Evaluation of treatment options for patients with advanced renal cell carcinoma: assessment of appropriateness, using the validated semi-quantitative RAND corporation/University of California, Los Angeles methodology.

A diverse range of treatment options and interventions are available for the management of renal cell carcinoma (RCC), allowing clinicians to tailor therapy to best meet their patient's needs and situation. However, choosing from the plethora of options can be problematic. RCC treatment guidelines advise on the most efficacious agents based upon specific clinical trial populations, but these do not always take into account all the patient factors that influence the suitability of treatment options for individual patients. This study used the validated RAND/UCLA (RAND corporation/University of California, Los Angeles) 'appropriateness methodology' to integrate clinical efficacy data with expert opinion concerning the use of specific RCC treatment options for particular patient scenarios, in an attempt to facilitate the widespread implementation of patient-focussed treatment choices. Use of the methodology has allowed us to develop treatment algorithms for patients with locally-advanced RCC and for those with metastatic disease post-nephrectomy or with primary tumour in situ. The algorithms take into account patient-specific characteristics such as tumour histology, prior treatment and known risk factors to advise whether a particular treatment intervention is appropriate, not appropriate or of uncertain appropriateness. Use of this methodology aims to develop a formalised process by which expert opinion can be integrated with clinical data and used as an additional source of information that can provide further guidance concerning difficult treatment decisions when data are absent or sparse.

Hormonal therapies for early breast cancer: systematic review and economic evaluation.

OBJECTIVES: To establish the clinical and cost-effectiveness of aromatase inhibitors (AIs) anastrozole, letrozole and exemestane compared with tamoxifen in the adjuvant treatment of early oestrogen receptor-positive breast cancer in postmenopausal women. DATA SOURCES: Major electronic databases and three trials registers were searched from May to June 2005. Three conference abstract databases were searched in December 2005. Industry submissions. REVIEW METHODS: Studies evaluating the clinical effectiveness of AIs against 5 years' tamoxifen treatment were included and critically appraised. The review of the health economics of AIs in early breast cancer in comparison with standard therapies included a review of existing economic evaluations of the relevant therapies, a critique of each of the economic evaluations submitted to the National Institute for Health and Clinical Excellence (NICE) by pharmaceutical manufacturers and a detailed explanation of the methodologies and results of the authors' economic model. The three treatment strategies (primary adjuvant therapy, unplanned switch therapy and extended adjuvant therapy) were considered separately within the authors' economic analysis. RESULTS: A meta-analysis of three trials found a significant difference in overall survival when an unplanned anastrozole switching strategy was compared with 5 years' tamoxifen. Significant improvements in overall survival are yet to be demonstrated in other strategies. Compared with 5 years' tamoxifen, disease-free survival (disease recurrence or death from any cause) was significantly improved in the primary adjuvant setting with anastrozole and letrozole, and with an exemestane switching strategy. Other trials did not report this outcome. Breast cancer recurrence (censoring death as an event) was significantly improved with primary adjuvant anastrozole and letrozole, anastrozole switching, extended adjuvant anastrozole or letrozole. The AIs and tamoxifen have different side-effect profiles, with tamoxifen responsible for small but statistically significant increases in endometrial cancer and, sometimes, thromboembolic events and stroke. AIs show a trend towards increases in osteoporosis, the statistical significance of which increases with follow-up time. The absence of tamoxifen treatment also increases the risk of hypercholesterolaemia and cardiac events in postmenopausal women. There was no significant difference in overall health-related quality of life between standard treatment and either primary adjuvant anastrozole and extended adjuvant letrozole strategies. The cost-effectiveness results for AIs compared with tamoxifen in the primary adjuvant setting, are estimated to be between 21,000 pounds and 32,000 pounds per quality-adjusted life-year (QALY) based on an analysis over 35 years. There is currently no trial evidence for exemestane in this setting. The cost-effectiveness results for anastrozole and exemestane, compared with tamoxifen in the unplanned switching setting, are estimated to be 23,200 pounds and 19,200 pounds per QALY, respectively, based on an analysis over 35 years. There is currently no trial evidence for letrozole in this setting. In the extended adjuvant setting, the cost per QALY for letrozole compared with placebo is estimated to be 9800 pounds, based on an analysis over 35 years. All these results are considered to be conservative. In the base case it is assumed that the benefits of AIs over tamoxifen or placebo seen during the therapy period are gradually lost during the following 10 years. An alternative scenario, the 'benefits maintained' scenario, is tested in sensitivity analysis. Here it is assumed that following the treatment period the annual rate of recurrence in both arms is the same. This reduces the cost-effectiveness ratio by over 50%, to around 10,000-12,000 pounds, 5000 pounds and 3000 pounds in the primary adjuvant, unplanned switching and extended adjuvant setting, respectively. The limited evidence to date of benefits after the therapy period suggests that the 'benefits maintained' scenario may be realistic. The results from the economic analyses within the industry submissions are generally lower than the results from the authors' model and are close to or below 12,000 pounds in all three settings. The authors' analyses generally produce a lower estimate of QALY gain for the aromatase inhibitors, due to the more conservative assumption regarding benefits, along with differences in the utility values used in the their analysis. CONCLUSIONS: On the basis of the current data and within their licensed indications, AIs can be considered clinically effective compared with standard tamoxifen treatment. However, their long-term effects, in terms of both benefits and harms, remain unclear. Under the conservative assumption that benefits gained by AIs during the treatment period are gradually lost over the following 10 years, the cost per QALY for AIs compared with tamoxifen is estimated to be between 21,000 pounds and 32,000 pounds in the primary adjuvant setting and around 20,000 pounds in the unplanned switch setting. The cost per QALY for AIs compared with placebo in the extended adjuvant setting is estimated to be around 10,000 pounds. Under the less conservative assumption that rates of recurrence are the same in both arms after the therapy period is complete, the incremental cost-effectiveness ratios are typically at least 50% lower, suggesting that AIs are likely to be considered cost-effective in all three settings. Understanding of the long-term treatment effects on cost-effectiveness is, however, incomplete. Data on the impact of AIs on survival are awaited from the majority of the trials to confirm whether or not the benefits seen in disease-free survival and recurrence rates are translated into overall survival benefit in the medium to long-term.

Epithelializing stent for benign prostatic hyperplasia: a systematic review of the literature.

PURPOSE: We systematically reviewed the literature on the effectiveness, durability and safety of the UroLume stent for men with benign prostatic hyperplasia. MATERIALS AND METHODS: We searched the MEDLINE and EMBASE databases for 1989 to 2005. Reference lists of included studies and review articles were also searched. We contacted the UroLume manufacturer and key authors for additional information. Primary outcomes were treatment failure and urological symptom scores. Secondary outcomes were uroflow parameters and minor complications. Two reviewers independently assessed the methodological quality of the studies and extracted data. RESULTS: A total of 20 case series evaluated the UroLume stent in a total of 990 patients with benign prostatic hyperplasia. Of the patients 84% who were catheter dependent voided spontaneously after stent insertion. Ten studies assessed symptoms before stent insertion and at some point within 1 year after stent insertion. All reported decreases in symptom scores, including Madsen-Iversen by 7.9 to 14.3 points and International Prostate Symptom Score by 10 to 12.4 points. Peak urine flow rates increased by 4.2 to 13.1 ml per second. A total of 104 stents (16%) failed in 606 patients who were evaluable at 1 year and migration was the commonest cause of failure (38 stents or 37%). Most patients initially experienced perineal pain or irritative voiding symptoms following stent placement. CONCLUSIONS: Of men who were catheter dependent 84% voided spontaneously after insertion of a UroLume stent and the improvement in symptoms was similar to that seen after transurethral prostate resection. However, 1 of 6 men needed the UroLume removed within a year because of complications. Inadequate followup prevented conclusions on stent durability beyond 1 year. This review supports the recommendation that stents should be considered only in patients at high risk.

Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation.

OBJECTIVES: To evaluate computerised cognitive behaviour therapy (CCBT) for the treatment of anxiety, depression, phobias, panic and obsessive-compulsive behaviour (OCD). The software packages to be considered include Beating the Blues (BtB), Overcoming Depression: a five areas approach, FearFighter (FF), Cope and BT Steps. Other packages or programmes incorporating CCBT were also considered. DATA SOURCES: Electronic databases from 1966 to March 2004. Evidence submitted by sponsors for CCBT products. REVIEW METHODS: A systematic review was a review of the literature and the evidence submitted by sponsors for each of the products. A series of cost-effectiveness models was developed and run by the project team for the five CCBT products across the three mental health conditions. RESULTS: Twenty studies were identified in the clinical effectiveness review. The analysis of these results showed some evidence that CCBT is as effective as therapist-led cognitive behaviour therapy (TCBT) for the treatment of depression/anxiety and phobia/panic and is more effective than treatment as usual (TAU) in the treatment of depression/anxiety. CCBT also appears to reduce therapist time compared with TCBT. When reviewing cost-effectiveness studies, only one published economic evaluation of CCBT was found. This was an economic evaluation of the depression software BtB alongside a randomised controlled trial (RCT), which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than 2000 pounds), however it contained weaknesses that were then addressed in the cost-effectiveness model developed for the study. The results of the model for the depression software packages in terms of incremental cost per QALY compared with TAU and the chance of being cost-effective at 30,000 pounds per QALY were for BtB 1801 pounds and 86.8%, for Cope 7139 pounds and 62.6% and for Overcoming Depression 5391 pounds and 54.4%. The strength of the BtB software being that it has been evaluated in the context of an RCT with a control group. The subgroup analysis found no differences across the severity groupings. For phobia/panic software, the model showed an incremental cost per QALY of FF over relaxation was 2380 pounds. Its position compared with TCBT is less clear. When modelling OCD packages, using the practice-level licence cost meant that BT Steps was dominated by TCBT, which had significantly better outcomes and was cheaper. However, the cheaper PCT licence resulted in the incremental cost-effectiveness of BT Steps over relaxation being 15,581 pounds and TCBT over BT Steps being 22,484 pounds. CONCLUSIONS: The study findings are subject to substantial uncertainties around the organisational level for purchasing these products and the likely throughput. This is in addition to concerns with the quality of evidence on response to therapy, longer term outcomes and quality of life. The position of CCBT within a stepped care programme needs to be identified, as well as its relationship to other efforts to increase access to CBT and psychological therapies. Research is needed to compare CCBT with other therapies that reduce therapist time, in particular bibliotherapy and to explore the use of CCBT via the Internet. Independent research is needed, particularly RCTs, that examine areas such as patient preference and therapist involvement within primary care.

Accurate, practical and cost-effective assessment of carotid stenosis in the UK.

OBJECTIVES: To determine whether less invasive imaging tests [ultrasound (US), magnetic resonance angiography (MRA), computed tomographic angiography (CTA) and contrast-enhanced MRA (CEMRA)], alone or combined, could replace intra-arterial angiography (IAA), what effect this would have on strokes and deaths, endarterectomies performed and costs, and whether less invasive tests were cost-effective. DATA SOURCES: Electronic databases covering the years 1980-2003 inclusive, updated to April 2004. Key journals from 1990 to the end of 2002. REVIEW METHODS: The authors constituted a panel of experts in stroke, imaging, vascular surgery, statistics and health economic modelling. The accuracy of less invasive carotid imaging was systematically reviewed using Standards for Reporting of Diagnostic Accuracy (STARD) methodology, supplemented by individual patient data from UK primary research and audit studies. A systematic review of the costs of less invasive tests, outpatient clinics, endarterectomy and stroke was performed, along with a microcosting exercise. A model of the process of care following a transient ischaemic attack (TIA)/minor stroke was developed, populated with data from stroke epidemiology studies in the UK, effects of medical and surgical interventions, outcomes, quality of life and costs. A survey of UK stroke prevention clinics provided typical timings. Twenty-two different carotid imaging strategies were evaluated for short- and long-term outcomes, quality-adjusted life-years (QALYs) and net benefit. RESULTS: In 41 included studies (2404 patients, median age 60-65 years), most data were available on 70-99% stenosis. CEMRA was the most accurate [sensitivity 0.94, 95% confidence interval (CI) 0.88 to 0.97; specificity 0.93, 95% CI 0.89 to 0.96], compared with US, MRA and CTA, which were all similar (e.g. for US: sensitivity 0.89, 95% CI 0.85 to 0.92; specificity 0.84, 95% CI 0.77 to 0.89). Data for 50-69% stenoses and on combinations of tests were too sparse to be reliable. There was heterogeneity between studies for all imaging modalities except for CTA. The individual patient data (2416 patients) showed that the literature overestimated test accuracy in routine practice and that, in general, tests perform with higher sensitivity and specificity in asymptomatic than in symptomatic arteries. In the cost-effectiveness model, on current UK timings, strategies allowed more patients to reach endarterectomy very quickly, and where those with 50-69% stenosis would be offered surgery in addition to those with 70-99%, prevented most strokes and produced greatest net benefit. This included most strategies with US as first or repeat test, and not those with IAA. However, the model was sensitive to less invasive test accuracy, cost and timing of endarterectomy. In patients investigated late after TIA, test accuracy is crucial and CEMRA should be used before surgery. CONCLUSIONS: In the UK, less invasive tests can be used in place of IAA if radiologists trained in carotid imaging are available. Imaging should be carefully audited. Stroke prevention clinics should reduce waiting times at all stages to improve speed of access to endarterectomy. In patients presenting late after TIA, test accuracy is very important and US results should be confirmed by CEMRA, as patients with 50-69% stenosis are less likely to benefit. More data are required to define the accuracy of the less invasive tests, with improvements made in the data collection methods used and how data are presented. Consideration should also be given to the use of new technologies and randomised trials.

A systematic review and economic evaluation of alendronate, etidronate, risedronate, raloxifene and teriparatide for the prevention and treatment of postmenopausal osteoporosis.

OBJECTIVES: To establish the clinical effectiveness and cost-effectiveness of selective oestrogen receptor modulators, bisphosphonates and parathyroid hormone (subject to licensing) for the prevention and treatment of osteoporosis and the prevention of osteoporotic fractures in postmenopausal women. DATA SOURCES: Electronic databases. REVIEW METHODS: Studies that met the review's entry criteria were eligible for inclusion in the meta-analyses provided that they reported fracture incidence in terms of the number of patients suffering fractures. Meta-analysis was carried out using the random-effects model. A model was constructed to estimate the cost-effectiveness of osteoporosis interventions. The model calculated the number of fractures that occurred and provided the costs associated with osteoporotic fractures, and the quality-adjusted life-years (QALYs). In addition, the conditions of breast cancer and coronary heart disease (CHD) were modelled, as some interventions have been shown to affect the risk of these conditions. RESULTS: Ninety randomised controlled trials (RCTs) met the inclusion criteria. They related to the five interventions (alendronate, etidronate, risedronate, raloxifene and teriparatide) and to five comparators (calcium, calcium plus vitamin D, calcitriol, hormone replacement therapy and exercise), as well as placebo or no treatment. All five interventions have been shown to reduce the risk of vertebral fracture in women with severe osteoporosis with adequate calcium intakes. However, none of these drugs has been demonstrated, by direct comparison, to be significantly more effective than either each other or the other active interventions reviewed in this report. The intervention costs of treating all osteoporotic women, for a period of 5 years, were in the region of pound 900-1500 million for alendronate, etidronate, risedronate and raloxifene. The cost per QALY ratios fell dramatically with age. Assuming the risks of a woman with severe osteoporosis at the threshold of osteoporosis, no treatment had a cost per QALY below pound 35,000 at 50 years of age. At 60 years of age, the cost per QALY of raloxifene was pound 26,000 assuming no impact on hip fractures, and pound 31,000 assuming an adverse effect. However, these results are driven by the effect on breast cancer and the assumptions made regarding this disease state. No other intervention had a cost per QALY below pound 35,000. When analyses were conducted assuming that the fracture risk is doubled at each site, alendronate and risedronate had cost per QALY ratios below pound 30,000 at all ages. For women at the threshold of osteoporosis, without a prior fracture and aged 70 years, the cost per QALY of the three bisphosphonates ranged from pound 34,000 to pound 41,000. Raloxifene had a cost per QALY of pound 23,000, assuming no effect on hip fracture, given assumptions regarding breast cancer. At 80 years of age, the cost per QALY of alendronate and risedronate was below pound 20,000. This was true for etidronate when incorporating observational data, but the value rose to pound 69,000 when only RCT data were used. No other intervention had a cost per QALY below pound 35,000. It was assumed that doubling the risk of fracture for women without a prior fracture would give results similar to patients at the threshold of osteoporosis with a prior fracture. CONCLUSIONS: Of the five interventions, only raloxifene appeared to reduce the risk of vertebral fracture in postmenopausal women unselected for low bone mineral density (BMD). However, as the full data have not been made public, there is some uncertainty regarding this result. None of the five interventions has been shown to reduce the risk of non-vertebral fracture in women unselected for low BMD. All of the proposed interventions provided gains in QALYs compared with no treatment in women with sufficient calcium and vitamin D intakes. The size of the QALY gain for each intervention was strongly related to the age of the patient. The estimated costs varied widely for the interventions. These net costs were markedly different by age, with some interventions becoming cost-saving at higher age ranges in patients with a prior fracture. Areas for future research include: the evidence base for the efficacy of fracture prevention in the very elderly, reanalysis of raloxifene using a dedicated breast cancer and CHD model, and more trials considering the cost-effectiveness of teriparatide.

Tendon involvement in rheumatoid arthritis of the wrist: MRI findings.

OBJECTIVE: To evaluate the distribution and extent of wrist tendon alterations in patients with active rheumatoid arthritis (RA) using magnetic resonance imaging (MRI). DESIGN AND PATIENTS: Forty-three clinically active RA patients with an illness duration of less than 4 years and no clinical evidence of tendons tears were enrolled in the study. There were 10 men and 33 women, with an average age of 52 years (range 33-63 years). MRI of both wrists, with one exception, was performed at 1.0 T using T1- and T2-weighted sequences (slice thickness 3 mm). Twelve healthy subjects (8 women, 4 men; mean age 31 years) were also evaluated as a control group. Two radiologists reviewed each of four schematic anatomical regions (volar, dorsal, ulnar, radial) for the degree of tendon and tendon sheath alterations using two progressive scales. RESULTS: In the control group all tendons had homogeneous low signal intensity on all sequences. A small amount of fluid was found in six subjects but the diameter was always less than 1 mm. In the patient group minimal fluid (< 2 mm) was found in 35 (41%) wrists, grade 2 fluid (< 2 > 5 mm) in 26 (31%) and grade 3 fluid (> 5 mm) in 24 (28%). Fifty-nine (69%) of the grade 1 changes were in the volar compartment but grade 2 involvement was evenly distributed. Grade 3 changes were most common in the dorsal compartment and combined grade 2 and 3 in the dorsal and ulnar compartments were 32 (38%) and 25 (30%) compared with 16 (18%) and 17 (20%) respectively in the volar and radial compartments. The tendons were normal (grade 0) in 47 (46%) wrists. A maximum tendon signal change (grade 1) was demonstrated in 28 wrists (32%). When associated with other individual tendons grades this grade was demonstrated in the dorsal compartment in 30 (35%) wrists, in the volar compartment in 12 (14%), in the radial compartment in 17 (20%) and in the ulnar compartment in 26 (30%). A partial tear (grade 2) was detected in 7 (8%) wrists, all involving the dorsal and ulnar compartments; five underwent surgical repair and one proved to have a complete rupture of extensor digitorum. Three (3%) had a grade 3 complete tendon tear: all of these were in extensor tendons. Surgical repair was successful in one case but two ruptured again within 3 months. CONCLUSIONS: Low grades of peritendinous effusion were more common in the volar compartment whereas moderate and high degrees of tendon sheath fluid collection and/or pannus and signs of tendonitis were more frequent in the dorsal and ulnar tendon sheaths.

[Magnetic resonance versus traditional breast imaging in solid nodular diseases of the breast]. / Risonanza magnetica versus imaging senologico tradizionale nelle malattie nodulari solide della mammella.

We report and compare the results obtained with conventional imaging (mammography and US) and MRI in the study of 46 solid nodular breast lesions verified with histologic, cytologic and/or instrumental follow-up examinations for 12-34 months. The variables we compared were relative to the identification, nature and size of the lesions. MRI, which was performed on the basis of previous mammographic and US findings, detected all the lesions but never modified the diagnosis of conventional imaging methods. Questionable MR diagnoses were fewer than mammographic and US ones (2 versus 11), but its role in correcting the questionable diagnoses of conventional imaging methods was controversial. Particularly, of 11 such cases on mammographic and US images, MRI made 8 correct diagnoses but exhibited 2 false positives and 1 false negative for carcinoma. Such MR mistakes are likely to be related to the non-use of contrast medium. As for size, US was more accurate than mammography and MRI; yet, very few misdiagnoses were make on the whole.

Evaluation of the pulmonary artery by cine MRI.

Twenty-four patients whose mediastinal (12 patients) and lung (12 patients) neoplasms were eventually verified were evaluated with cine MRI in addition to conventional methods (plain radiography, CT, MRI, and endoscopy). Using a 1.0 T system and gradient echo (FLASH repetition time 250-350 ms, echo time 12, flip angle 25-60 degrees) multislice pulse sequence, cine MRI was performed combined with cardiac gating. At the level of the pulmonary artery, the CT, spin echo (SE) MRI, and cine MRI findings were evaluated blindly by three groups of radiologists to determine whether the pulmonary artery was infiltrated or dynamically stenotic. Cine MRI allowed an overall diagnostic accuracy of 100% in comparison with SE MRI (91.6%) and CT (91.6%).

MR imaging of rheumatoid hand lesions: comparison with conventional radiology in 31 patients.

The purpose of this study was to evaluate the diagnostic accuracy of magnetic resonance imaging (MRI) in rheumatoid arthritis (RA) by comparing MRI with conventional radiology (CR) findings and by correlating these findings with the clinical and serological profile of the disease. The hands of 31 patients (24 females, 7 males) affected by classical RA were studied using a Magnetom 1.0 T tomograph. Coronal, axial, and/or sagittal SE T1 and GE (FLASH 2D FL: 70 degrees-15 degrees) images were obtained in all patients. Moreover, in 7 patients the MRI study was performed after i.v. injection of Gd DTPA contrast medium (0.2 mM/kg). Ten healthy volunteers were also studied as controls. In all patients a conventional radiological study was performed as well as a clinical and serological investigation. Two blinded observers evaluated the MRI and CR findings and checked 15 elementary pathological lesions, assigning an MRI and a CR score to each patient. MRI provided higher accuracy than CR in detecting rheumatoid soft tissue changes and minimal skeletal lesions, while the opposite was true for severe skeletal lesions. No correlations emerged between the MRI/CR findings and clinical and serological data. This study suggests that MRI and CR are complementary techniques in the evaluation of the anatomical changes in RA.

[Cine-MR in the assessment of the cardiovascular structures in extensive mediastinal pathology]. / La cine-RM nella valutazione delle strutture cardiovascolari nella patologia espansiva mediastinica.

The authors report their experience with cine-MRI in evaluating the infiltration of the main cardiovascular structures by expansive mediastinal masses. Twenty-four patients with proven lung (12 cases) and mediastinal (12 cases) cancers, previously selected with CT, underwent MRI examination of the chest. A superconductive 1.0 T unit was employed. Cytohistologic confirmation was obtained in all cases (6 thymomas, 6 lymphomas, 12 lung cancers). Ten normal subjects were also studied as a control group. Axial, coronal, and sagittal SE T1 images were obtained as the basis for MRI investigation of the chest. Subsequently, gradient-echo pulse-sequences images were obtained during the whole cardiac cycle, and later displayed on cine-Mode, on the section plane where vessel wall was closest to the tumor. The results prove cine-MRI to allow a correct diagnosis to be made in all cases, especially in those patients where CT and conventional SE MRI yielded questionable results. This preliminary experience suggests that cine-MRI could be used as a complementary method to CT and conventional SE MRI in evaluating mediastinal vessel involvement.

[Dynamic imaging with magnetic resonance in the diagnosis of breast disease]. / Imaging dinamico con risonanza magnetica nella senologia diagnostica.

MR imaging was employed for the identification and tissue characterization of nodular lesions in the breast. The study had poor outcome, but the clinical introduction of a paramagnetic contrast medium, Gd-DTPA, allowed better results to be obtained. This study was aimed at evaluating the possibilities of Gd-DTPA enhanced MRI in differentiating benign from malignant breast nodules and in staging cancer. Final diagnosis was made by means of either histology, in the patients who underwent surgery, or cytology. Sixty-one patients with nodules at mammography and US were examined with MRI. The results of US, mammography, and MRI were blindly evaluated and proved that combined mammography and US, together with Gd-DTPA enhanced MRI, correctly identified all nodular lesions. Moreover, enhanced MRI allowed benign lesions to be distinguished from malignant nodules. MRI with Gd-DTPA correctly assessed both T parameter and pectoral muscle infiltration. MRI cannot replace mammography, which is a quick and inexpensive examination, but it should be performed as an adjunct in the cases of questionable radiographic and US findings and to stage breast cancer.

[Magnetic resonance in the tunnel carpal syndrome. Possibilities and perspectives of an etiopathogenetic study]. / La risonanza magnetica nella sindrome del tunnel carpale. Possibilità e prospettive di studio etiopatogenetico.

Thirty-four selected patients were evaluated in order to define MRI capabilities in the preoperative evaluation and characterization of the pathogenetic patterns of carpal tunnel syndrome (CTS). MRI examinations were performed by means of a superconductive unit (1.0 T, Magnetom): SE T1 (500/17) and T2 (2000/90) axial images of the carpal region were obtained with a round surface coil. In 8 patients 3D GE (FLASH) pulse sequences were used to obtain 32 images of the hand; 3D reconstruction was also applied. Six patients with rheumatoid arthritis and amyloidosis were also studied after i.v. injection of Gd-DTPA (0.2 mM/kg). MRI findings were compared with both clinico-electrophysiologic and surgical results. High agreement was observed only between MRI and surgical findings. MRI allowed the direct demonstration of carpal tunnel abnormalities in 8 cases, while abnormal findings in the median nerve were observed in 18 patients. The possibility of depicting medial nerve lesions on T2-weighted images when no direct demonstration of the cause of compression is possible, could represent a guideline for the etiopathogenetic investigation of CTS. However, further experience in selected patients is necessary to define all the aspects relative to this very common syndrome.

[Psychologic reactions of patients undergoing magnetic resonance imaging. Preliminary study]. / Reazioni psicologiche di pazienti sottoposti a imaging con risonanza magnetica. Studio preliminare.

MR imaging, like other imaging techniques, can cause emotional and psychological reactions in the patients. Although reversible, these reactions sometimes lead the patient to absolutely refuse the examination or to make it impossible to carry it through. To investigate the patients' emotional distress, a study group of 28 subjects was examined. They were heterogeneous in sex, age, and pathologic condition. The main psychological reactions were analyzed, and anxiety--both of state and of trait. The anxiety parameter was evaluated as a specific index in the psycho-behavioral modifications induced by MR examination. The influence was also considered of the "fantasies" related to examination results on the patients' psyche. Talks and STAI X1 and STAI X2 were employed to this purpose, to identify possible disturbing elements related to both patients' character and examination situations. Our results point to anxiety as the major reaction observed in the subjects undergoing MR examination; it seems to be related to different parameters, which are difficult to identify. Claustrophobia, pathofobia, and the fear of an unknown examination play a major role. Talking to the patients and informing them of the characteristics of the examination proved useful to significantly reduce their emotional distress.

[Magnetic resonance of the rheumatoid hand]. / La risonanza Magnetica nella mano reumatoide.

The purpose of this study was to evaluate MRI diagnostic accuracy in rheumatoid arthritis (RA), to compare MRI and radiological findings and to correlate these findings with the clinical and serological profile of the disease. The hands of 24 patients (20 females, 4 males) affected with typical RA (ARA criteria) were studied using a tomograph Magnetom 1.0 T Siemens. Two patients affected with RA refractory to conventional second-line drugs who received a bolus of methylprednisolone (1 g) were studied before and after such treatment. The hands of healthy volunteers were examined as controls. Besides MRI study all patients underwent: (1) radiological examination of the hands performed with a standard technique and (2) clinical and serological investigation aimed at characterizing diseases activity and extent. The radiographic and MRI findings were evaluated by two different observers who found 15 pathological elementary lesions and assigned a MRI and a radiological score to each patient. MRI exhibited significantly higher accuracy than radiography in evaluating rheumatoid soft-tissue changes and in detecting minimal skeletal lesions, while severe skeletal lesions were better detected by radiology. No correlation was found between pathological MRI findings, radiological results and clinical or serological data. A significant drop in soft-tissue effusion was observed after methylprednisolone pulse in two patients. This study confirms MRI potential in the study of rheumatoid joint lesions and in the early detection of minimal soft-tissue changes. Its use appears to be suitable for accurate monitoring of RA patients under specific therapy.

[Magnetic resonance in the staging of bladder neoplasms: results of the use of JKA1, a ferrous contrast solution]. / La RM nello staging delle neoplasie vescicali: risultati dell'uso del JKA1, soluzione ferrosa contrastografica.

The authors report the results of the staging of urinary bladder cancers by means of MRI using a new ferrous contrastographic solution called JKA1. Eighteen patients with proved bladder neoplasms were examined by means of MRI: the bladder was filled with physiological solution first, and then with JKA1. Six patients were studied also after filling their bladders with Gd-DTPA solution (1:50). The results show that the use of JKA1, a T2-positive contrast medium, improved MR capabilities in the evaluation of small lesions (phi less than 1 cm) with minimal invasion of bladder wall; MR staging accuracy was 66.6% with the physiological solution and 77.8% with JKA1. The authors confirm the need for a wider MR study, in particular of T2 lesions (a critical subject for staging and surgical management) to assess MR diagnostic capabilities.

[Radiological study of the thorax. Evaluation of efficacy-efficiency of a large-field image intensifier in mass screening]. / Studio radiologico del torace. Valutazione dell'efficacia-efficienza dell'intensificatore di brillanza a grande campo nelle indagini di massa.

Chest X-ray is the most frequent examination in radiology and accounts for a considerable portion of total population radiation exposure, mostly in screening programs. The ideal radiographic system is the one providing the best image quality together with the lowest dose to the patient, at a low cost. In this paper the authors analyze the potentials of a new chest X-ray examination unit equipped with a large-screen image intensifier (TS 57-Siemens). Two-thousand subjects were examined with this unit. The technical aspects of everyday practice are analyzed from the radiologist's point of view, together with the dose to the patient, image quality, and costs.

[Radiologic and clinico-serological correlates in rheumatoid arthritis]. / Correlazioni radiologiche e clinico-sierologiche nell'artrite reumatoide.

In a study of 86 patients with rheumatoid arthritis a valid statistical correlation can be found between the entity of the osteo-articular lesions of the hand and wrist shown by radiography to a high definition and some clinical and serological parameters. The results indicate a good correlation with a large part of the considered parameters (anatomical stage, functional class, duration of the disease, VES, gamma-globulins, serological activity) and confirm the validity of the high definition radiographical study in the follow-up of the disease.