Should excretory urography be used as a routine diagnostic procedure in patients with acute ureteric colic: a single center study.

The aim of this study was to find an accurate, easily available and safe imaging modality as an alternative to intravenous urography for the diagnosis of acute urinary obstruction. This retrospective study included 332 patients, who underwent both excretory urography (EU) preceeded by plain radiograph as well as ultrasonography for evaluation of acute flank pain. There were 198 male and 134 female patients. The presence or absence of urinary stones, level of obstruction, excretion delay on EU and dilated excretory system on either or both techniques were recorded. The sensitivity, specificity, predictive values, and accuracy for plain radiograph, ultrasonography, and for both modalities together were measured considering EU as a standard reference. The sensitivity and specificity of combined plain radiograph and ultrasound were 97% and 67%, respectively, with positive and negative predictive values and accuracy rates of 92%, 99%, and 97%, respectively. Our study suggests that the combination of plain radiograph and ultrasonography yields a high sensitivity, negative predictive value, and accuracy in depiction of urinary stones. Thus, EU need not be used as a routine diagnostic procedure in patients with acute obstructive uropathy.

Utility of free prostate specific antigen serum level and its related parameters in the diagnosis of prostate cancer.

We evaluated the role of free prostate specific antigen (f-PSA) serum level and its related parameters in detecting prostate cancer. This retrospective study was conducted between January 2006 and March 2008. Transrectal ultrasound guided prostate biopsy was performed for 107 patients who had total PSA (t-PSA) level of either >4 ng/mL with or without palpable nodule or ≤4 ng/mL with palpable nodule on digital rectal examination. The performance measurements for f-PSA, percent free PSA (%f-PSA) and free PSA density (f-PSAD) were determined and compared with those for t-PSA and total PSA density (t-PSAD). Descriptive statistics for all variables of interest were calculated, and receiver operating characteristic curves were generated. Nine patients (8.4%) had normal histology, 69 patients (64.4%) had benign disease and 29 patients (27.1%) had prostate cancer. The performance of f-PSA in PCa detection was better than other evaluated parameters. The largest area under the curve for patients in the gray area (t-PSA range 4.1-10 ng/mL) was for f-PSA, with a value of 0.64 and a sensitivity and specificity of 44% and 87%, respectively. For %f-PSA, these values were 0.59, 63% and 62%, respectively. For patients with a t-PSA level of 10.1-20 ng/mL, they were 0.68, 67%, and 81%, respectively, for f-PSA, and 0.64, 67%, and 76%, respectively, for %f-PSA. In conclusion, f-PSA serum levels performed better than free to total PSA ratio and t-PSA for prostate cancer screening. It is of clinical value which could affect the biopsy decision avoiding unnecessary interventions.

New indicator for prostate gland biopsy when malignancy is in question.

The aim of our study was to find out a new indicator with a higher specificity level than prostate prostate-specific antigen (PSA) in order to achieve a better selection of patients who will undergo prostate biopsy. Trans-rectal ultrasound-guided prostate biopsy was performed in 135 patients who had elevated PSA level and/or palpable nodule on digital rectal examination. The PSA level was ≤ 10 ng/mL in 81 patients and >10 ng/mL in 54 patients. We designed a new formula consisting of prostate volume, patient's age, and free prostate specific antigen. Its resultant was defined as prostate biopsy index and was compared with the most currently used parameters. Histology results yielded prostate gland malignancy in 40 (30%) patients. Our new index differed significantly between the malignant and the non-malignant patient categories (P = 0.01). The ROC curve analysis at different specificity and sensitivity levels (85%, 90% and 95%) and regarding the area under the curve (AUC), our new index was significantly better than the other studied parameters (P = 0.001). Additionally, the AUC in patients with a PSA level ≤ 10 ng/mL and between 10.1 and 20 ng/mL was 0.75 and 0.78, with a sensitivity of 91% and 83% and a specificity of 24% and 73%, respectively, at a cut-off point of 1.7. The overall sensitivity and specificity at the same point were 80% and 41%, respectively. In conclusion, the performance of our new index was superior to all other evaluated parameters. At 83% sensitivity with a cut-off point of 1.7, 63.5% of the performed biopsies could have been avoided in patients with a PSA level between 10.1 and 20 ng/mL.

The role of B-mode ultrasonography in the detection of urolithiasis in patients with acute renal colic.

This study was conducted to assess the diagnostic yield of B-Mode Ultrasonography compared to unenhanced helical CT scan in detecting urinary stones in patients with acute renal colic. This retrospective study comprised of 156 patients who underwent unenhanced urinary tract CT scan and ultrasonography for suspicion of urolithiasis. Both techniques were used to determine the presence or absence, site, size, and number of urinary stones, as well as presence of any other intra-abdominal pathology. For statistical analysis, the sensitivity, specificity, predictive values, and diagnostic accuracy of ultrasonography were measured considering unenhanced CT scan as a gold standard. Unpaired two-tailed student's t-test was used for comparison between mean size of true positive, false positive, and false negative stones. There were 68 patients having 115 urinary stones. Ultrasound identified 54 stones, missed 43, and falsely diagnosed 18 stones. The mean size of true positive, false positive, and false negative stones were 4.8 +/- 3.3 mm, 6 +/- 1.8 mm and 4.18 +/- 3 mm, respectively. There were 23 patients with other intra-abdominal pathologies, equally detected by both techniques. Ultrasound helped in identifying the cause of acute flank pain in 62% of cases. The overall sensitivity, specificity, positive and negative predictive values, and accuracy of ultrasonography in the diagnosis of renal stone disease were 58%, 91%, 79%, 78%, and 78%, respectively. Our study suggests that, despite its limited value in detecting urinary stones, ultrasonography should be performed as an initial assessment in patients with acute flank pain. Unenhanced helical CT should be reserved for patients in whom ultrasonography is inconclusive.

Pituitary magnetic resonance imaging experience in Jordan.

OBJECTIVE: To assess the pituitary findings as demonstrated on MRI and to compare the results with the data published in the literature. METHODS: One thousand, one hundred and thirty-eight pituitary MRI`s with and without intravenous contrast media (gadolinium) were performed over 6 years from 2001 to 2007 in the Department of Diagnostic Radiology, Jordan University Hospital, Amman, Jordan. The patients were referred from various departments and were evaluated for pituitary, other sellar, and juxtasellar abnormalities. The results were compared with those in the published literature. RESULTS: Four hundred and eight-three normal scans were excluded from the study. The remaining 655 were abnormal, pituitary adenoma was detected in 327 (49.9%), microadenoma was present in 213 (32.5%), and macroadenoma in 114 (17.4%). Partial empty sella was seen in 157 (24%), diffuse pituitary gland enlargement in 98 (14.9%), ectopic pituitary posterior lobe in 13 (2%), and other findings in 31 (4.7%). CONCLUSION: The incidence of pituitary adenoma was equal in both genders; however, microadenoma was more common, affected a younger age group, and was predominately seen in females. The other parameters showed agreement with the published literature.

Macrodystrophia lipomatosa with syndactyly.

Macrodystrophia lipomatosa (MDL) is a rare form of congenital localized gigantism characterized by hypertrophy of all mesenchymal tissues of the affected digits, with particular overgrowth of fat. Syndactyly is a rare association. We report a case of MDL associated with syndactyly affecting the hand. We describe the characteristic radiographic and MRI findings that distinguish the abnormality from other causes of localized gigantism.

Value of serum bilirubin levels in selecting patients for magnetic resonance cholangiopancreatography.

BACKGROUND/AIMS: To determine the value of serum bilirubin levels in selecting patients for MRCP. METHODOLOGY: The medical records of 142 patients who underwent MRCP between January 2002 and December 2004 were retrospectively reviewed. Clinical features, serum bilirubin levels, and MRCP results were recorded. The patients were categorized into 4 groups, according to serum bilirubin levels and MRCP findings. Bilirubin levels were considered elevated above 23.9 micromol/L for total bilirubin and above 6.8 micromol/L for direct bilirubin. Sensitivity, specificity, accuracy, and predictive values of serum bilirubin levels in identifying pancreatobiliary duct diseases were assessed. RESULTS: Complete medical records were found for 135 patients. Abnormal MRCP results were found in 75 patients (56%). Choledocholithiasis and both malignant and benign bile duct strictures represented 40%, 28%, and 23% of abnormal MRCP findings, respectively, with mean values of total and direct serum bilirubin levels of 77.9 +/- 51.6 microM and 34.7 +/- 30.3 microM (for choledocholithiasis), 170 +/- 115 microM and 56 +/- 40 microM (for malignant bile duct stricture), and 44 +/- 32 microM and 20 +/- 16 microM (for benign bile duct stricture), respectively. Sensitivity, specificity, and accuracy of serum bilirubin level tests, for the diagnoses of pancreatobiliary duct diseases, were 77%, 80%, and 79%, respectively; the positive and negative predictive values were 83% and 74%, respectively, and the corresponding likelihood ratios were 3.8 and 0.3. CONCLUSIONS: Serum bilirubin level tests alone are not sufficiently accurate for the diagnoses of pancreatobiliary duct diseases, and hence, such tests are of low importance in selecting patients for MRCP.

Arachnoid granulations in the cerebral dural sinuses as demonstrated by contrast-enhanced 3D magnetic resonance venography.

INTRODUCTION: Identification of normal filling defects within the intracranial dural sinuses reduces the erroneous diagnosis of the presence of an intrasinus pathologic process. The aim of this prospective study was to assess the prevalence, distribution, and morphological characteristics of arachnoid granulations (AGs) in the dural sinuses. METHODS: This prospective study was carried out on 110 patients who had both normal conventional brain MRI and contrast-enhanced (CE) 3D turbo flash magnetic resonance venography (MRV). The dural sinuses were viewed on MRV images for the presence of filling defects. The prevalence, site, size, number, shape, outlines, internal structure, and presence of associated cortical vein were determined. RESULTS: One hundred and twenty-six AGs were observed among 71 patients. The superior sagittal sinus was the most common site of filling defects (58 AGs). The mean size of AGs was 6.45 +/- 3.55 mm. Eighty-three percent of AGs were round or oval, with sharp outlines and homogeneous internal structure; of these 81% were associated with cortical vein. CONCLUSIONS: In the majority of cases, the identification of AGs can be facilitated by their characteristic appearances: rounded or oval shaped, well-defined outlines and homogenous intensity. The presence of an adjacent cortical vein can be considered as an additional supportive element.

Hereditary multiple exostoses with pseudoaneurysm.

A 16-year-old male patient with hereditary multiple exostoses (HME) was found to have a pseudoaneurysm of the left popliteal artery caused by osteochondroma in the lower femur. The diagnosis was confirmed by ultrasound, magnetic resonance imaging and magnetic resonance angiography without the need to perform an angiogram. The osteochondroma was excised and the popliteal artery was repaired with a saphenous graft. Vascular complications are extremely rare in HME, pseudoaneurysm being the most common and mostly located in the popliteal artery. This complication should be considered in young HME patients with a mass at the knee region. The radiological spectrum of investigations allows the diagnosis of this complication with proper and less invasive management procedures for the patient.

Clinico-radiological correlates of achalasia.

OBJECTIVE: To study the clinical and radiographic characteristics of achalasia in a cohort Jordanian patients and to investigate the presence of any clinico-radiological relationships. METHODS: Thirty-five cases of recently diagnosed untreated achalasia patients were studied at Jordan University Hospital, Amman, Jordan during the period of January 1999 to December 2002. Measurements of maximum esophageal and gastroesophageal (GE) junction diameters, as radiographic features, were obtained from films. The clinical features included age; gender; nature; frequency and duration of typical and atypical symptoms; total number of symptoms; calculated typical symptoms score; and diagnostic delay. Pearson correlation coefficients were calculated between radiographic and clinical features, and among the radiographic features themselves. Using Spearman's correlation coefficients, the later analysis was repeated for patients with diagnostic delay of 2 years or less and patients with more than 2 years. All results were evaluated based on the 0.05 level of significance. RESULTS: There were 35 consecutive achalasia patients enrolled in this study (20 females and 15 males) with a mean age of 42.3 +/- 15.6 years and diagnostic delay of 29 +/- 26 months. On average, each patient has presented 2 typical symptoms and 2 atypical symptoms. The mean typical symptoms score was almost 3 out of the full score of 6. The mean GE junction diameter was 2.4 mms and maximum esophageal diameter was 29 mms. Maximum esophageal diameter was significantly correlated with the number of typical, atypical and total symptoms as well as with the typical symptom score and diagnostic delay. Negative correlation was found between GE junction diameter and maximum esophageal diameter; but only statistically significant for patients with diagnostic delay of more than 2 years. CONCLUSION: Statistically significant relationship exists between maximum esophageal diameter and all clinical variables. Negative correlation exists between maximum esophageal diameter and GE junction diameter; however, only significant for patients with a diagnostic delay more than 2 years. The possibility of achalasia is high in patients with longer diagnostic delay who demonstrate negative relationship between maximum esophageal diameter and GE junction diameter.