Multiparametric MR evaluation of uterine leiomyosarcoma and STUMP versus leiomyoma in symptomatic women planned for high frequency focussed ultrasound: accuracy of imaging parameters and interobserver agreement for identification of malignancy.

OBJECTIVE: To assess accuracy of and interobserver agreement on multiparametric MR findings to distinguish uterine leiomyoma (LM) from uterine leiomyosarcoma (LMS) and soft tissue tumour of unknown malignant potential. METHODS: Inclusion criteria: All females over 18 years with least one uterine mass measuring 5 cm or more in at least one of the three standard orthogonal dimensions on MR with histopathological confirmation of LM, LMS, or soft tissue tumour of unknown malignant potential (STUMP) in the 3 months following MR. Patients with LMS were drawn from a larger cohort being assessed for MR-guided focussed ultrasound (MRgFUS) suitability. Image evaluation: Assessed variables were: lesion margin, margin definition, T2 signal homogeneity, >50% of lesion with T2 signal brighter than myometrium, haemorrhage, restricted diffusion, contrast enhancement (CE), CE pattern, local lymphadenopathy and ascites. RESULTS: 32 LM, 10 LMS and 1 STUMP were evaluated. Ill-defined (p-value = 0.0003-0.0004) or irregular (p = 0.003-0.004) lesion margin, T2 hyperintensity >50% (p = 0.001-0.004), and peripheral CE (p = 0.02-0.05) were significantly more common in LMS/STUMP than LM for both radiologists. 10/11 (Reader 2) and 11/11 (Reader 1) LMS/STUMP displayed restricted diffusion but so did 63-80% of LM. Agreement was greatest for margin characteristics (κ = 0.73-0.81). CONCLUSION: Irregular/ill-defined lesion margin best distinguished LMS/STUMP from LM with good interrater reliability. ADVANCES IN KNOWLEDGE: Assessment of agreement regarding MR parameters distinguishing LM from LMS and STUMP has not previously been undertaken in a cohort including a large number of patients with LMS. This will help inform evaluation of females considering minimally invasive LM treatment.

Diagnostic assessment of foetal brain malformations with intra-uterine MRI versus perinatal post-mortem MRI.

PURPOSE: To evaluate differences in diagnostic yield of intra-uterine foetal (iuMR) and post-mortem MRI (PMMR) for complex brain malformations, using autopsy as the reference standard. METHODS: In this retrospective, multicentre study spanning 2 years, we reviewed 13 terminated singleton pregnancies with a prenatal ultrasound finding of complex foetal cerebral abnormalities, referred for both iuMR and PMMR. The iuMR and PMMR studies of the brain were reported independently by two groups of radiologists, blinded to each other's reports. Descriptive statistics were used to compare differences in intracranial abnormalities with autopsy (and genetic testing, where present) as reference standard. RESULTS: The median gestational age at termination was 24.6 weeks (IQR 22-29) with median time between delivery and PMMR of 133 h (IQR 101-165). There was full concordance between iuMR and PMMR findings and autopsy in 2/13 (15.3%) cases. Partial concordance between both imaging modalities was present in 6/13 (46.2%) and total discordance in the remainder (5/13, 38.5%). When compared to autopsy, PMMR missed important key findings specifically for neuronal migration and cerebellar anomalies, whereas iuMR appeared to overcall CSF space abnormalities which were less crucial to reaching the final overall diagnosis. CONCLUSIONS: iuMR should be performed to improve foetal phenotyping where there is a prenatal ultrasound for complex foetal brain abnormalities. Reliance on PMMR alone is likely to result in misdiagnosis in a majority of cases.

A pictorial guide for the second trimester ultrasound.

Introduction: The second trimester ultrasound remains an important screening tool for detecting fetal abnormalities. This pictorial guide for the second trimester ultrasound is designed to assist practitioners to produce a high quality diagnostic survey of the fetus by demonstrating and describing recommended images. Methods: Each image is discussed in detail and has an associated drawn line diagram to aid in the identification of the important features of that image. There is a description of the salient landmarks and relevant measurements. Result: The authors hope this article may act as a useful guide to all practitioners performing second trimester ultrasounds.

Inflammatory, hemostatic, and other novel biomarkers for diabetic retinopathy: the multi-ethnic study of atherosclerosis.

OBJECTIVE: There are conflicting data regarding relationships of systemic biomarkers of inflammation, hemostasis, and homocysteine with diabetic retinopathy. We examined these relationships in the Multi-Ethnic Study of Atherosclerosis. RESEARCH DESIGN AND METHODS: A total of 921 participants with diabetes were included. Diabetic retinopathy was graded from retinal photographs. We defined two outcomes: any diabetic retinopathy and vision-threatening diabetic retinopathy (severe nonproliferative diabetic retinopathy or worse). Systemic markers analyzed were C-reactive protein, homocysteine, fibrinogen, plasmin-alpha(2)-antiplasmin complex (PAP), interleukin-6, d-dimer, factor VIII, serum creatinine, and urinary albumin-to-creatinine (UAC) ratio. RESULTS: Prevalence of diabetic retinopathy was 33.2% and vision-threatening diabetic retinopathy 7.1%. After adjusting for established risk factors (diabetes duration, A1C, systolic blood pressure, waist-to-hip ratio, and use of diabetes medications), fibrinogen (odds ratio 1.14 [95% CI 1.01-1.32], P = 0.05) and PAP (1.25 [1.05-1.50], P = 0.01) were associated with any diabetic retinopathy, while PAP (1.54 [1.13-2.11], P = 0.007) and homocysteine (1.57 [1.16-2.11], P = 0.003) were associated with vision-threatening diabetic retinopathy. Only PAP remained significant after additional adjustment for serum creatinine and UAC ratio. Area under receiver-operator characteristic curve (AUROC) for diabetic retinopathy was constructed for established and novel risk factors. Established risk factors accounted for a 39.2% increase of the AUROC, whereas novel markers (fibrinogen, PAP, homocysteine, serum creatinine, and UAC ratio) only accounted for an additional 2.2%. CONCLUSIONS: There were few associations of novel markers of inflammation, hemostasis, and homocysteine with diabetic retinopathy after controlling for established risk factors. These data suggest that there is limited clinical use of these biomarkers for prediction of diabetic retinopathy.

Retinal vascular caliber and risk of retinopathy in young patients with type 1 diabetes.

OBJECTIVE: To examine the relationship between retinal vascular caliber and incident retinopathy in children and adolescents with type 1 diabetes mellitus. DESIGN: Hospital-based case-control study with prospective outcomes. PARTICIPANTS: Cases and controls were selected from a cohort of children and adolescents 12 to 20 years old with type 1 diabetes followed up at a tertiary diabetes clinic. Cases were patients who developed incident diabetic retinopathy (n = 166) after at least 1 year of follow-up (> or =2 clinic visits), and controls were patients who had not developed retinopathy (n = 165) after > or =2 years of follow-up (> or =3 clinic visits). Baseline retinal photographs of cases and controls were digitized, and retinal vascular calibers were measured using a computer-assisted program by a grader masked to case-control status. These measurements were combined into summary indices reflecting the average arteriolar and venular calibers. MAIN OUTCOME MEASURE: Development of diabetic retinopathy. RESULTS: Incident retinopathy cases had retinal arteriolar calibers (mean +/- standard deviation [SD], 206.5+/-18.4 microm) significantly larger than those of controls (200.2+/-16.5 microm) (P = 0.004) but similar retinal venular calibers (329.1+/-14.7 microm in cases vs. 326.4+/-15.1 microm in controls, P = 0.312). After adjusting for age, gender, diabetes duration, glycated hemoglobin levels, blood pressure, body mass index, and pubertal stage, larger arteriolar caliber was predictive of risk of diabetic retinopathy (odds ratio, 1.44 per SD increase in arteriolar caliber; 95% confidence interval, 1.11-1.86). CONCLUSION: Larger retinal arteriolar caliber predicts incident retinopathy in children and adolescents with type 1 diabetes, independent of conventional risk factors for retinopathy. Measurement of retinal vascular caliber may provide prognostic information regarding the subsequent risk of diabetic retinopathy.