[Comparison of ultrasonography, computerized tomography, and magnetic resonance in the study of parotid masses]

One hundred and seven patients were examined to compare advantages and pitfalls of the imaging methods currently used to stage parotid masses. Thirty patients underwent US and CT, 44 were investigated with US and MRI and 33 with US, CT and MRI. The accuracy of the three techniques was analyzed in detecting and assessing the intra-/extraglandular location of the parotid lesions and their benign/malignant nature. The intraglandular lesion spread to superficial/deep lobes was also investigated, together with its relationship to the surrounding structures. The findings were correlated with the cytohistological data from US-guided biopsy or from surgical resection. US was less accurate than CT and MRI, the latter being not statistically superior to the former. Because of the low incidence of pitfalls, US with fine-needle aspiration cytology should be the technique of choice; CT and MRI must be used for lesions > 3 cm or for masses in the deep gland lobes. In conclusion, CT accurately assesses parotid lesions but MRI demonstrates the relationship to adjacent structures better

[The role of magnetic resonance angiography in the assessment of arterial stenosis in the transplanted kidney]

Artery stenosis in the transplanted kidney is the most frequent vascular complication; hypertension onset or worsening may be associated and, at an end stage, also renal insufficiency. The diagnosis must be early and accurate and provide guidelines for medical, interventional or surgical therapy. To assess the diagnostic reliability or MRA, 27 patients were examined. On the basis of clinical, biochemical, pharmacological (Captopril test) and instrumental (color-Doppler US) examinations, the artery of the transplanted kidney was considered normal in 6 patients and stenotic in 21. In the control group, MRA results were in agreement with color-Doppler findings. On the contrary, in 8 of 21 abnormal conditions, the two techniques were in disagreement. Digital angiography, considered as the gold standard, was performed in any questionable case, confirming a slight overestimation of the stenoses by MRA (3 cases) and 2 false positives by color-Doppler US. The authors believe color-Doppler US to be a reliable technique for screening stenosed arteries in the transplanted kidney. MRA is proposed as a complementary investigation useful to define stenosis type and to provide guidelines for treatment

[Is mammography useful in the detection of breast cancer in women 35 years of age or younger?]

Breast cancer in women 35 years old or younger is unusual. It accounts for 1-3.6% of all breast cancers but is the leading cause of cancer mortality in women 15-35 years old. The diagnostic delay, with T2 or more advanced cancer at clinical presentation, is due to the patient's age and the opinion of low mammographic reliability for cancer diagnosis in this age group. To assess the usefulness of mammography in breast cancer patients aged 35 years or younger, we reviewed the clinical, mammographic and histologic data of 65 cancers collected in 7 breast diagnosis and counseling centers in Lombardy. Fifty-three patients (81.5%) were referred for a palpable breast mass, which was a T2 or more advanced cancer in 23 cases. Mammography showed malignant patterns (spiculated opacities, clusters of microcalcifications, casting, branching and ductal type calcifications) in 31 patients (47.7%). Mammography was not definitive but correctly suggested further examinations in 30 women and it had only 4 false negatives. Ultrasonography performed in 43 patients was negative in 3 (7%), pathologic and pathognomonic for cancer in 27 (62.8%) and pathologic but not indicative of malignancy in 13 (20.2%). The cytologic or histologic diagnosis of breast cancer was made under US guidance in 24 cases. In women aged 35 years or younger mammography was effective in identifying breast cancers; US and fine-needle aspiration biopsy (FNAB) complete mammography. We believe that mammography can be a valuable screening tool in young women at high risk for breast cancer because of family history

Italian multicenter, prospective study to evaluate the negative predictive value of 16- and 64-slice MDCT imaging in patients scheduled for coronary angiography (NIMISCAD-Non Invasive Multicenter Italian Study for Coronary Artery Disease)

Abstract This was a prospective, multicenter study designed to evaluate the utility of MDCT in the diagnosis of coronary artery disease (CAD) in patients scheduled for elective coro- nary angiography (CA) using different MDCT systems from different manu- facturers. Twenty national sites pro- spectively enrolled 367 patients between July 2004 and June 2006. Computed tomography (CT) was performed using a standardized/ optimized scan protocol for each type Coronary angiography (CA) represents the standard of reference to assess epicardial vessels and establish the presence of significant coronary artery disease (CAD). CA is a bi-dimensional diagnostic technique that allows evalua- tion of the vessel lumen [1] at high spatial (50 lps/cm) and temporal (<20 ms) resolution. However, CA has its limitations: it is an invasive technique, involves high costs, requires hospitalization, and has low patient compliance. The risks associated with CA are related to its invasiveness and result in a morbidity rate of 1.5% and a mortality rate of 0.15% [2]. In addition, a considerable proportion of patients undergoing CA are subsequently found not to have clinically significant disease [3, 4]. These limitations may justify the increasing clinical use of alternative non-invasive imaging techniques for the evaluation and exclusion of clinically significant CAD. Many centers have reported their experiences in using different multidetector computed tomography (MDCT) technologies, all of which have been characterized by high diagnostic accuracy in the assessment of patients scheduled for CA. Whether the reported diagnostic accuracy can be replicated in clinical practice needs to be established at different centers with varying expertise, in non-selected patient populations and with different MDCT systems before extensive clinical application of MDCT for CAD assessment. The primary aim of this study was to assess the negative predective value (NPV) of MDCT in a multicenter study using different MDCT machines/manufacturers to deter- mine if the technique could replace an invasive procedure to exclude the presence of significant CAD. Secondary objectives were to investigate whether MDCT performance is affected by patient characteristics such as pre-test CAD risk, body mass index (BMI), and coronary artery calcium score (CACS). Safety was also investigated. Materials and methods This was a national, multicenter, prospective trial sponsored by the Italian Society of Medical Radiology (SIRM). Adult patients previously scheduled for an elective CA evaluation for a diagnostic workup at each of the participating centers were consecutively evaluated for inclusion in the study. Exclusion criteria included preg- nancy or lactation, contraindication to intravenous admin- istration of iodinated contrast media, heart rate >70 beats per minute (bpm) despite beta-blocker treatment, absence of sinus rhythm, New York Heart Association (NYHA) class III–IV, previous coronary artery bypass graft surgery (CABG) or stenting, and creatinine value >2 mg/dl. The Institutional Review Boards of all centers approved the study protocol, and written informed consent was obtained from all patients before study inclusion in accordance with the national legislation and the Declaration of Helsinki. Patient preparation Patients with heart rates >70 bpm were given an oral dose of metoprolol tartrate 45–60 min before MDCT imaging or an intravenous beta-receptor blocker just before the scan. Heart rate, electrocardiogram (ECG), and blood pressure were monitored. MDCT protocol and image reconstructions Patients underwent 16- or 64-slice MDCT with a standardized and optimized protocol for each type of CT machine. Unenhanced prospective ECG-gated MDCT was performed for the assessment of calcium deposits by Agatston Score (AS). A bolus of 100– 120 ml of non-ionic iodinated contrast medium Ultra- vist® (Iopromide 370; Bayer Schering Pharma, Berlin, Germany) was intravenously injected, preferably through the right antecubital vein, at a flow rate of 3– 4 ml/s for the 16-slice MDCT system and 4–6 ml/s for the 64-slice MDCT system, and followed by a 40–50-ml saline chaser at the same flow rate. The main scan parameters have been given for each scanner type in Table 1, including the number of patients scanned on each CT system. ficity, and DA were 0.73 (95% CI 1115 of MDCT system (≥16 slices) and compared with quantitative CA per- formed within 2 weeks of MDCT. A total of 284 patients (81%) were studied by 16-slice MDCT systems, while 66 patients (19%) by 64-slice MDCT scanners. The primary analysis was on-site/off-site evaluation of the negative predictive value (NPV) on a per-patient basis. Secondary analyses included on-site evaluation on a per- artery and per-segment basis. On-site Introduction evaluation included 327 patients (CAD prevalence 58%). NPV, positive predictive value (PPV), sensitivity, specificity, and diagnostic accuracy (DA) were 0.91 (95% CI 0.85–0.95), 0.91 (95% CI 0.86–0.95), 0.94 (95% CI 0.89–0.97), 0.88 (95% CI 0.81– 0.93), and 0.91 (95% CI 0.88–0.94), respectively. Off-site analysis in- cluded 295 patients (CAD prevalence 56%). NPV, PPV, sensitivity, speci- 0.65–0.79), 0.93 (95% CI 0.87–0.97), 0.73 (95% CI 0.65–0.79), 0.93 (95% CI 0.87–0.97), and 0.82 (95% CI 0.77–0.86), respectively. The results of this study demonstrate the utility of MDCT in excluding significant CAD even when conducted by centers with varying degrees of expertise and using different MDCT machines

Tocilizumab for patients with COVID-19 pneumonia. The single-arm TOCIVID-19 prospective trial

BackgroundTocilizumab blocks pro-inflammatory activity of interleukin-6 (IL-6), involved in pathogenesis of pneumonia the most frequent cause of death in COVID-19 patients.MethodsA multicenter, single-arm, hypothesis-driven trial was planned, according to a phase 2 design, to study the effect of tocilizumab on lethality rates at 14 and 30 days (co-primary endpoints, a priori expected rates being 20 and 35%, respectively). A further prospective cohort of patients, consecutively enrolled after the first cohort was accomplished, was used as a secondary validation dataset. The two cohorts were evaluated jointly in an exploratory multivariable logistic regression model to assess prognostic variables on survival.ResultsIn the primary intention-to-treat (ITT) phase 2 population, 180/301 (59.8%) subjects received tocilizumab, and 67 deaths were observed overall. Lethality rates were equal to 18.4% (97.5% CI: 13.6-24.0, P=0.52) and 22.4% (97.5% CI: 17.2-28.3, P&lt;0.001) at 14 and 30 days, respectively. Lethality rates were lower in the validation dataset, that included 920 patients. No signal of specific drug toxicity was reported. In the exploratory multivariable logistic regression analysis, older age and lower PaO2/FiO2 ratio negatively affected survival, while the concurrent use of steroids was associated with greater survival. A statistically significant interaction was found between tocilizumab and respiratory support, suggesting that tocilizumab might be more effective in patients not requiring mechanical respiratory support at baseline.ConclusionsTocilizumab reduced lethality rate at 30 days compared with null hypothesis, without significant toxicity. Possibly, this effect could be limited to patients not requiring mechanical respiratory support at baseline.Registration EudraCT (2020-001110-38); clinicaltrials.gov (NCT04317092)