Intra-and Inter-observer Variability Research Articles

The accuracy and intra- and interobserver variability of PSMA PET/CT for the local staging of primary prostate cancer

PurposeProstate-specific membrane antigen (PSMA) positron emission tomography/ computed tomography (PET/CT) is recognized as the most accurate imaging modality for detection of metastatic high-risk prostate cancer (PCa). Its role in the local staging of disease is yet unclear. We assessed the intra- and interobserver variability, as well as the diagnostic accuracy of the PSMA PET/CT based molecular imaging local tumour stage (miT-stage) for the local tumour stage assessment in a large, multicentre cohort of patients with intermediate and high-risk primary PCa, with the radical prostatectomy specimen (pT-stage) serving as the reference standard.MethodsA total of 600 patients who underwent staging PSMA PET/CT before robot-assisted radical prostatectomy was studied. In 579 PSMA positive primary prostate tumours a comparison was made between miT-stage as assessed by four nuclear physicians and the pT-stage according to ISUP protocol. Sensitivity, specificity and diagnostic accuracy were determined. In a representative subset of 100 patients, the intra-and interobserver variability were assessed using Kappa-estimates.ResultsThe sensitivity and specificity of the PSMA PET/CT based miT-stage were 58% and 59% for pT3a-stage, 30% and 97% for ≥ pT3b-stage, and 68% and 61% for overall ≥ pT3-stage, respectively. No statistically significant differences in diagnostic accuracy were found between tracers.We found a substantial intra-observer agreement for PSMA PET/CT assessment of ≥ T3-stage (k 0.70) and ≥ T3b-stage (k 0.75), whereas the interobserver agreement for the assessment of ≥ T3-stage (k 0.47) and ≥ T3b-stage (k 0.41) were moderate.ConclusionIn a large, multicentre study evaluating 600 patients with newly diagnosed intermediate and high-risk PCa, we showed that PSMA PET/CT may have a value in local tumour staging when pathological tumour stage in the radical prostatectomy specimen was used as the reference standard. The intra-observer and interobserver variability of assessment of tumour extent on PSMA PET/CT was moderate to substantial.

Intra-and inter-observer variability of point of care ultrasound measurements to evaluate hemodynamic parameters in healthy volunteers

BackgroundPoint-of-care ultrasound (POCUS) is a valuable tool for assessing the hemodynamic status of acute patients. Even though POCUS often uses a qualitative approach, quantitative measurements have potential advantages in evaluating hemodynamic status. Several quantitative ultrasound parameters can be used to assess the hemodynamic status and cardiac function. However, only limited data on the feasibility and reliability of the quantitative hemodynamic measurements in the point-of-care setting are available. This study investigated the intra- and inter-observer variability of PoCUS measurements of quantitative hemodynamic parameters in healthy volunteers.MethodsIn this prospective observational study, three sonographers performed three repeated measurements of eight different hemodynamic parameters in healthy subjects. An expert panel of two experienced sonographers evaluated the images’ quality. The repeatability (intra-observer variability) was determined by calculating the coefficient of variation (CV) between the separate measurements for each observer. The reproducibility (inter-observer variability) was assessed by determining the intra-class correlation coefficient (ICC).Results32 subjects were included in this study, on whom, in total, 1502 images were obtained for analysis. All parameters were in a normal physiological range. Stroke volume (SV), cardiac output (CO), and inferior vena cava diameter (IVC-D) showed high repeatability (CV under 10%) and substantial reproducibility (ICC 0.61–0.80). The other parameters had only moderate repeatability and reproducibility.ConclusionsWe demonstrated good inter-observer reproducibility and good intra-observer repeatability for CO, SV and IVC-D taken in healthy subjects by emergency care physicians.

Abstract 5414: Automated detection of high-grade urothelial carcinoma from urine cytology slides using attention-based deep learning

Abstract Urine cytology has long been an effective and non-invasive test for the detection of bladder urothelial carcinomas (UC) routinely performed in cases of unexplained hematuria or for monitoring patients with UC. In cytopathology practice, urine cytology specimens are examined manually with a light microscope to identify morphologic features associated with different diagnostic categories based on the Paris System (TPS) for Reporting Urinary Cytology. Specifically, the diagnosis of high-grade urothelial carcinoma (HGUC) requires the identification of > 5-10 cells with a nuclear/cytoplasm ratio of 0.7 or greater and hyperchromasia together with coarse chromatin or irregular nuclear membranes. However, the task of identifying HGUC involves a substantial degree of manual review and is often associated with intra-and inter-observer variability. To address this, we have designed an accurate and efficient deep learning system capable of automatically distinguishing between HGUC and non-HGUC using digitized cytology slides. Our model has been developed using a retrospective cohort of 158 digitized urine ThinPrep cytology slides consisting of HGUC (n=98) and negative for HGUC (n=60). The model was then prospectively validated on a cohort of 105 urine cytology slides that were also independently reviewed prospectively in a blinded manner by a cytopathologist and cytotechnologist. Our system uses Otsu’s method for automatic image thresholding followed by dividing images into non-overlapping tiles of 500 × 500 pixels at the highest magnification. Subsequently, we use a pre-trained ResNet50 model to extract features which are used for training our attention-based multiple instance learning framework. For the training task, our retrospective cohort (158 slides) has been divided into 10 different splits each consisting of training (70%), validation (15%), and testing (15%) sets. The training and validation sets were used for the model training and optimalization, respectively, while the testing set was used for assessing the performance. This process yielded 10 different models with an average Area Under the ROC Curve (AUC) of 0.80 in the testing set. The best performing model had an AUC of 0.90 and an accuracy of 0.88. This model was subsequently validated prospectively in an independent testing cohort with 105 slides. In the prospective testing cohort, the model was able to accurately distinguish between HGUC and non-HGUC with an AUC of 0.83, accuracy of 0.76, sensitivity of 0.89, and specificity of 0.62. Additionally, our system can detect slide regions with high attention score for HGUC which are enriched in atypical urothelial cells. These findings show that our system can be utilized to assist cytopathologists in assessing urine cytology slides and to detect regions with high-diagnostic relevance for further assessment which is expected to reduce the time needed for manual review. Citation Format: Mohamed Omar, David Kim, Luigi Marchionni, Momin T. Siddiqui. Automated detection of high-grade urothelial carcinoma from urine cytology slides using attention-based deep learning. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5414.

Automated 4D flow cardiac MRI pipeline to derive peak mitral inflow diastolic velocities using short-axis cine stack: two centre validation study against echocardiographic pulse-wave doppler

BackgroundMeasurement of peak velocities is important in the evaluation of heart failure. This study compared the performance of automated 4D flow cardiac MRI (CMR) with traditional transthoracic Doppler echocardiography (TTE) for the measurement of mitral inflow peak diastolic velocities.MethodsPatients with Doppler echocardiography and 4D flow cardiac magnetic resonance data were included retrospectively. An established automated technique was used to segment the left ventricular transvalvular flow using short-axis cine stack of images. Peak mitral E-wave and peak mitral A-wave velocities were automatically derived using in-plane velocity maps of transvalvular flow. Additionally, we checked the agreement between peak mitral E-wave velocity derived by 4D flow CMR and Doppler echocardiography in patients with sinus rhythm and atrial fibrillation (AF) separately.ResultsForty-eight patients were included (median age 69 years, IQR 63 to 76; 46% female). Data were split into three groups according to heart rhythm. The median peak E-wave mitral inflow velocity by automated 4D flow CMR was comparable with Doppler echocardiography in all patients (0.90 ± 0.43 m/s vs 0.94 ± 0.48 m/s, P = 0.132), sinus rhythm-only group (0.88 ± 0.35 m/s vs 0.86 ± 0.38 m/s, P = 0.54) and in AF-only group (1.33 ± 0.56 m/s vs 1.18 ± 0.47 m/s, P = 0.06). Peak A-wave mitral inflow velocity results had no significant difference between Doppler TTE and automated 4D flow CMR (0.81 ± 0.44 m/s vs 0.81 ± 0.53 m/s, P = 0.09) in all patients and sinus rhythm-only groups. Automated 4D flow CMR showed a significant correlation with TTE for measurement of peak E-wave in all patients group (r = 0.73, P < 0.001) and peak A-wave velocities (r = 0.88, P < 0.001). Moreover, there was a significant correlation between automated 4D flow CMR and TTE for peak-E wave velocity in sinus rhythm-only patients (r = 0.68, P < 0.001) and AF-only patients (r = 0.81, P = 0.014). Excellent intra-and inter-observer variability was demonstrated for both parameters.ConclusionAutomated dynamic peak mitral inflow diastolic velocity tracing using 4D flow CMR is comparable to Doppler echocardiography and has excellent repeatability for clinical use. However, 4D flow CMR can potentially underestimate peak velocity in patients with AF.

A comprehensive review of content-based image retrieval systems using deep learning and hand-crafted features in medical imaging: Research challenges and future directions

Computer-based medical image retrieval (CBMIR) system helps practitioners to enhance their diagnostic abilities, speeds up accurate diagnosis, and minimizes intra-and inter-observer variability. We investigate in-depth insights on content-based image retrieval systems over the past 20 years, to enable improvements with an imperative feature set to enhance the performance of the proposed CBMIR. After a comprehensive survey, we have made some inferences from the literature survey which is beneficial for researchers and medical practitioners. Existing studies, consider patch sizes of 32 only where 16 and 64 are ignored. We conduct experiments using 16, 32, and 64 patch sizes and two retrieval approaches i.e. simple distance-based retrieval (SDR) and customized query-based approach (CQA). SDR exhibits high inter-class ambiguity, in which some of the retrieved images are from different classes posing similar feature values, which negatively impacts the retrieval performance. To tackle this, a framework has been proposed based on CQA-CBMIR which utilizes wavelet-based Riesz features and improves the retrieval outcomes. The proposed framework is compared with the state-of-the-art (SOTA) methods and obtained f1-score and accuracy i.e. 86.5% and 86.8% respectively. Furthermore, this study illustrates some of the unresolved issues in the literature that demand future researchers' utmost attention to investigate new pathways in this discipline.

O-004 The bias is out of the bag: IVF culture dish well number influences embryo selection decision-making and implantation outcome

Abstract Study question Is there a selection bias against embryos placed in higher-numbered wells inside a multi-well IVF culture dish. Does this selection bias alone impact implantation outcomes? Summary answer Top-quality embryos present in higher-numbered wells are statistically less likely to be selected for transfer, independent of any differences in quality or development between wells. What is known already Substantial intra-and inter-observer variability in embryo selection, as well as differences in quality assessment and laboratory environment, have been shown to affect IVF success. Currently many clinics have adopted stringent guidelines to control for human errors and workflow variation. Still, the impact of errors in laboratory and medical procedures was reported as high as 12%. This is particularly relevant for the IVF lab, where high workload and stress influence rate of errors and patient outcome. This groundbreaking study emphasizes how cognitive tendencies are inherent to the embryo selection process. Study design, size, duration This study used a retrospective dataset from three highly experienced fertility clinics (1 US and 2 European clinics). A total of 4,275 Fresh IVF cycles were analyzed. For each treatment cycle, embryo quality grades, corresponding embryo well numbers, day 5 selection and implantation outcomes were documented. All cycles were performed using the EmbryoSlide 12-well culture dish and a time-lapse system. All three datasets were analyzed separately and also combined. Participants/materials, setting, methods For each dataset, three analyses were conducted: (1) total number of selected embryos were calculated for each corresponding well number; (II) the proportion of implanted embryos, relative to the total number of selected embryos, were quantified to calculate the “success rate” for each well number; (II) the distribution of top-quality embryos between wells were quantified and compared. Results were normalized by total number of transferred embryos and IVF implantation success rates reported for each clinic. Main results and the role of chance A negative trend was found between well number, ranging from 1-12, and number of embryos selected for transfer. This trend was significant (p &amp;lt; 0.05) and occurred independently in each dataset. Odds ratios (OR) for the relation between selecting embryos for transfer from wells 1-5, and from 8-12 = Clinic A: 2.16, Clinic B: 1.78, Clinic C: 2.45. Alternative hypotheses were tested: (1) top-quality embryos are clustered in lower-numbered wells during culture; (2) enhanced embryo quality and conditions are found in lower-numbered wells, which should manifest in higher rates of implantation. Results for each clinic showed a statistically even distribution of top-quality embryos between wells (within 2 standard deviations from the mean; not significant), yet ‘success rate’ for transferred embryos increased by well number (by 12-30% between wells 1-5 and wells 8-12; OR = 1.19, 1.06, 1.08 for Clinic A, B, and C, respectively). An inverse trend existed between an embryo’s likelihood of being selected for transfer, and its likelihood of implanting. We conclude that embryologists may tend to select the first acceptable embryo for transfer. Embryos from higher-numbered wells were significantly more likely to implant, since they overcame this bias when equitably evaluated and selected for transfer. Limitations, reasons for caution Though our findings were significant, they need to be repeated on larger datasets with more inter-centre variation, and key embryo culture and outcome variables recorded. Wider implications of the findings This study emphasizes the inherent human error that exists inside IVF clinics. Machine learning systems that reduce human bias and increase objective standardization, even if they are not inherently better than embryologists, would improve implantation rates. Future studies should be directed toward AI based technologies that can accomplish this. Trial registration number Not Applicable

A deep-learning framework for metacarpal-head cartilage-thickness estimation in ultrasound rheumatological images

ObjectiveRheumatoid arthritis (RA) is a chronic disease characterized by erosive symmetrical polyarthritis. Bone and cartilage are the main joint targets of this disease. Cartilage damage is one of the most relevant determinants of physical disability in RA patients. Cartilage damage is nowadays assessed by clinicians, which manually measure cartilage thickness in ultrasound (US) imaging. This poses issues relevant to intra-and inter-observer variability. Relying on the acquisition of metacarpal-head US images from 38 subjects, this work addresses the problem of automatic cartilage-thickness measurement by designing a new deep-learning (DL) framework. MethodsThe framework consists of a Convolutional Neural Network (CNN), responsible for regressing cartilage-interface distance fields, followed by a post-processing step to delineate the two cartilage interfaces from the predicted distance fields and compute the cartilage thickness. ResultsOur framework achieved encouraging results with a mean absolute difference (ADF) of 0.032 (±0.026) mm against manual thickness annotation by an expert clinician. When evaluating the intra-observer variability, we obtained an ADF = 0.036 (±0.028) mm. ConclusionThe proposed framework achieved an ADF against manual annotation that was comparable to the intra-observer variability, proving the potential of DL in the field. SignificanceThis work is the first to address the problem of automatic cartilage-thickness estimation in US rheumatological images with DL, paving the way for future research in the field. From a clinical perspective, the proposed framework proved to be a valuable tool to support the clinical routine increasing the reproducibility of cartilage thickness measurements.

Ultrasound grading of thyroid nodules using the BTA U-scoring guidelines - Is there evidence of intra-and interobserver variability?

U-score ultrasound classification (graded U1-U5) is widely used to grade thyroid nodules based on benign and malignant sonographic features. It is well established that ultrasound is an operator-dependent imaging modality and thus more susceptible to subjective variances between operators when using imaging-based scoring systems. We aimed to assess whether there is any intra- or interobserver variability when U-scoring thyroid nodules and whether previous thyroid ultrasound experience has an effect on this variability. A total of 14 ultrasound operators were identified (five experienced thyroid operators, five with intermediate experience and four with no experience) and were asked to U-score images from 20 thyroid cases shown as a single projection, with and without Doppler flow. The cases were subsequently rescored by the 14 operators after six weeks. The first and second round U-scores for the three operator groups were then analysed using Fleiss' kappa to assess interobserver variability and Cochran's Q test to determine any intraobserver variability. We found no significant interobserver variability on combined assessment of all operators with fair agreement in round 1 (Fleiss' kappa = 0.30, p <0.0001) and slight agreement in round 2 (Fleiss' kappa = 0.19, p < 0.0001). Cochran's Q test revealed no significant intraobserver variability in all 14 operators between round 1 and round 2 (all p>0.05). We found no statistically significant inter- or intraobserver variability in the U-scoring of thyroid nodules between all participants reinforcing the validity of this scoring method in clinical practice, allaying concerns regarding potential subjective biases in reporting.

Feasibility and reproducibility of a cardiovascular magnetic resonance free-breathing, multi-shot, navigated image acquisition technique for ventricular volume quantification during continuous exercise.

Cardiovascular magnetic resonance (CMR) image acquisition techniques during exercise typically requires either transient cessation of exercise or complex post-processing, potentially compromising clinical utility. We evaluated the feasibility and reproducibility of a navigated image acquisition method for ventricular volumes assessment during continuous physical exercise. Ten healthy volunteers underwent supine cycle ergometer (Lode) exercise CMR on two separate occasions using a free-breathing, multi-shot, navigated, balanced steady-state free precession cine pulse sequence. Images were acquired at 3-stages, baseline and during steady-state exercise at 55% and 75% maximal heart rate (HRmax), based on a prior supine cardiopulmonary exercise test. Intra-and inter-observer variability and inter-scan reproducibility were derived. Clinical feasibility was tested in a separate cohort of patients with severe mitral regurgitation (n=6). End-diastolic volume (EDV) of both LV and RV decreased during exercise at 55% and 75% HRmax, although a reduction in RVEDV index was only observed at 75% HRmax. Ejection fractions (EF) for both ventricles were significantly higher at 75% HRmax compared to their respective baselines (LVEF 68%±3% vs. 58%±5%, P=0.001; RVEF 66%±4% vs. 58%±7%, P=0.02). Intra-observer and inter-observer reproducibility of LV parameters was excellent at all 3-stages. Although measurements of RVESV were more variable during exercise, the reproducibility of both RVEF and RV cardiac index was excellent (CV <10%). Inter-scan LV and RV ejection fraction were highly reproducible at all 3 stages, although inter-scan reproducibility of indexed RVESV was only moderate. The protocol was well tolerated by all patients. Exercise CMR using a free-breathing, multi-shot, navigated cine imaging method allows simultaneous assessment of left and right ventricular volumes during continuous exercise. Intra- and inter-observer reproducibility were excellent. Inter-scan LV and RV ejection fraction were also highly reproducible.

Measurement variability of liver metastases from neuroendocrine tumors on different magnetic resonance imaging sequences.

To assess dimension measurement variability of liver metastases from neuroendocrine tumors (LMNET) on different magnetic resonance imaging (MRI) sequences. In this institutional review board-approved retrospective study from January 2011 to December 2012, all liver MRI examinations performed at our department in patients with at least one measurable LMNET according to response evaluation criteria in solid tumors (RECIST1.1) were included. Up to two lesions were selected on T2-weighted MR images. Three reviewers independently measured long axes of 135 hepatic metastases in 30 patients (16 men, 14 women, mean age 61±11.4 (SD) years; range 28-78 years), during two separate reading sessions, on T2-weighted, diffusion-weighted MRI (DWI) (b; 50, 400, 800 s/mm2) and arterial, portal and late phases after intravenous administration of a gadolinium chelate. Intraclass-correlation coefficients and Bland-Altman plots were used to assess intra-and interobserver variability. Intra- and interobserver agreements ranged between 0.87-0.98, and 0.88-0.97, respectively. Intersequence agreements ranged between 0.92 [95%CI: 0.82-0.98] and 0.98 [95%CI: 0.93-0.99]. 95% limits of agreement for measurements were -10.2%,+8.9% for DWI (b=50s/mm2) versus -21.9%,+24.2% and -15.8,+17.2% for arterial and portal phases, respectively. An increase<9% in measurement and a decrease of -10% on DWI should not be considered as true changes, with 95% confidence, versus 24% and -22% on arterial and 17%, -16% on portal phases, respectively. DWI might thus be the most reliable MR sequence for monitoring size variations of LMNETs.

Kinematic analysis of diastolic function using the freely available software Echo E-waves – feasibility and reproducibility

BackgroundEarly diastolic left ventricular (LV) filling can be accurately described using the same methods used in classical mechanics to describe the motion of a loaded spring as it recoils, a validated method also referred to as the Parameterized Diastolic Filling (PDF) formalism. With this method, each E-wave recorded by pulsed wave (PW) Doppler can be mathematically described in terms of three constants: LV stiffness (k), viscoelasticity (c), and load (x 0). Also, additional parameters of physiological and diagnostic interest can be derived. An efficient software application for PDF analysis has not been available. We aim to describe the structure, feasibility, time efficiency and intra-and interobserver variability for use of such a solution, implemented in Echo E-waves, a freely available software application (www.echoewaves.org).ResultsAn application was developed, with the ability to open DICOM files from different vendors, as well as rapid semi-automatic analysis and export of results. E-waves from 20 patients were analyzed by two investigators. Analysis time for a median of 34 (interquartile range (IQR) 29–42) E-waves per patient (representing 63 %, IQR 56–79 % of the recorded E-waves per patient) was 4.3 min (IQR 4.0–4.6 min). Intra-and intraobserver variability was good or excellent for 12 out of 14 parameters (coefficient of variation 2.5–18.7 %, intraclass correlation coefficient 0.80–0.99).ConclusionKinematic analysis of diastolic function using the PDF method for Doppler echocardiography implemented in freely available semiautomatic software is highly feasible, time efficient, and has good to excellent intra-and interobserver variability.

Selecting the embryo with the highest implantation potential using a data mining based prediction model.

BackgroundEmbryo selection has been based on developmental and morphological characteristics. However, the presence of an important intra-and inter-observer variability of standard scoring system (SSS) has been reported. A computer-assisted scoring system (CASS) has the potential to overcome most of these disadvantages associated with the SSS. The aims of this study were to construct a prediction model, with data mining approaches, and compare the predictive performance of models in SSS and CASS and to evaluate whether using the prediction model would impact the selection of the embryo for transfer.MethodsA total of 871 single transferred embryos between 2008 and 2013 were included and evaluated with two scoring systems: SSS and CASS. Prediction models were developed using multivariable logistic regression (LR) and multivariate adaptive regression splines (MARS). The prediction models were externally validated with a test set of 109 single transfers between January and June 2014. Area under the curve (AUC) in training data and validation data was compared to determine the utility of the models.ResultsIn SSS models, the AUC declined significantly from training data to validation data (p < 0.05). No significant difference was detected in CASS derived models. Two final prediction models derived from CASS were obtained using LR and MARS, which showed moderate discriminative capacity (c-statistic 0.64 and 0.69 respectively) on validation data.ConclusionsThe study showed that the introduction of CASS improved the generalizability of the prediction models, and the combination of computer-assisted scoring system with data mining based predictive modeling is a promising approach to improve the selection of embryo with the highest implantation potential.Electronic supplementary materialThe online version of this article (doi:10.1186/s12958-016-0145-1) contains supplementary material, which is available to authorized users.

RE: Ultrasonic Measurement of Testicular Tumors and the Correlation with Pathologic Specimen Sizes.

We read with great interest the article “The value of testicular ultrasound in the prediction of the type and size of testicular tumors” by Shtricker et al. (1). They aimed to assess the correlation between ultrasound (US) findings and testicular tumor type and size. The authors concluded that the testis US findings underestimated the size in 25% of the malignant testicular lesions and 16% of the cases were proven to be benign. Thus they recommended putting into practice frozen sections for borderline cases. This study gives substantial information on this clinically relevant condition. The awareness of this diagnostic finding and its clinical results may increase the accuracy of preoperative management of the patients with testicular lesions. Thanks to the authors for this contribution. Several medical subspecialties manage their treatments with respect to anatomic measurements. The reproducibility and accuracy of the measurements are especially crucial in radiology as important clinical decisions are often based on the assumption that radiologic measurements are accurate and any measurement differences on follow-up imagings represent a real change in size. Favorably, measurements of the tumors on images should be accurate, reproducible, and practiced in a standardized method with low rates of intra-and interobserver variability. Even so, there a lot of factors, which may affect the consistency of the measurement, including patientdependent factors, technical factors and radiologist-dependent factors (2,3). World Health Organization criteria (WHO) (4) and the Response Evaluation Criteria in Solid Tumors (RECIST) (5) are two widely accepted guidelines of measurement methods to obtain standardized results (6). WHO criteria recommend the measurement method on the basis of an approximation of cross-sectional area (bidimensional measurement), whereas RECIST suggests to measure only the tumor’s greatest diameter (unidimensional measurement) on a transverse plane (7). Shtricker et al. have designed this study as a multicenter study (1). This design may increase the variabilities in the tumor measurement. However, the authors did not mention any measurement method for standardization in the study. A lot of published studies based on the variability and reproducibility of tumor measurements define their measurement methods and they generally use WHO or RECIST criteria. Therefore a measurement variability might occur due to lack of measurement standardization. Vol. 42 (1): 172-173, January February, 2016

How to differentiate the etiology of LV dysfunction as to whether it is “ischemic cardiomyopathy” or “dilated non-ischemic cardiomyopathy”? Invasive coronary and myocardial assessment is the approach of first choice

Despite of the obvious practical attractiveness of noninvasive modalities such as echocardiography, nuclear perfusion imaging, coronary computed tomography angiography, and cardiac magnetic resonance imaging, we advocate an invasive diagnostic workup for this patient. Indeed, the etiology of left ventricular (LV) dysfunction in this 57-year-old woman with shortness of breath, diabetes, and hypertension could be complex, multifactorial, and include (1) severe obstructive coronary artery disease (CAD) resulting in ischemic cardiomyopathy (pure hibernating, non-infarcted), (2) obstructive or non-obstructive epicardial CAD with ischemic cardiomyopathy related to either transmural or nontransmural myocardial infarction with subsequent recanalization of coronary arteries, (3) diffuse coronary microvascular dysfunction due to atherosclerosis, left ventricular hypertrophy, or diabetes, (4) coronary vasospasm or Takotsubo apical ballooning, (5) nonischemic (e.g., post-viral, post-partum, drug induced, tachycardia mediated), and (6) some combination of ischemic and non-ischemic cardiomyopathy. This patient will likely require dietary and heart failure counseling and escalating medical therapy including diuretics, beta blockers, angiotensin-converting enzyme inhibitors, and possibly nitrates, hydralazine, and aldosterone inhibitors. In addition to initiating this therapy, the critical importance of identifying ischemia as the primary etiology for cardiomyopathy in this patient is related to its high prevalence (approximately 65% of patients with cardiomyopathy have an ischemic cause), its prognostic significance (ischemic etiology is an independent predictor of mortality in patients with cardiomyopathy) and its potential for the cardiomyopathy’s response to therapy (coronary revascularization can reduce cardiovascular mortality in appropriately selected patients). Is coronary angiography the gold standard for invasive assessment of ischemia? Not in 2015! Despite being a powerful cornerstone modality for evaluation of CAD against which all noninvasive ischemia detection modalities have been validated, coronary angiography has the inherent pitfalls of being a luminogram. This leads to frequently overor underestimation of disease severity due to eccentricity of atheroma and vascular remodeling, significant intraand inter-observer variability, and lack of physiological information on lesion severity or on collateral blood flow. Fortunately, in the previous two decades, there has been an explosion of invasive physiologic and anatomic technologies that complement the diagnostic capabilities of coronary angiography and have emerged as gold standard modalities for uncovering the precise mechanisms of ischemia as required in the case of our patient (Figure 1). These novel modalities allow precise identification of whether Reprint requests: Habib Samady, MD, FACC, FSCAI, Division of Cardiology, Department of Medicine, Andreas Gruentzig Cardiovascular Center, Emory University School of Medicine, 1364 Clifton Road, Suite F606, Atlanta, GA 30322; hsamady@emory.edu J Nucl Cardiol 2015;22:953–6. 1071-3581/$34.00 Copyright 2015 American Society of Nuclear Cardiology.

Selecting the embryo with the highest implantation potential using developmental and morphometric scoring.

Embryo selection has been based on developmental and morphological characteristics. However, the presence of an important intra-and inter-observer variability in the microscopic evaluation of standard scoring system (SSS) has been reported. A golden standard for selection of embryos on day 3 is currently lacking. New technology using multilevel images combined with a computer-assisted scoring system (CASS) has the potential to overcome most of these disadvantages associated with the SSS. The aim of this study was to construct a multivariable prediction model, with data mining approaches, and compare the predictive performance of models in SSS and CASS. A total of 871 single embryo transfers between 2008 and 2013 were included. Embryos were evaluated with two scoring systems: SSS and CASS. Prediction models were developed using multivariable logistic regression (LR) and multivariate adaptive regression splines (MARSplines). The prediction models were externally validated with a test set of 109 single transfers between January and June 2014. Results showed that prediction of implantation was superior using CASS when compared with SSS. With CASS, two final prediction model were obtained using LR and MARSplines, which showed moderate discriminative capacity (c-statistic 0.64 and 0.69 respectively) on validation data. The findings of this study show that combination of computer-assisted scoring system and machine learning based prediction method is a promising approach for in the selection of embryo with the highest implantation potential.

Reproducibility of functional aortic analysis using MRI: the multi-ethnic study of atherosclerosis

Methods Twenty-five participants underwent aortic MRI twice over 13 ± 7 days. All aortic variables (ascending aortic area, descending aortic area, ascending and descending aortic strain [maximum area minus minimum area divided by minimum area], aortic arch transit time and pulse wave velocity [PWV]) from baseline and repeat MR were analyzed using a semi-automated method by the ARTFUN software. Phase contrast (PC) cine at the level of the pulmonary artery bifurcation was used for assessment of aortic area, aortic strain, and PWV. Steady State Free Precession (SSFP) sagittal images were used to measure aortic arch transit distance. To assess the inter-study reproducibility of aortic variables, we calculated intraclass correlation coefficient (ICC) for individual aortic measurements. Intraand inter-observer variability was also assessed using the baseline MR data.

Sa1004 Measurement of Liver and Spleen Stiffness by ARFI Elastography: Intra-and Inter-Observer Variability and Predictors of Variability

Staging hepatocellular carcinoma (HCC) is an esential step in the decision regarding treatment options. Malignant portal vein thrombosis is a contraindication for all curative treatment, thus establishing the nature (benign or malignant) of PVT is mandatory for staging the disease. The AIM of this paper was to assess the role of contrast enhanced ultrasound (CEUS) for the staging of HCC in patients with liver cirrhosis. METHODS: We evaluated 86 consecutive patients with liver cirrhosis and known HCC, who were discovered with PVT located in different parts of the portal system. Before CEUS we performed a standard ultrasound and a Doppler examination. We used 2.4 ml of second generation contrast agent (SonoVue) for every examination. During the CEUS examination we followed the arterial, portal and late phases as defined in the EFSUMB Guidelines (1) and also the enhancement pattern as described by Rossi et al. (Type 1: thrombus enhancement is absent in all three phasesbenign thrombus; and for malign thrombus-Type 2: diffuse thrombus enhancement that is visible only during the early arterial phase; Type 3: linear or punctate enhancement; Type 4: multilinear or multipunctate enhancement)(2). RESULTS: PVT was located in the proximity of HCC in 63 of the 86 cases (73.2 %). 11 cases (12.7%) were Type 1 Rossi (benign thrombus), 44 cases (51.1%) were Type 2, 14 cases (16.2%) were Type 3 and 17 cases (19.7%) were Type 4 Rossi. Using CEUS we could characterise and obtain a conclusive diagnosis in 85 of the 86 patients (98.8%). CONCLUSIONS CEUS is a method with a good sensibility for the characterisation of PVT in patients with HCC, that allows the staging of the disease for a good therapeutic decision. BIBLIOGRAPHY: 1. M. Claudon, C. F. Dietrich, B. I. Choi, D. O. Cosgrove, M. Kudo, C. P. Nolsoe, F. Piscaglia, S. R. Wilson, R. G. Barr, M. C. Chammas, N. G. Chaubal, M.-H. Chen, D. A. Clevert, J. M. Correas, H. Ding, F. Forsberg, J. B. Fowlkes, R. N. Gibson, B. B. Goldberg, N. Lassau, E. L. S. Leen, R. F. Mattrey, F. Moriyasu, L. Solbiati, H.-P. Weskott, H.-X. Xu. Guidelines and Good Clinical Practice Recommendations for Contrast Enhanced Ultrasound (CEUS) in the Liver-Update 2012. Published online: 2012 Ultraschall in Med. 2. Rossi S. et al. Contrast-Enhanced Versus Conventional and Color Doppler Sonography for the Detection of Thrombosis of the Portal and Hepatic Venous Systems. AJR 2006; 186:763-773.

Optic nerve sheath diameter: An ultrasonographic window to view raised intracranial pressure?

Raised Intracranial Pressure (ICP) is a dreaded complication of neurological disease that often leads to adverse outcomes. Clinical signs of raised ICP are often unreliable or too late to manifest and may lead to unacceptable delay in therapeutic intervention. Neuroimaging by computed tomography (CT) or magnetic resonance imaging (MRI) scans entail transfer of a critically ill patient out of the Intensive Care Unit (ICU), besides being an impracticable tool for repeat examinations at frequent intervals as may be necessary in patients with raised ICP. Invasive measurement by an intraventricular or intraparenchymal catheter is the gold standard and used extensively in the management of traumatic brain injury; however, it may not be feasible in a heterogenous group of medical patients. The optic nerve sheath is an anatomical extension of the duramater and the subarachnoid space around the optic nerve is continuous with the intracranial subarachnoid space. Any pressure rise within the intracranial compartment impacts on the optic nerve head as swelling of the optic disc and papilledema. However, papilledema evolves over time and may be a delayed manifestation, besides requiring a skilled observer for precise identification. Dilatation of the optic nerve sheath has been shown to be a much earlier manifestation of ICP rise.[1,2] The optic nerve sheath is fairly easy to visualize by ultrasonography by insonation across the orbit in the axial plane. A-mode ultrasonography was used to view the optic nerve sheath more than four decades ago; B-mode scanning was performed subsequently to assess intraocular lesions.[3] Evolution of ultrasound technology and the development of high frequency (> 7.5 MHz) linear probes with improved spatial resolution have enabled excellent views of the optic nerve sheath. The optic nerve sheath diameter (ONSD), measured at a fixed distance behind the retina has been evaluated to diagnose and measure intracranial hypertension in traumatic brain injury and intracranial hemorrhage.[4,5] Shirodkar and colleagues[6], in the current edition of IJCCM, studied the efficacy of ONSD measurement by ultrasonography to predict intracranial hypertension. The case mix studied included meningoencephalitis, stroke, intracranial hemorrhage and metabolic encephalopathy. Using cut-off values of 4.6 mm for females, and 4.8 mm for males, they found a high level of sensitivity and specificity for the diagnosis of intracranial hypertension as evident on CT or MRI imaging. There is wide variation reported in the optimal cut-off values, when ONSD was compared with invasive ICP monitoring, ranging from 4.8 to 5.9 mm.[7,8] In a study that tested the accuracy of ultrasonography with MRI scans, the maximum ONSD noted was as high as 6.4 mm among healthy volunteers. Opening cerebrospinal fluid (CSF) pressure on lumbar puncture has been compared to ONSD in previous studies; using a cut off of 5.5 mm, Amini et al. found a high sensitivity and specificity for ICP of >20 cm H2O.[9] However, using similar methodology, Caffery et al. could not demonstrate a reliable estimate using a cut-off of 5.0 mm.[10] There seems to be considerable differences across studies on the cut-off values used as well as the efficacy of ultrasonographic ONSD measurements to predict ICP. Besides, intra-and inter-observer variability needs to be considered with measurements down to a standard deviation of 0.1 mm.[11] The current study adds to the body of knowledge that supports the use of ONSD as a bedside tool to diagnose intracranial hypertension in a general ICU setting. The investigators used neuroimaging to assess efficacy of ONSD, unlike previous studies[8,9] that sought correlation with lumbar CSF pressures. Despite its limitations, ultrasonographic ONSD measurement is likely to be more reliable than clinical assessment in the diagnosis of intracranial hypertension especially in situations, when an altered level of sensorium or administration of sedative medication precludes such assessment.[12] Neuroimaging, although helpful in arriving at a specific diagnosis, may not reveal elevated ICP at an early stage.[13] The obvious utility of bedside ultrasonography to assess intracranial hypertension must be tempered with the occurrence of wide variations in cut-off values reported, inter- and intra-individual variability in measurements and the requirement for adequate observer experience. Although no adverse effects have been reported with the optic nerve ultrasonography, there is a potential to cause harm through heating and cavitation of soft tissue,[14] besides possible damage from inadvertent application of excessive pressure. It would also make sense to cut down examination times to as low as possible. Last but not the least, ONSD should not be considered in isolation, but must form part of a holistic approach towards the management of a patient with possible intracranial hypertension.

Cobb angle changes after standardized chiropractic intervention in 12 females with adolescent idiopathic scoliosis with double major curve types: a retrospective review of patient records

Background Scoliosis is a 3-dimensional spinal deformity measured in two dimensions. [1] and is the leading orthopedic problem seen in school-aged children, affecting approximately 2-4% of children 10 to 16 years of age. First introduced in 1948, the Cobb angle is the current standard for measuring the severity of scoliosis. As stated by Gstoettner et al. in 2007, “It is an objective measure and is generally used to make decisions about the progression of a curve, as well as the need and success of treatment. Measurements of the Cobb angle bare an intraand interobserver variability of approximately 4° to 8°. The definition of end vertebrae introduces the main source of error.”[2]

Intra- and interobserver variability of left ventricular diastolic inflow parameters measured by three chamber view 2D cine three-directionally encoded (3Ch. 2D-cine-3 dir.) Phase contrast MR velocity vector map

Background One-directionally-encoded cine 2D Phase-Contrast MRI (PC MRI) of basal short axial image is generally used for the evaluation of diastolic function, but has potential limitations due to the longitudinal cardiac motion and inflow direction. Time-resolved 3D PC MRI is not affected by the flow direction and left ventricular motion, however, requires long acquisition time. In theory, three chamber view 2D cine three directionallyencoded (3ch. 2D-cine-3dir.) PC MR velocity vector map could overcome such limitations. The aim of this study is to assess intraand interobserver variability of diastolic parameters measured by 2D-cine-3dir. PC MR velocity vector map.