Hipertensão Arterial Pulmonar com Características de Envolvimento Venoso: Um Trabalho Investigativo / Pulmonary Arterial Hypertension with Features of Venous Involvement: A Detective's Task

Resumo A doença veno-oclusiva pulmonar (DVOP) e a hemangiomatose capilar pulmonar são tipos raros de substratos histopatológicos dentro do espectro da hipertensão arterial pulmonar (HAP) com prognóstico muito ruim. Caracterizam-se por um processo fibroproliferativo generalizado das veias e/ou capilares de pequeno calibre com preservação das veias maiores, resultando em um fenótipo de hipertensão pulmonar pré-capilar. A apresentação clínica é inespecífica e semelhante a outras etiologias de HAP. O diagnóstico definitivo é obtido por meio de análise histológica, embora a biópsia pulmonar não seja aconselhada devido ao maior risco de complicações. No entanto, alguns achados adicionais podem permitir um diagnóstico clínico presuntivo de DVOP, especialmente história de tabagismo, uso de drogas quimioterápicas, exposição a solventes orgânicos (particularmente tricloroetileno), baixa capacidade de difusão do monóxido de carbono (DLCO), dessaturação ao esforço e evidências de doença venosa sem doença cardíaca esquerda no exame de imagem, manifestada por uma tríade clássica de opacidades em vidro fosco, linhas septais, e linfadenopatias. O transplante pulmonar é o único tratamento eficaz e os pacientes devem ser encaminhados no momento do diagnóstico, devido à rápida progressão da doença e ao prognóstico ruim. Apresentamos o caso de um homem de 58 anos com HAP com características de envolvimento venoso/capilar em que a suspeita clínica, o pronto diagnóstico e o encaminhamento precoce para transplante pulmonar foram determinantes para um bom desfecho.

Abstract Pulmonary veno-occlusive disease (PVOD) and pulmonary capillary hemangiomatosis are rare types of histopathological substrates within the spectrum of pulmonary arterial hypertension (PAH) with a very poor prognosis. They are characterized by a widespread fibroproliferative process of the small caliber veins and/or capillaries with sparing of the larger veins, resulting in a pre-capillary pulmonary hypertension phenotype. Clinical presentation is unspecific and similar to other PAH etiologies. Definitive diagnosis is obtained through histological analysis, although lung biopsy is not advised due to a higher risk of complications. However, some additional findings may allow a presumptive clinical diagnosis of PVOD, particularly a history of smoking, chemotherapy drug use, exposure to organic solvents (particularly trichloroethylene), low diffusing capacity for carbon monoxide (DLCO), exercise induced desaturation, and evidence of venous congestion without left heart disease on imaging, manifested by a classical triad of ground glass opacities, septal lines, and lymphadenopathies. Lung transplant is the only effective treatment, and patients should be referred at the time of diagnosis due to the rapid progression of the disease and associated poor prognosis. We present a case of a 58-year-old man with PAH with features of venous/capillary involvement in which clinical suspicion, prompt diagnosis, and early referral for lung transplantation were determinant factors for the successful outcome.

Infarto com Supra-ST em Adulto Jovem: Rara Apresentação de Mixoma Atrial Gigante / Acute ST-Elevation Myocardial Infarction in a Young Adult: Rare Presentation of Giant Atrial Myxoma

Resumo Neoplasias cardíacas são raras, tendo como principal representante o mixoma atrial (MA), que corresponde a cerca de metade de todos os casos. O MA tem incidência estimada entre 0.001% e 0.3% na população em geral, no entanto apenas aproximadamente 0,06% desses cursam com eventos embólicos coronarianos. Homem de 33 anos, tabagista, admitido com quadro de precordialgia intensa e irradiação para membro superior esquerdo com duração de uma hora. O eletrocardiograma evidenciou elevação de segmento ST nas derivações D2, D3 e aVF troponina sérica elevada, confirmando infarto com supra desnivelamento do segmento ST (IAMCSST). Foi realizada cineangiocoronariografia, a qual revelou oclusão em terço proximal de artéria coronária direita por trombo. Realizada tentativa de aspiração do trombo, sem sucesso, seguido por angioplastia primária com balão sem colocação de stent. Durante a investigação do quadro, paciente realizou ecocardiograma transtorácico o qual demonstrou massa homogênea de superfície regular, de 5.2 cm x 2.3 cm, aderida ao septo interatrial, com lobulações de características emboligênicas prolapsando para valva mitral e ventrículo esquerdo na diástole, compatível com MA. Foi realizada ressecção cirúrgica com paciente evoluindo assintomático, recebendo alta para seguimento ambulatorial. O caso relatado difere em idade e sexo do perfil epidemiológico típico sendo um dos poucos descritos com acometimento da parede inferior apresentando a artéria coronária direita como culpada. Este relato ratifica a importância do diagnóstico diferencial frente às apresentações de IAMCSST em jovens.

Abstract Cardiac tumors are rare entities, among which atrial myxoma (AM) stands as the most frequent, accounting for approximately half of all reported cases. The incidence of AM is estimated to range from 0.001% to 0.3% within the general population, yet only about 0.06% of these cases present with coronary embolic events. We report on a 33-year-old male smoker who experienced acute, severe precordial pain radiating to the left upper limb, lasting for one hour. The electrocardiographic evaluation demonstrated ST-segment elevation in leads D2, D3, and aVF, alongside significantly elevated serum troponin levels, confirming a diagnosis of ST-segment elevation myocardial infarction (STEMI). Subsequent coronary angiography revealed proximal occlusion of the right coronary artery due to thrombus. An initial attempt of thrombus aspiration was unsuccessful, followed by primary angioplasty with balloon inflation without stent placement. Further diagnostic exploration through transthoracic echocardiography identified a homogenous, smooth-surfaced mass measuring 5.2 cm x 2.3 cm attached to the interatrial septum. This mass, characterized by lobulations, prolapsed into the mitral valve and left ventricle during diastole, consistent with AM. Surgical resection of the mass was successfully performed, with the patient being discharged asymptomatic. In the reported case, the patient's profile, notably his age, and gender, diverges from the typical epidemiological characteristics associated with AM. This case adds to the limited number of reports where the inferior wall is affected by the right coronary artery being occluded. This report emphasizes the significance of differential diagnoses in younger patients presenting with STEMI.

Quistes Dentígeros Asociados a Mesiodens. Revisión de la Literatura a Propósito de Dos Casos

El mesiodens es el diente supernumerario que se origina en la premaxila, siendo considerado el más prevalente o el más diagnosticado debido a las numerosas alteraciones que producen y que incluyen malposición de los dientes permanentes, formación de diastemas, retraso en la erupción de los incisivos anteriores superiores, y formación de quistes. La etiología de los mesiodens no está completamente comprendida, aunque se piensa que pueda deberse a la proliferación de la lámina dental u otros factores genéticos. El diagnóstico generalmente es tardío debido a que la mayoría permanece sin erupcionar, pudiendo generar complicaciones dentomaxilares que finalmente son el motivo de consulta de los pacientes. El quiste dentígero es un quiste odontogénico del desarrollo asociado a la corona de un diente incluido, numerario o supernumerario y su tratamiento es quirúrgico. El diagnóstico temprano y la planificación del tratamiento debe considerar una anamnesis minuciosa, un examen clínico e imágenes 3D. La cirugía debe consistir en la desinclusión del diente causal, la exéresis y legrado de la lesión, con o sin regeneración ósea inmediata del lecho quirúrgico con injerto. Se presentan dos casos de quiste dentígero asociado a un mesiodens que se diagnosticaron como hallazgo radiográfico. El plan de tratamiento consistió en evaluación y tratamiento endodóntico de los dientes desvitalizados, enucleción y legrado del quiste, junto a la desinclu sión del diente supernumerario, y seguimiento clínico y radiográfico en el largo plazo.

Mesiodens is the supernumerary tooth that originates in the premaxilla, considered the most prevalent or, the most diagnosed due to the multiple alterations that produce and that include malposition of the permanent teeth, formation of gaps, delayed eruption of the upper anterior incisors and cyst formation. The etiology of mesiodens is not fully established, although it is thought that it may be due dental lamina alteration or other genetic factors. Diagnosis is usually late because most remain unerupted, and can generate dentomaxillary complications that are ultimately the reason for patient consultation. The dentigerous cyst is a developmental odontogenic cyst associated with the crown of an included, numerary or supernumerary tooth and its treatment is surgery. Early diagnosis and treatment planning should consider a careful history, clinical examination, and 3D imaging. The surgery must consist of the disinclusion of the offending tooth, the exeresis and curettage of the lesion, with or without immediate bone regeneration of the surgical bed with a graft. Two cases of a dentigerous cyst associated with a mesiodens that were diagnosed as a radiographic finding are presented. The treatment plan consisted in evaluation and endodontic treatment of devitalized teeth, enucleation and curettage of the cyst, together with the disinclusion of the supernumerary tooth, and long-term clinical and radiographic follow-up.

Enfermedad de Lhermitte-Duclos y síndrome de Cowden. Reporte de un caso / Lhermitte-Duclos Disease and Cowden Syndrome. A Case Report

Presentación del caso. Se trata de una paciente femenina de 45 años con antecedentes de hipertensión arterial y múltiples cirugías por cáncer, entre ellas, cáncer de tiroides, carcinoma de parótida, cáncer de mama y cáncer endometrial. De manera incidental se identificó una lesión en el hemisferio cerebeloso derecho en una tomografía de senos paranasales, que fue confirmada a través de una resonancia magnética cerebral. La lesión presentaba una apariencia estriada, característica de gangliocitoma displásico del cerebelo o enfermedad de Lhermitte-Duclos. Considerando los antecedentes de diversos tipos de cáncer y los criterios de diagnóstico propuestos por el Consorcio Internacional Cowden y la Red Nacional Integral del Cáncer, se estableció el diagnóstico de síndrome de Cowden que había pasado desapercibido hasta el momento. Intervención terapéutica. Posteriormente, la paciente fue hospitalizada debido al crecimiento de una masa metastásica en el hemicuello derecho con afectación del plexo braquial, adenopatías cervicales, infraclaviculares y axilares derechas. Evolución clínica. En la actualidad, se encuentra recibiendo tratamiento paliativo con el objetivo de controlar los síntomas y mejorar su calidad de vida, ya que expresó su negativa a someterse a una intervención quirúrgica de resección tumoral

Case presentation. The report is of a 45-year-old female patient with a history of high blood pressure and multiple surgeries for cancer, including thyroid cancer, parotid carcinoma, breast cancer, and endometrial cancer. Incidentally, a lesion in the right cerebellar hemisphere was identified in a tomography of the paranasal sinuses, which was later confirmed in a brain magnetic resonance. The lesion had a striated appearance, characteristic of dysplastic gangliocytoma of the cerebellum or Lhermitte-Duclos disease. Considering the history of various types of cancer and the diagnostic criteria proposed by the International Cowden Consortium and the National Comprehensive Cancer Network, the diagnosis of Cowden syndrome, which had gone unnoticed until now, was established. Treatment. Subsequently, the patient was hospitalized due to the growth of a metastatic mass in the right hemicollar with involvement of the brachial plexus, cervical, infraclavicular, and right axillary lymph nodes. Outcome. She is receiving palliative treatment to control the symptoms and improve her quality of life, since she expressed her refusal to undergo tumor resection surgery

Evaluación de la agudeza diagnóstica de la Ecografía Translaríngea Transcutánea (ETLTC) en la valoración de la movilidad de las cuerdas vocales en cirugía de tiroides y paratiroides / Evaluation of the diagnostic acuity of the Transcutaneous Translaryngeal Ultrasound (TCTLUS) in the assessment of the vocal cords mobility in thyroid and parathyroid surgery

Introducción. La evaluación de la movilidad de las cuerdas vocales en cirugía de tiroides y paratiroides hace parte de la adecuada valoración integral. Aunque la laringoscopia directa es prueba de referencia, su uso real no es rutinario por lo que se propone la ecografía translaríngea como alternativa de evaluación. Métodos. Estudio prospectivo de evaluación de una prueba diagnóstica de la movilidad de las cuerdas vocales pre y posoperatoria, comparando la ecografía translaríngea con la video laringoscopia, en pacientes con cirugía de tiroides y paratiroides, de febrero 1° a noviembre 30 de 2022. Se describieron las variables usando frecuencias absolutas y relativas. En el análisis univariado se calcularon Chi cuadrado y T de Student y en el bivariado, regresión logística binaria. La agudeza diagnóstica se determinó con sensibilidad, especificidad y valores predictivos; se consideró la significancia estadística con p < 0,05. Resultados. Se incluyeron 267 pacientes, 219 mujeres y 48 hombres; 196 pacientes (73,4%) tenían malignidad. Se encontró en el preoperatorio, sensibilidad 100 %, especificidad 99,6 %, VPP 83,3 %, VPN 100 %, odds de probabilidad positiva 83 % y Odds de probabilidad negativa 0,004 %. En el posoperatorio, sensibilidad 82,8 %, especificidad 99,2 %, VPP 92,3 % VPN 97,9 %, odds de probabilidad positiva 92 % y odds de probabilidad negativa 0,2 %. Conclusiones. La ecografía translaríngea en nuestro medio tiene alta agudeza diagnóstica. Podría ser usada en el abordaje inicial de la evaluación de la movilidad de las cuerdas vocales y reemplazar la laringoscopia directa, dejando ésta para cuando la visualización ecográfica no sea adecuada, o en casos de afectación o sospecha de invasión, para su confirmación.

Introduction. The evaluation of the mobility of the vocal cords in thyroid and parathyroid surgery is part of the adequate comprehensive assessment. Altough, direct laryngoscopy is the gold standard, its real use is not routine, so translaryngeal ultrasound approach is proposed as an alternative. Methods. A prospective diagnostic test study was carried out to evaluate the translaryngeal ultrasound compared with video laryngoscopy in visualizing vocal mobility in patients with thyroid and parathyroid surgery from February 1 to November 30, 2022. Patients were described using absolute and relative frequencies. Univariate statistical analysis with Chi-square and Student's t tests. T. Bivariate analysis using binary logistic regression. Diagnostic acuity was calculated with sensitivity, specificity, PPV, NPV. Statistical significance with p< 0.05, 95% confidence interval. Results. 267 patients undergoing thyroid or parathyroid surgery were included, 219 women and 48 men. Malignant: thyroid neoplasm 196 patients (73.4%). The findings were for the preoperative period, 100% sensitivity, 99.6% specificity, PPV 83.33%, NPV 100%, 83% positive probability odds, and 0.004% negative probability odds. For the postoperative period, 82.8% sensitivity, 99.2% specificity, 92.3% PPV, 97.9% NPV, 92% positive probability odds, and 0.2% negative probability odds were found.Conclusions. Translaryngeal ultrasound in our series has high diagnostic acuity. It could be used as the initial approach to evaluate vocal mobility and might replace direct laryngoscopy, leaving it when its visualization is not adequate or in cases of involvement or suspected invasion for confirmation.

Reflectance confocal microscopy - Consensus terminology glossary in Brazilian Portuguese for normal skin, melanocytic and non-melanocytic lesions

Abstract Background: Currently, there is no uniform and official terminology in Portuguese for reflectance confocal microscopy analysis, despite the increasing number of Brazilian dermatologists using this new tool. Objective: To present the terminology in Brazilian Portuguese for the description of reflectance confocal microscopy and establish the first Brazilian consensus on terms related to normal skin and cutaneous tumors. Methods: 10 Brazilian specialists from different institutions and states of Brazil were selected to evaluate the best corresponding terms in Portuguese for normal skin, melanocytic and non-melanocytic tumors. The terms used were translated from international consensuses in the English language. The modified Delphi method was used to create the consensus in 3 steps. Results: The terms considered the most appropriate in the Portuguese language to describe the findings of normal skin, melanocytic and non-melanocytic lesions in the reflectance confocal microscopy analysis were presented. Study limitations: The limitations of the present study include the number of participants and limited regional representation (only two of the five Brazilian regions were represented). Conclusion: This Brazilian consensus represents an opportunity for dermatologists and physicians specializing in cutaneous oncology to become familiar with reflectance confocal microscopy, propagating the technique in clinical and research environments to stimulate national and international publications on this subject.

Rendimiento diagnóstico de la endosonografía biliopancreática en pacientes con riesgo intermedio de coledocolitiasis / Diagnostic performance of biliopancreatic endosonography in patients with intermediate risk of choledocholithiasis

RESUMEN Objetivo: Determinar la sensibilidad y la especificidad de la endosonografía biliopancreática (ESBP) para diagnóstico en pacientes con riesgo intermedio de coledocolitiasis, derivados a un centro especializado de Gastroenterología quirúrgica de Unión de Cirujano SAS - Oncólogos de Occidente grupo Zentria - Manizales - Colombia entre el 01 de marzo de 2020 al 31 de enero de 2022. Materiales y métodos: Estudio retrospectivo transversal en pacientes con riesgo intermedio para coledocolitiasis. Se calculó el rendimiento diagnóstico de la ESBP y se confirmó con CPRE. Se hizo seguimiento telefónico a los ESBP negativas. Resultados: Se analizaron 752 casos con ESBP de los cuales el 43,2% (n=325) fue positivo y el 56,8% (n=427) fue negativo. Se practicó CPRE en los casos positivos que aceptaron el procedimiento (n=317); el 73,5% (n=233) fueron positivos para coledocolitiasis, el 25,8% (n=82) tumores y el 0,6% (n=2) áscaris biliares. Pacientes con ESBP positiva fueron intervenidos con CPRE. Se obtuvo S= 98,3% (IC 95%: 95,7-99,5); E= 88,1% (IC 95%: 79,2-94,1); VPP = 95,8% (IC 95%: 92,4-98,0); VPN = 94,9% (IC 95%: 87,4-98,7). El AUC de ESBP fue de 0,9319 (IC 95% 0,8961-0,967). Conclusión: En pacientes con riesgo intermedio para coledocolitiasis, la ESBP es una opción diagnostica útil en el estudio de patologías pancreáticas, árbol biliar extrahepático, y la identificación de microlitiasis biliares; por lo que nos permite además poder complementarla con una intervención terapéutica como la CPRE en un solo tiempo.

ABSTRACT Objective: Determine the sensitivity and specificity of the ESBP for diagnosis in patients with intermediate risk of choledocholithiasis, referred to the specialized surgical Gastroenterology center of Unión de Cirujanos SAS - Oncologists of the West Zentria group - Manizales - Colombia between March 01, 2020 to January 31, 2022. Materials and methods: Retrospective cross-sectional study in patients with intermediate risk for choledocholithiasis. The diagnostic performance of ESBP was calculated and confirmed with ERCP. Negative ESBPs were followed up by telephone. Results: 752 cases with ESBP were analyzed, of which 43.2% (n=325) were positive and 56.8% (n=427) were negative. ERCP was performed in positive cases who accepted the procedure (n=317); 73.5% (n:233) were positive for choledocholithiasis, 25.8% (n=82) tumors and 0.6% (n=2) biliary roundworms. Patients with positive ESBP underwent ERCP. S= 98.3% (95% CI: 95.7-99.5) was obtained; E= 88.1% (95% CI: 79.2-94.1); PPV = 95.8% (95% CI: 92.4-98.0); NPV = 94.9% (95% CI: 87.4-98.7). The AUC of ESBP was 0.9319 (95% CI 0.8961-0.967). Conclusion: In patients with intermediate risk for choledocholithiasis, ESBP is a useful diagnostic option in the study of pancreatic pathologies, extrahepatic biliary tree, and the identification of biliary microlithiasis; Therefore, it also allows us to complement it with a therapeutic intervention such as ERCP in a single time.

Applicability of portable retinal cameras and telemedicine as facilitating tools in screening diabetic retinopathy in the COVID-19 pandemic scenario / Aplicabilidade do retinógrafo portátil e telemedicina como ferramentas facilitadoras na triagem de retinopatia diabética no cenário de pandemia de COVID-19

ABSTRACT Purpose: Diabetes mellitus is a leading cause of impaired vision. The objective of this study was to evaluate the feasibility of use of portable retinograph and remote analysis of images along with a virtual questionnaire for screening for diabetic retinopathy in basic health units in the city of Ribeirão Preto/SP during the Covid-19 pandemic. Methods: Standard Covid-19 protocol was followed during the screening. Blood pressure and capillary blood glucose were measured. Demographic and social data were collected through a standardized online questionnaire via smartphone. After pupillary dilation, fundal images were obtained with portable retinographs by trained ophthalmology residents. Two standardized 45° images were acquired: one posterior segment and another nasal to the optic nerve. Diabetic retinopathy was classified according to the Early Treatment Diabetic Retinopathy Study. Results: A total of 350 patients (64% female; 45% aged 55-70 years; 55% Caucasian) were evaluated. For 40.5% of patients, the campaign was the first opportunity for retinal evaluation; 47.56% had diabetes mellitus for >10 years. On repeat analysis of images stored in a cloud-based repository by retinal specialist, a 7.8% difference was observed in the Early Treatment Diabetic Retinopathy Study diabetic retinopathy classification, compared to the screening findings. Mild diabetic retinopathy was observed in 12.23%, moderate diabetic retinopathy in 6.31%, and proliferative diabetic retinopathy in 2.58% patients. Macular edema was present in 4.58% patients. Diabetic retinopathy was not detected in 72.78% patients. Conclusion: Use of portable retinographs together with telemedicine can provide efficient alternative to traditional methods for screening and diagnosis of diabetic retinopathy.

RESUMO Objetivo: A diabetes mellitus é considerada uma epidemia global e causa de baixa visual em países em desenvolvimento. Este estudo foi realizado com o objetivo de avaliar a viabilidade do retinógrafo portátil e análise remota de imagens associada a questionário virtual para o rastreio de retinopatia diabética em Unidades Básicas de Saúde da cidade de Ribeirão Preto/SP durante a pandemia de Covid-19. Métodos: Trezentos e sessenta pacientes compareceram a campanha. O acolhimento foi realizado na Unidade Básica de Saúde pela equipe de enfermagem, respeitando medidas de prevenção do Covid-19 Os realizou-se aferição da pressão arterial e glicemia capilar seguida de dilatação. Dados demográficos e sociais foram coletados através de questionário on-line padronizado via smartphone e realizou-se a triagem da retinopatia diabética através da obtenção de imagens com retinógrafos portáteis realizados por residentes de oftalmologia previamente treinados, com a aquisição de 2 imagens padronizadas de 45º: uma do segmento posterior e outra nasal ao nervo óptico. Resultados: Trezentos e sessenta pacientes foram atendidos durante a campanha. Dez pacientes (1,02%) foram excluídos devido à opacidade de meios e impossibilidade de obtenção de imagens de fundo de olho. Foram avaliados 350 pacientes, 64% do sexo feminino, 45% entre 55 e 70 anos e 55% brancos. A Campanha foi a primeira avaliação de retina para 40,5% dos pacientes e 47,56% apresentavam diabetes mellitus há mais de 10 anos. Na análise comparativa da classificação da retinopatia diabética segundo Early Treatment Diabetic Retinopathy Study (triagem X Nuvem) observou-se uma diferença de 7,8% nos resultados. Retinopatia diabética leve foi observada em 12,23%, moderada em 6,31%, proliferativa em 2,58%; edema macular presente em 4,58% e ausência de retinopatia diabética em 72,78% dos pacientes. Conclusão: A utilização de retinógrafos portáteis juntamente a telemedicina, para o rastreamento da retinopatia diabética pode ser considerada uma alternativa eficiente para triagem e diagnóstico da retinopatia diabética dentro ou fora do cenário pandêmico, auxiliando na prevenção de perda visual pelo diabetes.

Adenoma Hepatocelular: a propósito de un caso / Hepatocellular adenoma: about a case / Adenoma hepatocelular: sobre um caso

El Adenoma Hepatocelular (AH) es un tumor hepático benigno, su diagnóstico ha avanzado gracias a los avances en los métodos moleculares, facilitaron dividirlos en subtipos, con diferentes pronósticos e indicaciones terapéuticas. Se presenta el caso clínico de una paciente, de 40 años con hallazgo ecográfico de tumor hepático, la Tomografía de Abdomen y Pelvis voluminosa lesión sólida heterogénea, en la Resonancia Magnética compatible con Adenoma esteatósico (asociado a mutación HNF1 alfa). Se decide tratamiento quirúrgico, con resección de los segmentos 6 y 7. La Anatomía patológica concluye: Compatible con el subtipo inflamatorio. Los Adenoma hepáticos (AH) son tumores raros, solitarios de estirpe epitelial, benignos. Se presentan en mujeres de edad fértil y asociado al consumo de anticonceptivos orales y estrógenos. Estos tumores predominan en hígado derecho, con proliferación de células parecidas a los hepatocitos normales, pero desorganizados y sin arquitectura lobular normal, sin ductos biliares ni tejido conectivo de sostén. Los AH así como el resto de los tumores hepáticos benignos, han aumentado su incidencia de la mano con el avance de la imagenología abdominal. La importancia de la diferenciación con el resto de los tumores hepáticos benignos surge del potencial maligno de éstos. Podemos clasificar a los pacientes según el perfil molecular asociado a marcadores inmunohistoquímicos. Los estudios de imagen son fundamentales para la diferenciación tumoral en diagnóstico y planear la terapéutica. El tratamiento será individualizado, determinada por la clínica, la variedad de subtipos, y la evolución. Debido a la complejidad de la enfermedad, el tratamiento de la HA es uno de los mejores ejemplos de abordaje individualizado en unidades hepatobiliares.

Hepatocellular adenoma (HA) is a benign liver tumor, its diagnosis has advanced thanks to advances in molecular methods, which facilitated its division into subtypes, with different prognoses and therapeutic indications. We present the clinical case of a 40-year-old patient with an ultrasound finding of a liver tumor, a voluminous heterogeneous solid lesion on a CT scan of the abdomen and pelvis, compatible with a steatotic adenoma on MRI (associated with HNF1 alpha mutation). Surgical treatment was decided, with resection of segments 6 and 7. The pathology concluded in short: Compatible with the inflammatory subtype. Hepatic adenomas (HA) are rare, solitary, benign epithelial tumors. They occur in women of childbearing age and associated with the consumption of oral contraceptives and estrogens. These tumors predominate in the right liver, with proliferation of cells similar to normal hepatocytes, but disorganized and without normal lobular architecture, without bile ducts or supporting connective tissue. HA, as well as the rest of the benign liver tumors, have increased their incidence in the hand with the advancement of abdominal imaging. The importance of differentiation with the rest of the benign liver tumors arises from the malignant potential of these. We can classify patients according to the molecular profile associated with immunohistochemical markers. Imaging studies are fundamental for tumor differentiation in diagnosis and therapeutic planning. The treatment will be individualized, determined by the clinic, the variety of subtypes, and the evolution. Due to the complexity of the disease, the treatment of AH is one of the best examples of an individualized approach in hepatobiliary units.

O adenoma hepatocelular (AH) éum tumor benigno do fígado, seu diagnóstico avançougraçasaosavanços dos métodos moleculares, que facilitaramsuadivisão em subtipos, com diferentes prognósticos e indicaçõesterapêuticas. Apresentamos o caso clínico de umadoente de 40 anoscomachadoultrassonográfico de tumor hepático, volumosalesão sólida heterogénea à TC de abdómen e pelve, compatívelcom adenoma esteatótico à RM (associado a mutação HNF1 alfa ). Optou-se por tratamentocirúrgico, comressecção dos segmentos 6 e 7. A patologiaconcluiu-se resumidamente: Compatívelcom o subtipo inflamatório. Os adenomas hepáticos (AH) são tumores epiteliais raros, solitários e benignos. Ocorrem em mulheres em idadereprodutiva e associadasao consumo de anticoncepcionaisorais e estrogênios. Esses tumores predominam no fígadodireito, comproliferação de células semelhantesaoshepatócitosnormais, porém desorganizados e semarquitetura lobular normal, sem ductos biliares outecido conjuntivo de sustentação. O HA, assim como os demais tumores hepáticos benignos, têm aumentado suaincidêncianamãocom o avanço da imagem abdominal. A importância da diferenciaçãocom os demais tumores hepáticos benignos decorre do potencial maligno destes. Podemos classificar os pacientes de acordocom o perfil molecular associado a marcadores imuno-histoquímicos. Os estudos de imagemsãofundamentais para a diferenciação tumoral no diagnóstico e planejamentoterapêutico. O tratamento será individualizado, determinado pela clínica, variedade de subtipos e evolução. Pela complexidade da doença, o tratamento da HA é um dos melhoresexemplos de abordagem individualizada nas unidades hepatobiliares.

Influence of notebook computers screens and undergraduate level of dental students in the radiographic detection of carious lesions

Aim: To evaluate the influence of notebook computers screens and undergraduate level of dental students in the radiographic detection of carious lesions. Methods: Bitewing digital radiographs were presented to 3rd and 5th year dental students in three different notebooks computers: Notebook 1 with anti-glare screen (1366×768 pixels), Notebook 2 without anti-glare screen (1366×768 pixels), and Notebook 3 with anti-glare screen (1920×1080 pixels). A reference standard based on a consensus analysis was set by three senior professors of Oral Radiology and Cariology. Sensitivity, specificity and accuracy values were measured and submitted to two-way ANOVA at a significance level of 5%. Results: Notebook 2 provided significantly lower sensitivity values (Mean 56.5% ± 2.94) than notebook 3 (71.1% ± 2.82) (p = 0.002). We found no statistically significant differences between the two undergraduate years (p > 0.05). Conclusion: The anti-glare screen of notebook computers screens can influence the radiographic detection of carious lesions, but the undergraduate level of dental students does not influence this diagnostic task

Inflammatory Modifications in Paranasal Sinuses and Ostiomeatal Complex Anatomical Variations in Jet Aircraft Pilots: A Computed Tomography Study

Abstract Introduction Jet aircraft pilots are exposed to huge pressure variation during flight, which affect physiological functions as systems, such as the respiratory system. Objectives The objective of the present investigation was to evaluate inflammatory changes of paranasal sinuses of jet aircraft pilots before and after a jet aircraft training program, using multislice computed tomography (CT), in comparison with a group of nonairborne individuals with the same age, sex, and physical health conditions. A second objective of the present study was to assess the association between the ostiomeatal complex obstruction and its anatomical variations. Methods The study group consisted of 15 jet aircraft pilots participating in the training program. The control group consisted of 41 nonairborne young adults. The 15 fighter pilots were evaluated before initiating the training program and after their final approval for the presence of inflammatory paranasal sinus disease. The ostiomeatal complex anatomical variations and obstructions were analyzed in pilots after the training program. Results Jet aircraft pilots presented higher incidence of mucosal thickening in maxillary sinus and anterior ethmoid cells than controls. Prominent ethmoidal bulla showed significant association with obstruction of the osteomeatal complex. Conclusions Jet aircraft pilots present increased inflammatory disease when compared with nonairborne individuals. The presence of a prominent ethmoidal bulla is associated with ostiomeatal complex obstruction.

Three-Dimensional Volumetric Investigation of Onodi Cells: A Multi-Slice Computed Tomography Study

Abstract Introduction Onodi cells (OCs) are posterior ethmoid cells that are located above the sphenoid sinus, close to or even surrounding the carotid artery and optic nerve. Objective To investigate and evaluate the volumetric variation of OCs through multi-slice computed tomography (MSCT) scans. Methods We performed a retrospective review of MSCT scans of 79 subjects, 40 male and 39 female patients, Whose age ranged from 18 to 83 (mean: 39.6) years. The volumes of the OCs on the right and left sides were measured using the ITK-SNAP software (open-source) with semiautomatic segmentation. The possible relationships involving age, gender, contact with the optic nerve, extension of the pneumatization of the posterior ethmoid cells into the clinoid processes, mucous thickening in the anterior and posterior ethmoid cells, and obliteration of the sphenoethmoidal complex were analyzed with the Pearson correlation and Chi-squared tests according to the type of data compared and logistic regression models (p < 0.05). Results We observed that an increase of one unit in the volume of OCs also increases the chance of extension of pneumatization into the clinoid processes by 0.15% (p = 0.001). No significant correlations were identified regarding age, gender, and volume of the OCs. Conclusion The volume of the OCs has effects on the extension of pneumatization into the clinoid processes.

Evaluation of Diagnostic Values of a Gender Discrimination Function, Based on Mandibular Dimorphic Parameters in Iranian Population

Abstract Objective: To evaluate mandibular dimorphic parameters for sex determination by using panoramic radiographs and comparing the results with another equation. Material and Methods: In this analytical-descriptive study, the mandible variables, including the ramus height, the coronoid height, the mental height, and the distance between the right and left condyle, were measured in 326 panoramic radiographs. The discriminant function of the statistical method has previously been used to evaluate the diagnostic value of sex. The level of significance was considered 0.05. Results: The detection function obtained was statistically significant in quantitative correlation (p<0.001) with 99% agreement. Moreover, good sensitivity (81.72%), specify (80.25%), and moderate to good predictive values (PPV: 62.29 and NPV:91.6) were found. Among the mandibular parameters, chin height, ramus height, coronoid height, and distance between two condyles showed the highest gender dimorphism. Conclusion: Chin height, and ramus height have the most quality in gender dimorphism. A unique gender discrimination function has been obtained from the results.

Accuracy of an artificial intelligence algorithm for detecting moderate-to-severe vertebral compression fractures on abdominal and thoracic computed tomography scans / Acurácia de um algoritmo de inteligência artificial na detecção de fraturas compressivas moderadas a graves na tomografia computadorizada abdominal e torácica

Abstract Objective: To describe the accuracy of HealthVCF, a software product that uses artificial intelligence, in the detection of incidental moderate-to-severe vertebral compression fractures (VCFs) on chest and abdominal computed tomography scans. Materials and Methods: We included a consecutive sample of 899 chest and abdominal computed tomography scans of patients 51-99 years of age. Scans were retrospectively evaluated by the software and by two specialists in musculoskeletal imaging for the presence of VCFs with vertebral body height loss > 25%. We compared the software analysis with that of a general radiologist, using the evaluation of the two specialists as the reference. Results: The software showed a diagnostic accuracy of 89.6% (95% CI: 87.4-91.5%) for moderate-to-severe VCFs, with a sensitivity of 73.8%, a specificity of 92.7%, and a negative predictive value of 94.8%. Among the 145 positive scans detected by the software, the general radiologist failed to report the fractures in 62 (42.8%), and the algorithm detected additional fractures in 38 of those scans. Conclusion: The software has good accuracy for the detection of moderate-to-severe VCFs, with high specificity, and can increase the opportunistic detection rate of VCFs by radiologists who do not specialize in musculoskeletal imaging.

Resumo Objetivo: Descrever a acurácia do software HealthVCF na detecção incidental de fraturas compressivas de corpos vertebrais moderadas a graves em exames de tomografia computadorizada do tórax e abdome. Materiais e Métodos: Foram incluídos 899 exames consecutivos de pacientes com idades entre 51 e 99 anos. As imagens foram retrospectivamente avaliadas pelo software e por dois radiologistas especializados em musculoesquelético que investigaram fraturas compressivas de corpos vertebrais com perda da altura somática > 25%. A análise comparativa foi realizada entre o software e um radiologista geral, usando a avaliação do especialista como referência. Resultados: O software apresentou uma acurácia de 89,6% (IC 95%: 87,4-91,5%) para fraturas compressivas moderadas a graves, com sensibilidade de 73,8%, especificidade de 92,7% e valor preditivo negativo de 94,8%. Entre as 145 tomografias positivas detectadas pelo software, o radiologista geral deixou de relatar as fraturas em 62 (42,8%) e o algoritmo detectou fraturas adicionais em 38 dessas tomografias. Conclusão: O software possui boa acurácia na detecção de fraturas compressivas moderadas a graves, com alta especificidade, podendo aumentar a taxa de detecção oportunística dessas fraturas por radiologistas não especializados em musculoesquelético.

Analysis of the indications for and results of breast cancer screening by magnetic resonance imaging at a cancer center in Brazil / Análise das indicações e resultados da ressonância magnética para rastreamento de câncer de mama em um centro oncológico brasileiro

Abstract Objective: To evaluate the indications for and results of magnetic resonance imaging (MRI) examinations for breast cancer screening at a cancer center in Brazil. Materials and Methods: This was a retrospective observational study, based on electronic medical records, of patients undergoing MRI for breast cancer screening at a cancer center in Brazil. Results: We included 597 patients between 19 and 82 years of age. The main indications for MRI screening were a personal history of breast cancer, in 354 patients (59.3%), a family history of breast cancer, in 102 (17.1%), and a confirmed genetic mutation, in 67 (11.2%). The MRI result was classified, in accordance with the categories defined in the Breast Imaging Reporting and Data System, as benign (category 1 or 2), in 425 patients (71.2%), probably benign (category 3), in 143 (24.0%), or suspicious (category 4 or 5), in 29 (4.9%). On MRI, 11 malignant tumors were identified, all of which were invasive carcinomas. Among those 11 carcinomas, six (54.5%) were categorized as minimal cancers (< 1 cm), and the axillary lymph nodes were negative in 10 (90.9%). The cancer detection rate was 18.4/1,000 examinations, and the positive predictive value for suspicious lesions submitted to biopsy was 37.9%. Conclusion: In our sample, the main indication for breast MRI screening was a personal history of breast cancer. The results indicate that MRI is a highly accurate method for the early detection of breast neoplasms in this population.

Resumo Objetivo: Avaliar as indicações e resultados de exames de ressonância magnética (RM) para rastreamento de câncer de mama em um centro oncológico no Brasil. Materiais e Métodos: Estudo observacional, realizado mediante análise retrospectiva de pacientes submetidos a RM das mamas para rastreamento de câncer de mama, por meio de revisão do prontuário eletrônico em um centro oncológico. Resultados: Foram incluídas 597 pacientes com idade variando de 19 a 82 anos. As principais indicações para rastreamento foram história pessoal de câncer de mama em 354 (59,3%) pacientes, história familiar em 102 (17,1%) e mutação genética confirmada em 67 (11,2%). O resultado da RM foi benigno (BI-RADS 1 ou 2) em 425 (71,2%) pacientes, provavelmente benigno (BI-RADS 3) em 143 (24,0%) e suspeito (BI-RADS 4 ou 5) em 29 (4,9%). Foram identificados 11 tumores malignos na RM, todos carcinomas invasivos, porcentagem de cânceres "mínimos" (< 1 cm) de 54,5% e porcentagem de axila negativa de 90,9%. A taxa de detecção de câncer na RM foi 18,4/1000 exames e o valor preditivo positivo para as lesões suspeitas submetidas a biópsia foi 37,9%. Conclusão: A principal indicação para RM de rastreamento na nossa população foi história pessoal de câncer de mama. Os resultados mostraram que a RM constitui um método com alta acurácia para detecção precoce de neoplasias da mama nessa população.

Imaging findings of acute calcific periarthritis, with emphasis on magnetic resonance imaging: pictorial essay / Achados de imagem da periartrite cálcica aguda, com ênfase na ressonância magnética: ensaio iconográfico

Abstract Acute calcific periarthritis (ACP) is defined as periarticular inflammation associated with intra-articular deposits of hydroxyapatite and other basic calcium phosphate crystals. Patients with ACP present with a sudden onset of pain, together with localized swelling, as well as erythema, tenderness, and reduced range of motion. Familiarity with the clinical and radiological manifestations of ACP aids in the diagnosis and helps differentiate it from other conditions, particularly infectious or inflammatory pathologies such as septic arthritis and gout, thereby reducing the number of unnecessary diagnostic and therapeutic procedures. The objective of this pictorial essay is to illustrate the imaging findings of ACP in various joints, with an emphasis on the findings obtained by magnetic resonance imaging.

Resumo A periartrite cálcica aguda (PCA) é uma inflamação periarticular aguda associada a depósitos justa-articulares de hidroxiapatita e outros cristais básicos de fosfato de cálcio. Os pacientes apresentam início súbito de dor, edema localizado, eritema, sensibilidade e redução da amplitude de movimentos. A familiaridade com as manifestações clínicas e radiológicas da PCA facilita o diagnóstico e permite diferenciá-la de outras entidades, em particular, com doenças infecciosas ou inflamatórias, como artrite séptica e gota, reduzindo procedimentos diagnósticos e terapêuticos desnecessários. O objetivo deste ensaio iconográfico é ilustrar os achados de imagem de PCA em algumas articulações, com ênfase na ressonância magnética.

Effects of antenatal corticosteroids on fetal hemodynamics: a longitudinal study / Efeitos do corticoide antenatal na hemodinâmica fetal: um estudo longitudinal

Abstract Objective: To study the effect of antenatal corticosteroid administration on fetal hemodynamics using longitudinal analysis of Doppler waveforms in the umbilical artery (UA) and middle cerebral artery (MCA). Materials and Methods: This was a retrospective study that included 30 fetuses at risk for preterm birth. Twenty-eight pregnant women were treated with betamethasone for fetal lung maturation. Doppler examinations of the UA and MCA were performed once before and three or eight times after corticosteroid administration. We used a Bayesian hierarchical linear model. Reference ranges were constructed, and associations between variables (gestational age and pre-eclampsia) were tested. Results: The mean maternal age, gestational age at betamethasone administration, and gestational age at delivery were 32.6 ± 5.89 years, 30.2 ± 2.59 weeks, and 32.9 ± 3.42 weeks, respectively. On UA Doppler, there was a significant decrease in the pulsatility index (PI) after corticosteroid administration, with a mean of 0.1147 (credibility interval: 0.03687-0.191) in three observations and a median of 0.1437 (credibility interval: 0.02509-0.2627) in eight observations. However, there was no significant change in the Doppler MCA PI, regardless of gestational age and the presence or absence of pre-eclampsia. Conclusion: Although antenatal corticosteroid administration induced a significant decrease in the Doppler UA PI, we observed no change in the cerebral vasculature.

Resumo Objetivo: Estudar o efeito da administração antenatal de corticosteroides na hemodinâmica fetal mediante análise longitudinal do Doppler na artéria umbilical e artéria cerebral média (ACM). Materiais e Métodos: Este foi um estudo retrospectivo que incluiu 30 fetos com risco de nascimento pré-termo. Vinte e oito gestantes foram tratadas com betametasona para maturação pulmonar fetal. Os exames de Doppler da AU e da ACM foram realizados uma vez antes e depois da administração de corticosteroides, num total de três ou oito observações. Utilizamos o modelo linear hierárquico com abordagem Bayesiana. Foram construídos os intervalos de referência e testadas associações entre variáveis (idade gestacional e pré-eclâmpsia). Resultados: A média ± desvio-padrão da idade materna, idade gestacional na administração de betametasona e idade gestacional no parto foram 32,6 ± 5,89 anos, 30,2 ± 2,59 semanas e 32,9 ± 3,42 semanas, respectivamente. No Doppler da AU, verificou-se diminuição significativa do índice de pulsatilidade (IP) com a terapêutica com corticosteroides (média: 0,1147 [0,03687-0,191]; em três observações) (mediana: 0,1437 [0,02509-0,2627]; em oito observações). No entanto, não foi observada alteração significativa no IP do Doppler da ACM, independentemente da idade gestacional e do diagnóstico de pré-eclâmpsia. Conclusão: Os corticosteroides pré-natais induziram diminuição significativa no IP do Doppler da AU, mas não houve alteração na vasculatura cerebral.

Performance of ChatGPT on questions from the Brazilian College of Radiology annual resident evaluation test / Desempenho do ChatGPT nas questões da avaliação anual de residentes do Colégio Brasileiro de Radiologia

Abstract Objective: To test the performance of ChatGPT on radiology questions formulated by the Colégio Brasileiro de Radiologia (CBR, Brazilian College of Radiology), evaluating its failures and successes. Materials and Methods: 165 questions from the CBR annual resident assessment (2018, 2019, and 2022) were presented to ChatGPT. For statistical analysis, the questions were divided by the type of cognitive skills assessed (lower or higher order), by topic (physics or clinical), by subspecialty, by style (description of a clinical finding or sign, clinical management of a case, application of a concept, calculation/classification of findings, correlations between diseases, or anatomy), and by target academic year (all, second/third year, or third year only). Results: ChatGPT answered 88 (53.3%) of the questions correctly. It performed significantly better on the questions assessing lower-order cognitive skills than on those assessing higher-order cognitive skills, providing the correct answer on 38 (64.4%) of 59 questions and on only 50 (47.2%) of 106 questions, respectively (p = 0.01). The accuracy rate was significantly higher for physics questions than for clinical questions, correct answers being provided for 18 (90.0%) of 20 physics questions and for 70 (48.3%) of 145 clinical questions (p = 0.02). There was no significant difference in performance among the subspecialties or among the academic years (p > 0.05). Conclusion: Even without dedicated training in this field, ChatGPT demonstrates reasonable performance, albeit still insufficient for approval, on radiology questions formulated by the CBR.

Resumo Objetivo: Testar o desempenho do ChatGPT em questões de radiologia formuladas pelo Colégio Brasileiro de Radiologia (CBR), avaliando seus erros e acertos. Materiais e Métodos: 165 questões da avaliação anual dos residentes do CBR (2018, 2019 e 2022) foram apresentadas ao ChatGPT. Elas foram divididas, para análise estatística, em questões que avaliavam habilidades cognitivas de ordem superior ou inferior e de acordo com a subespecialidade, o tipo da questão (descrição de um achado clínico ou sinal, manejo clínico de um doente, aplicação de um conceito, cálculo ou classificação dos achados descritos, associação entre doenças ou anatomia) e o ano da residência (R1, R2 ou R3). Resultados: O ChatGPT acertou 53,3% das questões (88/165). Houve diferença estatística entre o desempenho em questões de ordem cognitiva inferior (64,4%; 38/59) e superior (47,2%; 50/106) (p = 0,01). Houve maior índice de acertos em física (90,0%; 18/20) do que em questões clínicas (48,3%; 70/145) (p = 0,02). Não houve diferença significativa de desempenho entre subespecialidades ou ano de residência (p > 0,05). Conclusão: Mesmo sem treinamento dedicado a essa área, o ChatGPT apresenta desempenho razoável, mas ainda insuficiente para aprovação, em questões de radiologia formuladas pelo CBR.