HIDA scan ejection fraction does not predict sphincter of Oddi hypertension or clinical outcome in patients with suspected chronic acalculous cholecystitis

Background Hepatobiliary iminodiacetic scan with ejection fraction (HIDA EF) is used to evaluate chronic acalculous cholecystitis (CAC). A presumed etiology of CAC is sphincter of Oddi hypertension (SOH). In this study, we evaluated the value of HIDA EF to predict patient response to laparoscopic cholecystectomy and to identify SOH. Methods A prospective study of 93 patients with biliary pain but without gallstones (CAC) who underwent preoperative HIDA EF was conducted. At laparoscopic cholecystectomy, transcystic antegrade biliary manometry was performed to determine the SO pressure. Patients were evaluated postoperatively for response to cholecystectomy. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. The outcomes were compared with the clinical impression. Results Of the 93 patients with both HIDA EF and SOP measurements, 50 had abnormal EF (<35%); of these, 29 had SOH (SO pressure ≥40 mmHg). Of the 43 patients with normal HIDA EF, 30 had SOH. The sensitivity was 49%, specificity 38%, PPV 58%, and NPV 30%. Eighty-six of the 93 patients returned for follow-up evaluation. Follow-up ranged from 0 to 99 months, with a mean of 26.4 months. Overall, 73 patients (85%) improved. Of the 46 with abnormal HIDA EF, 42 (91%) improved. Of the 40 patients with normal HIDA EF, 31 (77.5%) improved. The sensitivity was 57.7%, specificity 69.2%, PPV 91.3%, and NPV 22.5%. Conclusion Although the PPV of abnormal HIDA EF is high, it is not much better than the clinical impression. The sensitivity and specificity are marginal. The NPV is poor. Based on the review of these 93 patients, HIDA EF is not reliable for identifying CAC. We recommend that patients with normal HIDA EF have additional testing or consultation before ruling out CAC. HIDA EF does not predict SOH. Paper presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Ft. Lauderdale, Florida, USA, April 2005     

Coronary Artery Calcification in Renal Transplant Recipients

Cardiovascular disease is the leading cause of mortality in renal transplant recipients. Although renal transplant recipients frequently undergo cardiac functional tests prior to surgery, coronary atherosclerosis can remain undetected. Coronary artery calcification (CAC), an early marker of atherosclerosis can be quantified using EBCT. The purpose of this study was to determine the extent and characteristics of CAC at the time of renal transplantation. We evaluated 79 consecutive incident asymptomatic renal transplant recipients. Patients were mostly White (62%), male (54%) and had a deceased donor renal transplant (61%). The mean age was 47 (12.1) years. Sixty-five percentage of subjects had CAC. The mean CAC score was 331.5 (562.4) with a median of 43.3. Older age, presence of diabetes, not having a preemptive transplant, deceased donor transplantation and hypercholesterolemia were significantly associated with presence of CAC univariately. Median CAC scores were significantly increased in subjects with diabetes (127.8 vs. 28.9, p=0.05), exposed to dialysis (102.9 vs. 3.7, p<0.001) and deceased donor recipients (169.7 vs. 7.5, p=0.02). Using multiple logistic regression, age and time on dialysis were significantly associated with the presence of CAC at the time of transplant. In summary, CAC is prevalent in patients undergoing kidney transplant. CAC may be a method to identify renal transplant recipients at increased risk for future cardiovascular events.     

Impact of risk factors on the performance of the nuclear matrix protein 22 point-of-care test for bladder cancer detection

OBJECTIVES

To evaluate the impact of different risk factors and symptoms on the performance characteristics of the nuclear matrix protein 22 (NMP22) BladderChek® test (Matritech Inc., Newton, MA, USA) for the detection of bladder cancer, as this is a point‐of‐care assay that measures NMPs in voided urine.

PATIENTS AND METHODS

In all, 23 academic, private practice and veterans’ facilities in 10 states prospectively enrolled consecutive patients from September 2001 to May 2002. Participants included 1328 patients at elevated risk of bladder cancer from factors such as a history of smoking or symptoms including haematuria and/or dysuria. Patients at risk of malignancy of the urinary tract provided a voided urine sample for analysis of NMP22 protein and cytology before cystoscopy.

RESULTS

Of the 1328 patients: no urinary disease, benign disease and malignancy were found in 545 (41%), 704 (53%) and 79 (6%) patients, respectively. Overall, the positive predictive value (PPV) for detection of bladder cancer was 20.3% (45/222) and negative predictive value (NPV) was 96.9% (1072/1106). The PPV was higher in men (24.0%) than women (13.2%). In men, the PPV increased with smoking (35.4%), gross haematuria (51.2%) and a combination of both factors (70.6%). The impact on the PPV of smoking (9.7%) and gross haematuria (28.6%) was less dramatic in women. The PPV increased from 16.8% in patients aged <65 years to 23.5% in those aged >65 years. The NPV remained almost always >95% except in men with gross haematuria where it decreased to 77% in smokers and 94% in non‐smokers.

CONCLUSION

The PPV of the BladderChek test improves in patients at higher risk of bladder cancer reaching 77% in men presenting with gross haematuria who are aged >65 years and smoke. The NPV is highest in women aged <65 years, up to 100%.     

The value of clinical characteristics and breast-imaging studies in predicting a histopathologic diagnosis of cancer or high-risk lesion in patients with spontaneous nipple discharge

BACKGROUND: The purpose of this study was to determine the utility of breast-imaging studies in identifying cancer and high-risk lesions among patients with spontaneous, single-duct, nipple discharge (SSND). METHODS: The medical records of 168 cases with SSND treated with duct excision between June 1998 and May 2004 were reviewed. The sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of mammogram, ultrasound, and ductogram in predicting high-risk lesions and cancer were calculated. RESULTS: The sensitivity of mammography was 10%, the specificity 94%, the NPV 88%, and the PPV 18%. Ultrasonography had a sensitivity of 36%, specificity of 68%, PPV of 14%, and NPV of 89%. Ductography had a sensitivity of 75%, specificity of 49%, and NPV and PPV of 93% and 18%, respectively. CONCLUSIONS: Conventional imaging studies do not accurately identify cancer or high-risk lesions in patients with SSND.All patients with SSND should be offered duct excision.     

The logistic organ dysfunction score as a tool for making ethical decisions

PURPOSE: We examined whether the change of the logistic organ dysfunction score (LOD) between the first and the fourth day in the intensive care unit (ICU) could be predictive of death in the ICU. The LOD could then be used to help make decisions concerning therapeutic limitations (TL). METHODS: One hundred fifty-four patients were included. Exclusion criteria were: discharge from the ICU or TL before the 72nd hr. Ninety-three patients remained for evaluation. The LOD was calculated on the day of admission (LOD1) and between the 72nd and 96th hr (LOD4). The DeltaLOD = LOD4-LOD1 index was calculated for survivors and non-survivors; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated. RESULTS: Sixteen patients died in the ICU, they had a higher DeltaLOD (0 vs -2; P = 0.0046) than the survivors. After logistic regression, a high DeltaLOD was associated with a higher risk of death in the ICU independent of the initial severity of disease. The PPV concerning death in the ICU was 0.66 for a DeltaLOD > or = 4 cut-off. The NPV was 0.89 for a cut-off of > or = 1. CONCLUSION: DeltaLOD appears to be a predictor of death in the ICU, independent of the initial severity of disease. The PPV is not high enough to assist with making individual TL decisions. The NPV can help to identify patients at low risk of death. The DeltaLOD deserves to be evaluated in a population exhibiting greater severity of disease.     

Clinical utility of vesical imaging-reporting and data system (VI-RADS) in non−muscle invasive bladder cancer (NMIBC) patients candidate for en-bloc transurethral resection: A prospective study

ObjectivesTo assess accuracy of vesical imaging-reporting and data system (VI-RADS) 5-point score in detection of muscle invasive bladder cancer and avoiding second look transurethral resection of the tumors (TURBT). Additionally, to assess safety and efficacy of bipolar en-block transurethral urethral resection of bladder tumor.MethodsPatients with bladder mass up to 5 cm were included in the study. VI-RADS 5-point score was done preoperative for all cases and postoperatively before second look TURBT. Patients were followed up for 12 months.ResultsIn all, 80 cases were eligible for the study. Preoperative VI-RADS score at cutoff of 3 had sensitivity of 89.3 %, specificity 83.3 %, postive predective value (PPV) 92.6 %, negative predictive value (NPV) 76.9 %, accuracy of 87.5 %, while at cutoff 2 sensitivity was 82.1%, specificity 91.7%, PPV 95.8%, NPV 68.8%, accuracy of 85.0%. Operative time 28.8 ± 9.4 minutes, hemoglobin drop 0.3 ± 0.05 g/dl, catheterization time 2.8 ± 0.8 days, hospital stay 1.4 ± 0.4 days. No complications occurred. Recurrence in field of resection 3.75%. Detrusor muscle was available in 76 cases (95%). Postoperative VI-RADS score at cutoff of 3 had sensitivity of 78.6%, specificity 77.8%, PPV 84.6%, NPV 70.0%, accuracy of 78.3%. At cutoff 2 VI-RADS score sensitivity was 71.4%, specificity 77.8%, PPV 83.3%, NPV 63.6%, accuracy of 73.9%.ConclusionVI-RADS 5-point score showed high sensitivity and specificity in preoperative discrimination of non?muscle invasive bladder cancer (NMIBC) from muscle invasive bladder cancer cases and in avoiding unnecessary second look TURBT. Bipolar en-block TURBT technique is both safe and efficacious in resecting NMIBC cases with low recurrence rate.     

Risk factors influencing the early outcome results after laparoscopic repair of perforated duodenal ulcer and their predictive value

Background and aims Clear patient selection criteria and indications for laparoscopic repair of perforated duodenal ulcers are necessary. The aims of our study are to report the early outcome results after operation and to define the predictive values of risk factors influencing conversion rate and genesis of suture leakage.Patients/methods Sixty nonrandomly selected patients operated on laparoscopically in a tertiary care academic center between October 1996 and May 2004 for perforated duodenal ulcers were retrospectively analyzed. The primary outcome measures included the duration of symptoms, shock, underlying medical illness, ulcer size, age, Boey score, and the collective predictive value of these variables for conversion and suture leakage rates.Results Laparoscopic repair was completed in 46 patients (76.7%). Fourteen patients (23.3%) underwent conversion to open repair. Eight patients (13.3%) had postoperative complications. Suture leakage was confirmed in four patients (6.7%). Hospital stay was 7.8±5.3 days. There was no mortality. Patients with an ulcer perforation size of >8 mm had a significantly increased risk for conversion to open repair (p<0.05): positive predictive value (PPV) 75%, sensitivity 27%, specificity 98%, and negative predictive value (NPV) 85%. The significance of ulcer perforation size was confirmed by a stepwise logistic regression test (p=0.0201). All patients who developed suture leakage had acute symptoms for >9 h preoperatively (p<0.001): PPV 31%, specificity 84%, sensitivity 100%, and NPV 100%. Conversions happened with surgeons whose previous experience involved 1.8±2.3 cases compared to 3.9±2.9 cases in successful laparoscopic repair (p=0.039, t test).Conclusions Ulcer perforation size of >8 mm is a significant risk factor influencing the conversion rate. An increase in the suture leakage rate is predicted by delayed presentation of >9 h.     

The role of flow cytometric ANCA detection in screening for acute pauci-immune crescentic glomerulonephritis.

BACKGROUND: Most cases of pauci-immune crescentic glomerulonephritis (PICGN) are associated with serum anti-neutrophil cytoplasmic antibodies (ANCA). This article studied the sensitivity and specificity of serum ANCA, determined by flow cytometry and indirect immunofluorescence (IIF), to identify patients with acute PICGN. METHODS: 577 adults presenting for first biopsy of their native kidneys with serum taken for ANCA (flow cytometry and IIF) determination were studied. A positive ANCA was defined using a flow cytometric ANCA assay as a screening test, followed by a slide-based indirect IIF technique. Pathological confirmation of acute PICGN was used to assess the sensitivity and specificity of this combined approach and its positive predictive value (PPV) and negative predictive value (NPV) in patients presenting for renal biopsy due to abnormal urinary sediment. RESULTS: Forty-nine patients were found to have acute PICGN on renal biopsy. Of these 47 were ANCA positive (sensitivity 95.9%). Overall 93 of the renal biopsy patients were ANCA positive, (specificity 91.3%). A further seven patients (two ANCA positive) had advanced sclerosing disease consistent with PICGN but without evidence of current disease activity. The PPV and NPV of ANCA, assessed by flow cytometry and slide IIF, in predicting that patients presenting with undifferentiated renal disease would have acute PICGN was 50.5 and 99.8%, respectively. CONCLUSIONS: Flow cytometric screening of serum for ANCA in patients undergoing renal biopsy has a high NPV for determining those with acute PICGN. It may provide a rapid, simple screening test for this lesion in laboratories using diagnostic flow cytometry and may complement IIF/ELISA in evaluating ANCA positive patients.     

APACHE III Score Is Superior to King's College Hospital Criteria,MELD score and APACHE II Score to Predict Outcomes After Liver Transplantation for Acute Liver Failure

Objectives

The Model for End–Stage Liver Disease score and king's College Hospital (KCH) criteria are accepted prognostic models acute liver failure (ALF), while the use of (APACHE) scores predict to outcomes of emergency liver transplantation is rare.

Materials and Methods

The present study included 87 patients with ALF who underwent liver transplantation. We calculated (KCH) criteria, as well as MELD, APACHE II, and APACHE III scores at the listing date for comparison with 3-month outcomes.

Results

According to the Youden-Index, the best cut-off value for the APACHE II score was 8.5 with 100% sensitivity, 49% specificity, 24% positive predictive value (PPV), and 100% negative predictive value (NPV). Patients with <8.5 points had a significantly higher survival rate (P < .05). The proposed APACHE III cut-off was 80. The APACHE III score demonstrated the highest specificity and PPV (90% specificity, 50% PPV). The NPV was 92%. With a 90-point threshold the specificity increased to 98% with 75% PPV and 89% NPV. Only 1 of 4 patients with a score >90 survived transplantation (P = .001). MELD score and KCH criteria were not significant (P > .05). According to the Hosmer-Lemeshow test, only the APACHE III score adequately describe the data.

Conclusions

The APACHE III score was superior to KCH criteria, MELD score, and APACHE II score to predict outcomes after transplantation for ALF. It is a valuable parameter for pretransplantation patient selection.     

Evaluation of the Simple Calculated Osteoporosis Risk Estimation (SCORE) in Older Caucasian Women: The Rancho Bernardo Study

Osteoporosis is a major health problem in older women. A risk assessment tool, the Simple Calculated Osteoporosis Risk Estimation (SCORE), has been developed to identify postmenopausal women likely to have low bone mass who should be referred for bone densitometry. The objective of this study was to calculate the sensitivity, specificity and predictive values of SCORE in a community-dwelling sample of older women. A total of 1013 postmenopausal Caucasian women aged 44–98 years provided a standard medical history including history of osteoporotic fractures and medication use. Bone mineral density (BMD) was measured at the femoral neck using dual-energy X-ray absorptiometry. In accordance with the SCORE protocol, low BMD was defined as 2 or more standard deviations below the mean BMD in healthy young women. Among these older women (mean age = 72.5 years), 67% had low BMD. Using the recommended SCORE cutpoint of 6, the sensitivity of SCORE was 98% but the specificity was only 12.5%. The positive predictive value (PPV) and negative predictive value (NPV) were 69% and 75%, respectively, meaning that all but 5.5% of the women would be recommended for bone densitometry. Increasing the cutpoint of 11, based on ethnicity and the receiver operating characteristic (ROC) curve, reduced sensitivity to 80% but improved specificity to 46%. The PPV and NPV were 75% and 53%, respectively, meaning that bone scans would not be recommended for 28% of the women. However, 13% of the women with low BMD would be missed. Analyses restricted to women <74 years of age reduced the rate of recommended bone densitometry but increased the number of women with low BMD who would be missed. We conclude that SCORE has limited value as a method for appropriately referring older ambulatory women for bone densitometry. Received: 28 December 1998 / Accepted: 30 December 1998     

Detection of clinical unilateral T3a prostate cancer – by digital rectal examination or transrectal ultrasonography?

OBJECTIVE: To assess, in a retrospective study, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of digital rectal examination (DRE), transrectal ultrasonography (TRUS) and the combination of both in unilateral clinical T3a (cT3a) prostate cancer. PATIENTS AND METHODS: The long-term outcome of surgical treatment for locally advanced prostate cancer is very good and surpasses that for radiotherapy outcomes, so it is anticipated that surgical management for cT3a disease will become more important, but staging methods for cT3a disease are not well studied. Between 1990 and 2004, 2240 patients had a radical prostatectomy at our institution; 267 were diagnosed as having clinical cT3a prostate cancer either by DRE or TRUS. The final histopathology was compared with the findings of DRE and TRUS. The sensitivity, specificity, PPV and NPV for DRE, TRUS and the combination of both were calculated. RESULTS: The sensitivity, specificity, PPV and NPV by DRE only was 90.9%, 15.8%, 47.2% and 67.7%, by TRUS only was 80.2%, 25.3%, 47.1% and 60.7%, and by both DRE and TRUS was 71.1%, 41.1%, 50.0% and 63.2%. Although the sensitivity was lower in the combined group, it had the highest specificity (41.1%) and PPV (50.0%). The combination of DRE and TRUS can detect T3a prostate cancer more accurately than either method alone. CONCLUSION: Until data on staging methods like magnetic resonance imaging become available, the combination of DRE and TRUS is advisable in selecting cT3a patients for primary radical prostatectomy.     

Is a palpable short saphenous vein a useful clinical sign in varicose vein assessment?

The short saphenous vein (SSV) may be palpable in the popliteal fossa in patients with varicose veins. A prospective study has been carried out to determine the significance of this sign in the presence of primary varicose veins. The SSV was assessed by palpation of the popliteal fossa with the knee slightly flexed. Hand-held Doppler insonation (HHD) was also used in the out-patient clinic. All patients had SSV assessment by duplex scanning. One hundred and sixty legs were examined. In 68 the SSV was palpable; 39 (57%) of these had SSV reflux on duplex examination. When the SSV was not palpable (92 legs), only 1% (1 leg) refluxed on duplex scanning. SSV palpability had a 98% sensitivity, 75% specificity, 57% positive predictive value (PPV), and 99% negative predictive value (NPV). In comparison, HHD had 80% sensitivity, 87% specificity, 67% PPV and 93% NPV. The combined tests had 78% sensitivity, 73% specificity, 76% PPV and 100% NPV. Palpation of the SSV is a valuable part of clinical examination. If the SSV is not palpable, it is unlikely to reflux.     

Myocardial perfusion imaging is an effective screening test for coronary artery disease in liver transplant candidates

A reliable screening test for coronary artery disease (CAD) in liver transplant (LT) candidates with end‐stage liver disease is essential because a high percentage of perioperative mortality and morbidity is CAD‐related. In this study, the effectiveness of myocardial perfusion imaging (MPI) for identification of significant CAD in LT candidates was evaluated. Records of 244 patients meeting criteria for MPI were evaluated: 74 met inclusion criteria; 40 had a positive MPI and cardiology follow‐up; 27 had a negative MPI and underwent LT; and seven had a negative MPI and then had coronary angiography or a significant cardiac event. A selective MPI interpretation strategy was established where MPI‐positive patients were divided into high, intermediate, and low CAD risk groups. The overall incidence of CAD in this study population was 5.1% and our strategy resulted in PPV 20%, NPV 94%, sensitivity 80%, and specificity 50% for categorizing CAD risk. When applied only to the subset of patients categorized as high CAD risk, the strategy was more effective, with PPV 67%, NPV 97%, sensitivity 80%, and specificity 94%. We determined that renal dysfunction was an independent predictive factor for CAD (p < 0.0001, odds ratio = 8.1), and grades of coronary occlusion correlated significantly with chronic renal dysfunction (p = 0.0079).     

The validity and accuracy of MRI arthrogram in the assessment of painful articular disorders of the hip

The assessment of a patient with chronic hip pain can be challenging. The differential diagnosis of intra-articular pathology causing hip pain can be diverse. These includes conditions such as osteoarthritis, fracture, and avascular necrosis, synovitis, loose bodies, labral tears, articular pathology and, femoro-acetabular impingement. Magnetic resonance imaging (MRI) arthrography of the hip has been widely used now for diagnosis of articular pathology of the hip. A retrospective analysis of 113 patients who had MRI arthrogram and who underwent hip arthroscopy was included in the study. The MRI arthrogram was performed using gadolinium injection and reported by a single radiologist. The findings were then compared to that found on arthroscopy. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), accuracy and 95% confidence interval were calculated for each pathology. Labral tear—sensitivity 84% (74.3–90.5), specificity 64% (40.7–82.8), PPV 91% (82.1–95.8), NPV 48% (29.5–67.5), accuracy 80%. Delamination —sensitivity 7% (0.8–22.1), specificity 98% (91.6–99.7), PPV 50% (6.8–93.2), NPV 74% (65.1–82.2) and accuracy 39%. Chondral changes—sensitivity 25% (13.3–38.9), specificity 83% (71.3–91.1), PPV 52% (30.6–73.2), NPV 59% (48.0–69.2) and accuracy 58%. Femoro-acetabular impingement (CAM deformity)—sensitivity 34% (19.6–51.4), specificity 83% (72.2–90.4), PPV 50% (29.9–70.1), NPV 71% (60.6–80.5) and accuracy 66%. Synovitis—sensitivity 11% (2.3–28.2), specificity 99% (93.6–100), PPV 75% (19.4–99.4), NPV 77% (68.1–84.6) and accuracy 77%. Our study conclusions are MRI arthrogram is a useful investigation tool in detecting labral tears, it is also helpful in the diagnosis of femoro-acetabular impingement. However, when it comes to the diagnosis of chondral changes, defects and cartilage delamination, the sensitivity and accuracy are low.     

Coronary calcium in adults with type 1 diabetes: a stronger correlate of clinical coronary artery disease in men than in women

We studied the relationship of coronary artery calcification (CAC), a marker of coronary atherosclerosis, with prevalent clinical coronary artery disease (CAD) and established cardiovascular disease (CVD) risk factors in a type 1 diabetic population. At the 10-year follow-up examination of the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study cohort, 302 adults (mean age 38.1 +/- 7.8 years) received electron beam tomography (EBT) scanning of the heart and a clinical examination. Clinical CAD was defined as a confirmed history of myocardial infarction (MI), angiographic stenosis > or =50%, Pittsburgh EDC Study physician-diagnosed angina, or ischemic electrocardiogram (ECG). CAC correlated with most CVD risk factors. CAC had 84 and 71% sensitivity for clinical CAD in men and women, respectively, and 100% sensitivity for MI or obstructive CAD. A CACS cut point of 400 was the most efficient coronary calcium correlate of CAD. In subjects with angina only, CAC sensitivity was 83% in men and 46% in women. In logistic regression, CAC, ECG R-R variation, peripheral vascular disease, and Beck Depression Inventory independently correlated with prevalent CAD in men and overall. Except for CAC, the same variables independently correlated with CAD in women, and age also entered the model. CAC was an independent correlate of MI or obstructive CAD in both sexes and was the strongest independent correlate in men, but CAC was not independently associated with angina and ischemic ECG in either sex. It is concluded that EBT-detected CAC is strongly correlated with CAD in type 1 diabetes-particularly in men.     

3.0 T multiparametric prostate MRI using pelvic phased-array coil: Utility for tumor detection prior to biopsy

ObjectiveTo evaluate the role of multiparametric magnetic resonance imaging (MRI) performed in men without a biopsy-proven diagnosis of prostate cancer using follow-up biopsy as the reference standard.Materials and methodsForty-two patients without biopsy-proven cancer and who underwent MRI were included. In all patients, MRI was performed at 3T using a pelvic phased-array coil and included T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast-enhanced imaging. Thirteen had undergone no previous biopsy, and 29 had undergone at least 1 previous negative biopsy. All patients underwent prostate biopsy following MRI. Two fellowship-trained radiologists in consensus reviewed all cases and categorized each lobe as positive or negative for tumor. These interpretations were correlated with findings on post-MRI biopsy.ResultsFollow-up biopsy was positive in 23 lobes in 15 patients (36% of study cohort). On a per-patient basis, MRI had a sensitivity of 100%, specificity of 74%, positive predictive value (PPV) of 68%, and negative predictive value (NPV) of 100%. On a per-lobe basis, MRI had a sensitivity of 65%, specificity of 84%, PPV of 60%, and NPV of 86%. There was a nearly significant association between Gleason score and tumor detection on MRI (P = 0.072).ConclusionsIn our sample, MRI had 100% sensitivity in predicting the presence of tumor on subsequent biopsy on a per-patient basis, suggesting a possible role for MRI in selecting patients with an elevated prostatic specific antigen (PSA) to undergo prostate biopsy. However, MRI had weaker specificity for prediction of a subsequent positive biopsy, as well as weaker sensitivity for tumor on a per-lobe basis, indicating that in patients with a positive MRI result, tissue sampling remains necessary for confirmation of the diagnosis as well as for treatment planning.     

Ultrasonography in the evaluation of renal scarring using DMSA scan as the gold standard

Dimercaptosuccinic acid (DMSA) renal scan is presently the technique of choice for assessing renal scars. Recent advances suggest that ultrasonography could replace DMSA scan for this purpose. This paper describes the experience of a tertiary pediatric referral hospital performing ultrasonography and DMSA scans in the assessment of renal scarring. Investigations were conducted 3–6 months after patients presented with urinary tract infection (UTI). Results were extracted from the radiology information system and recorded for analysis. All children with a UTI who had undergone DMSA and ultrasound examination on the same day between January 1995 and December 1999 were included; 930 kidneys were compared. DMSA scan was utilized as the reference method. When used to detect focal renal scarring, ultrasonography had a sensitivity of 5.2%, specificity of 98.3%, a positive predictive value (PPV) of 50% and a negative predictive value (NPV) of 75.8%. When used to detect diffuse renal scarring, ultrasonography had a sensitivity of 47.2%, specificity of 91.8%, PPV of 60.8% and NPV of 86.6%. Our results demonstrate that although ultrasonography has a good specificity for the detection of renal scarring compared with DMSA, it has low sensitivity, PPV and NPV. Ultrasonography cannot be substituted for DMSA scan in the evaluation of focal renal scarring.     

Observer performance in diagnosing osteoporosis by dental panoramic radiographs: results from the osteoporosis screening project in dentistry (OSPD)

Mandibular cortical erosion detected on dental panoramic radiographs (DPRs) may be useful for identifying women with osteoporosis, but little is known about the variation in diagnostic efficacy of observers worldwide. The purpose of this study was to measure the accuracy in identifying women at risk for osteoporosis in a worldwide group of observers using DPRs. We constructed a website that included background information about osteoporosis screening and instructions regarding the interpretation of mandibular cortical erosion. DPRs of 100 Japanese postmenopausal women aged 50 years or older who had completed skeletal bone mineral measurements by dual energy X-ray absorptiometry were digitized at 300 dpi. These were displayed on the website and used for the evaluation of diagnostic efficacy. Sixty observers aged 25 to 66 years recruited from 16 countries participated in this study. These observers classified cortical erosion into one of three groups (none, mild to moderate, and severe) on the website via the Internet, twice with an approximately 2-week interval. The diagnostic efficacy of the Osteoporosis Self-Assessment Tool (OST), a simple clinical decision rule based on age and weight, was also calculated and compared with that of cortical erosion. The overall mean sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the 60 observers in identifying women with osteoporosis by cortical erosion on DPRs were 82.5, 46.2, 46.7, and 84.0%, respectively. Those same values by the OST index were 82.9, 43.1, 43.9, and 82.4%, respectively. The intra-observer agreement in classifying cortical erosion on DPRs was sufficient (weighted kappa values>0.6) in 36 (60%) observers. This was significantly increased in observers who specialized in oral radiology (P<0.05). In the 36 observers with sufficient intra-observer agreement, the overall mean sensitivity, specificity, PPV, and NPV in identifying women with osteoporosis by any cortical erosion were 83.5, 48.7, 48.3, and 85.7%, respectively. The mean PPV and NPV were significantly higher in the 36 observers with sufficient intra-observer agreement than in the 24 observers with insufficient intra-observer agreement. Our results reconfirm the efficacy of cortical erosion findings in identifying postmenopausal women at risk for osteoporosis, among observers with sufficient intra-observer agreement. Information gathered from radiographic examination is at least as useful as that gathered from the OST index.     

Re-evaluation of the role of impedance plethysmography in the diagnosis of deep vein thrombosis in surgical patients

The clinical diagnosis of deep-vein thrombosis (DVT) is nonspecific and nonsensitive. As a result invasive and non-invasive laboratory tests are needed. In order to detect the diagnostic value of impedance plethysmography (IPG), a widely used non-invasive laboratory test, a prospective clinical trial was performed to compare IPG with color Doppler-ultrasonography (CDUS) and venography. Seventy-six (41 female, 35 male) high-risk abdominal surgery patients were included in the study. IPG and CDUS were performed preoperatively. During the postoperative period IPG, CDUS and venography were carried out. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy of IPG were all determined. The preoperative IPG was positive in 32 patients, being (+) in 29 patients postoperatively. On the other hand, two of the 29 postoperative IPG (+) patients had DVT diagnosed postoperatively by CDUS and venography. One of 47 IPG (-) patients had DVT diagnosed postoperatively. According to these findings, the sensitivity of IPG was 67%, specificity 63%, and PPV, NPV and accuracy were 7%, 98% and 63%, respectively. Our study showed that IPG was not a reliable non-invasive laboratory method in the diagnosis and screening of DVT of the lower extremity.     

Role of Fusion of Prone FDG‐PET and Magnetic Resonance Imaging of the Breasts in the Evaluation of Breast Cancer

Abstract: The purpose of this study is to report further about the statistically significant results from a prospective study, which suggests that fusion of prone F‐18 Fluoro‐deoxy‐glucose (FDG) positron emission tomography (PET) and magnetic resonance (MR) breast scans increases the positive predictive value (PPV) and specificity for patients in whom the MR outcome alone would be nonspecific. Thirty‐six women (mean age, 43 years; range, 24–65 years) with 90 lesions detected on MR consented to undergo a FDG‐PET scan. Two blinded readers evaluated the MR and the computer tomography (CT) attenuation‐corrected prone FDG‐PET scans side‐by‐side, then after the volumes were superimposed (fused). A semiautomatic, landmark‐based program was used to perform nonrigid fusion. Pathology and radiologic follow‐up were used as the reference standard. The sensitivity, specificity, PPV, negative predictive value (NPV), and accuracy (with 95% confidence intervals) for MR alone, FDG‐PET alone, and fused MR and FDG‐PET were calculated. The median lesion size measured from the MR was 2.5 cm (range, 0.5–10 cm). Histologically, 56 lesions were malignant, and 15 were benign. Nineteen lesions were benign after 20–47 months of clinical and radiologic surveillance. The sensitivity of MR alone was 95%, FDG‐PET alone was 57%, and fusion was 83%. The increase in PPV from 77% in MR alone to 98% when fused and the increase in specificity from 53% to 97% were statistically significant (p < 0.05). The false‐negative rate on FDG‐PET alone was 26.7%, and after fusion this number was reduced to 9%. FDG‐PET and MR fusions were helpful in selecting which lesion to biopsy, especially in women with multiple suspicious MR breast lesions.