MR appearance of parathyroid adenomas at 3 T in patients with primary hyperparathyroidism: what radiologists need to know for pre-operative localization.

OBJECTIVES: To identify frequent MRI features of parathyroid adenomas (PTAs) in patients with primary hyperparathyroidism (PHPT) using a fast protocol with a 3 T magnet. METHODS: Thirty-eight patients with PHPT underwent a 3 T-MR. All patients had positive US and Tc-99 sestamibi, for a total number of 46 PTAs. T2-weighted IDEAL-FSE and T1 IDEAL-sequences, before and after contrast, were performed. Five features of PTAs were recognised: hyperintensity, homogeneous or "marbled" appearance and elongated morphology on T2-sequences; cleavage plane from thyroid gland on T2-outphase; rapid enhancement in post-contrast T1. Image quality for T2-weighted IDEAL FSE and usefulness for IDEAL post-contrast T1-weighted and T2-outphase sequences were also graded. RESULTS: PTAs were hyperintense in T2-sequences in 44/46 (95.7%), "marbled" in 30/46 (65.2%) and elongated in 38/46 (82.6%) patients. Cleavage plane was observed in 36/46 (78.3%), and rapid enhancement in 20/46 (43.5%) patients. T2-sequences showed both excellent fat suppression and image quality (average scores of 3.2 and 3.1). T2-outphase images demonstrated to be quite useful (score 2.8), whereas, post-contrast T1 images showed a lower degree of utility (score 2.4). CONCLUSIONS: A fast protocol with 3.0-T MRI, recognising most common features of PTAs, may be used as a second-line method in the preoperative detection of PTAs. KEY POINTS: 3 T MRI protocol based on T2-weighted IDEAL FSE sequences was used. T2-hyperintensity and elongated morphology are common features of PTAs. 3 T MRI could be used in the preoperative detection of PTAs.

CEUS Time Intensity Curves in the Differentiation Between Leydig Cell Carcinoma and Seminoma: A Multicenter Study.

PURPOSE: Ultrasound (US) is the main imaging technique in the assessment of testicular masses, as it has proved to be highly accurate in the visualization of these pathologies. Identification of a Leydig cell tumor is essential since the lesion is benign in 90% of cases. The aim of this multicenter study is to assess the effectiveness of contrast-enhanced ultrasound (CEUS) in differentiating Leydig cell tumors from seminoma using qualitative and quantitative features. MATERIALS AND METHODS: From February 2011 to December 2013, 31 patients (mean age: 34 years; range: 25 - 52) were recruited for this prospective study. Three of them were monorchid. Therefore, a total of 59 testicles were assessed. All patients underwent grayscale US, color Doppler ultrasound (CDUS), CEUS and orchiectomy. The paired one-tailed Student's t-test was carried out to differentiate between Leydig cell tumors and seminomas. RESULTS: 31 lesions suspicious for malignancy were hypoechoic on grayscale US while they did not show a typical pattern on CDUS. CEUS qualitative analysis, based on contrast enhancement pattern, during the arterial and venous phases, did not allow discrimination of Leydig cell tumors from seminoma. Quantitative analysis of time-intensity curves (TICs) demonstrated that only three parameters presented statistical significance, i. e. wash-in rate (WiR) p = 0.014, peak enhancement (PE) p = 0.001 and time to peak (TTP) p = 0.003. CONCLUSION: The vascular bed of a Leydig cell tumor is wider and the blood flow velocity is higher than that of a seminoma due to more regular neovascularization. In contrast, a seminoma presents large areas of necrosis due to irregular neovascularization. This explains the different PE and WiR values. Further studies involving larger patient populations are mandatory to confirm these encouraging preliminary results.

Diagnostic accuracy of 1.5 Tesla breast magnetic resonance imaging in the pre-operative assessment of axillary lymph nodes.

The purpose of this study was to test the accuracy of 1.5 Tesla magnetic resonance imaging (1.5T MRI) in the preoperative evaluation of axillary lymph nodes in patients with invasive breast cancer. The authors retrospectively analyzed 26 patients with invasive breast cancer who had undergone sentinel lymph node biopsy (SLNB) and/or axillary lymph node dissection (ALND). All patients had been submitted to preoperative contrast enhanced breast 1.5T MRI. On the basis of lymph nodes morphological and dynamic characteristics, lymph nodes were classified as "negative" (short axis < 5 mm), "borderline" (short axis > 5 mm, absence of a hilum) or "positive" (short axis > 5 mm, absence of a hilum and also other suspicious features). The authors compared 1.5T MRI results with the outcome of histological analysis performed according to the TNM criteria; sensitivity (SE), specificity (SP), positive predictive value (PPV), and negative predictive value (NPV) of 1.5T MRI were evaluated. Considering only the lymph nodes "positive", 1.5 T MRI showed: SE 37.8%, SP 99.3%, FP 0.7%, PPV 92.5%, and NPV 88.1%. However, considering also "borderline", 1.5T MRI achieved: SE 75.7%, SP 99.3%, FP 0.7%, PPV 96.1%, and NPV was 95%. Contrast enhanced breast 1.5T MRI is not yet a valid alternative to histological analysis but it is a valid tool for a preoperative study of the topography of axillary lymph nodes and has the potential to become a routine method for evaluating the metastatic lymph nodes before submission to ALND.

Apparent diffusion coefficient on 3.0 Tesla magnetic resonance imaging and prognostic factors in breast cancer.

AIM: The aim of the study was to evaluate whether the apparent diffusion coefficient (ADC) provided by 3.0 Tesla diffusion-weighted imaging (3T DWI) varies with the prognostic factors Ki67 and grading in invasive breast cancer. MATERIALS AND METHODS: Seventy-three patients with 75 invasive breast cancer lesions who had undergone 3.0 Tesla magnetic resonance imaging (MRI) for local staging were enrolled. All lesions were confirmed by histologic and immunohistochemical analysis. MRI included both dynamic contrast-enhanced and DWI sequences. ADC value was obtained for each lesion. Histologic tumor grade was established according to the Nottingham Grading System (NGS), while Ki67 expression was evaluated by MM1 clone IgG1 mouse anti-human monoclonal antibody. Patients were divided into the following groups: grade 1 (G1), grade 2 (G2), grade 1 plus grade 2 (G1+G2) and grade 3 (G3), and low Ki67 (< or = 14%), intermediate Ki67 (15%-30%), and high Ki67 (> or = 30%). ADC values were compared with the G and Ki67 groups. Statistical comparison was carried out using the Mann-Whitney U and the Kruskal-Wallis H test. RESULTS: ADC values were significantly higher in G3 than in G1+G2 tumors; no significant difference was observed when G1, G2, and G3 were compared. There was no statistically significant correlation between ADC values and Ki67 percentage (p > 0.05). DISCUSSION: ADC values obtained on 3T DWI correlate with low (G1+G2) and high-grade (G3) invasive breast carcinomas. CONCLUSION: ADC may be a helpful tool for identifying high-grade invasive breast carcinoma.

Role of psa levels and pathological stadiation before radiation therapy in predicting mp-MRI results in patients with prostate cancer recurrence after radical prostatectomy.

OBJECTIVE: To evaluate PSA value in mp-MRI results prediction, analyzing patients with high (GS≥8, pT≥3, pN1) and low grade (GS<8, pT<3, pN0) Prostate Cancer (PCa). MATERIALS AND METHODS: One hundred eighty-eight patients underwent 1.5-Tmp-MRI after Radical Prostatectomy (RP) and before Radiotherapy (RT). They were divided into 2 groups: A and B, for patients with biochemical recurrence (BCR) and without BCR but with high local recurrence risk. Considering Gleason Score (GS), pT and pN as independent grouping variables, ROC analyses of PSA levels at primary PCa diagnosis and PSA before RT were performed in order to identify the optimal cut-off to predict mp-MRI result. RESULTS: Group A and B showed higher AUC for PSA before RT than PSA at PCa diagnosis, in low and high grade tumors. For low grade tumors the best AUC was 0.646 and 0.685 in group A and B; for high grade the best AUC was 0.705 and 1 in group A and B, respectively. For low grade tumors the best PSA cut-off was 0.565-0.58ng/mL in group A (sensitivity, specificity: 70.5%, 66%), and 0.11-0.13ng/mL in B (sensitivity, specificity: 62.5%, 84.6%). For high grade tumors, the best PSA cut-off obtained was 0.265-0.305ng/mL in group A (sensitivity, specificity: 95%, 42.1%), and 0.13-0.15ng/mL in B (sensitivity, specificity: 100%). CONCLUSION: Mp-MRI should be performed as added diagnostic tool always when a BCR is detected, especially in high grade PCa. In patients without BCR, mp-MRI results, although poorly related to pathological stadiation, still have a good diagnostic performance, mostly when PSA>0.1-0.15ng/mL.

Contrast-enhanced ultrasound examination of the breast: a literature review.

Angiogenesis is the basis for neoplastic growth in human tissues. Nevertheless, neovascularization may be present both in benign and malignant lesions. Although microvascular density assessment is a useful tool for the study of neoplastic vascularization, it cannot be used on a large scale because of the invasiveness of the method. When contrast-enhanced ultrasonography (CEUS) was introduced in clinical practice, the initial results in the field of breast lesions were disappointing because differentiation between benign and malignant masses was not possible. Magnetic resonance imaging (MRI) assessment of the microvascular features was therefore immediately accepted because of the higher diagnostic accuracy. However, in the last decade the sensitivity and specificity of CEUS have greatly improved due to the development of more sophisticated ultrasound (US) equipment, the introduction of second-generation contrast agents and the development of dedicated software able to perform quantitative analysis. This literature review compares the main results reported in the literature regarding the use of CEUS for the characterization of neoplastic lesions of the breast. All the authors agreed that malignant lesions show early wash-in with more intense enhancement and fast wash-out in comparison with benign masses. However, there is still no observer agreement regarding vascularization patterns, and different classifications are proposed. The conclusion of this literature review is therefore that the clinical role of CEUS in the diagnostic process and in follow-up is still to be clearly defined.

Mammographic features in infertile women as a potential risk for breast cancer: a preliminary study.

The purpose of the present study was to evaluate breast mammographic features, particularly mammographic density in a selected population of infertile women and to assess if these women should be considered at higher risk for breast cancer. The prevalence of female infertility in Western countries is approximately 10-15% and since causes affecting the female are involved in 35-40%, concerns have developed about the future health of these women, specifically whether infertility could represent a risk factor for future cancer development. Moreover, infertility is now often treated with medication and procedures that could modify the hormonal environment and be cofactors in the cellular changes towards cancer development. Mammographic breast density is a useful marker for breast cancer risk and breast density is considered one of the strongest risk factors for breast cancer. Breast density is associated with known breast cancer risk factors such as reproductive and menstrual factors including serum estrogen and progesterone concentrations. In Italy the National Federation for Breast Cancer (FONCAM) guidelines suggest the usefulness of mammography from 35 years of age for women who undergo infertility hormone therapy (FONCAM Guidelines, 2005). According to this recommendation 294 women aged > or = 35, with primary infertility, sent to our breast service before joining an IVF program were recruited and then underwent clinical examination and X-ray mammography. Women were divided into two groups: dense breast (DB) and non-dense breast (NDB). Univariate analysis was employed to evaluate if there was an association between mammographic density and other risk factors. Evaluation of mammographic features showed the presence of BI-RADs C and D in the sample of 200 (68%) patients with DB and in 94 (32%) patients with NDB BI-RADS A and B. Univariate analysis showed that there were no statistically significant differences between the groups BD and NDB as regards age at mammography, age at menarche, BMI and family history for breast cancer, while ovulatory etiology of infertility was found to be associated with high mammographic density (p < 0.05). In conclusion, bearing in mind that 68% of our study sample had high breast density, we can assume that patients with primary infertility might represent a group at high risk for breast cancer, particularly if infertility is due to an ovulatory factor. We suggest breast screening from the age of 35 in infertile patients who undergo treatment with fertility drugs in accordance with FONCAM recommendations. This might allow the identification of higher risk patients who need more closely monitored breast examinations.

Possible effects of insulin-like growth factor-I, IGF-binding protein-3 and IGF-1/IGFBP-3 molar ratio on mammographic density: a cross-sectional study.

The purpose of this study was to examine the possible effects of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density and assess whether this relationship was similar in subgroups of pre- and postmenopausal women. A group of 341 Italian women of childbearing age or naturally postmenopausal who had performed mammographic examination at the section of radiology of our department a maximum three months prior to recruitment were enrolled. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels and IGF-1/IGFBP-3 molar ratio was calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). To assess the association between mammographic density and IGF-1, IGFBP-3 and Molar ratio Student's t-test was employed before and after stratified by menopausal status. The analysis of the relationship between mammographic density and plasma levels of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group whereas IGFBP-3 showed similar values in both groups (DB and NDB). After stratification of the study population by menopausal status, no association was found. Our study provides strong evidence of a crude association between breast density, and plasma levels of IGF-1 and molar ratio. IGF-1 and molar ratio might increase mammographic density and thus the risk of developing breast cancer.

The impact of presurgical magnetic resonance in early breast cancer: an observational study.

The aim of this study was to evaluate the impact of presurgical breast magnetic resonance imaging (MRI) on the surgical management of selected patients with early-stage breast cancer who were candidates for BCT. The sample was built up according to the EUSOMA (European Society of Breast Cancer Specialists) recommendations enrolling women with unifocal unilateral early-stage breast carcinoma diagnosed by mammography, ultrasound (US) examination and in some cases also by histological analysis; all were scheduled for wider local excision. All eligible patients underwent presurgical breast MRI and findings were classified according to the BI-RADS system. In the presence of additional foci classified as BI-RADS 3-4, a targeted second-look US study was performed. If second-look US confirmed the presence of foci, needle biopsy was performed. Possible changes in the therapeutic approach resulting from preoperative MRI findings were decided upon by a multidisciplinary team. Outcome of histological examination of the surgical specimen and particularly analysis of tumor infiltration of the resection margins was the standard for determining the appropriateness of surgical strategy. A total of 123 patients underwent presurgical breast MRI. Additional foci were detected in 41.6% of patients, a greater local extension of the index lesion in 6.4%, whereas MRI confirmed local staging established by conventional imaging in 52%. However, 13.8% of additional foci were not confirmed by second-look and needle biopsy. More extensive surgery as a result of MRI findings was performed in 34.2%. This decision proved to be appropriate in 29.3% thus resulting in an over-treatment rate of 4.9%. Presurgical breast MRI resulted in confirmation of planned surgical strategy in 65.8% with an appropriateness rate of 54.5%. Surgical resection margins were positive for malignancy in 11.3% and repeated surgery was therefore required. Therapeutic strategy established on the basis of MRI was appropriate in 83.8% of cases. This study confirms the utility of MRI in presurgical workup of selected breast cancer patients. The results obtained suggest the importance of a sensitive tool such as MRI in the local staging of breast cancer before treatment planning.

Magnetic resonance hysterosalpingography in the evaluation of tubal patency in infertile women: an observational study.

The purpose of this study was to evaluate the ability of magnetic resonance hysterosalpingography (MR-HSG) to demonstrate fallopian tube patency in infertile women and to improve the MR-HSG technique. Sixteen consecutive infertile women were recruited for this trial. All subjects underwent clinically indicated MR-HSG: 10-15 ml of 1:10 solution of gadolinium and normal sterile saline (0.9%) was gently hand-injected intracervically through a 7 French balloon catheter while seven consecutive flash-3D dynamic (FL 3D DY) T1-weighted MR sequences were acquired. Two readers independently assessed image quality as well as anatomic and pathologic correlations. Patient comfort was evaluated using a specific score questionnaire. MR-HSG was successfully completed in all patients. In 14/16 (87.4%) patients, MR-HSG showed bilateral tubal patency with symmetric contrast agent diffusion and a regular tubo-ovarian relationship. One patient (6.3%) with monolateral hydrosalpinx presented no contrast agent diffusion in the affected side (monolateral tubal occlusion); in another patient (6.3%) the fallopian tube was displaced upward causing loss of the tubo-ovarian anatomical relationship resulting in asymmetric and inadequate contrast agent diffusion. Eight women (50%) were found to have abnormalities on MR imaging; these abnormalities included multi follicular ovaries (5 cases 31.1%), endometrioma (1 case, 6.3%), leiomyoma (1 case/6.3%) and endometrial polyp (1 case/6.3%). The average time required for the study was 25-30 minutes. Analysis of the questionnaires administered to the patients showed that 15/16 patients (93.7%) were fully satisfied with the procedure. All examinations were judged to be of high diagnostic quality and the two readers made similar diagnoses. In conclusion, MR-HSG is a feasible, useful and well tolerated tool for the assessment of the uterus, fallopian tubes, ovaries and extra-uterine structures. MR-HSG is a new promising imaging approach to female infertility.

Insulin-like growth factor-I (IGF-1), IGF-binding protein-3 (IGFBP-3) and mammographic features.

INTRODUCTION: The IGF system has recently been shown to play an important role in the regulation of breast tumor cell proliferation. However, also breast density is currently considered as the strongest breast cancer risk factor. It is not yet clear whether these factors are interrelated and if and how they are influenced by menopausal status. The purpose of this study was to examine the possible effects of IGF-1 and IGFBP-3 and IGF-1/IGFBP-3 molar ratio on mammographic density stratified by menopausal status. PATIENTS AND METHODS: A group of 341 Italian women were interviewed to collect the following data: family history of breast cancer, reproductive and menstrual factors, breast biopsies, previous administration of hormonal contraceptive therapy, hormone replacement therapy (HRT) in menopause and lifestyle information. A blood sample was drawn for determination of IGF-1, IGFBP-3 levels. IGF-1/ IGFBP-3 molar ratio was then calculated. On the basis of recent mammograms the women were divided into two groups: dense breast (DB) and non-dense breast (NDB). Student's t-test was employed to assess the association between breast density and plasma level of IGF-1, IGFBP-3 and molar ratio. To assess if this relationship was similar in subgroups of pre- and postmenopausal women, the study population was stratified by menopausal status and Student's t-test was performed. Finally, multivariate analysis was employed to evaluate if there were confounding factors that might influence the relationship between growth factors and breast density. RESULTS: The analysis of the relationship between mammographic density and plasma level of IGF-1, IGFBP-3 and IGF-1/ IGFBP-3 molar ratio showed that IGF-1 levels and molar ratio varied in the two groups resulting in higher mean values in the DB group (IGF-1: 109.6 versus 96.6 ng/ml; p= 0.001 and molar ratio 29.4 versus 25.5 ng/ml; p= 0.001) whereas IGFBP-3 showed similar values in both groups (DB and NDB). Analysis of plasma level of IGF-1, IGFBP-3 and IGF-1/IGFBP-3 molar ratio compared to breast density after stratification of the study population by menopausal status (premenopausal and postmenopausal) showed that there was no association between the plasma of growth factors and breast density, neither in premenopausal nor in postmenopausal patients. Multivariate analysis showed that only nulliparity, premenopausal status and body mass index (BMI) are determinants of breast density. CONCLUSIONS: Our study provides a strong evidence of a crude association between breast density and plasma levels of IGF-1 and molar ratio. On the basis of our results, it is reasonable to assume that the role of IGF-1 and molar ratio in the pathogenesis of breast cancer might be mediated through mammographic density. IGF-1 and molar ratio might thus increase the risk of cancer by increasing mammographic density.

Prenatal diagnosis of OEIS (omphalocele, bladder exstrophy, imperforate anus, clubfeet) variant associated with increased nuchal translucency and OEIS complex with ambiguous genitalia associated with corrected transposition of the great arteries: case series and review of the literature.

INTRODUCTION: The OEIS complex refers to a combination of defects consisting in omphalocele, bladder exstrophy, imperforate anus and spinal defects and represents a rare nosologic entity (from 1:200,000 to 1:400,000 pregnancies). The defect probably occurs in early blastogenesis or in mesodermal migration during the primitive streak period. MATERIALS AND METHODS: Two cases of OEIS complex diagnosed prenatally by ultrasound are reported. The medical record regarding differential diagnosis, associated anomalies, treatment and prognosis has also been sought and reported. CONCLUSION: Differential diagnosis with exstrophy-epispadias complex and/or cloacalexstrophy complex may be difficult antenatally by means of ultrasound. However, color Doppler has been proved to aid the diagnosis of bladder exstrophy by depicting the urine flow in direct communication with the abdominal cavity and has been useful in showing the course of the perivesical umbilical arteries. Prenatal 3D ultrasound with tomographic ultrasound imaging (TUI) and antenatal MR imaging might be useful adjuncts to conventional 2D scan in aiding the prenatal diagnosis of such malformation.

Cervical and oral teratoma in the fetus: a systematic review of etiology, pathology, diagnosis, treatment and prognosis.

INTRODUCTION: The aim of the study was to produce a systematic review about etiology, pathology, diagnosis, prognosis and clinical management regarding oral and cervical teratomas. MATERIALS AND METHODS: A systematic review of Pubmed/Medline using the following keywords was made: epignathus, cervical teratoma, fetus, oral teratoma, prenatal diagnosis, prognosis, treatment, ultrasound. CONCLUSION: The following clinical conclusions can be reached: (1) teratomas are rare, usually benign congenital tumors which recognized multifactorial etiology; (2) prenatal ultrasound diagnosis can be made early in pregnancy (15-16 weeks); (3) 3D ultrasound and MRI may enhance the accuracy of the antenatal diagnosis (location, extension and intracranial spread) and may aid in the selection of patients requiring treatment; (4) prenatal karyotype and search for associated abnormalities is mandatory in all teratomas; (5) delivery should involve elective Cesarean section with ex utero intrapartum treatment procedure or resection of the tumor mass, which may be performed on placental support operation on placental support procedure to increase the chances of postnatal survival.

Role of low-mechanical index CEUS in the differentiation between low and high grade bladder carcinoma: a pilot study.

PURPOSE: To assess the efficacy of low-mechanical index contrast-enhanced ultrasonography (CEUS) in the differentiation of a series of histologically proven bladder lesions identified via conventional cystoscopy and biopsied. MATERIALS AND METHODS: 36 patients (mean age: 62 years; range 45 - 72 years) with bladder lesions previously detected by color power Doppler ultrasonography (CDUS) were prospectively examined with low-mechanical index contrast-enhanced US after bolus administration of 2.4 ml of Sonovue (Bracco, Milan, Italy). All lesions were evaluated in real-time continuous scanning for 2 minutes and the videos were registered. Two ultrasound (US) experts evaluated the videos by consensus and assigned a score to the enhancement pattern. Subsequently, a specific sonographic quantification software (Qontrast, Bracco, Milan, Italy) based on pixel by pixel signal intensity over time was used to obtain contrast-enhanced sonographic perfusion maps for each lesion. Time-intensity curves (TICs) of each lesion were then extracted from the region of interest positioned within the lesion and in the closest bladder wall. The sensitivity and specificity of CDUS and CEUS were compared using McNemar's test. All patients subsequently underwent conventional cystoscopy with biopsy or transurethral resection. RESULTS: 22 high-grade and 14 low-grade transitional cell carcinomas (TCCs) were histologically diagnosed (mean diameter 2.1 cm; range: 1 - 4.5 cm). The sensitivity and specificity of CDUS were 86.4% (19 / 22; 95% CI = 66.7 - 95.3%) and 42.9% (6 / 14; 95% CI = 21.4 - 67.4%), respectively. The sensitivity and specificity of CEUS were 90.9% (20 / 22; 95% CI = 72.2 - 97.5%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. The sensitivity and specificity of CEUS using TICs were 95.4% (21 / 22; 95% CI = 78.2 - 99.2%) and 85.7% (12 / 14; 95% CI = 60.1 - 95.9%), respectively. There was no significant difference between the sensitivity of CDUS versus CEUS, CDUS versus TIC, and CEUS versus TIC (p > 0.05; McNemar's test). The specificity of CEUS and TIC was significantly higher than that of CDUS (p < 0.05; McNemar test). CONCLUSION: CEUS is a reliable noninvasive method for differentiating low- and high-grade bladder carcinomas since it provides typical enhancement patterns as well as specific contrast-sonographic perfusion curves. However, further studies involving larger patient populations is mandatory to confirm these promising results.

Effectiveness of etanercept biosimilar SB4 in maintaining low disease activity in patients with psoriatic arthritis switched from etanercept originator: an open-label one year study.

Background: Currently, there are no studies specifically aimed at investigating the effectiveness of etanercept biosimilar SB4 in psoriatic arthritis (PsA).Objectives: Our primary objective was to verify the ability of SB4 to maintain low disease activity in patients switching from reference etanercept to SB4 after 1 year of treatment with this last drug.Methods: Eighty-seven PsA patients with low disease activity at baseline measured by using the clinical Disease Activity Index for Psoriatic Arthritis ≤ 13 (cDAPSA; range 0-154) were prospectively evaluated after 6 and 12 months when switching from the reference etanercept to SB4.Results: One year after switching from the reference etanercept to SB4, 76 (87.3%) out of 87 patients maintained a cDAPSA ≤ 13.Conclusions: SB4 was effective in maintaining a state of low disease activity in the majority of patients switched from the reference etanercept. However, the proportion of patients (11 subjects) who failed to maintain a state of low disease activity at the end of the study was statistically significant. Loss of effectiveness in the above subjects was mainly due to subjective evaluations given by the patients, rather than an objectifiable exacerbation of disease.

Infertility in women: combined sonohysterography and hysterosalpingography in the evaluation of the uterine cavity.

PURPOSE: To evaluate the diagnostic effectiveness of combined hysterosalpingography (HSG) and sonohysterography (SHG) in the study of infertile women. MATERIALS AND METHODS: 208 women affected by primary (184) or secondary sterility (24) were divided in two random groups. Group 1 underwent only HSG and group 2 underwent simultaneous HSG and SHG. The results obtained in the two groups were correlated with the results of hysteroscopy or laparoscopy, considered Gold Standard. Sensitivity, specificity, positive (PPV) and negative (NPV) predictive values and likelihood ratio (LR) of HSG alone and combined HSG/SHG were calculated. Results were evaluated with t-test, Pearson's Chi square or Fisher exact test when appropriate and ROC analysis. RESULTS: In group 1, hysteroscopy revealed no pathology in the uterine cavity in 70/104 patients, but evidenced 47 abnormalities related to the uterine cavity in 34 women. HSG outcome was in accordance with hysteroscopy in 27/34 cases of abnormalities, and in 64/70 cases of normal outcome. Sensitivity 0.79, specificity 0.91, PPV 0.82, NPV 0.90, LR+ 9.26. In group 2, hysteroscopy revealed no pathology in the uterine cavity in 64/104 patients but 52 abnormalities related to the uterine cavity in 40 women. HSG and SHG outcomes were confirmed by hysteroscopy in 39/40 cases of abnormalities of the uterine cavity and in 60/64 cases of normal uterine cavity. Sensitivity 0.97, specificity 0.94, PPV 0.91, NPV 0.98, LR+ 15.60. Statistical analysis showed that combined HSG and SHG yielded elevated specificity and LR+ and therefore few cases of false positive outcome. CONCLUSION: Combined performance of HSG and SHG can shorten diagnostic investigation time and reduce the discomfort to the patient as the injector is fed into the cervix only once. This may also reduce the patient's anxiety level as one of the causes of infertility.

Early activation of the hypothalamic-pituitary-adrenal-axis in very-low-birth-weight infants with small thymus at birth.

BACKGROUND: An acute thymic involution in human fetuses and newborns has been described in very-low-birth-weight (VLBW) infants with histological chorioamnionitis. However, the mechanisms of thymic involution remain to be clarified. Here, we tested the hypothesis that an activation of the hypothalamic-pituitary-adrenal (HPA) axis occurs in VLBW infants with acute thymic involution at birth. METHODS: A total of 180 randomly selected VLBW newborns (28.8 +/- 3.15 wk gestation; 1093 +/- 305 g) entered the study. Thymic size was measured on standard chest radiographs at birth, and expressed as the ratio between the transverse diameter of the cardiothymic image at the level of the carina (CT) and that of the thorax (T). CT/T < 0.28 was considered to indicate a small thymic size. Plasma cortisol and adrenocorticotropic hormone (ACTH) concentrations were determined on days 1 (d-1) and 7 (d-7), and at 1 month (mo-1). Results. A total of 66 (36.7%) newborns had CT/T < 0.28. Infants with small thymus had significantly increased cortisol on d-1 ( approximately 5.2-folds) [median: 18.95 (95% CI: 11.20-39.4) microg/dl vs. 3.66 (1.94-6.82) microg/dl, p < 0.0001)] and d-7( approximately 1.7-folds) [12.0 (4.39-22.97) microg/dl vs. 7.8 (3.63-12.8) microg/dl, p = 0.0384)], as compared with those with normal thymic size, together with higher adrenocorticotropic hormone (ACTH) concentrations on d-1 ( approximately 1.9-folds) [28 (15.6-61.07) pg/ml vs. 14.9 (9.0-23.42) pg/ml, p = 0.0005)], while no significant differences for cortisol at mo-1 or ACTH concentrations on d-7 and mo-1 were evidenced (p > 0.50). From a multivariate logistic regression analysis, a small thymus at birth was a significant independent predictor of plasma cortisol concentrations in the top-quartile (OR = 14.4; 95% CI: 6.079-34.11), and plasma ACTH concentrations in the top-quartile (OR = 4.40 (95% CI: 1.99-9.74) on d-1 (results adjusted for variables significant at univariate analysis). CONCLUSIONS: Our data indicated the presence of a previously unrecognized, early activation of the HPA axis in VLBW newborns with a small thymus at birth.

Tamoxifen in women with breast cancer and mammographic density.

PURPOSE OF INVESTIGATION: To evaluate the effect of tamoxifen on mammographic density using a qualitative and a semiquantitative method. METHODS: Mammograms from 148 women treated for breast cancer before and after surgery were reviewed: 68 were administered tamoxifen; 80 did not receive tamoxifen. The mammograms were classified in one of the four BIRADS density categories by two radiologists blinded to the treatment and by a computer-assisted method after digitizing images. RESULTS: At mammographic one-year-follow-up density was reduced in both groups and remained stable in the following years. A comparison of mammograms performed before surgery and after one year showed a statistically significant difference in density reduction between the tamoxifen and the non-tamoxifen-treated group. Good agreement was obtained between the qualitative and semiquantitative method. CONCLUSION: Breast density reduction observed in women treated with tamoxifen may help in the detection of small tumors in dense breasts by means of reducing the masking effect of parenchyma.

Fetal acid-base and neonatal status after general and neuraxial anesthesia for elective cesarean section.

OBJECTIVE: To analyze the relation between fetal acid-base and neonatal status in an observational cohort study of 900 consecutive women with singleton pregnancies at term undergoing elective cesarean section. METHODS: The women were divided into 3 groups according to the type of anesthesia administered. Fetal acid-base status was assessed from umbilical cord blood (both artery and vein) and intermediate neonatal outcome was noted. RESULTS: Epidural anesthesia was associated with the highest pH. The lowest pH and the highest pC0(2) values were associated with spinal anesthesia. Although maternal general anesthesia was associated with the highest values for partial pressure and saturation of oxygen in umbilical arterial blood, the newborns were more likely to be depressed than those born following spinal (P=0.0016) or epidural (P=0.0002) anesthesia. CONCLUSIONS: If fetal oxygenation is the goal, general anesthesia provides the highest values for partial pressure and saturation of oxygen in umbilical arterial blood. However, epidural anesthesia was associated with better fetal and neonatal status than either spinal or general anesthesia.

Abnormal oral mucosal light reflectance: a new clinical marker of high risk for colorectal cancer.

BACKGROUND: A familial predisposition to colorectal cancer (CRC) has been clearly established, consisting of familial clustering in 15-20% and clear hereditary aetiology in 5-10% of overall CRC cases. Early identification of families and individuals at high risk is essential as intensive surveillance has been demonstrated to reduce cancer incidence and overall mortality. In the present study, the value of oral mucosal light reflectance in identifying hereditary non-polyposis colorectal cancer (HNPCC) carriers was investigated. METHODS: Twenty members of six different genetically unrelated HNPCC kindred and 30 genetically unrelated age and sex matched healthy controls were examined. Lower gingival and vestibular oral mucosal reflectance was measured using an imaging spectrophotometer. RESULTS: HNPCC carriers showed significantly lower values in the 590-700 nm wavelength range (p