Value of shoulder US compared to MRI in infants with obstetric brachial plexus paralysis

PURPOSEChildren with brachial plexus birth injury (BPBI) may eventually develop glenohumeral instability due to development of unbalanced muscular strength. Our major goal in this study is to compare the accuracy of physical examination and ultrasonography (US) in determination of glenohumeral instability in infants with BPBI compared with magnetic resonance imaging (MRI) as a gold standard, and to investigate the role and value of US as a screening modality for assessing glenohumeral instability.METHODSForty-two consecutive patients (mean age, 2.3±0.8 months) with BPBI were enrolled into this prospective study. Patients were followed up with physical examination and US with dynamic evaluation in 4–6 weeks intervals. Patients who developed glenohumeral instability based on physical examination and/or US (n=21) underwent MRI. Glenohumeral instability was defined as alpha angle >30° and percentage of posterior humeral head displacement >50%. Diagnostic accuracy of physical examination and US was calculated and quantitative parameters were compared with Wilcoxon test.RESULTSGlenohumeral instability was confirmed with MRI in 15 of 21 patients. Accuracy and sensitivity of physical examination and US were 47%, 66% and 100%, 100%, respectively in determination of glenohumeral instability. No significant difference was found for the alpha angle (p = 0.173) but the percentage of posterior humeral head displacement was statistically significant between US and MRI (p = 0.028).CONCLUSIONOur results indicate that US with dynamic evaluation is a good alternative for MRI in assessment of glenohumeral instability in infants with BPBI, since it is highly accurate and specific, and quantitative measurements used for glenohumeral instability were comparable to MRI. US can be used as a screening method to assess glenohumeral instability in infants with BPBI.

Children with brachial plexus birth injury (BPBI) may eventually develop glenohumeral instability (GI) due to development of unbalanced muscular strength. Shoulder related problems in patients with BPBI include internal rotation contracture, impaired physeal growth, and articular changes (glenoid retroversion and posterior glenoid deformation) (1, 2). Despite the fact that GI is most commonly believed to develop gradually after birth, the exact timing is not clear (3, 4). In order to prevent the development of osseous deformity, early diagnosis and intervention of GI is critical (5–7). Recent studies showed that development of GI can be detected with ultrasonography (US) as early as 3 months of age (8, 9). Clinical diagnosis of GI can be challenging and imaging modalities are important for the evaluation of stability of the joint (2). Because of the lack of ossification in the humeral head and glenoid, conventional radiographs and computerized tomography have only minor roles in the assessment of GI (10, 11). Although magnetic resonance imaging (MRI) is the current gold standard imaging modality for dysplasia in the whole age spectrum, US is also a very promising modality that can be used for this purpose. Since it is cost effective and, unlike MRI, requires no anesthesia, frequent follow-up examinations are possible with US (1, 2, 9, 12, 13). Furthermore, it is also possible to perform dynamic examination and assess the reducibility of the humeral head with US (13), which can be used as a good indicator for GI. In the literature, a variety of quantitative parameters has been used to assess the presence of GI but the alpha (α) angle and the percentage of posterior humeral head displacement (PPHHD) are the most valuable parameters for overall evaluation of the GI (2, 12, 14). Intra- and interobserver reliability of these measurements was shown to be good to excellent for US (12, 15) but there was poor agreement between US and MRI (15).The major goal of our study is to compare the accuracy of primary physical examination and US in infants with BPBI and determine whether the diagnostic success of US is comparable to MRI, the current gold standard modality. In addition, the secondary objective of this study is to assess the agreement between US and MRI measurements for detecting GI in this patient population.     

Do the combination of multiparametric MRI-based radiomics and selected blood inflammatory markers predict the grade and proliferation in glioma patients?

PURPOSEWe aimed to explore whether multiparametric magnetic resonance imaging (MRI)-based radiomics combined with selected blood inflammatory markers could effectively predict the grade and proliferation in glioma patients.METHODSThis retrospective study included 152 patients histopathologically diagnosed with glioma. Stratified sampling was used to divide all patients into a training cohort (n=107) and a validation cohort (n=45) according to a ratio of 7:3, and five-fold repeat cross-validation was adopted in the training cohort. Multiparametric MRI and clinical parameters, including age, the neutrophil-lymphocyte ratio and red cell distribution width, were assessed. During image processing, image registration and gray normalization were conducted. A radiomics analysis was performed by extracting 1584 multiparametric MRI-based features, and the least absolute shrinkage and selection operator (LASSO) was applied to generate a radiomics signature for predicting grade and Ki-67 index in both training and validation cohorts. Statistical analysis included analysis of variance, Pearson correlation, intraclass correlation coefficient, multivariate logistic regression, Hosmer–Lemeshow test, and receiver operating characteristic (ROC) curve.RESULTSThe radiomics signature demonstrated good performance in both the training and validation cohorts, with areas under the ROC curve (AUCs) of 0.92, 0.91, and 0.94 and 0.94, 0.75, and 0.82 for differentiating between low and high grade gliomas, grade III and grade IV gliomas, and low Ki-67 and high Ki-67, respectively, and was better than the clinical model; the AUCs of the combined model were 0.93, 0.91, and 0.95 and 0.94, 0.76, and 0.80, respectively.CONCLUSIONBoth the radiomics signature and combined model showed high diagnostic efficacy and outperformed the clinical model. The clinical factors did not provide additional improvement in the prediction of the grade and proliferation index in glioma patients, but the stability was improved.

Glioma is the most common primary malignant tumor in the brain, accounting for nearly 81% of malignant tumors in the brain (1). In the 2016 World Health Organization (WHO) classification system, gliomas can be graded from level I to level IV according to the histopathological and clinical criteria. Low-grade gliomas (LGGs) include grades I and II, whereas high-grade gliomas (HGGs) include grades III and IV (2, 3). Patients with LGGs may remain indolent for years or progress to glioblastoma (4) and are generally treated with only surgery and in some cases with radiotherapy (5). For patients with HGGs, radiotherapy and/or chemotherapy are usually followed after surgery, which often indicates a poor prognosis (6). Although genetic factors play an increasingly important role in indicating prognosis and survival (2, 3, 7), false classification could directly cause inappropriate treatment, which significantly affects patient outcomes. Hence, precise grading is still crucial for therapy planning and progression assessment in patients with gliomas.The nuclear protein Ki-67 is a reliable biomarker for evaluating the proliferation of tumor cells, because it only exists in active phase of the cell cycle. (8). The Ki-67 labeling index (LI) is defined as the percentage of Ki-67-positive tumor nuclei of all tumor nuclei (9). The WHO reported that the Ki-67 LI values are below 4% of the mean value for grade II glioma, 5%–10% for grade III glioma, and 15%–20% for grade IV glioma (2). The overexpression of Ki-67 infers poor differentiation and prognosis (10). Hence, the accurate preoperative evaluation of the Ki-67 LI maybe helpful in treatment decision-making for glioma patients.Recently, there is a newly emerging area in radiology: radiomics, which is realized by quantifying image data with advanced image post-processing techniques (11). For tumor radiomics, a complete characterization of the tumor is established by feature selection and high-throughput analysis (12, 13). The radiomics analysis of glioma MRI could predict the grade and proliferation potency in glioma patients (14–16). A study showed that multiparametric MRI-based radiomics analysis, assisted by T2-weighted imaging, gadolinium-based contrast-enhanced T1-weighted imaging and the apparent diffusion coefficient (ADC), could help clinicians classify gliomas more accurately (17).Chronic inflammation, which is part of the tumor microenvironment, is associated with tumor occurrence and progression (18, 19). Some blood inflammatory biomarkers, such as the neutrophil-lymphocyte ratio (NLR), platelet count, and red cell distribution width (RDW), have been proposed to predict the prognosis of tumors (20–22). And recent studies showed that the NLR and platelet count in glioblastoma patients (23, 24) and the NLR and RDW in glioma patients were significant in predicting prognosis (25).To our knowledge, there have been no studies on MRI-based radiomics combined with selected blood inflammatory markers to predict the grade and proliferation potency in glioma patients. The purpose of this study is to build and assess a radiomics nomogram to preoperatively predict glioma grade and proliferation potency by incorporating MRI-based radiomics and clinical signatures, including age, NLR, and RDW.     

Application of ultrasonic dual-mode artificially intelligent architecture in assisting radiologists with different diagnostic levels on breast masses classification

PURPOSEWe aimed to compare the diagnostic performance and interobserver variability in breast tumor classification with or without the aid of an innovative dual-mode artificial intelligence (AI) architecture, which can automatically integrate information from ultrasonography (US) and shear-wave elastography (SWE).METHODSDiagnostic performance assessment was performed with a test subset, containing 599 images (from September 2018 to February 2019) from 91 patients including 64 benign and 27 malignant breast tumors. Six radiologists (three inexperienced, three experienced) were assigned to read images independently (independent diagnosis) and then make a secondary diagnosis with the knowledge of AI results. Sensitivity, specificity, accuracy, receiver-operator characteristics (ROC) curve analysis and Cohen’s κ statistics were calculated.RESULTSIn the inexperienced radiologists’ group, the average area under the ROC curve (AUC) for diagnostic performance increased from 0.722 to 0.765 (p = 0.050) with secondary diagnosis using US-mode and from 0.794 to 0.834 (p = 0.019) with secondary diagnosis using dual-mode compared with independent diagnosis. In the experienced radiologists’ group, the average AUC for diagnostic performance was significantly higher with AI system using the US-mode (0.812 vs. 0.833, p = 0.039), but not for dual-mode (0.858 vs. 0.866, p = 0.458). Using the US-mode, interobserver agreement among all radiologists improved from fair to moderate (p = 0.003). Using the dual-mode, substantial agreement was seen among the experienced radiologists (0.65 to 0.74, p = 0.017) and all radiologists (0.62 to 0.73, p = 0.001).CONCLUSIONAI assistance provides a more pronounced improvement in diagnostic performance for the inexperienced radiologists; meanwhile, the experienced radiologists benefit more from AI in reducing interobserver variability.

As a global medical problem, breast cancer is the most commonly diagnosed cancer and the leading cause of cancer death among females (1). The development of imaging technologies have made great contribution to breast cancer diagnosis (2). Ultrasonography (US) is a valuable supplemental scanning modality for women with dense breasts (3–5). Radiologists make final diagnosis based on the morphological characteristics of breast masses according to the interpretation of Breast Imaging Reporting and Data System (BI-RADS) (6). For US BI-RADS classification, interobserver agreement ranging from fair to substantial has been reported among radiologists with different experience levels (7). Therefore, the subjectivity and empirical dependence aroused controversy towards its true diagnostic efficacy. Many studies have shown that the combined use of US-mode and ultrasound elastography has greater diagnostic efficacy than US-mode alone (8–11). However, until now, there was no consistent standard value of shear-wave elastography (SWE) in differentiation between malignant and benign breast masses which might result from the numerous reference parameters including maximum (Emax) and standard deviation (SD) (12). Both US-mode and SWE provide us with abundant uncertain information, which inexperienced radiologists cannot extract from, interpret, and utilize accurately. Therefore, the standardization and precision diagnosis of US and SWE are the challenges and research hotspots of ultrasound technology currently.The field of biomedical image analysis benefited substantially from rapid developments in artificial intelligence (AI) techniques. Previous studies on traditional computer-aided diagnosis (CAD) for breast cancer have shown that the segmentation of US and SWE images and integration of extracted features achieved better classification performance than their individual uses (13–15). With the CAD system, the average diagnostic performance of radiologists was improved or at least comparable to the independent diagnosis based on breast US images (16, 17). An observational study conducted by Van Zelst et al. (18) concluded that CAD software for automated breast US may speed up the screening time without compromising the screening performance of radiologists. As a revolutionary advance, the deep learning algorithm (convolution neural network for image processing) has a strong feature extraction ability, which can extract higher level features rather than superficial features and provide more possibilities for medical image processing. Recently few studies have shown the great potential of deep learning framework in ultrasound image processing of breast lesions (19–22).However, the abovementioned observational studies were focused only on a single mode of ultrasonic breast images. Throughout these papers, there was no deep learning model which is capable of integrating US with SWE images of breast lesions rationally. In clinical practice, comprehensive analysis with dual-mode ultrasound is of great importance for breast lesions. To meet the clinical needs, we designed a novel module named “shared latent subspace learning,” which captures the inter-mode relationship between SWE-mode and US-mode via a shared-parameter Dense Block that is optimized under adversarial loss and orthogonality constraint. Similar to the normal working mode of radiologists and just like the workflow of CAD software (23), radiologists will combine the diagnostic results given by software and achieve the secondary diagnostic results after comprehensive consideration. Therefore, we conducted a dual-mode reader study where we investigated the benefits of incorporating an innovative AI architecture. We compared the diagnostic performance and interobserver agreement of different radiologists in breast mass classification through independent diagnosis and secondary diagnosis.     

Radiomics signature as a new biomarker for preoperative prediction of neoadjuvant chemoradiotherapy response in locally advanced rectal cancer

PURPOSEWhether radiomics methods are useful in prediction of therapeutic response to neoadjuvant chemoradiotherapy (nCRT) is unclear. This study aimed to investigate multiple magnetic resonance imaging (MRI) sequence-based radiomics methods in evaluating therapeutic response to nCRT in patients with locally advanced rectal cancer (LARC).METHODSThis retrospective study enrolled patients with LARC (06/2014–08/2017) and divided them into nCRT-sensitive and nCRT-resistant groups according to postoperative tumor regression grading results. Radiomics features from preoperative MRI were extracted, followed by dimension reduction using the minimum redundancy maximum relevance filter. Three machine-learning classifiers and an ensemble classifier were used for therapeutic response prediction. Radiomics nomogram incorporating clinical parameters were constructed using logistic regression. The receiver operating characteristic (ROC), decision curves analysis (DCA) and calibration curves were also plotted to evaluate the prediction performance.RESULTSThe machine learning classifiers showed good prediction performance for therapeutic responses in LARC patients (n=189). The ROC curve showed satisfying performance (area under the curve [AUC], 0.830; specificity, 0.794; sensitivity, 0.815) in the validation group. The radiomics signature included 30 imaging features derived from axial T1-weighted imaging with contrast and sagittal T2-weighted imaging and exhibited good predictive power for nCRT. A radiomics nomogram integrating carcinoembryonic antigen levels and tumor diameter showed excellent performance with an AUC of 0.949 (95% confidence interval, 0.892–0.997; specificity, 0.909; sensitivity, 0.879) in the validation group. DCA confirmed the clinical usefulness of the nomogram model.CONCLUSIONThe radiomics method using multiple MRI sequences can be used to achieve individualized prediction of nCRT in patients with LARC before treatment.

Colorectal cancer is one of the most common malignancies. It ranks fourth for morbidity and third for mortality among malignant tumors, among which the proportion of rectal cancer with poor prognosis is over 60% (1, 2). Neoadjuvant therapy, combined with total mesorectal excision, has become a common strategy for rectal cancer (3). Response to neoadjuvant chemoradiotherapy (nCRT) is a marker of good prognosis in patients with locally advanced rectal cancer (LARC) (4). Tumor regression grading (TRG) is a reliable biomarker for evaluating the efficacy of nCRT (5, 6). TRG reflects the treatment effect of nCRT by evaluating fibrosis and the ratio of residual tumor cells (4). The accurate nCRT evaluation can only be achieved by postoperative histopathological TRG (3, 4), and there is still no technology that can noninvasively evaluate the therapeutic response.Magnetic resonance imaging (MRI) is commonly used in the diagnosis, preoperative staging, and therapeutic efficacy evaluation of rectal cancer. Prediction of the efficacy of nCRT by MRI has been rarely reported, partly due to the heterogeneity of the tumor combined with the prevalence of fibrosis and edema of lesions and surrounding tissue after nCRT. Over the recent years, a magnetic resonance TRG system was proposed for the evaluation of nCRT efficacy by using MRI and evaluating residual tumor and fibrosis. Nevertheless, the magnetic resonance TRG method has a low predictive value for pathological TRG and poor consistency, which hinders its clinical applications (7, 8).In recent years, radiomics has drawn increasing attention in oncology. Radiomics features selected from medical images have shown to be highly associated with the diagnosis and prognosis of cancers, and even with gene expression patterns (9). Studies highlighted the value of radiomics approaches in determining tumor status, preoperative staging, and efficacy evaluation (9, 10). Nevertheless, the application of the radiomics methods in evaluating therapeutic responses to nCRT is limited (11).Accordingly, the aim of the present study was to establish an nCRT prediction model based on multiple MRI sequences combined with tumor anatomy and biological characteristics so as to achieve a comprehensive preliminary prediction of nCRT efficacy for rectal cancer before treatment, to provide an essential basis for the rational formulation of clinical diagnosis and treatment decisions, and to avoid unnecessary exposure to radiotherapy and chemotherapy and the related risks such as toxicity and delayed definitive surgery.     

Discontinuous moving shot technique for conformal thermal ablation in an ex vivo porcine liver model

PURPOSEWe aimed to determine the ablation characteristics of discontinuous moving shot technique (DMST) in microwave ablation (MWA), radiofrequency ablation (RFA) and laser ablation (LA), and analyze the differences compared with fixed electrode technique (FET) in an ex vivo porcine liver model.METHODSFET was defined as the ablation needle remaining fixed during ablation. In DMST, ablation needle moved backward for a fixed distance twice along the long axis during ablation. Four moving distances (0.5 cm, 0.75 cm, 1 cm and 2 cm) were used in DMST. Long-axis diameter (LAD) and short-axis diameter (SAD) of ablation zones were measured. The ratio of LAD/SAD was calculated.RESULTSThe shape and size of ablation zones were different between DMST and FET. Compared with FET, DMST could achieve greater LAD when the moving distance became long enough. In MWA with DMST, SAD decreased with the extension of moving distance and finally became smaller than the SAD in FET. While in LA and RFA, the change of moving distance did not affect SAD significantly.CONCLUSIONIn MWA, RFA and LA, the characteristics of ablation zone of DMST were different from that of FET. This unique ablation technique may be suitable for conformal thermal ablation.

Thermal ablation therapies, including radiofrequency ablation (RFA), microwave ablation (MWA) and laser ablation (LA), have been widely used in the treatment of solid tumors (1–5). Usually, fixed electrode technique (FET) is used in tumor ablation therapy, with the electrode in the central portion of the tumor and remaining fixed during the entire ablation time (6). This will create a large round ablation zone, including the whole tumor and part of surrounding normal tissue, to obtain sufficient safety margin (5, 7, 8).In the clinical practice of thermal ablation of solid tumors, surgeons often encounter tumors which are elliptical in shape (9–11). At this point, if FET is adopted, surgeons need to increase the ablation power or time to create an ablation zone with a greater long axis. At the same time, the short axis of ablation zone will be much greater than is needed, and this can easily damage surrounding normal tissues (12, 13). Therefore, we need a more flexible and conformal ablation technique which can easily adjust the long axis and short axis to make the ablation range more suitable for the tumor lesion. Previous studies (10, 14–16) have suggested moving shot technique (MST) for RFA in the treatment of thyroid nodules, and achieved successful clinical outcomes. Effective MWA using MST has also been reported in the treatment of benign breast lesions (17, 18). MST may be more suitable for accurate and conformal thermal ablation than FET. By moving the ablation needle, it can create an ablation zone that conforms to the tumor lesion. However, MST is not easy to perform because the moving of ablation needle is continuous and it is difficult for operators to keep the moving speed steady and uniform (10, 17). If the operator moves ablation needle too fast, it can easily cause incomplete ablation. Studies have shown that incomplete ablation may promote tumor progression (19–21). In this study, we reported a different ablation technique, discontinuous moving shot technique (DMST), in MWA, RFA and LA. The ablation characteristics of DMST were compared with that of FET in the three kinds of thermal ablation using an ex vivo porcine liver model. Furthermore, the influence of moving distance in this technique was analyzed.     

Evaluation of common carotid artery in type 1 diabetes mellitus patients through speckle tracking carotid strain ultrasonography

PURPOSEWe aimed to evaluate the effectiveness of speckle tracking carotid strain (STCS) technique, which enables measurement of arterial stiffness and strain parameters, in the detection of early atherosclerotic findings in type 1 diabetes mellitus (T1DM).METHODSWe prospectively enrolled 30 T1DM patients and 30 age- and sex-matched control participants with no history of cardiovascular disease. All study population underwent carotid ultrasonography. Radial and circumferential movement of the common carotid artery (CCA) in the transverse plane as the well as the radial movement of the CCA in the longitudinal plane were calculated automatically by using the STCS method. In addition, the strain (%), strain rate (per second), and peak circumferential and radial displacements (mm) were calculated. Arterial stiffness parameters, such as elastic modulus, distensibility, arterial compliance, and β-stiffness index, were calculated using the radial measurements. The mean value of the carotid intima media thickness (CIMT) was calculated semi-automatically for each CCA, in the longitudinal plane. We also analyzed the patients’ overall body composition.RESULTST1DM and control groups were compared in terms of strain and stiffness parameters and no statistically significant difference was found (p > 0.05). CIMT was higher in diabetic patients than in the control group (p = 0.039). In both groups, age was correlated with all arterial stiffness and strain parameters (p < 0.05). The duration of diabetes was also correlated with β-stiffness index, distensibility, and elastic modulus in the longitudinal plane (p < 0.05). In the diabetic group, abdominal fat ratio, whole body fat ratio, and fat mass were correlated with radial and circumferential displacement and strain parameters in transverse plane, and radial displacement in longitudinal plane (p < 0.05, for each). Diabetic patients were divided into subgroups according to the presence of nephropathy and dyslipidemia. Although no significant difference was found between the groups in terms of CIMT, patients with nephropathy had higher values for transverse and longitudinal elastic modulus, pulse-wave velocity, and longitudinal β-stiffness index, as well as lower values for longitudinal arterial compliance and distensibility, compared with patients without nephropathy (p < 0.05). Also, patients with dyslipidemia had higher longitudinal β-stiffness and elastic modulus values compared with patients without dyslipidemia (p < 0.05).CONCLUSIONSTCS ultrasonography is an effective, easy, and noninvasive method for evaluating the arterial elasticity. It may provide an early assessment of atherosclerosis in patients with T1DM, especially in the presence of nephropathy and dyslipidemia; thus, together with CIMT measurement, it may be used more frequently to detect subclinical damage and stratify atherosclerosis.

Researchers have shown that the mortality rate in type 1 diabetes mellitus (T1DM) patients is three times higher than in the general population (1). The major cause of mortality in T1DM patients of both sexes is atherosclerosis; on average, cardiovascular events occur 10 years earlier in this population than in the general population (1, 2). Long-term nonenzymatic glycosylation of arterial wall proteins and excessive superoxide production are thought to play a role in the etiology (3). Advanced glycation end-products (AGEs) accumulate at a high rate in T1DM and form abnormal protein-protein crosslinks on the collagen molecule. AGEs-mediated crosslinks may prevent enzymatic digestion and slow degradation, resulting in increased overall collagen content in the arterial wall and collagen:elastin ratio (4). These factors are thought to play a role in the etiology, cause endothelial dysfunction, stiffening of the arterial wall, and consequently atherosclerotic changes (3).Studies have shown that the atherosclerotic process typically manifest early in the carotid arteries (5). Therefore, evaluation of carotid arteries is very important in cardiovascular risk assessment. Carotid B-mode ultrasonography allows for noninvasive evaluations of atherosclerotic changes, including the measurement of carotid intima media thickness (CIMT), as well as the presence and extent of carotid plaque and arterial stiffness (6–9). The existence of carotid plaque or thickened CIMT is indicative of the morphological changes that result from the progression of atherosclerosis in the carotid artery. The local common carotid artery (CCA) stiffness parameters such as the elastic modulus, distensibility coefficient, strain, strain rate reflect the functional characteristics of atherosclerotic alterations in the carotid artery; these functional alterations manifest before structural alterations such as the intimal thickening of the artery wall and carotid plaque (10).Applanation tonometry is the gold standard technique used to evaluate arterial wall stiffness. However, this technique is time consuming, requires dedicated equipment and is not widely used in clinical routine (11, 12). Moreover, it assumes vascular homogeneity and does not provide sufficient information about the localized deformation characteristics of the arterial wall (13).Another approach to evaluate arterial wall stiffness is the speckle tracking carotid strain (STCS) method, which enables both morphological and functional analysis of the CCA by providing arterial stiffness measurements and CIMT measurements, and which leads to earlier detection of cardiovascular disease, especially for at-risk populations (14). Studies have shown that the STCS method can be an alternative to applanation tonometry in the evaluation of arterial wall stiffness (15, 16). The feasibility of STCS method has been validated by in vitro, in silico, and in vivo studies (15, 17–22). Arterial analysis software using an ultrasound-based STCS method provides the measurement of changes in arterial diameter created by each pulse pressure. From the diameter and pressure measurement, variables concerning arterial wall stiffness such as distensibility, compliance, elastic modulus index, β-stiffness index, and pulse wave velocity (PWV) and variables concerning arterial strain such as displacement, strain and strain rate can be calculated. Studies have shown that subclinical signs of arterial wall stiffening due to increased cardiovascular risk can be detected by the STCS method (10, 15, 17, 18, 23–25). Moreover, it has been proposed that the STCS method allows determination of the vulnerability of atherosclerotic plaques (26). Also, in another study, STCS imaging-based measurements have been shown to allow early assessment of potential effects of statins on vascular function (27). This suggests that early determination of arterial stiffness has the potential to be a valuable tool in the prevention of cardiovascular events. In several studies, the STCS method has been used to identify cardiovascular risk in many different patient populations such as atherothrombotic stroke, end-stage renal disease, rheumatoid arthritis, obstructive sleep apnea, and hypertension (28–32). This method promises to be beneficial, noninvasive, quick, and easily applicable, especially in the evaluation of the CCA (11, 32).Arterial stiffness has been defined as an early marker of atherosclerosis in T1DM patients (3, 33). However, to the best of our knowledge, no prior study evaluated the effectiveness of the STCS method and arterial analysis software in the detection of early atherosclerotic signs in adult T1DM patients.We aimed to evaluate the effectiveness of STCS technique, which enables measuring arterial stiffness and strain parameters in the detection of early atherosclerotic findings in T1DM.     

MRI of lateral hindfoot impingement

Lateral hindfoot impingement (LHI) is a subtype of ankle impingement syndrome with classic MRI findings. Biomechanically, LHI is the sequela of lateral transfer of weight bearing from the central talar dome to the lateral talus and fibula. The transfer occurs due to collapse of the medial arch of the foot, most commonly from posterior tibial tendon (PTT) and spring ligament (SL) insufficiency. Clinical features include lateral hindfoot pain, deformity, and overpronation on gait analysis. MRI changes continuously reflect the altered biomechanics as the syndrome progresses over time, including typical and often sequential changes of PTT and SL failure, increasing heel valgus, talocalcaneal and subfibular impingement, and finally lateral soft tissue entrapment. In addition to diagnosis, MRI is a useful adjunct to plan surgical treatment.

Lateral hindfoot impingement (LHI) is a subtype of ankle impingement with classic MRI findings (1). Biomechanically, LHI is the sequela of lateral transfer of weight bearing from the central talar dome to the lateral talus and fibula.Primary LHI is rare and may occur due to an accessory anterolateral talar facet (2). Although a common accessory articulation; it can cause impingement in the occasional obese patient with subtalar eversions.Secondary LHI is common and consequent to posterior tibial tendon (PTT) dysfunction, collapse of the medial longitudinal arch and lateral weight transfer (1). Less frequent causes of secondary LHI are neuropathic, inflammatory and degenerative arthritis of the subtalar, and transverse talar articulations. Tarsal coalitions and malunited fractures of the calcaneum are also among the uncommon causes of secondary LHI (3, 4).MRI is useful in the diagnosis of LHI as there are several causes of lateral hindfoot pain other than impingement with overlapping clinical features. Conversely, MRI morphology and signal alteration of LHI are distinct. The multiplanar capability of MRI allows accurate assessment of the complex biomechanics and corresponding joint malalignments of LHI syndrome. Moreover, inherent sensitivity to marrow signal allows depiction of marrow edema in characteristic locations of osseous impingement. Finally, high contrast resolution permits depiction of endstage soft tissue entrapments of small ligaments and nerves (5).In this pictorial essay, common etiologies and the resulting wide spectrum of bone and soft tissue abnormalities of LHI seen on MRI are demonstrated. The accompanying diagrams depict sequential derangements in alignment that lead to typical MRI appearances.     

Percutaneous mechanical thrombectomy in acute and subacute lower-extremity ischemia: impact of adjunctive,solely nonthrombolytic endovascular procedures

PURPOSEWe aimed to evaluate the role of adjunctive, solely nonthrombolytic endovascular therapy in treatment of acute lower-extremity ischemia by rotational percutaneous mechanical thrombectomy.METHODSA retrospective, single-center evaluation of 165 patients (167 limbs) that underwent rotational percutaneous mechanical thrombectomy between 2009 and 2016 was performed.RESULTSRotational percutaneous mechanical thrombectomy was used as a single therapy in 9.0% (15 limbs), followed by percutaneous aspiration thrombectomy in 6.0% (10 limbs), percutaneous transluminal angioplasty in 19.8% (33 limbs) and stenting in 25.7% (43 limbs). Rotational percutaneous mechanical thrombectomy was followed by any combination of these three interventions in 39.5%. Clinical and technical success was documented in 92.2%, complications in 10.3% (n=17). No significant difference in clinical and technical success was observed using rotational percutaneous mechanical thrombectomy alone or with additional endovascular therapy. On a long-term basis, the re-ischemia-free survival was nearly twice as high as in previous studies that reported more cases treated by rotational percutaneous mechanical thrombectomy alone.CONCLUSIONTo assure a long-lasting primary patency after percutaneous mechanical thrombectomy, concomitant treatment of underlying lesions with adjunctive, nonthrombolytic endovascular methods should be considered.

Acute limb ischemia (ALI) is one of the most frequent causes for amputation and a potentially life-threatening condition, affecting approximately 1.5 persons per 10 000 per year (1). Endovascular management ranges from catheter-directed intraarterial thrombolysis (CDT), percutaneous aspiration thrombectomy (PAT) to percutaneous mechanical thrombectomy (PMT), all of which may be used independently or in combination. Surgical reperfusion therapy involves higher risks especially in elderly patients, with surgical mortality rates as high as 29% in high-risk populations (2–4). Several studies have shown that systemic administration of a thrombolytic agent alone to treat ALI carries high morbidity and mortality with poor clinical outcome (2, 5–7). Endovascular therapy by thrombolysis is known to be associated with hemorrhagic complications, and lower rates of technical success compared with open surgical repair (8, 9). The development of advanced aspiration techniques, such as PMT has helped to achieve a more complete and faster removal of the clot in a controlled selective angiography setting and possibly unmasks the underlying causative lesion (2, 10, 11). Supplemental stenting and percutaneous transluminal angioplasty (PTA) after rotational PMT or the need of additional fibrinolysis in cases of outflow occlusion have been reported (12, 13). Little evidence is found in the literature regarding the role of exclusively non-CDT based endovascular procedures in combination with rotational PMT.In order to address the need for more data, the objective of this retrospective study was to evaluate the impact of additional, solely nonthrombolytic endovascular therapy in treatment of (sub-) acute lower-extremity ischemia by rotational percutaneous mechanical thrombectomy (rotational PMT).     

Evaluation of prostate volume in mpMRI: comparison of the recommendations of PI-RADS v2 and PI-RADS v2.1

PURPOSEWe aimed to evaluate the prostate volumes calculated as recommended in the PI-RADS v2 and PI-RADS v2.1 guidelines, intraobserver and interobserver variability, and the agreement between the two measurement methods.METHODSProstate mpMRI examinations of 114 patients were evaluated retrospectively. T2-weighted sequences in the axial and sagittal planes were used for the measurement of the prostate volume. The measurements were performed by two independent observers as recommended in the PI-RADS v2 and PI-RADS v2.1 guidelines. Both observers conducted the measurements twice and the average values were obtained. In order to prevent bias, the observers carried out measurements at one-week intervals. In order to assess intraobserver variability, observers repeated the measurements again at one-week intervals. The prostate volume was calculated using the ellipsoid formula (W×H×L×0.52).RESULTSIntraclass correlation coefficient (ICC) revealed almost perfect agreement between the first and second observers for the measurements according to both PI-RADS v2 (0.93) and PI-RADS v2.1 (0.96) guidelines. The measurements were repeated by both observers. According to the ICC values, there was excellent agreement between the first and second measurements with respect to both PI-RADS v2 and PI-RADS v2.1 for first (0.94 and 0.96, respectively) and second observer (0.94 and 0.97, respectively). For both observers, the differences had a random, homogeneous distribution, and there was no clear relationship between the differences and mean values.CONCLUSIONThe ellipsoid formula is a reliable method for rapid assessment of prostate volume, with excellent intra- and interobserver agreement and no need for expert training. For the height measurement, the recommendations of the PIRADS v2.1 guideline seem to provide more consistently reproducible results.

The prostate gland is one of the organs for which the disease incidence and prevalence in men increases with age. Prostate volume (PV) has an important role in the evaluation and management of both malignant and benign prostate diseases (1–3). In benign prostatic hyperplasia (BPH), prostate volume is used to decide upon treatment and evaluate response to medical therapy (3–5). In the diagnosis of prostate cancer, one of the important markers is prostate-specific antigen (PSA), but it has low specificity, and therefore PSA derivatives are used to increase its specificity. One example is PSA density, which is obtained by dividing the PSA value by PV. In the treatment of prostate cancer, PV is important, and the effectiveness of brachytherapy decreases in prostates with a volume greater than 50 mL (6). Furthermore, PV is used to identify appropriate patients for brachytherapy and select the number of radioactive seeds, and also determine fractionation for external beam radiation, radical prostatectomy operating planning and continence rate counseling, and focal therapy candidacy preparation (7, 8). For these reasons, it is vital to accurately calculate PV.There are many methods that can be used to calculate PV, with the ellipsoid formula being one of the most preferred since it is easy to apply and highly time-efficient (1–4, 9). Many studies have shown that this method has high accuracy due to the elliptic shape of the prostate (1, 2, 10–13). The ellipsoid formula is obtained by multiplying the height (anterior-posterior), width (medio-lateral) and length (cranio-caudal) values of the prostate by 0.52. These measurements can be performed by transrectal ultrasonography (TRUS) or magnetic resonance imaging (MRI). TRUS has certain disadvantages, such as being operator-dependent and susceptible to sonographic artifacts (14). MRI, which has become increasingly popular in recent years, allows for an accurate definition of the prostate boundaries and multiplanar measurements through its high contrast resolution of soft tissues (1, 5). It also provides more accurate measurements than TRUS (4, 15, 16).In order to ensure global standardization in the reporting of prostate MRI findings, PI-RADS v2 published in 2015, which is the revised version of PI-RADS 1.0, and the last updated version PI-RADS v2.1 made available in 2019, propose different calculation methods for the measurement of height in obtaining PV (17, 18). The midaxial plane is recommended for this measurement in PI-RADS v2, while the midsagittal plane is recommended in PI-RADS v2.1. This study aimed to evaluate the interobserver and intraobserver variability of PV calculated by both measurement methods and the agreement between the two measurement methods.     

MRI-guided focal laser ablation of prostate cancer: a prospective single-arm,single-center trial with 3 years of follow-up

PURPOSEWe aimed to assess post-interventional and 36-month follow-up results of a single-center, single-arm, in-bore phase I trial of focal laser ablation (FLA) guided by multiparametric magnetic resonance imaging (mpMRI).METHODSFLA procedures were done in-bore MRI using a transperineal approach. Primary endpoints were feasibility and safety expressed as lack of grade 3 complications. Secondary endpoints were changes in international prostate symptom score (IPSS), sexual health inventory for men (SHIM), quality of life (QoL) scores, and serum prostate specific antigen (PSA) levels. Treatment outcomes were assessed by combined mpMRI-ultrasound fusion-guided and extended sextant systematic biopsy after 12, 24, and optionally after 36 months.RESULTSFifteen participants were included. Seven patients (46.67%) had Gleason 3+3 and 8 patients (53.33%) had Gleason 3+4 cancer. All patients tolerated the procedure well, and no grade 3/4 complications occurred. All grade 1 and 2 complications were transient and resolved completely. There was no significant change in mean IPSS from baseline (−1, p = 0.460) and QoL (0, p = 0.441) scores following FLA but there was a significant drop in mean SHIM scores (−2, p = 0.010) compared to pretreatment baselines. Mean PSA significantly decreased after FLA (−2.5, p < 0.001). Seven out of 15 patients (46.67%) had residual cancer in, adjacent, or in close proximity to the treatment area (1 × 4+3=7, 1 × 3+4=7, and 5 × 3+3=6). Four out of 15 patients (26.67%) underwent salvage therapy (2 repeat FLA, 2 radical prostatectomy).CONCLUSIONAfter 3 years of follow-up we conclude focal laser ablation is safe and feasible without significant complications.

Since the introduction of population-based prostate specific antigen (PSA) screening, there has been an increase in the detection of prostate cancer (PCa) which is often low or intermediate grade (1). The proven benefit for PSA screening in improving cancer-specific survival comes at the cost of over-diagnosis and over-treatment of low-risk PCa, with significant treatment-related morbidity (2). To counteract this, active surveillance is becoming a widely practiced standard of care treatment option for certain low-risk PCa patients, with excellent long-term survival. Up to one-third of patients drop off active surveillance protocols because they are no longer comfortable with surveillance and opt for definitive treatment (3). Meanwhile, there is growing evidence that more patients with tumors deemed “intermediate-risk” receive unnecessary radical treatments based on the indolent biology of their tumors (4). Thus, there is a growing interest in alternatives to whole-gland definitive therapies for low-to-intermediate risk PCa.PCa lesions can be visualized at mpMRI and targeted for biopsy (5, 6). Focal therapy with different ablative methods has the potential to be an alternative for low-risk and selected intermediate-risk patients (7, 8). mpMRI-guided focal laser ablation (FLA) in which thermal laser energy is applied to lesions to achieve coagulation necrosis has advantages such as having homogeneous tissue necrosis with sharp margins between dead and uninjured tissue, real-time MRI thermometry monitoring and rapid ablation times (9). Prior focal therapy trials demonstrated good functional outcomes for continence and potency, although longer follow-up data are still missing (10–13). In this study, we aimed to assess the feasibility, safety and efficacy of mpMRI-guided FLA, and report on 3-year functional and oncologic outcomes.     

A randomized comparison of transradial and transfemoral access in uterine artery embolization

PURPOSEWe aimed to compare duration of uterine artery embolization, radiation exposure, safety and quality of life associated with the procedure in patients undergoing uterine artery embolization using transradial and transfemoral access.METHODSThis randomized controlled trial was conducted from February 2013 to March 2017 in three hospitals. Transradial access was used in 78 patients and transfemoral access in 75 patients. Clinical characteristics of the patients were comparable between the two groups. Patients were evaluated for the success and duration of the procedure, radiation exposure, major and minor complications. Quality of life associated with the procedure was assessed among patients with uterine fibroids.RESULTSEmbolization procedures were successfully performed in all patients in both groups. The duration of uterine artery embolization (32.27±7.99 vs. 39.24±9.72 minutes, p < 0.001), uterine artery catheterization time (12.36±5.73 vs. 19.08±6.06 minutes, p < 0.001) and radiation exposure (0.28±0.14 vs. 0.5±0.21 mZv, p < 0.001) were significantly lower in the transradial access group. The rate of major (0% vs. 2.7%, p = 0.37) and minor (11.53% vs. 17.3%, p = 0.42) complications was comparable between the two groups. Transradial access was associated with a statistically significant improvement in the quality of life associated with the procedure among patients with uterine fibroids.CONCLUSIONTransradial access in uterine artery embolization has the same efficacy and safety compared to transfemoral access. This access reduces radiation exposure and duration of the procedure.

Uterine fibroids are the most common neoplasm in women, with a negative impact on women’s health and reproductive function. According to statistics, the incidence of uterine fibroids is more than 70% by the onset of menopause (1). Most often it occurs in women aged 30 to 50 years, including patients who plan to retain reproductive function (2).One of the contemporary methods of treatment for uterine fibroids is uterine artery embolization (UAE), which was first performed by Oliver et al. (3) in 1979 in a patient with postpartum hemorrhage. Ravina (4) started to use this technique in patients with uterine leiomyoma in 1991. Since then, uterine fibroid embolization (UFE) has received wide interest and acceptance.Most UAE are currently performed using a transfemoral approach (TFA). In case of failure, transbrachial or transaxillar vascular access can be used, but these techniques have more access-related complications.Transradial approach (TRA) can significantly reduce the incidence of access-related complications, which was confirmed in numerous interventional cardiology studies (e.g., RIFLE-STEACS, RIVAL, MATRIX) (5–7). Moreover, this vascular access allows early mobilization of the patient, increases quality of life associated with the procedure, reduces cost and duration of hospitalization (8, 9). TRA was first described by Campeau (10) in 1989 in a series of patients who underwent coronary angiography. Since then this vascular access got a widespread use in interventional cardiology. According to statistics, in 2012 more than 65% of percutaneous coronary interventions in the UK were done using TRA, and in some hospitals in Europe, Canada and Asia, more than 95% of all coronary interventions are performed through this vascular access (11, 12). Moreover, TRA is used for brachiocephalic, renal, visceral, iliac and femoral artery interventions (13, 14).Until recently, the use of TRA in interventional radiology has been limited. The first study involving TRA in liver chemoembolization was published by Shiozawa et al. (15) in 2003 and showed significant reduction in the incidence of access-related complications compared to TFA. The retrospective analysis of TRA in 29 UFE patients was published in 2014. The technical success of the procedure was 100%, showing no major or minor complications (16). Moreover, recent reports have shown the benefits of TRA in prostatic artery embolization, embolization of epistaxis and hemoptysis (17–19).The aim of our study was to perform a comparative prospective randomized study of TRA and TFA efficacy and safety in patients undergoing UAE.     

Intermittent quick-check CT fluoroscopy-guided percutaneous drainage placement in patients with infected renal and perirenal fluid collections: 11-year experience

PURPOSEWe aimed to evaluate technical and clinical success and safety of computed tomography fluoroscopy (CTF)-guided percutaneous pigtail drainage (PPD) placement in patients with infected renal and perirenal fluid collections.METHODSThis retrospective analysis comprised 44 patients (52.27% men; age, 57.1±18.5 years) undergoing low-milliampere (10–20 mA) CTF-guided PPD placement in 61 sessions under local anesthesia from August 2005 to November 2016. Infected fluid collections (n=71) included infected renal cysts (12.68%), renal and perirenal abscesses due to comorbidities (23.94%), or fluid collections after renal surgery or urological intervention (63.38%). Technical success was defined as PPD placement with consecutive fluid aspiration, clinical success as normalization or marked improvement of clinical symptoms (e.g., flank pain, fever) and inflammatory parameters (leukocyte count, C-reactive protein) after minimally invasive combination therapy (intravenous broad-spectrum antibiotics and drainage). Complications were classified according to the CIRSE classification.RESULTSOverall, 73 single lumen PPD (7.5–12 F) were utilized (1 PPD per session, 69.86%; 2 PPD per session, 15.07%). In 4 cases, PPD could not be inserted into the fluid collection (4.11%) or could not be aspirated (1.37%), yielding overall 94.5% primary technical success. Mean duration of functioning PPD before removal was 10.9 days. Adverse events within 30 days comprised PPD failure (2.27%) or secondary dislocation (Grade 3, 11.36%) and one death (Grade 6, unrelated to intervention, 2.27%). Additional invasive measures after primary CTF-guided PPD were required in 5 patients (nephrectomy 6.82%, partial nephrectomy 2.27%, surgical drainage 2.27%). Thus, clinical success using only minimally invasive measures was achieved in 39 of 44 patients (88.64%).CONCLUSIONGiven a minor proportion of patients requiring surgical revision, combined antibiotics and CTF-guided PPD of infected renal and perirenal fluid collections provides an excellent technical and clinical outcome.

Urinary tract infections (UTIs) are the most commonly observed bacterial infection, characterized by uncomplicated cystitis or pyelonephritis in most patients (1). While uncomplicated UTIs predominantly affect healthy and nonpregnant young women with good response to adequate antibiotic treatment and without further necessary diagnostic imaging, complicated UTIs comprise infections with an uncommon organism, symptoms suggesting obstruction (e.g., renal colic) or fever lasting more than 72 hours in spite of adequate antibiotics (2). Diabetic patients are particularly prone to upper tract UTIs, bilateral involvement and atypical underlying organisms (3). If severe clinical symptoms and altered laboratory parameters are found in a patient with suspected renal abscess, the first step is an ultrasound examination of the kidney. In some cases, the abscess may present as an echogenic mass, in which case the diagnosis with ultrasound is difficult and a contrast-enhanced computed tomography (CT) is essential for the diagnosis. Furthermore, ultrasound is less sensitive than CT or magnetic resonance imaging (MRI) for assessing spread to perirenal space (2, 4).Renal and perirenal abscesses are a comparatively rare complication of UTIs whose prognosis has been markedly improved during the last 20 years through earlier diagnosis by state-of-the-art cross-sectional imaging modalities on the one hand, and more widely available and earlier minimally invasive image-guided or surgical treatment on the other hand (2, 5–10). For instance, in superinfected renal cysts, CT fluoroscopy (CTF) facilitates a precise and near real-time targeting and drainage of the affected cyst. This may allow for a “nephron-sparing” preservation of renal parenchyma unaffected by the inflammation, microbiological sampling and potentially a faster patient recovery (11). Notably, infected renal cysts represent a particularly rare entity of infected renal fluid collections predominantly described in case reports.For small renal abscesses (<3 cm diameter), antibiotic therapy should be sufficient for resolution. Otherwise, ultrasound- or CT-guided percutaneous aspiration and drainage is indicated for treatment in combination with antibiotics (2, 12, 13). Besides renal and perirenal abscesses due to UTIs, symptomatic infected and sterile retroperitoneal fluid collections are frequently observed after renal surgery such as nephrectomy, partial and allograft nephrectomy as well as renal transplantation, affecting the renal parenchyma, perirenal space or iliac fossa (14, 15). Thus, it can be said that CT-guided percutaneous aspiration and drainage plays an important role for minimally invasive treatment of renal or perirenal abscesses.Thus, the purpose of this retrospective study was the evaluation of the technical outcome, clinical success, and safety of percutaneous pigtail drainage (PPD) placement performed under low-milliampere CTF in one of the biggest patient cohorts to our knowledge, presenting with symptomatic renal and perirenal fluid collections comprising renal abscesses, infected renal cysts, as well as infected, delineated postoperative retroperitoneal fluid collections.     

Effect of music on anxiety and pain during ultrasound-guided core needle breast biopsy: a randomized controlled trial

PURPOSEAlthough imaging-guided core needle breast biopsy is a minimally invasive diagnostic procedure, it is reported that patients may experience anxiety and pain. Interventions to reduce anxiety are important for high quality health services during imaging-guided core needle breast biopsy. The purpose of this study was to evaluate the effect of music intervention on anxiety and pain levels of patients undergoing ultrasound-guided core needle breast biopsy.METHODSIn a prospective randomized controlled design, patients who were referred for ultrasound-guided core needle breast biopsy were invited to the study and randomized into the intervention group who received standard care with classical music intervention before and during the biopsy procedure, and the control group who received only standard care. Both groups received local anesthesia. The Spielberger State-Trait Anxiety Inventory and the Visual Analogue Scale (VAS) were used for measuring anxiety and pain levels after the procedure. One-way multivariate analysis of variance test was used to find the effect of music intervention on patient anxiety and pain.RESULTSThere were 31 patients (48.4%) in the intervention group and 33 (51.6%) in the control group; the groups were similar in terms of sociodemographic characteristics and general (trait) anxiety levels. The patients in the music intervention group had significantly lower state anxiety score than the control group (p = 0.008) with a mean difference of 3.8 (95% CI, 1.0–6.6). The mean difference of VAS pain score was 6.0 (95% CI, 2.2–14.2), which not statistically significant between groups (p = 0.150). There was no significant correlation between the VAS and the state anxiety scale (r = 0.003, p = 0.980).CONCLUSIONMusic reduced anxiety, but not pain during ultrasound-guided core needle breast biopsy. These results have implications especially for low and middle-income countries where low-cost and easily implemented interventions are needed to address patient anxiety during breast biopsy procedures.

Imaging-guided core needle breast biopsy is a safe and cost-effective procedure that is essential for managing suspicious breast lesions (1, 2). Although imaging-guided core needle breast biopsy is a minimally invasive procedure, patients may experience anxiety and distress (3). Reducing anxiety during biopsy procedures is important as higher anxiety during different biopsy procedures was found to be associated with higher pain (4, 5), and reducing anxiety may reduce the pain and increase the patient comfort. Furthermore, the regulation of anxiety during breast biopsy plays an important role in adherence to follow-up (6).Music regulates emotions by affecting the expression of opiate, nitric oxide, cytokine, and hormone levels through neuroendocrinological pathways (7). Music has been shown to reduce anxiety and pain levels in different medical procedures like chemotherapy, chest tube removal, endoscopy, colonoscopy, magnetic resonance imaging, fine needle aspiration biopsy, transrectal ultrasound-guided prostate biopsy, bone marrow biopsy, surgery, labor and caesarian section (8–11). A systematic review recommended that music intervention should be applied to clinical management of biopsy patients (12). However, there is scarce research on the effect of music on ultrasound-guided core needle breast biopsy patients’ anxiety and pain levels (13–15). Two of these trials showed that music reduced the anxiety levels of breast biopsy patients (13, 15), whereas one study reported that music intervention was not effective (14). All of the mentioned studies are from high income countries and have inconsistent results. There is no study on the effect of music intervention on anxiety and pain levels of ultrasound-guided core needle breast biopsy patients from low- and middle-income countries where there may be cultural and socioeconomical differences that may affect the patients’ response to music interventions. Furthermore, these countries are in need of low-cost interventions to increase the quality of life of patients.This study investigated whether or not classical music changed patient anxiety and/or pain levels of patients undergoing ultrasound-guided core needle breast biopsy in Turkey. It was hypothesized that music intervention will decrease the patients’ anxiety and pain levels.     

Determination of disease severity in COVID-19 patients using deep learning in chest X-ray images

PURPOSEChest X-ray plays a key role in diagnosis and management of COVID-19 patients and imaging features associated with clinical elements may assist with the development or validation of automated image analysis tools. We aimed to identify associations between clinical and radiographic features as well as to assess the feasibility of deep learning applied to chest X-rays in the setting of an acute COVID-19 outbreak.METHODSA retrospective study of X-rays, clinical, and laboratory data was performed from 48 SARS-CoV-2 RT-PCR positive patients (age 60±17 years, 15 women) between February 22 and March 6, 2020 from a tertiary care hospital in Milan, Italy. Sixty-five chest X-rays were reviewed by two radiologists for alveolar and interstitial opacities and classified by severity on a scale from 0 to 3. Clinical factors (age, symptoms, comorbidities) were investigated for association with opacity severity and also with placement of central line or endotracheal tube. Deep learning models were then trained for two tasks: lung segmentation and opacity detection. Imaging characteristics were compared to clinical datapoints using the unpaired student’s t-test or Mann-Whitney U test. Cohen’s kappa analysis was used to evaluate the concordance of deep learning to conventional radiologist interpretation.RESULTSFifty-six percent of patients presented with alveolar opacities, 73% had interstitial opacities, and 23% had normal X-rays. The presence of alveolar or interstitial opacities was statistically correlated with age (p = 0.008) and comorbidities (p = 0.005). The extent of alveolar or interstitial opacities on baseline X-ray was significantly associated with the presence of endotracheal tube (p = 0.0008 and p = 0.049) or central line (p = 0.003 and p = 0.007). In comparison to human interpretation, the deep learning model achieved a kappa concordance of 0.51 for alveolar opacities and 0.71 for interstitial opacities.CONCLUSIONChest X-ray analysis in an acute COVID-19 outbreak showed that the severity of opacities was associated with advanced age, comorbidities, as well as acuity of care. Artificial intelligence tools based upon deep learning of COVID-19 chest X-rays are feasible in the acute outbreak setting.

The imaging features of novel coronavirus (SARS-CoV-2) and coronavirus disease 2019 (COVID-19) pandemic are still being fully characterized and understood (1, 2). The estimated mortality rate is reported between 1.4% and 7% (3). Health services and intensive care units (ICUs) are facing critical saturation in this pandemic (4), where early and wise resource allocation decisions may impact population outcomes.Radiology departments play a key role in this pandemic (5–8), with imaging data potentially contributing towards detection (9–14), characterization (9), monitoring (15–18), triage (19–22), resource allocation, early intervention, and isolation (8). Although speculative, models that correlate imaging findings to outcomes could be helpful or predictive in the management and triage of the 20% of SARS-CoV-2 positive patients who develop more serious manifestations of COVID-19 pneumonia. Epidemiology standards require a waiting period in between patients with airborne viral diseases, which may practically limit computed tomography (CT) use. To date, radiology and thoracic professional societies have pointed to the efficiency, ease of access, field availability, and repeatability of chest X-ray as well as its ease of cleaning and decontamination. These strengths are balanced against the higher sensitivity and specificity of CT. Moreover, when patients are encouraged to present early in the course of their disease, as was the case in Hubei Province, China, chest X-ray may have less value than CT.Typical and characteristic CT features for COVID-19 related pneumonia have been recently defined (23–28). Chest X-ray findings might help address clinical decision-making in screening, management and prioritization that may unfortunately arise in the care of COVID-19 patients. Resource allocation may be most critical during peak prevalence, when imaging equipment may also be stretched thin, or not accessible to intensive care or “medical surge facility” settings.Deep learning uses convolutional neural networks that are like a “black box” in that they may or may not use conventional imaging features to function and classify the outputs. Machine learning on the other hand, would use specific features, and generally requires less data points to ensure clinically relevant accuracy or validity. This study uses tools for explanatory purposes, not for producing a refined or usable model at this early stage. There are currently limited reports of the role of chest X-ray in COVID-19 patients with scarce details of the application and role of deep learning of chest X-rays in patients with COVID-19. Previous papers stated that the main findings were bilateral reticular nodular opacities, ground-glass opacities and peripheral consolidations (29–31). Deep learning and artificial intelligence (AI) applications in chest radiography are in their infancy, but there are multiple commercial platforms for computer-aided detection for pulmonary nodule detection, characterization and quantification of interstitial lung disease (32–34). We aimed to identify associations between clinical and radiographic features as well as to assess the feasibility of deep learning applied to chest X-rays in the setting of an acute COVID-19 outbreak.     

Mechanical rotational thrombectomy in long femoropopliteal artery and bypass occlusions: risk factors for periprocedural peripheral embolization

PURPOSEWe aimed to examine lesion characteristics influencing technical outcome and periprocedural peripheral embolization (PPE) during percutaneous mechanical rotational thrombectomy (PMT) of long femoropopliteal artery and bypass occlusions.METHODSRetrospectively, 65 consecutive patients (43 male patients, mean age 70±12 years; Rutherford category I–III), undergoing PMT (Rotarex^®, Straub Medical AG) with acutely/subacutely occluded femoropopliteal arteries/bypasses were included. Occlusions (mean length, 217±98 mm) were treated by PMT followed by percutaneous transluminal angioplasty (PTA) plus drug-coated balloon or PTA plus stenting/stentgrafting. Technical success was defined as residual stenosis <30%. Follow-up included duplex ultrasound and ankle-brachial index (ABI) after 12 months. Endpoints were technical success, complications, improvement of Rutherford category, ABI, and patency (re-stenosis <50%). The influence of lesion length, duration, and thrombus density (measured in preinterventional computed tomography angiography) on technical success and PPE was analyzed.RESULTSTechnical success was 18% (12/65) after PMT alone, 92% (60/65) after additional means. Four patients (6%) underwent bypass surgery and one patient (2%) amputation. PPE occurred in 11% (7/65). During the 12-month follow-up, three patients (5%) were lost to follow-up. ABI increased from baseline 0.5±0.12 to 0.81±0.14 (p = 0.001) and Rutherford category increased by at least one level in 57 patients at 12-month follow-up (clinical success, 88%). At 12 months, primary patency was 57.4% (95% CI, 45.8%–68.9%) and secondary patency was 75.0% (95% CI, 59.8%–72.3%). As risk factors for PPE, we identified lesion length >200 mm (15%; 6/39; OR 4.5; 95% CI, 0.5–40; p = 0.014) and thrombus density ≤45 HU (20%; 2/10; OR 3.0; 95% CI, 0.2–38.9; p = 0.05). No significant relation between risk factors and technical success was found.CONCLUSIONPMT followed by PTA or implantation of stent (grafts) appears to be effective and safe for revascularization of acute/subacute long occlusions. Thrombus density <45 HU and lesion length above 20 cm represent risk factors for PPE during PMT.

The Rotarex^® percutaneous mechanical rotational thrombectomy (PMT) device (Straub Medical AG) has been used for almost two decades and has been proven to be safe and effective in several studies analyzing endovascular revascularization of acute and subacute iliac and femoropopliteal arteries (1–5) as well as venous and synthetic bypass graft occlusions (4, 6, 7). The combination of PMT and additional devices such as drug-coated balloons, stents, or stentgrafts has shown satisfactory long-term patency rates (3, 8, 9). Therefore, PMT has evolved to an effective endovascular alternative to vascular surgery and other minimal invasive techniques such as thrombolysis and thrombus aspiration. However, in studies with larger patient populations technical success rates vary between 90% and 97% (3–5), and the most common complication, acute periprocedural peripheral embolization (PPE), has been reported between 0% and 24% (1–3, 5). Several factors may pose risks for technical failure or acute PPE such as lesion length or duration of the lesion. Studies investigating the correlation between potential risk factors influencing technical success and the risk for occurrence of PPE during PMT interventions do not exist to the best of our knowledge. Therefore, the objectives of this analysis were to evaluate technical success, effectiveness, and safety of the Rotarex percutaneous mechanical rotational thrombectomy device, as well as to analyze the influence of lesion length, duration of the occlusion, and thrombus density on technical success and the occurrence of PPE.     

Gianturco Z-stent placement for the treatment of chronic central venous occlusive disease: implantation of 208 stents in 137 symptomatic patients

PURPOSETo report the technical successes, adverse events, and long-term stent patency rates of Gianturco Z-stents for management of chronic central venous occlusive disease.METHODSOverall, 137 patients, with mean age 48.6±16.1 years (range, 16–89 years), underwent placement of Gianturco Z-stents for chronic central venous occlusions. Presenting symptoms included lower extremity edema (n=66, 48.2%), superior vena cava syndrome (n=30, 21.9%), unilateral upper extremity swelling (n=20, 14.6%), hemodialysis fistula or catheter dysfunction (n=11, 8.0%), ascites (n=8, 5.8%), and both ascites and lower extremity edema (n=2, 1.5%). Most common etiologies of central venous occlusion were prior central venous access placement (n=58, 42.3%), extrinsic compression (n=29, 21.2%), and post-surgical anastomotic stenosis (n=27, 19.7%). Number of stents placed, stent implantation location, stent sizes, technical successes, adverse events, need for re-intervention, follow-up evaluation, stent patencies, and mortality were recorded. Technical success was defined as recanalization and stent reconstruction with restoration of in-line venous flow. Adverse events were defined by the Society of Interventional Radiology Adverse Event Classification criteria. Primary and primary-assisted stent patencies were analyzed using Kaplan-Meier analysis.RESULTSIn total, 208 Z-stents were placed. The three most common placement sites were the inferior vena cava (n=124, 59.6%), superior vena cava (n=44, 21.2%), and brachiocephalic veins (n=27, 13.0%). Technical success was achieved in 133 patients (97.1%). There were two (1.5%) severe adverse events (two cases of stent migration to the right atrium), one (0.7%) moderate adverse event, and one (0.7%) mild adverse event. Mean follow-up was 43.6±52.7 months. Estimated 1-, 3-, and 5-year primary stent patency was 84.2%, 84.2%, and 82.1%, respectively. Estimated 1-, 3-, and 5-year primary-assisted patency was 92.3%, 89.6%, and 89.6%, respectively. The 30- and 60- day mortality rates were 2.9% (n=4) and 5.1% (n=7), none of which were directly attributable to Z-stent placement.CONCLUSIONGianturco Z-stent placement is safe and effective for the treatment for chronic central venous occlusive disease with durable short- and long-term patencies.

Chronic central venous occlusive disease (central venous obstruction) arises most commonly as a sequela of deep vein thrombosis, implantable pacemaker wires, malignancy, indwelling central venous catheters, and post-surgical anastomotic strictures (1). Clinically, patients present with pain and edema in the involved extremity, or in the case of patients on chronic hemodialysis, elevated central venous pressures which may increase the risk of bleeding and access site pseudoaneurysms (1). Additionally, superior vena cava (SVC) syndrome may cause symptoms such as chest pain, swelling of the head and neck, and respiratory distress secondary to pleural effusions (2). Balloon angioplasty and stent placement is the standard of care for management of chronic venous occlusive disease (3).Historically there have been limited commercially available stents designed for placement in the venous systems, and there are unique aspects of stent placement in the venous systems, including the need for more flexible, larger stents relative to arterial applications (4). However, several types of metallic stents have successfully been used for venous stent reconstruction procedures, with the Wallstent (Boston Scientific) being the most commonly used device (3). Gianturco Z-stents; however, have large diameters, high rigidity, high radial force (5, 6), and large interstices that prevent occlusion of venous tributaries and have been utilized in patients with venous disease due to malignant compression, anastomotic strictures, and for inferior vena cava (IVC) extension in patients requiring bilateral iliocaval stenting (5–9). There are several case series describing the use of Gianturco Z-stents for the treatment of venous disease, primarily focused on occlusion of the SVC (6, 7, 10, 11).The purpose of this study was to report the technical successes, adverse events, and long-term stent patencies of Gianturco Z-stent placement for management of chronic central venous occlusive disease in 137 patients.     

Combined Y-configured stents for revising occluded transjugular intrahepatic portosystemic shunt

PURPOSEWe aimed to determine the technical feasibility, safety and prognosis of the transjugular intrahepatic portosystemic shunt (TIPS) revision by combined Y-configured stents placement.METHODSWe retrospectively evaluated 12 patients who received TIPS revision using Y-stenting technique between June 2015 and January 2019. The rates of technical success, complication, shunt patency, hepatic encephalopathy and mortality were described and analyzed.RESULTSThe combined Y-configured stents were successfully placed in 11 of 12 patients (92%) without major complications. The median portosystemic pressure gradient (PPG) decreased from 23 mmHg (interquartile range, IQR, 18.5–27.5 mmHg) to 10 mmHg (IQR, 9–14 mmHg). The left internal jugular vein approach was used in 5 patients. Four patients required a shunt extension with an extra stent to resolve the stenosis at the portal venous terminus. Two patients developed hepatic encephalopathy, which was medically controlled within 3 months after the procedure. The TIPS patency and survival rates were both 100% during a median follow-up period of 10 months (IQR, 5.5–14 months).CONCLUSIONTIPS revision by combined Y-configured stents placement was technically feasible and safe with favorable clinical outcomes.

Transjugular intrahepatic portosystemic shunt (TIPS) has been widely used for the treatment of portal hypertension complications by decompressing the portal venous system (1). Shunt patency has been greatly improved since the introduction of dedicated polytetrafluoroethylene-covered stents. However, dysfunction still occurs in 8%–20% of patients within the first year after TIPS creation (2).TIPS dysfunction can arise from acute thrombosis and pseudointimal hyperplasia within the stent or at the hepatic vein outflow (3–5). Angioplasty, with or without stent placement, is frequently attempted to restore adequate TIPS function. In some cases where TIPS dysfunction is associated with altered shunt configuration or stent displacement, especially in a “T-bone” configuration, entry to the previous shunt seems to be challenging (6). This troublesome situation is more likely to occur when TIPS is created with a non-Viatorr stent, such as Fluency stent-grafts (Bard & BD). This type of stent is still widely used due to its relatively low cost, though its rigid structure may change the shunt orientation gradually. Moreover, a combined transjugular and transhepatic approach has been described (7, 8). After a percutaneous transhepatic puncture of the stent strut, a wire is passed through the lumen to inferior vena cava (IVC) and snared from the transjugular access to establish the channel. Of note, this approach brings a relatively high risk for bleeding and prolonged operative time when compared with only transjugular access (9). Parallel TIPS is generally used as the last resort (10, 11). Despite its proven efficacy, parallel stent placement through the portal vein may increase the risk of intraabdominal hemorrhage and aggravate liver function.Herein, inspired by the stent-in-stent technique used in the placement of bilateral biliary metallic stents and coronary stents (12–14), we tried to recanalize the occluded TIPS via endovascular puncture of the strut of the existent stent and followed with deployment of a new covered stent with a “Y” configuration (Fig. 1). The purpose of the present study is to evaluate the technical feasibility, safety and clinical outcomes of this new TIPS revision technique.Open in a separate windowFigure 1A schematic of Y-configured stents implantation. The angle between the initial stent (arrowheads) and the right hepatic vein was approximately 90°. A new stent (long arrow) was deployed through the mesh of the initial stent to restore the portosystemic shunt.     

Percutaneous radiofrequency ablation for hepatic tumors: factors affecting baseline impedance

PURPOSEWe aimed to evaluate factors that affect baseline impedance of percutaneous radiofrequency ablation.METHODSIn this retrospective study, we analyzed 51 patients with 55 hepatic tumors from November 2015 until April 2018. We measured the baseline impedance nine times with three adjustable tip sizes (2 cm, 2.5 cm, 3 cm) and three different pad locations (two pads attached on the thigh, four on the thigh, two on the back). The first roll-off time was measured with two grounding pads attached on the back. Body mass index, cirrhotic or non-cirrhotic liver parenchyma, previous procedure, tumor location, artificial ascites, active tip size, and the pad location were evaluated as potential factors affecting baseline impedance using the Mann–Whitney U test, t-test and analysis of variance test.RESULTSComplete radiofrequency ablation was achieved in 51 patients. Body mass index (p = 0.897), cirrhotic or non-cirrhotic liver parenchyma (p = 0.767), previous procedure (p = 0.957), tumor location (p = 0.906), and artificial ascites (p = 0.882) did not significantly affect baseline impedance. Grounding pads located on the back showed the lowest baseline impedance (p < 0.001). Increase in active tip size showed gradual decrease in baseline impedance (p = 0.016).CONCLUSIONThe factors affecting baseline impedance were the pad location and the tip size. Positioning pads on the back lowers the baseline impedance and can shorten the first roll-off time, ultimately resulting in reduced total ablation time.

Hepatocellular carcinoma (HCC) continues to be the most prevalent primary liver malignancy and is the third leading cause of cancer-related deaths worldwide (1–3). According to the 2018 European Association for the Study of the Liver clinical practice guidelines (4), ablation is the standard of care for patients with very early stage HCC (Barcelona clinic liver cancer staging system, BCLC-0), and can be adopted as first-line therapy even in surgical patients. Additionally, thermal ablation in single tumors sized 2 to 3 cm is an alternative to surgical resection based on tumor location and patient condition (4). Baseline impedance of radiofrequency ablation (RFA) is measured with a single monopolar electrode before ablation automatically (5). The impedance-controlled mode is generated with an initial set value, which can be adjusted by means of a radiofrequency (RF) output control (5). The first roll-off occurs when the impedance is increased 60% over the initial value (5). Hence, low baseline impedance suggests a short first roll-off time, which is expected to eventually reduce the entire ablation time (6). The aim of this study was to evaluate factors that significantly affect baseline impedance during RFA.