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To evaluate the performance of 2D Shear-Wave Elastography from General Electric (2D-SWE.GE), implemented on the new LOGIQ P9 system, for the non-invasive assessment of liver fibrosis, and to identify liver stiffness (LS) cut-off values for predicting different stages of fibrosis, using Transient Elastography (TE) as the reference method. Our study included 234 consecutive subjects, with or without chronic hepatopathies, in whom LS was evaluated in the same session by means of two elastographic techniques: TE (FibroScan, EchoSens) and 2D-SWE.GE (LOGIQ P9, GE Healthcare). Reliable liver stiffness measurements (LSM) were defined for TE as the median value of 10 measurements with an interquartile range/median ratio (IQR/M) < 0.30 and for 2D-SWE.GE as the median value of 10 measurements acquired in a homogenous area, with an IQR/M < 0.30. To discriminate between fibrosis stages by TE we used the following cut-offs: F2 - 7 kPa; F3 - 9.5 kPa and F4 - 12 kPa [1]. Reliable LS measurements were obtained in 217/234 (92.7%) subjects by 2D-SWE.GE and in 222/234 (94.8%) by TE, so the final analysis included 205 subjects (p = 0.454). 36% (74/205) of subjects included in the study were healthy liver subjects. Based on TE [1] cut-off values we divided the rest of our cohort into 4 groups: F < 2: 40/131 (30.5%); F2: 24/131 (18.3%); F3 = 22/131 (16.8%); F4 = 45/131 (34.4%). The mean LS values for normal subjects for 2D-SWE-GE was 5.05 ± 0.83 kPa and for TE 4.4 ± 0.87 kPa. A very good correlation was found between the LS values obtained by 2D-SWE.GE and TE: r = 0.81, p < 0.0001. The best 2D-SWE.GE cut-off value for F ≥ 2 it was 6.8 kPa (AUROC 0.93, Sensitivity 83.5%. Specificity 91.2%), for F ≥ 3 it was 7.6 kPa (AUROC 0.94, Sensitivity 86.5%, Specificity 92.7%) and for F = 4 it was 9.3 kPa (AUROC 0.91, Sensitivity 75.5%, Specificity 92.5%). The mean LS values for normal subjects for 2D-SWE-GE (P9) was 5.05 ± 0.83 kPa. The best 2D-SWE.GE (P9) cut-off values for predicting F ≥ 2, F ≥ 3 and F = 4 were 6.8 kPa, 7.6 kPa and 9.3 kPa. [ABSTRACT FROM AUTHOR]

OBJECTIVES AND BACKGROUND The aim of this study was to find an alternative to Transient Elastography when its’ application is impossible or when no valid and reliable measurements can be obtained through its usage. MATERIALS AND METHODS Liver stiffness values were assessed with transient elastography [TE- (Fibroscan)], 2D shear wave elastography (SuperSonic Shear Imaging-SSI) and point shear wave elastography (pSWE) using VTQ and ElastPQ, in a cohort of 90 patients with chronic liver diseases. With the help of linear regression, we made a multivariate analysis in order to test the relationship between TE and the other three methods (ElastPQ, SSI, VTQ). Given the very well correlated factors, we consider them predictors for our model. RESULTS The model conducted with all the used factorsElastPQ+SSI+VTQ compared with TE explained the 90.7% of the model variability (R=0.907). We tempted the probability to exclude the factors one by one. SSI+VTQ explained 90% of the model variability (R=0.90). ElastPQ+VTQ explained 77% of the model variability (R=0.77) and SSI+ElastPQ explained 89% of the model variability (R=0.89). CONCLUSIONS SSI in combination with ElastPQ or VTQ is as good as the TE single use. Therefore, these combinations can be applied when TE can’t be performed or is not valid. REFERENCES 1.Tsochatzis EA el al,.Elastography for the diagnosis of severity of fibrosis in chronic liver disease: a meta-analysis of diagnostic accuracy. J Hepatology. 2011;54:650-9. 2.Nierhoff J et.al . The efficiency of acoustic radiation force imaging for the staging of liver fibrosis: a meta-analysisEurRadiol. 2013;23:3040-53. 3.Ferraioli G et al. Performace of ElastPq Shear Wave Elastography Technique for Assessing Fibrosis in Chronic Vira Hepatitis. J. Hepatology. 2013;58:S7. 4.Herrmann E et al. 2D-shear wave elastography is equivalent or superior to transient elastography for liver fibrosis assessment: an individual patient data based meta-analysis . EASL 2015

OBJECTIVES AND BACKGROUND To evaluate the performance of 2D share wave elastography from General Electric (2D-SWE.GE) for the noninvasive assessment of liver fibrosis and to identify liver stiffness (LS) cut-off values for predicting different stages of fibrosis, using Transient Elastography (TE) as the reference method. MATERIALS AND METHODS The study group included 331 consecutive subjects with or without chronic hepatopathies in whom liver stiffness (LS) was evaluated in the same session by means of 2 elastographic techniques: TE (FibroScan, EchoSens, Paris, France, M or XL probes) and 2D-SWE.GE (LOGIQ E9, GE Healthcare, Chalfont St Giles, United Kingdom, C1-6-D convex probe). Reliable LS measurements were defined as follows: for TE – the median value of 10 measurements with a success rate of ≥60% and an interquartile range

OBJECTIVES CEUS improved the characterization of focal lesions of the liver (FLLs), but it remains an operator-dependent method. The goal of this scientific paper was to test a computer assisted diagnosis (CAD) prototype. MATERIALS AND METHODS 97 CEUS videos [34% hepatocellular carcinomas (HCC), 12.3% hypervascular metastases (HiperM), 11.3% hypovascular metastases (HipoM), 24.7% hemangiomas (HMG), 17.5% focal nodular hyperplasia (FNH)] were used to develop a CAD prototype based on an algorithm that tested a binary decision classifier. Two young MDs, two experts and the CAD prototype, reevaluated 50 CEUS videos (diagnosis of benign vs. malignant lesions), in order to evaluate the beginner vs. expert diagnostic gap, the first being blinded by clinical data. RESULTS I-Beginner misdiagnosed 4/10-FNH, 3/10-HCC, 2/10-HMG, 1/10-HiperM, 1/10-HipoM. After being informed about the clinical data 2/10-FNH, 1/10-HCC. II-beginner misdiagnosed: 3/10-FNH; 3/10-HCC, 2/10- HMG, 1/10-HiperM. Unblinded: 1/10-HCC, 1/10- HMG. I-Expert: only 1/10-FNH, 1/10-HCC, 1/10- HMG misdiagnosed. Unblinded: all lesions were correctly diagnosed. II-Expert: 1/10-FNH, 1/10-HCC misdiagnosed. Unblinded: only 1/10-FNH was misdiagnosed. The CAD classifier managed a 75.2% overall correct classification rate. The overall classification before and after the uncovering of clinical data was: I beginner 78 %; 94%, II 82%; 96%. I expert 94%; 100%. II 96%; 98%. CONCLUSIONS The CAD prototype can assist a beginner for a better CEUS diagnostic accuracy. The integration of clinical data in the CAD algorithm is essential. Graphical abstract: Average Intensity variation in Arterial and Late Phase with supra unitary (meaning wash in) and sub unitary pattern (meaning washout). REFERENCES 1.Sugimoto K, Shiraishi J, Moriyasu F, Doi K. Computer-aided diagnosis for contrast-enhanced ultrasound in the liver. World J Gastroenterol. 2010;2:215-223. 2. Gatos I, Tsantis S, Spiliopoulos S, Skouroliakou A, Theotokas I, Zoumpoulis P, Hazle JD, Kagadis GC. A new automated quantification algorithm for the detection and evaluation of focal liver lesions with contrastenhanced ultrasound. Med Phys. 2015;42:3948-59.

OBJECTIVES AND BACKGROUND To assess the variability of a new point shear wave elastography that uses ARFI technique – ElastPQ, as a non-invasive method for liver fibrosis assessment. MATERIALS AND METHODS The study included 88 consecutive subjects (43.2% women, 56.8% men, mean age 52.2±14.7 years old, 20.5% with BMI ≥ 30kg/m2 ), with or without chronic viral hepathopaties and healthy volunteers. Two operators, with at least 2 years of experience in the field of liver elastography, performed 10 consecutive valid elastographic measurements in the liver parenchyma using ElastPQ (Philips, Affinity) technique (Fig1). Large vessels were avoided. Reliable liver stiffness measurements (LSM) were defined as the median value of 10 LSM expressed in kPa. The intra and interobserver variability of ElastPQ technology was analyzed with intraclass correlation (ICC) coefficient. RESULTS The overall intra- and interobserver agreement was excellent: ICC 0.97 vs. ICC 0.89. A strong correlation was obtained between measurements assessed by both operators (r=0.84, p

Aims: Ultrasound (US) is an essential diagnostic and educational tool in medical practice, and its effective implementation into medical curricula is critical. This study aimed to compare the efficacy of two disparate educational approaches-an optional semester course and a specifically curated intensive workshop-on the learning curve of medical students in abdominal ultrasonography. Material and methods: Engaging fourth and fifth-year medical students, this study, incorporated both theoretical and practical elements of US, providing participants with hands-on experience and evaluative assessments pre- and post-training. Students were segregated into two groups: one experienced a 14-hour optional semester course and the other a 6-hour intensive workshop, both yielding distinct teaching methodologies yet aspiring for synonymous educational outcomes. Results: Involving a total of 93 participants, findings elucidated that regardless of the educational method employed, post-training identification of US structures exhibited a significant enhancement compared to pre-training. Interestingly, no substantial disparities were discerned between the two educational approaches nor gender-based differences in learning outcomes. Conclusions: This investigation provides pivotal insights into the versatile utility of different educational strategies in abdominal US training for medical students, affirming that varied pedagogical methods can achieve comparable augmentations in student proficiency. Further research is paramount to ascertain the optimal integration of US education into medical curricula, considering aspects such as duration, depth, and mode of delivery. [ABSTRACT FROM AUTHOR]

Progressive fibrosis is encountered in almost all chronic liver diseases. Its clinical signs are diagnostic in advanced cirrhosis, but compensated liver cirrhosis is harder to diagnose. Liver biopsy is still considered the reference method for staging the severity of fibrosis, but due to its drawbacks (inter and intra-observer variability, sampling errors, unequal distribution of fibrosis in the liver, and risk of complications and even death), non-invasive methods were developed to assess fibrosis (serologic and elastographic). Elastographic methods can be ultrasound-based or magnetic resonance imaging-based. All ultrasound-based elastographic methods are valuable for the early diagnosis of cirrhosis, especially transient elastography (TE) and acoustic radiation force impulse (ARFI) elastography, which have similar sensitivities and specificities, although ARFI has better feasibility. TE is a promising method for predicting portal hypertension in cirrhotic patients, but it cannot replace upper digestive endoscopy. The diagnostic accuracy of using ARFI in the liver to predict portal hypertension in cirrhotic patients is debatable, with controversial results in published studies. The accuracy of ARFI elastography may be significantly increased if spleen stiffness is assessed, either alone or in combination with liver stiffness and other parameters. Two-dimensional shear-wave elastography, the ElastPQ technique and strain elastography all need to be evaluated as predictors of portal hypertension.

Aim: To identify severe adverse events (SAEs) leading to treatment discontinuation that occur during antiviral therapy in hepatitis C virus (HCV)-infected cirrhotic patients., Methods: We identified all the articles published prior to December 2011 in the PubMed, Medline, Lilacs, Scopus, Ovid, EMBASE, Cochrane and Medscape databases that presented these data in cirrhotic patients. These studies evaluated the rate of SAEs leading to discontinuation of standard care treatment: Pegylated interferon (PegIFN) alpha 2a (135-180 μg/wk) or PegIFN alpha 2b (1 or 1.5 μg/kg per week) and ribavirin (800-1200 mg/d). Patients with genotype 1 + 4 underwent treatment for 48 wk, whereas those with genotypes 2 + 3 were treated for 24 wk., Results: We included 17 papers in this review, comprising of 1133 patients. Treatment was discontinued due to SAEs in 14.5% of the patients. The most common SAEs were: severe thrombocytopenia and/or neutropenia (23.2%), psychiatric disorders (15.5%), decompensation of liver cirrhosis (12.1%) and severe anemia (11.2%). The proportion of patients who needed to discontinue their therapy due to SAEs was significantly higher in patients with Child-Pugh class B and C vs those with Child-Pugh class A: 22% vs 11.4% (P = 0.003). A similar discontinuation rate was found in cirrhotic patients treated with PegIFN alpha 2a and those treated with PegIFN alpha 2b, in combination with ribavirin: 14.2% vs 13.7% (P = 0.96). The overall sustained virological response rate in cirrhotic patients was 37% (95%CI: 33.5-43.1) but was significantly lower in patients with genotype 1 + 4 than in those with genotype 2 + 3: 20.5% (95%CI: 17.9-24.8) vs 56.5% (95%CI: 51.5-63.2), (P < 0.0001)., Conclusion: Fourteen point five percent of HCV cirrhotic patients treated with PegIFN and ribavirin needed early discontinuation of therapy due to SAEs, the most common cause being hematological disorders.

Background: Acute pancreatitis (AP) is an acute inflammation of the pancreas with an unpredictable evolution. The aim of this study was to assess the factors associated with severe evolution of AP and to create a new score for predicting a severe outcome., Methods: The initial group included 334 patients hospitalized in 2006-2009. The validation group included 195 patients admitted in 2010-2011. AP was classified according to the Atlanta criteria., Results: In the initial group, C-reactive protein (CRP), creatinine, white blood count, body mass index (BMI), age and male gender were correlated with severe evolution of AP. Using only parameters available in emergency, by multiple regression analysis we obtained in the initial group the following score for predicting severe evolution of AP: Prediction pancreatic severity I score (PPS I score) = -1.038 + 0.119 × creatinine (mg/dL) + 0.012 × BMI (kg/m²) + 0.027xwhite blood count/1000 (cells/mm³) + 0.195 × gender (1-women, 2-men) + 0.005 × age (years). For a cut-off value >0.325, PPS I score had 71.8% accuracy (AUC=0.790) for predicting a severe evolution of AP. In the validation group the accuracy was 71.7%. Since CRP was proven to be a good predictor of severe evolution in AP, we calculated another score, PPS II, obtained using PPS I and CRP: PPS II score = -0.192 + 0.760 x PPS I + 0.003 x CRP (mg/L). For a cut-off value >0.397, PPS II score had 87.1% accuracy (AUROC=0.942) in the initial group and 75.3% accuracy in the validation group for predicting severe AP., Conclusions: PPS I and especially PPS II score are accurate predictors of severe outcome in patients with AP.

Aim: To assess whether acoustic radiation force impulse (ARFI) elastography can differentiate normal from pathological thyroid parenchyma., Methods: We evaluated 136 subjects (mean age 45.8 ± 15.6 years, 106 women and 30 men): 44 (32.3%) without thyroid pathology, 48 (35.3%) with Basedow-Graves' disease (GD), 37 (27.2%) with chronic autoimmune thyroiditis (CAT; diagnosed by specific tests), 4 (2.9%) with diffuse thyroid goiter and 3 (2.2%) cases with thyroid pathology induced by amiodarone. In all patients, 10 elastographic measurements were made in the right thyroid lobe and 10 in the left thyroid lobe, using a 1-4.5 MHZ convex probe and a 4-9 MHz linear probe, respectively. Median values were calculated for thyroid stiffness and expressed in meters/second (m/s)., Results: Thyroid stiffness (TS) assessed by means of ARFI in healthy subjects (2 ± 0.40 m/s) was significantly lower than in GD (2.67 ± 0.53 m/s) (P < 0.0001) and CAT patients (2.43 ± 0.58 m/s) (P = 0.0002), but the differences were not significant between GD vs CAT patients (P = 0.053). The optimal cut-off value for the prediction of diffuse thyroid pathology was 2.36 m/s. For this cut-off value, TS had 62.5% sensitivity, 79.5% specificity, 87.6% predictive positive value, 55.5% negative predictive value and 72.7% accuracy for the presence of diffuse thyroid gland pathology (AUROC = 0.804). There were no significant differences between the TS values obtained with linear vs convex probes and when 5 vs 10 measurements were taken in each lobe (median values)., Conclusion: ARFI seems to be a useful method for the assessment of diffuse thyroid gland pathology.

Aim: To assess the feasibility of performing acoustic radiation force impulse (ARFI) elastography in patients with ascites and its predictive value for the cirrhotic or non-cirrhotic etiology of ascites., Methods: Our study included 153 patients with ascites, mean age 58.8 ± 13.1 years. One hundred and fifteen (75.2%) patients had ascites in the context of cirrhosis, 29 (18.9%) had non-cirrhotic ascites (diagnosed by clinical, ultrasound, endoscopic and/or laparoscopic criteria) and in 9 (5.9%) cases we could not establish the etiology of ascites. We performed 10 ARFI measurements and the median value was calculated and expressed in meters/second (m/s). Among the 29 patients with non-cirrhotic ascites were included: 20 laparoscopically demonstrated peritoneal carcinomatosis with histological confirmation, 7 acute pancreatitis with ascites which later resolved, and one case each of lymphatic ascites and ascites in the context of a liver abscess. In 11 of the 20 patients with peritoneal carcinomatosis, the liver structure was homogenous in the ultrasound examination and in 9 patients the ultrasound exam revealed liver metastases., Results: We could not obtain valid ARFI measurements in 5 patients (3.2%). The mean liver stiffness measurements by means of ARFI were statistically significantly higher in patients with cirrhotic ascites than in those with non-cirrhotic ascites: 3.04 ± 0.70 vs 1.45 ± 0.59 m/s (P < 0.001). For a cut-off value of 1.8 m/s for predicting cirrhosis (and ascites in the context of cirrhosis), as obtained in a previous study, ARFI had 98.1% sensitivity, 86.2% specificity, 96.4% positive predictive value, 92.5% negative predictive value and 95.6% accuracy for predicting cirrhotic ascites. For a cut-off value of 1.9 m/s the accuracy was 94.9% and for a 2 m/s cut-off value it was 92.8%., Conclusion: ARFI elastography is feasible in most patients with ascites and has a very good predictive value for the cirrhotic or non-cirrhotic etiology of ascites.

Aim: To determine whether acoustic radiation force impulse (ARFI) elastography is a reliable method for predicting fibrosis severity in patients with chronic hepatitis C virus (HCV) hepatitis., Methods: We performed a multicenter study including 274 subjects with HCV chronic hepatitis in which we compared ARFI with liver biopsy (LB). In each patient we performed LB (evaluated according to the Metavir score) and ARFI measurements (using a Siemens Acuson S2000™ ultrasound system: 10 valid measurements were performed and median values were calculated and expressed in meters/second (m/s)., Results: A direct, strong, correlation (Spearman r = 0.707) was found between ARFI measurements and fibrosis (P < 0.0001). For predicting the presence of fibrosis (F ≥ 1 Metavir), significant fibrosis (F ≥ 2), severe fibrosis (F ≥ 3) and cirrhosis (F = 4), the cut-off values of 1.19, 1.21, 1.58 and 1.82 m/s were determined, respectively, liver stiffness measurements had 73%, 84%, 84% and 91% Se respectively; 93%, 91%, 94%, 90% Sp, respectively; with AUROCs of 0.880, 0.893, 0.908 and 0.937, respectively., Conclusion: ARFI measurement is a reliable method for predicting the severity of fibrosis in HCV patients.