High Interobserver Correlation Research Articles

Coronavirus disease 2019 and lung cancer: where are we?

Oncology patients are more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection due to hospital contact and an immunological system that can be compromised by antineoplastic therapy and supportive treatments. Certain similarities have been described in the physiopathology of coronavirus disease 2019 (COVID-19) and lung cancer (LC) that may explain the higher probability of these patients of developing a more serious disease with more frequent hospitalizations and even death, especially with the addition of smoking, cardiovascular and respiratory comorbidities, old age and corticosteroids use. Pre-existing lesions and cancer therapies change the normal architecture of the lungs, so diagnostic scales such as COVID-19 Reporting and Data System (CO-RADS) are of vital importance for a correct diagnosis and patient homogenization, with a high inter-observer correlation. Moreover, anticancer treatments have required an adaptation to reduce the number of visits to the hospital [hypofractionated radiotherapy (RT), larger intervals between chemotherapy cycles, delay in follow-up tests, among others]. In a way, this has also caused a delay in the diagnosis of new cancers. On the other hand, vaccination has had a positive impact on the mortality of these patients, who maintain a similar seroprevalence to the rest of the population, with a similar impact in mortality.

A New Finding on Magnetic Resonance Imaging for Diagnosis of Hemifacial Spasm with High Accuracy and Interobserver Correlation.

Among patients with clinical hemifacial spasm (HFS), imaging exams aim to identify the neurovascular conflict (NVC) location. It has been proven that the identification in the preoperative exam increases the rate of surgical success. Despite the description of specific magnetic resonance image (MRI) acquisitions, the site of neurovascular compression is not always visualized. The authors describe a new MRI finding that helps in the diagnosis of HFS, and evaluate the sensitivity, specificity, and interobserver correlation of the described sign. A cross-sectional study including cases of hemifacial spasm treated surgically from 1 August 2011 to 31 July 2021 was performed. The MRIs of the cases were independently evaluated by two experienced neuroradiologists, who were blinded regarding the side of the symptom. The neuroradiologists were assigned to evaluate the MRIs in two separate moments. Primarily, they evaluated whether there was a neurovascular conflict based on the standard technique. Following this initial analysis, the neuroradiologists received a file with the description of the novel sign, named Prevedello Sign (PS). In a second moment, the same neuroradiologists were asked to identify the presence of the PS and, if it was present, to report on which side. A total of 35 patients were included, mostly females (65.7%) with a mean age of 59.02 (+0.48). Since the 35 cases were independently evaluated by two neuroradiologists, a total of 70 reports were included in the analysis. The PS was present in 66 patients (sensitivity of 94.2%, specificity of 91.4% and positive predictive value of 90.9%). When both analyses were performed in parallel (standard plus PS), the sensitivity increased to 99.2%. Based on the findings of this study, the authors conclude that PS is helpful in determining the neurovascular conflict location in patients with HFS. Its presence, combined with the standard evaluation, increases the sensitivity of the MRI to over 99%, without increasing risks of harm to patients or resulting in additional costs.

Transoral removal of submandibular hilar lithiasis: results on the salivary duct system, glandular parenchyma, and quality-of-life recovery

Objective(s)To confirm that hilar transoral submandibular sialolitectomy (TOSL) is the first treatment option for submandibular hilar lithiasis (SHL) in terms of glandular parenchyma recovery, salivary system restoration, and patient quality of life (QoL) improvement.MethodsDepending on whether the stone was easily palpable, TOSL was carried out with or without sialendoscopy. For the first time in the literature, Magnetic Resonance Sialography (MR-Si) was performed before and after TOSL, to evaluate stone characteristics, glandular parenchyma status, hilum dilation and main duct recanalization. Radiological data was examined independently by two radiologists. COSQ, a recently validated and specific questionnaire, was used to assess associated QoL.ResultsBetween 2017 and 2022, 29 TOSL patients were examined. With a high interobserver correlation, MR-Si was confirmed as a very useful radiological test in the pre- and post-surgical evaluation of SHL. The salivary main duct was completely recanalized in all cases. The presence of lithiasis was found in 4 patients (13.8%). After surgery, the majority of patients (79.31%) had hilum dilation. There was a statistically significant improvement in parenchyma status, but no significant progression to glandular atrophy. After surgery, COSQ mean values always improved (22.5 to 4.5).ConclusionsTOSL is the ideal surgical technique for the management of SHL, resulting in improved parenchymal inflammatory changes, recanalization of Wharton’s duct, and enhancement patients’ QoL. As a result, before removing the submandibular gland, TOSL should be considered as the first treatment option for SHL.

Measurement of Intervertebral Disc Heights in the Lumbar Spine. Comparison of X-Ray and Magnetic Resonance Imaging, Method of Measurement and Determination of Inter-observer Reliability.

Retrospective radiological examination (X-ray and MRI) aims to investigate the diagnostic value of various methods of measurement with regard to the determination of the intervertebral disc heights of the lumbar spine. Of 130 patients without detectable damage to the intervertebral discs, the X-ray and MRI images of the lumbar spine were evaluated. The measurements were made either in the center line (Hurxthal) or in the 2-point method according to Dabbs or in the 3-point method according to Fyllos. The average intervertebral disc height for all measured segments was 8.8mm (SD 1.4mm). In the Hurxthal measurement, the significantly (p<0.001) highest values were measured with an average of 9.1mm (SD 1.3mm). The average readings for the Fyllos method were 7.5mm (SD 1.2mm) and according to Dabbs 6.7mm (SD 1.2mm). The measured values of Observer I were on average 1.2mm (SD 0.3mm) smaller than those of Observer II (p<0.001). The highest interobserver correlation was found in the measurements in projection radiography in the AP method according to Dabbs and Fyllos. The measured values in men were 0.5mm (SD 0.01mm) larger than in women (p<0.001), regardless of the method. The height of the intervertebral discs increases significantly until the age of 40, but beyond the age of 40, the height of the intervertebral discs either remains constant or falls off slightly, but not significantly. The lordosis angle of the lumbar spine and the concavity index of the vertebral bodies showed no correlation with the measured disc heights. The radiological measurements to determine the intervertebral disc height have only moderate reliability. The results of X-rays are superior to those of MRI examination. The most accurate results are provided by measurements based on exact landmarks of the vertebral bodies. The method according to Dabbs seems to be the most accurate at the moment. There is no clear age-atypical chondrosis in patients without intervertebral disc damage.

Defining Reference Values for the Normal Adult Lisfranc Joint Using Weightbearing Computed Tomography

The uninjured contralateral feet of consecutive patients undergoing cone-beam weightbearing computed tomography for acute Lisfranc injury between July 2017 and October 2019 were retrospectively analyzed. Of these, any cases with history or radiological evidence of trauma to the Lisfranc interval were excluded. The area of the non-weightbearing (NWBA) and weightbearing (WBA) Lisfranc joint was calculated (in mm2) using a novel technique. Area difference (AD) was calculated as WBA-NWBA. Area ratio (AR) was calculated as WBA/NWBA. A subset of cases was double-measured by 2 technologists to evaluate inter- and intraobserver variability. A total of 91 patients aged 15 to 74 years were included in the study. The measurement technique was reproducible with excellent intraobserver correlation (intraclass correlation coefficient [ICC]: 0.998, 95% confidence interval [CI]: 0.996-0.999) and high interobserver correlation (ICC: 0.964, CI: 0.939-0.979). The median NWBA was 83 (range 52-171) and median WBA was 86 (range 52-171). Median AD was 1 mm2 (range -3 to 10) and median AR was 1.01 (range 0.96-1.11). No significant difference was identified in AD or AR when adjusted for age, gender, patient-weight or weight put through the foot. Both AD and AR distributions were highly skewed toward 0 and 1, respectively. Based on 95% CI, normal reference range for AD is -1 to 7 mm2 and for AR is 0.98 to 1.09. Absolute area of the Lisfranc joint is highly variable between individuals. The Lisfranc joint is rigid with little to no physiologic widening in most subjects. The normal upper limit of widening of the Lisfranc area on weightbearing was 9%. Differences in age, sex, patient-weight or weight put through the foot were not significantly associated with the extent of joint widening.

Interobserver and Intraobserver Reliability in Sonoelastographic Assessment of Thyroid Nodules.

Thyroid ultrasonography is the first and perhaps most fundamental step for the radiological distinction of benign and malignant nodules. In this study, 2 radiologists reviewed the sonoelastographic and Doppler images of thyroid nodules and evaluated for the intraobserver and interobserver reliability. We aimed to determine confusing nodule identifiers and sonographic features differently defined by observers. A total of 157 nodules in 91 patients (male/female, 72:19) with ages ranging from 18 to 72 years old were included in the study. Ultrasonographic images and video clips of the nodules were obtained and presented to 2 reviewers unaware of the cytopathology results. Two observers defined the characteristics of the nodules based on previously determined criteria. Then, intraobserver and interobserver correlation coefficients were calculated for each subcategory. In the grayscale ultrasonographic examination, varying degrees from low to high interobserver correlation coefficients were obtained for different subcategories (between κ = 0.359 and κ = 0.821). In color Doppler examination, we obtained medium correlation coefficients ( κ = 0.493 and κ = 0.553). On the other hand, there was a high correlation coefficient in tissue compression elastography ( κ = 0.617 and κ = 0.638).According to our study results, elastographic pattern, shape of the nodule, presence of echogenic foci, and pathological lymph nodes are better predictors to determine the malignant potential of thyroid nodule with higher interobserver correlation. Therefore, these criteria may be used primarily for the evaluation of thyroid nodules. The intraobserver correlation coefficient was higher in the practitioner with longer experience, suggesting the importance of professional practice period on the decision-making process.

Anatomical accuracy of the KODEX-EPD novel 3D mapping system of the left atrium during pulmonary vein isolation: a correlation with computer tomography imaging

Abstract Funding Acknowledgements Type of funding sources: None. Background A novel 3D mapping system (KODEX - EPD, EPD Solutions, Best, The Netherlands) enables catheter localization and real-time 3D cardiac mapping. Purpose To evaluate left atrium (LA) anatomical mapping accuracy created by the KODEX-EPD system during pulmonary vein isolation (PVI) compared with gold standard computed tomography (CT) images acquired from the same patients prior to the procedure. Methods In 15 consecutive patients who underwent PVI, 3D mapping of the LA was created on the KODEX-EPD system using the Achieve catheter. Pulmonary vein (PV), posterior wall, and appendage anatomy and diameters, were compared to the CT 3D reconstruction measured on the CARTO 3 system. Measurements were done independently by 2 physicians in each method. Linear correlation and agreement between CT and EPD measurements were assessed by Spearman correlation and Bland-Altman plot. Results Mean LA mapping time was 7.7± 3.6 min. Very high interobserver correlation was found for both EPD and CT measurements (Spearman-r=0.9). High correlation (r=0.75) was found between CT and EPD measurements. Bland-Altman plot method revealed that measurements assessed by EPD were slightly higher than those assessed by CT. Mean difference was 3.5mm, p&amp;lt;0.01. In 2 (13.5%) patients each, disagreement regarding the presence of a left common PV and a right middle accessory vein anatomy was seen. Conclusion The new KODEX-EPD mapping system allows quick and accurate mapping of the LA with high correlation to CT imaging. Some differences in left common and accessory right middle vein anatomy were seen. Central illustration: An example of the anatomy created by the KODEX- EPD system compared with the CT image of the same patient. A standard 4 vein anatomy is demonstrated by both modalities, with early branching of the right inferior pulmonary vein. A: KODEX- EPD pre-CRYO map during atrial fibrillation demonstrating connected pulmonary veins. B: 3D CT image viewed on the CARTO auto-segmentation module. C,D: KODEX- EPD posterior-anterior and PANO images post-CRYO map during sinus rhythm demonstrating pulmonary vein isolation with the same anatomy. E: Spearman correlation demonstrating a high correlation (r 0.75) between CT and KODEX-EPD measurements, p&amp;lt;0.01.

Anatomical accuracy of the KODEX-EPD novel 3D mapping system of the left atrium during pulmonary vein isolation: A correlation with computer tomography imaging.

BackgroundA novel 3D mapping system (KODEX‐EPD, EPD Solutions) enables catheter localization and real‐time 3D cardiac mapping.ObjectiveTo evaluate left atrium (LA) anatomical mapping accuracy created by the KODEX‐EPD system during pulmonary vein isolation (PVI) compared with gold standard computed tomography (CT) images acquired from the same patients before the procedure.MethodsIn 15 consecutive patients who underwent PVI, 3D mapping of the LA was created on the KODEX‐EPD system using the Achieve catheter. Pulmonary vein (PV), posterior wall, and appendage anatomy and diameters, were compared to the CT 3D reconstruction measured on the CARTO 3 system. Measurements were done independently by two physicians in each method. Linear correlation and agreement between CT and EPD measurements were assessed by Spearman correlation and Bland‐Altman plot.ResultsMean LA mapping time was 7.7 ± 3.6 min. Very high interobserver correlation was found for both EPD and CT measurements (Spearman r = .9). High correlation (r = .75) was found between CT and EPD measurements. Bland‐Altman plot method revealed that measurements assessed by EPD were slightly higher than those assessed by CT. Mean difference was 3.5 mm, p < .01. In 2 (13.5%) patients each, disagreement regarding the presence of a left common PV and a right middle accessory vein anatomy was seen.ConclusionThe new KODEX‐EPD mapping system allows quick and accurate mapping of the LA with high correlation to CT imaging. Some differences in left common and accessory right middle vein anatomy were seen.

Moiré topography as a screening and diagnostic tool-A systematic review.

Diagnostic investigation can be carried out using non-radiological and non-contact methods. Moiré topography (MT) seems to be a viable alternative to radiographic research in evaluating the spine and/or trunk deviations. The aim of this systematic review was to analyze the current knowledge regarding the reliability and validity of Moiré topography as a screening and diagnostic tool. The systematic review was performed from 2010 until March 2021 in the PubMed, EBSCO, Web of Science, and Scopus databases, according to the eligibility criteria. This review fulfilled the following criteria according to the PICO system: population (children and adolescents), intervention (MT measurement), comparison (repeated MT measurements, MT compared to Cobb angle or scoliometer), outcome (reliability and validity of MT). Eight studies fulfilled the inclusion criteria for further analysis. All the studies were assessed to be of high quality. Included studies found that MT had high repeatability and high intraobserver and interobserver correlation, and correlation between MT parameters and radiographic Cobb angle ranged from moderate to high. The authors reported difficulty in defining the cut-off values for MT parameter (Surface Trunk Rotation—STR), and unsatisfactory sensitivity and specificity of MT examination. The studies did not reveal the advantage of MT as a screening method in the detection of idiopathic scoliosis in comparison to radiograph. Based on the evidence from eight studies, the results indicated moderate evidence for reliability and validity of Moiré topography as a screening and diagnostic tool. There is still no strong evidence for the accuracy of MT.

Dual-Layer Spectral CT Imaging of Upper Aerodigestive Tract Cancer: Analysis of Spectral Imaging Parameters and Impact on Tumor Staging.

Dual-layer spectral CT is a novel technology that utilized conventional single-tube CT acquisition with a dual-layer detector for the separation of high and low-energy photons to create spectral data for material decomposition. We evaluated the spectral parameters of iodine density and Z-effective values in primary head and neck squamous cell carcinoma and determined its impact on local tumor staging. Twenty-one patients with primary head and neck squamous cell carcinoma and 15 healthy controls were retrospectively evaluated. Iodine density (milligram/milliliter) and Z-effective values were compared quantitatively between head and neck squamous cell carcinoma and normal neck mucosa. The receiver operating characteristic area under the curve determined the diagnostic performance of the spectral data for local staging. We compared conventional CT images without and with iodine density and Z-effective images to determine its impact on local tumor staging. Primary head and neck squamous cell carcinoma showed higher mean iodine density (2.01 [SD, 0.26] mg/mL, P < .001) and Z-effective values (8.21 [SD, 0.36], P < .001). A high interobserver correlation was demonstrated for ROI measurements for both the control group (iodine density, κ = 0.71, and Z-effective values, κ = 0.78) and head and neck squamous cell carcinoma (iodine density, κ = 0.84, and Z-effective values, κ = 0.75) group. The area under the curve for iodine density and Z-effective values was 0.98 and 0.93, respectively. Optimal thresholds were identified as 1.58 mg/mL (95% CI, 1.45-1.71 mg/mL; P < .001; sensitivity = 1.0; specificity = .0.93) for iodine density and 8.08 (95% CI, 7.96-8.19; P < .001; sensitivity = 0.86; specificity = 0.93) for Z-effective values. Conventional CT with the addition of dual-layer spectral data (iodine density and Z-effective values) improved the accuracy of local tumor staging in 3 of 21 patients (14%) with head and neck squamous cell carcinoma compared with the criterion standard surgical staging/histopathology. Dual-layer spectral iodine density and Z-effective values provided increased quantitative and qualitative differentiation between upper aerodigestive head and neck squamous cell carcinoma and normal mucosa. Increased tissue differentiation improved the local tumor staging accuracy.

Validation of the translation and cross-cultural adaptation into Spanish of the Postoperative Nausea and Vomiting Intensity Scale

Postoperative nausea and vomiting (PONV) is a common problem in patients undergoing surgical procedures, generating patient dissatisfaction and increasing hospital costs. The Postoperative Nausea and Vomiting Intensity Scale identifies clinically significant cases; however, it has not been validated in Spanish. To carry out a cross-cultural adaptation of the PONV Intensity Scale into Spanish and validate it for use in the postoperative period of patients undergoing elective non-cardiac and non-intracranial surgery. Cross-sectional validation study of a diagnostic test. The NVPO Intensity Scale was culturally adapted to Spanish and administered to 393 adult hospitalized patients at 6 postoperative hours. The data were compared with the Apfel Scale and nausea measured on a visual analogue scale (VAS). Internal consistency and inter-observer concordance were calculated. 59.8% of patients presented NVPO, of which 14.5% were clinically significant. An acceptable internal consistency was obtained for the NVPO Intensity Scale (Cronbach's alpha 0.7) and a high inter-observer correlation (Kappa 0.9, 95% CI 0.86−0.92), statistically significant, for the overall scale. The correlation with VAS was high (Rho Spearman 0.9). The mean VAS and Apfel scale score was significantly higher in patients with clinically significant PONV. The PONV Intensity Scale adapted to Spanish is a valid and reliable instrument for monitoring and evaluating postoperative nausea and vomiting. Las náuseas y vómitos postoperatorios (NVPO) representan un problema usual en los pacientes sometidos a procedimientos quirúrgicos, generando insatisfacción del paciente e incremento de costes hospitalarios. La Escala de Intensidad de Náusea y Vómito Postoperatorio identifica casos clínicamente significativos; sin embargo, no ha sido validada al español. Realizar una adaptación cultural de la Escala de Intensidad de NVPO al español y validarla para su uso en el postoperatorio de los pacientes sometidos a cirugía electiva no cardiaca y no intracraneal. Estudio transversal de validación de una prueba diagnóstica, donde se realizó la adaptación cultural de la Escala de Intensidad de NVPO al español, y se aplicó a 393 pacientes adultos hospitalizados a las 6 horas del postoperatorio. Los datos fueron comparados con la Escala de Apfel y la Escala Visual Análoga de Náusea (EVA). Se calculó la consistencia interna y concordancia inter-observador. El 59,8% de los pacientes presentaron NVPO y en un 14,5% fueron clínicamente significativas. Se obtuvo una consistencia interna aceptable para la Escala de Intensidad de NVPO (alfa de Cronbach 0,7) y una alta correlación inter-observador (Kappa 0,9, IC95% 0,86−0,92), estadísticamente significativa, para toda la escala. La correlación con la EVA fue alta (Rho Spearman 0,9). La media de EVA y de la escala de Apfel fue significativamente mayor en los pacientes con NPVO clínicamente significativos. la Escala de Intensidad de NVPO adaptada al español es un instrumento válido y confiable de monitorización y de evaluación de las náuseas y vómitos posoperatorios.

Adaptación cultural y validación al español de la Escala de intensidad de náuseas y vómitos postoperatorios

IntroductionPostoperative nausea and vomiting (PONV) is a common problem in patients undergoing surgical procedures, generating patient dissatisfaction and increasing hospital costs. The Postoperative Nausea and Vomiting Intensity Scale identifies clinically significant cases; however, it has not been validated in Spanish. ObjectiveTo carry out a cross-cultural adaptation of the PONV Intensity Scale into Spanish and validate it for use in the postoperative period of patients undergoing elective non-cardiac and non-intracranial surgery. Materials and methodsCross-sectional validation study of a diagnostic test. The NVPO Intensity Scale was culturally adapted to Spanish and administered to 393 adult hospitalized patients at 6 postoperative hours. The data were compared with the Apfel Scale and nausea measured on a visual analogue scale (VAS). Internal consistency and inter-observer concordance were calculated. Results59.8% of patients presented NVPO, of which 14.5% were clinically significant. An acceptable internal consistency was obtained for the NVPO Intensity Scale (Cronbach's alpha 0.7) and a high inter-observer correlation (Kappa 0.9, 95% CI 0.86-0.92), statistically significant, for the overall scale. The correlation with VAS was high (Rho Spearman 0.9). The mean VAS and Apfel scale score was significantly higher in patients with clinically significant PONV. ConclusionsThe PONV Intensity Scale adapted to Spanish is a valid and reliable instrument for monitoring and evaluating postoperative nausea and vomiting.

The interrater reliability of ultrasonography for Achilles tendon structure.

Aim of the studyReliable assessment of Achilles tendon structure (architecture and morphology) may help prevent clinical symptoms or progression of Achilles tendinopathy. The objective of this study was to determine the interrater reliability of musculoskeletal ultrasonography for the assessment of the mid-portion of the Achilles tendon: (1) structure, (2) anteroposterior diameter and (3) neovascularization, in asymptomatic military personnel.Material and methodsTwo sonographers acquired B-mode images of the Achilles tendon mid-portion in 74 volunteers (148 tendons) in short-axis and long-axis planes to assess its structure and measure the maximum anteroposterior diameter. Power Doppler ultrasound was performed to assess neovascularization. Tendon structure and neovascularization were graded using a modified four-graded Öhberg score.ResultsWeighted kappa for assessing tendon structure showed almost perfect agreement (0.87; 95% CI: 0.79, 0.95). Spearman’s rho showed: a very high positive interobserver correlation for tendon structure (0.92; 95% CI: 0.89, 0.94), a very high positive interobserver correlation for the diameter measurement in the short-axis plane (0.91; 95% CI: 0.87, 0.93) and a high positive interobserver correlation in the long-axis plane (0.87; 95% CI: 0.83, 0.91). The Wilcoxon signed-rank test showed no significant differences between observers during diameter measurements (p value >0.05). Both sonographers reported absent neovascularization in all the subjects, resulting in overall Öhberg score of 0.Conclusions(1) Interrater reliability of ultrasonography for grading the mid-portion Achilles tendon structure shows almost perfect agreement, and (2) ultrasonography is highly reliable in measuring the anteroposterior diameter. (3) In a large group of asymptomatic service members neovascularization of the Achilles tendon is consistently absent.

VALIDATION OF THE RECENTLY DEVELOPED ATN CLASSIFICATION AND GRADING SYSTEM FOR MYOPIC MACULOPATHY

To validate the recently developed ATN grading system for myopic maculopathy to classify eyes with pathologic myopia. Cross-sectional study. A series of consecutive eyes diagnosed with pathologic myopia and signs of myopic maculopathy (grade ≥1 for atrophic, tractional, or neovascular components of the ATN), with a refractive error > -6.0 diopters (D), were included. All patients underwent complete ophthalmological examination including fundus photography and swept-source optical coherence tomography. Six observers graded each eye twice using the ATN system (≥15 days between assessments) based only on the aforementioned data. Sixty eyes from 47 patients (61.7% female) were graded. Mean patient age was 63.2 ± 11.7 years. The mean spherical equivalent was -13.8 ± 6.5 D. Mean axial length was 28.6 ± 2.16 mm. Overall, the mean intraobserver agreement (%) for the same image was 92.0%, and the mean interobserver agreement for the second image was 77.5%. The weighted Fleiss k showed excellent correlation (k > 0.8) for the traction and neovascularization components and good correlation (0.75) for atrophy. Interobserver agreement for each of these three components was 95.2%, 98.4%, 95.0%, respectively. Application of the ATN resulted in high intraobserver and interobserver correlation, underscoring the reproducibility of the system.

Ultrasound imaging of the fetal secondary palate: Methodological description of a two-dimensional approach and a case series.

The study aims to describe our two-dimensional (2D) ultrasound approach to visualize the fetal secondary palate and plot its growth curve and to describe and demonstrate its clinical implementation. This is a two parts retrospective study. First, we measured the antero-posterior length of the bony secondary palate, from the soft to hard palate interface (SHPI) line to the alveolar ridge, blindly by two operators during routine scans of low-risk fetuses, and plot a longitudinal growth curve. In the second part, we describe four cases of prenatal diagnosis of secondary palate cleft. Sixty-eight fetuses were included: 14 to 15weeks (n=20), 21 to 24weeks (n=32), and 29 to 35weeks (n=16). The bony secondary palate elongates along gestation from a mean of 5.3mm (+/-0.46mm) at 14 to 15weeks to 15.9mm (+/-1.7mm) at 29 to 35weeks. We found high intraobserver and interobserver correlation between measurements. All four cases diagnosed by this approach were confirmed postnatally. The SHPI, representing the normally developed secondary bony palate, can be imaged in the fetus by direct 2D ultrasound as early as 14weeks. A gap within or nonvisualization of the SHPI is highly suggestive for a secondary palate cleft.

Reliability of patellotrochlear index in patellar height assessment on MRI-correction for variation due to change in knee flexion.

To assess the reliability of patellotrochlear Index (PTI) in patellar height assessment on successive MRI scans in asymptomatic patients. Sixty-four patients with two successive MRI scans (128 studies) of the same knee for non-patellofemoral joint symptoms were identified retrospectively. PTI and knee flexion angle were assessed independently by three observers to assess interobserver reliability. The effect of knee flexion on PTI was assessed by comparing the change in values of PTI in each patient correlated with change in knee flexion. Sixty-four MRIs of patients (M:F) aged between 18 and 35years (mean 24.6) years were assessed. The mean PTI for initial scan group was 0.33% (95% CI: 0.29-0.37; SD: 0.15) and consecutive scan group was 0.30% (CI: 0.27-0.33; SD: 0.3). The difference was not significant (p= 0.097 using a paired t test) with high inter-observer correlation (0.9) in both sets. Spearman's rho for knee flexion angle and PTI was found to be positive and statistically significant (0.41; p = 0.001). A linear regression model was derived using a scatter chart of change in PTI with change in knee flexion for each patient. The gradient of the linear regression line was used to estimate a cPTI (corrected PTI) value (corrected to 0 degrees of knee flexion), defined as cPTI = PTI - 1.3a (a = knee flexion angle). This study demonstrates high inter-observer correlation of PTI on MRI and high test-retest reliability indicating unconscious quadriceps contraction does not change the index sufficiently. Knee flexion significantly alters PTI, increased patellotrochlear engagement with flexion increases the index. We propose use of the formula cPTI = PTI -1.3a to correct the index to 0 degree knee flexion in clinical practice.

Optimization of late gadolinium enhancement cardiovascular magnetic resonance imaging of post-ablation atrial scar: a cross-over study

BackgroundCardiovascular magnetic resonance (CMR) imaging may be used to visualize post-ablation atrial scar (PAAS), and three-dimensional late gadolinium enhancement (3D LGE) is the most widely employed technique for imaging of chronic scar. Detection of PAAS provides a unique non-invasive insight into the effects of the ablation and may help guide further ablation procedures. However, there is evidence that PAAS is often not detected by CMR, implying a significant sensitivity problem, and imaging parameters vary between leading centres. Therefore, there is a need to establish the optimal imaging parameters to detect PAAS.MethodsForty subjects undergoing their first pulmonary vein isolation procedure for AF had detailed CMR assessment of atrial scar: one scan pre-ablation, and two scans post-ablation at 3 months (separated by 48 h). Each scan session included ECG- and respiratory-navigated 3D LGE acquisition at 10, 20 and 30 min post injection of a gadolinium-based contrast agent (GBCA). The first post-procedural scan was performed on a 1.5 T scanner with standard acquisition parameters, including double dose (0.2 mmol/kg) Gadovist and 4 mm slice thickness. Ten patients subsequently underwent identical scan as controls, and the other 30 underwent imaging with a reduced, single, dose GBCA (n = 10), half slice thickness (n = 10) or on a 3 T scanner (n = 10). Apparent signal-to-noise (aSNR), contrast-to-noise (aCNR) and imaging quality (Likert Scale, 3 independent observers) were assessed. PAAS location and area (%PAAS scar) were assessed following manual segmentation. Atrial shells with standardised %PAAS at each timepoint were then compared to ablation lesion locations to assess quality of scar delineation.ResultsA total of 271 3D acquisitions (out of maximum 280, 96.7%) were acquired. Likert scale of imaging quality had high interobserver and intraobserver intraclass correlation coefficients (0.89 and 0.96 respectively), and showed lower overall imaging quality on 3 T and at half-slice thickness. aCNR, and quality of scar delineation increased significantly with time. aCNR was higher with reduced, single, dose of GBCA (p = 0.005).Conclusion3D LGE CMR atrial scar imaging, as assessed qualitatively and quantitatively, improves with time from GBCA administration, with some indices continuing to improve from 20 to 30 min. Imaging should be performed at least 20 min post-GBCA injection, and a single dose of contrast should be considered.Trial registrationTrial registry- United Kingdom National Research Ethics Service 08/H0802/68 – 30th September 2008.

Therapeutic response assessment using 3D ultrasound for hepatic metastasis from colorectal cancer: Application of a personalized, 3D-printed tumor model using CT images.

Background & aimsTo evaluate accuracy and reliability of three-dimensional ultrasound (3D US) for response evaluation of hepatic metastasis from colorectal cancer (CRC) using a personalized 3D-printed tumor model.MethodsTwenty patients with liver metastasis from CRC who underwent baseline and after chemotherapy CT, were retrospectively included. Personalized 3D-printed tumor models using CT were fabricated. Two radiologists measured volume of each 3D printing model using 3D US. With CT as a reference, we compared difference between CT and US tumor volume. The response evaluation was based on Response Evaluation Criteria in Solid Tumors (RECIST) criteria.Results3D US tumor volume showed no significant difference from CT volume (7.18 ± 5.44 mL, 8.31 ± 6.32 mL vs 7.42 ± 5.76 mL in CT, p>0.05). 3D US provided a high correlation coefficient with CT (r = 0.953, r = 0.97) as well as a high inter-observer intraclass correlation (0.978; 0.958–0.988). Regarding response, 3D US was in agreement with CT in 17 and 18 out of 20 patients for observer 1 and 2 with excellent agreement (κ = 0.961).Conclusions3D US tumor volume using a personalized 3D-printed model is an accurate and reliable method for the response evaluation in comparison with CT tumor volume.

Maximum Aortic Valve Opening Phase for Annulus Sizing in Pre-TAVR CTA

The optimal phase for the measurement of the aortic annular area for transcatheter aortic valve replacement (TAVR) is not standardized, although most agree that systolic measurements are preferred, when the annulus is larger. We hypothesized that the maximum annular area occurs at the cardiac phase of the maximum aortic valve opening (MAVO) and that this phase can be accurately and reproducibly assessed by visual inspection only. The aortic valve opening area was inspected visually by two readers to determine the MAVO phase. The annular area was measured at the MAVO phase and the typical systolic phase (35% of the R-R interval). Differences in the annular area that would change valve sizing for prostheses were noted. Fifty patients (mean age 81) were studied. Ninety percent had the MAVO at the 15%-25% R-R interval. There was high interobserver correlation (0.89) for determining the MAVO phase by visual inspection. For 49 out of 50 patients, the annular area was maximal at the MAVO phase. The mean difference in the annular area between the MAVO phase and 35% was 22.3 (±4.57) mm2. In 12% of the patients, the difference in the annular area changed the recommended size of a self-expanding prosthesis and would have altered the procedure in 32% for balloon-expandable prostheses. Visually assessed MAVO occurs in early systole for most patients and is almost always the cardiac phase of the maximal aortic annular area. This method allows rapid and reproducible determination of the appropriate phase for TAVR planning measurements. Consideration should be given to optimizing pre-TAVR computed tomography acquisitions for early systolic reconstruction and visual determination of the MAVO.

In Vitro Comparison of Five Different Elastography Systems for Clinical Applications, Using Strain and Shear Wave Technology

Several different platforms providing ultrasound elastography have emerged in recent years. In this in vitro study on a single tissue-mimicking phantom (CIRS Model 49), we aimed to compare the performance of quantitative elastography measurements from platforms running strain elastography and others running shear wave elastography. We evaluated five different elastography platforms using both linear and curvilinear probes. All measurements were performed in parallel by two independent investigators who recorded the elasticity quantitatively. We investigated intra- and inter-observer agreement by intra-class correlation analysis and coefficient of variation, by correlation and limits of agreement. The reproducibility of elasticity measurements was good to excellent for shear wave and strain elastography. All five elastography platforms had high intra-observer (intra-class correlation coefficient: 0.932–1.0) and inter-observer correlation (intra-class correlation coefficient: 0.845–0.996). All inclusions could be differentiated by quantitative elastography by all systems (p < 0.001). The use of a linear probe yielded more reproducible measurements compared with use of a convex probe in 3/4 platforms.