B. A prevalência da expressão de AR em todas as amostras foi de 87.5%, com cutoff ≥ 10%. Com um valor de cutoff ≥ 1%, a CNB teve precisão de 95.8% (Kappa = 0.64; intervalo de confiança [IC] 95%: 0.272-1.000; p< 0.001) e 86.1% (Kappa = 0.365; CI95%: 0.052-0.679]; p< 0.001) quando um cutoff ≥ 10% foi usado para AR positivo. A expressão de AR na CNB (cutoff ≥ 1%) teve a sensibilidade de 98.5%, especificidade de 60%, valor preditivo positivo de 97.0% e valor preditivo negativo de 76.9% na detecção. Conclusão -Biópsia com agulha de grande calibre tem uma boa precisão em avaliar a expressão de AR no câncer de mama. A precisão do método cai com valores elevados de cutoff para AR positivo.

Feasibility of endoscopic papillary large balloon dilation to remove difficult stones in patients with nondilated distal bile ducts.

BACKGROUND: Current guidelines recommend not performing papillary large balloon dilation in patients with nondilated distal bile ducts. AIM: To assess the feasibility of balloon dilation to remove difficult stones in patients with nondilated distal bile ducts. METHODS: Data from 1289 endoscopic retrograde cholangiopancreatography (ERCP) procedures were obtained from two prospective studies. While 258 cases had difficult stones (> 1 cm, multiple > 8, impacted, or having a thin distal duct), 191 underwent biliary dilation up to 15 mm after endoscopic sphincterotomy. Cholangiographies of these cases were retrospectively reviewed in order to classify the distal bile duct and both the stone size and number. Primary outcomes were clearance rate at first ERCP and complications. RESULTS: Of the 191 patients (122 women and 69 men; mean age: 60 years) who underwent biliary dilation for difficult stones, 113 (59%) had a nondilated or tapered distal duct. Patients with a dilated distal duct were older than those with nondilated distal ducts (mean 68 and 52 years of age, respectively; P < 0.05), had more stones (median 4 and 2 stones per patient, respectively; P < 0.05), and had less need for additional mechanical lithotripsy (6.4% vs 25%, respectively; P < 0.05). Clearance rate at first ERCP was comparable between patients with a dilated (73/78; 94%) and nondilated distal ducts (103/113; 91%). Procedures were faster in patients with a dilated distal duct (mean 17 vs 24 min, respectively; P < 0.005). Complications were similar in both groups (6.4% vs 7.1%, respectively). CONCLUSION: Large balloon dilation for difficult stones is feasible in patients with a nondilated or even tapered distal duct.

The Normal Lung Index From Quantitative Computed Tomography for the Evaluation of Obstructive and Restrictive Lung Disease.

PURPOSE: Our objective was to evaluate whether the normal lung index (NLI) from quantitative computed tomography (QCT) analysis can be used to predict mortality as well as pulmonary function tests (PFTs) in patients with chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD). MATERIALS AND METHODS: Normal subjects (n=20) and patients with COPD (n=172) and ILD (n=114) who underwent PFTs and chest CT were enrolled retrospectively in this study. QCT measures included the NLI, defined as the ratio of the lung with attenuation between -950 and -700 Hounsfield units (HU) over the total lung volume (-1024 to -250 HU, mL), high-attenuation area (-700 to -250 HU, %), emphysema index (>6% of pixels < -950 HU), skewness, kurtosis, and mean lung attenuation. Coefficients of correlation between QCT measurements and PFT results in all subjects were calculated. Univariate and multivariate survival analyses were performed to assess mortality prediction by disease. RESULTS: The Pearson correlation analysis showed that the NLI correlated moderately with the forced expiratory volume in 1 second in subjects with COPD (r=0.490, P<0.001) and the forced vital capacity in subjects with ILD (r=0.452, P<0.001). Multivariate analysis revealed that the NLI of <70% was a significant independent predictor of mortality in subjects with COPD (hazard ratio=3.14, P=0.034) and ILD (hazard ratio=2.72, P=0.005). CONCLUSION: QCT analysis, specifically the NLI, can also be used to predict mortality in individuals with COPD and ILD.

Expiratory CT scanning in COVID-19 patients: can we add useful data?

OBJECTIVE: To evaluate small airway disease in COVID-19 patients using the prevalence of air trapping (AT) and correlating it with clinical outcomes. The relationship between CT-based opacities in small blood vessels and ventilation in patients with SARS-CoV-2 pneumonia was also assessed. METHODS: We retrospectively included 53 patients with positive RT-PCR results for SARS-CoV-2 between March and April of 2020. All subjects underwent HRCT scanning, including inspiratory and expiratory acquisitions. Subjects were divided into two groups based on visual identification of AT. Small blood vessel volumes were estimated by means of cross-sectional areas < 5 mm2 (BV5) derived from automated segmentation algorithms. Mixed-effect models were obtained to represent the BV5 as a function of CT-based lobar opacities and lobar ventilation. RESULTS: Of the 53 participants, AT was identified in 23 (43.4%). The presence of AT was associated with increased SpO2 at admission (OR = 1.25; 95% CI, 1.07-1.45; p = 0.004) and reduced D-dimer levels (OR = 0.99; 95% CI, 0.99-0.99; p = 0.039). Patients with AT were less likely to be hospitalized (OR = 0.27; 95% CI, 0.08-0.89; p = 0.032). There was a significant but weak inverse correlation between BV5 and CT-based lobar opacities (R2 = 0.19; p = 0.03), as well as a nonsignificant and weak direct correlation between BV5 and lobar ventilation (R2 = 0.08; p = 0.54). CONCLUSIONS: AT is a common finding in patients with COVID-19 that undergo expiratory CT scanning. The presence of AT may correlate with higher SpO2 at admission, lower D-dimer levels, and fewer hospitalizations when compared with absence of AT. Also, the volume of small pulmonary vessels may negatively correlate with CT opacities but not with lobar ventilation.

In vivo brain iron concentration in healthy individuals at 3.0 T magnetic resonance imaging: a prospective cross-sectional study.

OBJECTIVE: To quantify iron deposits in the basal ganglia and to evaluate its relation to age, sex, body mass index and brain laterality. METHODS: Prospective observational study. Data were collected from the patients' electronic medical records. The concentration of iron deposits in the brain was assessed using whole-brain MRI at 3.0 Tesla. RESULTS: 138 participants were selected, 69.6% were female and the mean age was 47 ± 19 years. The κ coefficient was very strong (k = 0.92, p < 0.001). Age showed a moderate correlation between iron deposits in the caudate and putamen nuclei, on both right and left sides. In overall and right-handed individuals, a significantly higher iron concentration was observed on the left side for the caudate nucleus, putamen, thalamus, globus pallidus, and centrum semiovale, and for left-handed individuals, it was also observed in the left side-for the putamen and centrum semiovale. A weak correlation was shown between body mass index and left and right substantia nigra, left caudate nuclei, left putamen and right globus pallidus. CONCLUSION: Our results showed a significantly higher iron deposit on the left side in most brain regions. In addition, the body mass index may also be related to iron overload, especially in the caudate nucleus. ADVANCES IN KNOWLEDGE: Brain iron deposits may be normal, owing to aging, or be pathological, such as neurodegeneration. Thus, it is important to know how much is expected of iron deposition in the brain of healthy populations.

Expiratory CT scanning in COVID-19 patients: can we add useful data? / TC expiratória em pacientes com COVID-19: podemos adicionar dados úteis?

ABSTRACT Objective: To evaluate small airway disease in COVID-19 patients using the prevalence of air trapping (AT) and correlating it with clinical outcomes. The relationship between CT-based opacities in small blood vessels and ventilation in patients with SARS-CoV-2 pneumonia was also assessed. Methods: We retrospectively included 53 patients with positive RT-PCR results for SARS-CoV-2 between March and April of 2020. All subjects underwent HRCT scanning, including inspiratory and expiratory acquisitions. Subjects were divided into two groups based on visual identification of AT. Small blood vessel volumes were estimated by means of cross-sectional areas < 5 mm2 (BV5) derived from automated segmentation algorithms. Mixed-effect models were obtained to represent the BV5 as a function of CT-based lobar opacities and lobar ventilation. Results: Of the 53 participants, AT was identified in 23 (43.4%). The presence of AT was associated with increased SpO2 at admission (OR = 1.25; 95% CI, 1.07-1.45; p = 0.004) and reduced D-dimer levels (OR = 0.99; 95% CI, 0.99-0.99; p = 0.039). Patients with AT were less likely to be hospitalized (OR = 0.27; 95% CI, 0.08-0.89; p = 0.032). There was a significant but weak inverse correlation between BV5 and CT-based lobar opacities (R2 = 0.19; p = 0.03), as well as a nonsignificant and weak direct correlation between BV5 and lobar ventilation (R2 = 0.08; p = 0.54). Conclusions: AT is a common finding in patients with COVID-19 that undergo expiratory CT scanning. The presence of AT may correlate with higher SpO2 at admission, lower D-dimer levels, and fewer hospitalizations when compared with absence of AT. Also, the volume of small pulmonary vessels may negatively correlate with CT opacities but not with lobar ventilation.

RESUMO Objetivo: Avaliar a doença das pequenas vias aéreas em pacientes com COVID-19 por meio da prevalência de aprisionamento aéreo (AA) e sua correlação com desfechos clínicos. Também foi avaliada a relação entre opacidades tomográficas nos pequenos vasos sanguíneos e ventilação em pacientes com pneumonia por SARS-CoV-2. Métodos: Foram incluídos, retrospectivamente, 53 pacientes com teste de RT-PCR positivo para SARS-CoV-2 entre março e abril de 2020. Todos os indivíduos foram submetidos à TCAR, incluindo aquisições inspiratórias e expiratórias. Os indivíduos foram divididos em dois grupos com base na identificação visual de AA. Os volumes dos pequenos vasos sanguíneos foram estimados por meio de seções transversais < 5 mm2 (VS5) derivadas de algoritmos automatizados de segmentação. Modelos de efeito misto foram obtidos para representar o VS5 em função das opacidades lobares tomográficas e da ventilação lobar. Resultados: Identificou-se AA em 23 (43,4%) dos 53 participantes. A presença de AA apresentou associação com SpO2 elevada na admissão (OR = 1,25; IC95%: 1,07-1,45; p = 0,004) e níveis reduzidos de dímero D (OR = 0,99; IC95%: 0,99-0,99; p = 0,039). Pacientes com AA apresentaram menor probabilidade de hospitalização (OR = 0,27; IC95%: 0,08-0,89; p = 0,032). Houve correlação inversa significativa, mas fraca, entre VS5 e opacidades lobares tomográficas (R2 = 0,19; p = 0,03) e correlação direta não significativa e fraca entre VS5 e ventilação lobar (R2 = 0,08; p = 0,54). Conclusões: AA é um achado comum em pacientes com COVID-19 submetidos à TC expiratória. A presença de AA pode apresentar correlação com SpO2 elevada na admissão, níveis reduzidos de dímero D e menor probabilidade de hospitalização. Além disso, o volume dos pequenos vasos pulmonares pode apresentar correlação negativa com opacidades tomográficas, mas não com ventilação lobar.