Interobserver agreement in breast radiological density attribution according to BI-RADS quantitative classification.

PURPOSE: The authors sought to assess interobserver agreement in classifying mammography density according to quantitative Breast Imaging Reporting and Data System (BI-RADS) criteria. MATERIALS AND METHODS: Six expert mammography readers were tested on a set of 100 mammograms. Interobserver agreement was determined according to the kappa statistic, adjusting for chance agreement, on a four-category (D1 vs. D2 vs. D3 vs. D4) or two-category (D1-2 vs. D3-4) basis. Agreement with a panel of 12 readers who had been tested on the same set in a previous study was also assessed. RESULTS: The six readers showed good agreement when compared in pairs [agreement on a four-category basis was substantial (kappa=0.60-0.80) for 13 pairs and almost perfect (kappa>0.80) for two pairs); agreement on a two-category basis was substantial for 12 pairs and almost perfect for three pairs) or compared with the panel (on a four-category basis, agreement was substantial for five of six readers and almost perfect for one; on a two-category basis, agreement was substantial for all readers). CONCLUSIONS: In agreement with previous studies, visual classification of mammography density according to BI-RADS quantitative criteria was highly reproducible among readers; nevertheless, attribution to the "dense breast" (BI-RADS D3-4) category, which might be adopted as a determinant of different screening protocols (such as adjunct ultrasonography or yearly interval) varied among readers (range 6-15%). Controlled studies should be performed comparing visual with computer-density category attribution, the latter possibly being a better alternative due to its absolute reproducibility.

Analysis of proportional incidence and review of interval cancer cases observed within the mammography screening programme in Trento province, Italy.

PURPOSE: The aim of this study was to assess the performance of the mammography screening programme in Trento Province, Italy, by analysing the interval cancers (IC) observed from 2001 to 2008. MATERIAL AND METHODS: IC were identified by linking screening archives with local cancer registry and pathology archives as well as with hospital discharge records. Proportional incidence was determined according to breast cancers expected in the absence of screening, estimated on the basis of patients/year at risk and age-specific incidence. The review of screening mammograms preceding ICs was performed by an external (three radiologists) and an internal (five radiologists) panel and aimed at assessing the proportion of IC reviewed as screening errors. Results were compared with European Community (EC) recommended standards. RESULTS: IC proportional incidence was 15.90% for the first year (EC standard <30%) and 25.77% for the second year (EC standard <50%) of the interval. At external review, 18.4% of cases were reviewed as screening errors (identified by at least two of three reviewers), whereas at internal review (identified by at least three of five reviewers) it was 17.4% (EC standard <20%). No significant difference was observed between external and internal review (mean recall rate 8.3% vs. 9.0%; mean identification rate 19.7% vs 19.6%). CONCLUSIONS: The study confirms good performance of the mammography screening programme in Trento Province, Italy. Comparable results of external and internal reviews suggest that the latter, no doubt easier to be implemented, might be adopted as a routine procedure to assess this early efficacy indicator.

Noninvasive assessment of coronary artery stenoses by multidetector-row spiral computed tomography: comparison with conventional angiography.

BACKGROUND: Coronary artery disease (CAD) is the most common cause of hospitalization and mortality in many industrialized countries. We analysed the diagnostic accuracy of multi-detector row spiral computed tomography (MDCT) in determining mid- to high-grade coronary artery stenoses (> 50%). METHODS: Sixty-nine patients with suspected CAD were referred to MDCT coronary angiography. Patients with a heart rate above 60 bpm received 20-40 mg propranol before the scan. The left main (LM), the left anterior descending artery (LAD), the first diagonal branch (D1), the right coronary artery (RCA) and the proximal tract of the circumflex artery (LCX) were independently evaluated by two blinded observers and screened for > 50% stenoses. The mean values of MDCT coronary narrowings assessed by two observers were compared to quantitative coronary angiography. RESULTS: MDCT correctly detected 95 of 123 coronary lesions (sensitivity 77.2%) and absence of stenoses was correctly identified in 388 of 426 segments (specificity 91%). The sensitivity for the LM, LAD, RCA and the proximal tract of LCX was 100%, 86.5%, 69.8% and 80% respectively. Classification of patients as having 1-vessel, 2-vessels, 3-vessels or left main disease was accurate in 75.4% (46/61) of patients. CONCLUSIONS: MDCT technology, combined with heart rate control, allows reliable noninvasive detection of hemodynamically significant CAD.

Detection of coronary artery stenoses using breath-hold magnetic resonance coronary angiography. Comparison with conventional x-ray angiography.

PURPOSE: To detect coronary artery stenoses, we compare breath-hold magnetic resonance coronary angiography (MRCA) to conventional coronary angiography (CA). MATERIALS AND METHODS: Sixty-five patients with suspected coronary artery disease underwent MRCA and CA within one week. MRCA examination was performed by using the two-dimensional (2D) breath-hold technique with a fast spoil gradient-echo sequence/spiral. Each imaging sequence was obtained within one breath-hold in expiration (14 seconds of apnoea). The assessment of coronary artery stenoses on magnetic resonance (MR) angiograms was independently performed by two blinded readers and compared to conventional CA images. RESULTS: Three hundred and ninety segments were evaluated by the two imaging techniques. MRCA correctly detected 76 of 88 (86%) stenoses, and recognized 242 of 302 (80%) not affected segments. The Pearson correlation coefficient between MRCA and CA in assessing coronary narrowings was very high: r = 0.85. Despite this the mean difference was 4.5 with a standard error of estimate of 0.21, indicating that MRCA slightly overestimates the degree of stenoses. CONCLUSIONS: Our study showed that 2D breath-hold MRCA is an accurate technique in displaying and quantifying the most significant stenoses in the proximal and middle segments of the coronary arteries.

Prominent crista terminalis mimicking a right atrial mixoma: cardiac magnetic resonance aspects.

A 68-year-old woman came to our observation with a clinical history of isolated systolic hypertension poorly controlled by the combination of ramipril 5 mg and hydrochlorothiazide 12.5 mg o.d. The ECG showed sinus rhythm with heart rate of 68 beats per minute and signs of left ventricular hypertrophy without strain. Further investigation included an echocardiogram that showed normal left and right cavities and normal cardiac valves. At the level of the posterior wall of the right atrial (RA) an apparent smooth, bean-like tumor, having a thin pedicle, was identified as a RA mixoma. Cardiac MRI was requested and showed in two sequential slices a muscular ridge, identified as a prominent crista terminalis. Some para-physiological structures sited in the RA may have the appearance of tumors, as crista terminalis, Eustachian valve extending into the RA chambers and Chiari network. The multiplain projections of MRI allow the cardiologist to identify the presence of intracardiac masses and to make a differential diagnosis between neoplasms and variant anatomic structures.

A case of non-conducted atrial bigeminy simulating a second-degree atrioventricular block. A holter ECG diagnosis.

A 82-years-old man, symptomatic for fatigue and lypothymia, was referred to our centre in order to evaluate the opportunity of a permanent pacemaker insertion. A 12-lead ECG was described as a Mobitz type II second-degree atrioventricular block with 2:1 conduction. This surface ECG revealed some sinus beats with normal AV conduction, everyone followed by a bizarre, non-conducted P' wave, inscripted in the previous T wave. The Holter ECG showed a sinus rhythm with a mean rate of 70 beats/minute: during the night and at 06:39 pm of the following day, ECG strip showed some sinus beats, everyone followed by an atrial non-conducted ectopic beat, characterized by prematurity and abnormal shape (P' wave), that appears as a small deformation on the preceding T wave. At the beginning and the end of the strip we can estimate respectively 9 and 4 sinus beats, that represent the normal rhythm of this patient. So, it is possible to compare the normal P-P interval (P-P = 0.84 sec) to the shorter P-P' interval (P-P = 0.40 sec) and make the correct diagnosis of non-conducted atrial bigeminy simulating a second-degree AV block with 2:1 conduction.

The effect of subclinical hypothyroidism on metabolic control in children and adolescents with Type 1 diabetes mellitus.

AIMS: Associated autoimmune phenomena might influence metabolic control in children and adolescents with Type 1 diabetes mellitus. A retrospective case control study was performed in order to explore the effect of subclinical hypothyroidism on metabolic control in Type 1 diabetes mellitus. PATIENTS AND METHODS: For this purpose each patient with Type 1 diabetes and subclinical hypothyroidism (cases) was matched for age, duration of disease and, if possible, for sex, with two to three diabetic patients without hypothyroidism (controls). Parameters of metabolic control such as HbA1c, total insulin requirement and frequency of symptomatic hypoglycaemia were retrieved for 12, 6 and 3 months before and after diagnosis of hypothyroidism. RESULTS: Thirteen patients (two male/11 female) patients were diagnosed with subclinical hypothyroidism and were matched with 31 controls (nine male/22 female). There was no difference (mean and range) in terms of age (11.9 years (4.4-18.1) vs. 11.7 years (3.5-18.1), P = 0.9) and duration of disease (5.1 years (1.2-10.5) vs. 4.38 years (0.9-10.8), P = 0.6) between the two groups. There was no difference in HbA1c and total insulin requirement between the two groups at any time point of assessment (anova P = 0.8 and P = 0.1, respectively). Patients with hypothyroidism had significantly more symptomatic hypoglycaemic episodes during the 12 months before diagnosis (anova P = 0.05), increasing progressively during this time period and reaching a peak at time 0 (5.5+/-0.4 vs. 1.6+/-0.1 episodes/month, P = 0.01). No difference could be detected within 6 months of starting substitution therapy (2.4+/-0.2 vs. 1.6+/-0.1 episodes/week, P = 0.8). CONCLUSIONS: These data suggest that subclinical hypothyroidism is associated with an increased risk of symptomatic hypoglycaemia. The prompt introduction of substitution therapy is recommended as it reduces its frequency.

The role of catecholamines in desmopressin induced locomotor stimulation.

Central and peripheral administration of DDAVP increase locomotor activity in rats in doses that alter brain dopamine neurochemistry. In order to delineate the role of catecholamines in this behavioural effect of DDAVP, the effects of different catecholamine manipulating agents on DDAVP-induced locomotor stimulation were studied in rats. The catecholamine depleting agent reserpine (5 mg/kg), administered alone or together with the catecholamine synthesis inhibitor alpha-methyltyrosine (250 mg/kg), completely prevented the locomotor stimulatory effect of DDAVP. The dopamine D1 receptor antagonist Sch-23390 (0.01 and 0.03 mg/kg) significantly antagonized the DDAVP-induced locomotor stimulation when administered in the higher dose, that also produced a significant reduction of locomotor activity per se, whereas the dopamine D2 receptor antagonist raclopride (0.08 and 0.16 mg/kg) had no significant effect. The two dopamine blockers administered together produced a significant, dose-dependent reduction of DDAVP-induced locomotor stimulation, while controls were not significantly affected. Also the alpha-adrenoceptor antagonist phenoxybenzamine decreased the DDAVP-induced locomotor stimulation in a dose (20 mg/kg) that did not influence locomotor activity in controls, and, finally, administration of Sch-23390, raclopride and phenoxybenzamine antagonised the DDAVP-induced effect in a dose combination that failed to influence locomotor activity per se. In vivo microdialysis experiments in awake, freely moving rats indicated that DDAVP increases dopamine overflow in the nucleus accumbens, a brain area of importance for initiation of locomotor activity, by approximately 25%, as compared to baseline levels. Taken together, these results indicate that the central stimulatory action of DDAVP involves granula-mediated dopamine release and subsequent activation of dopamine D1 and D2 receptors, and that alpha-adrenoceptors possibly also are involved.