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PurposeThis study aimed to review and pool the current literature on intra-articular ozone injection in knee osteoarthritis (OA) patients.MethodsA systematic review of three big databases was performed to identify all English-language randomized clinical trials (RCTs) that evaluated the efficacy of intra-articular ozone injection vs a control injection for knee OA sufferers, using the following two measuring tools: pain VAS and Western Ontario and McMaster Universities Arthritis Index (WOMAC).ResultsA total of 428 patients in five RCTs were included, from which 53% (n=225) were in the ozone group and 47% in the control (hyaluronic acid [HA], dextrose, and air injection) group (n=203). The mean age of the patients in both groups was 64 years. Females were the majority. All studies had at least 2 months of follow-up (F/U). Mean difference (MD) between the groups for VAS in the first month was –0.23 with a P-value of 0.71 (negative value was in favor of ozone), whereas this difference in the third and sixth months reached 1.04 and 1.31, respectively, favoring the control group. These data demonstrated that control injection had a more prolonged pain relief period. A similar trend was seen regarding WOMAC scores; pooled results showed that ozone was slightly better than the control injections during the first month (MD =–7.84 [P=0.15]), but it declined to MD=2.55 and 8.23 at 2- to 3- and 4- to 6-month F/U, respectively, again in favor of control injections. Also, adverse events occurred homogeneously in both ozone (6/150 cases, 4%) and control groups (7/129 cases, 5.4%; P-value=0.31).ConclusionBased on the current meta-analysis, intra-articular ozone injection efficacy was significantly superior to placebo and slightly lower to other control injections with non-significant difference. Therefore, ozone could be recommended as an efficient non-surgical treatment, durable for at least 3–6 months, in mild or moderate knee OA management.

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Background: Genicular artery embolization (GAE) is an innovative technique that has been investigated as a supplementary treatment method for chronic pain secondary to knee osteoarthritis (OA). Purpose: To evaluate the current evidence on the effectiveness and safety of GAE for OA-related knee pain. Study Design: Systematic review; Level of evidence, 4. Methods: A systematic literature search was conducted in the PubMed, Web of Science, EMBASE, and Scopus databases to identify studies related to knee OA treated with GAE. Treatment agents were categorized as Embozene, imipenem/cilastatin, resorbable microspheres, and polyvinyl alcohol. The main outcomes were the mean difference (MD) in pre- and postembolization pain based on the visual analog scale (VAS) or the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores as well as changes in the need for pain medication. Random- and fixed-effects models were applied for data analysis. Results: Of 379 initially inspected publications, 11 (N = 225 patients; 268 knees) were included in the final review. The quality of the studies was fair in 8 and poor in 3—categorized according to the National Institutes of Health quality assessment tool. Overall, 119, 72, 13, and 21 patients were treated with imipenem/cilastatin, Embozene, resorbable microspheres, and polyvinyl alcohol, respectively. Symptomatic improvement was reported in all studies. The pooled effect size, characterized by MD, showed a significant improvement in the VAS and WOMAC pain scores, with better functional status after GAE. Pre- versus postembolization MDs in VAS scores ranged from 32 within the first week to 58 after a 2-year follow-up (equivalent to 54% and 80% improvement, respectively). There was a similar trend in the overall WOMAC scores, with MDs ranging from 28.4 to 36.8 (about 58% and 85% improvement, respectively). GAE resulted in a decreased need for pain medication for knee OA, with a 27%, 65%, and 73% decline in the number of patients who used opioids, nonsteroidal anti-inflammatory drugs, and intra-articular hyaluronic acid injection, respectively ( P < .00001 for all). No significant difference between embolic agents was seen with regard to post-GAE pain reduction. No severe or life-threatening complications were reported. Conclusion: OA treated by GAE using different embolic particles can be considered generally safe, with good efficacy and no reported serious complications.

Background Post-hysterectomy histopathological examination is currently the main diagnostic tool for differentiating uterine sarcomas from leiomyomas. This study aimed to investigate the diagnostic accuracy of preoperative quantitative metrics based on T2-weighted sequences and contrast-enhanced MRI (CE-MRI) for distinguishing uterine sarcomas from leiomyomas. Materials and methods The institutional review board approved the study. Sixty-five women confirmed to have a total of 105 lesions participated. Routine pelvic MRI sequences, T2 map and CE-MRI images were performed preoperatively using a 3 T MR scanner. Six quantitative metrics—T2 mapping parameter, T2 scaled ratio, tumor myometrium contrast ratio on T2, tumor psoas contrast ratio on T2, tumor myometrium contrast-enhanced ratio, and tumor psoas contrast-enhanced ratio—were extracted from the acquired image sets. Chi-square test was used to compare the percentage of malignant lesions with the central necrosis to the corresponding percentage for the benign masses. Using the area under receiver operating characteristic (AUC) curve, the performance of different metrics for distinguishing uterine sarcomas from leiomyomas was measured. Moreover, for each metric, we extracted the optimal cut-off value. The values of sensitivity, specificity, negative predictive value, and positive predictive value were calculted for the classifiers based on different metrics. Results The average age, average lesion size, and proportion of premenopausal women in benign and malignant groups were comparable in our dataset. The signal intensity of uterine sarcomas at T2-weighted sequences was significantly higher than that of leiomyomas ( p < 0.001), while intensity at T1-weighted sequences exhibited no significant difference between the two masses ( p = 0.201). Our data also suggested that a central necrosis was ten times more common among malignant lesions compared to benign ones ( p < 0.001). Among different metrics, T2 mapping parameter achieved the highest AUC value and accuracy in differentiating two groups. Three measures—T2 scaled ratio, tumor myometrium contrast ratio on T2, and tumor myometrium contrast-enhanced ratio—achieved a sensitivity of 100%, therefore none of the malignant lesions would have been missed if these metrics had been adopted in patient management. Conclusions The findings suggested that the evaluated metrics could be useful in the preoperative assessment of myometrial masses to differentiate uterine sarcomas from leiomyomas. The proposed framework has major implications for improving current practice in the management of myometrial masses.

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Objective: The present study aimed to compare the qualitative (time intensity curve analysis), the semi-quantitative and the quantitative multiphase 3T dynamic contrast-enhanced (DCE) MRI parameters as predictors of malignancy in adnexal masses. Materials and Methods: In this prospective study, women with an adnexal mass who were scheduled for surgical resection or were followed for more than one year period to confirm the benignity of their lesions, underwent multiphase 3T DCE-MRI. The qualitative (time intensity curve), semi-quantitative (SImax, SIrel, WIR) and quantitative (Ktrans, Kep, Vb) analyses were performed on DCE-MRI sequences and their predictive values were compared. Results: A total of 17 benign and 14 malignant lesions were included. According to the qualitative analysis, none of the lesions with Type I time intensity curves (TIC) were malignant and none of the masses with Type III TICs were benign. The accuracy of the quantitative parameters in detection of malignancy was found to be higher than that of semi-quantitative variables, particularly when calculated for a small ROI within the high signal area of the mass (sROI) rather than the largest ROI including the whole mass (lROI), and when inter-MRI variations were omitted using ratios. The Kep(tumor)/Kep(myometrium) ratio measured from sROI was the best parameter for differentiating a malignant lesion with a sensitivity of 100% and a specificity of 92.3%. Conclusion: We concluded that a Type I TIC confirms a benign lesion, and a type III TIC confirms the malignancy and further evaluation is not recommended for these lesions. So complementary quantitative analysis is only recommended for adnexal masses with type II TICs.

This study aimed to develop a diagnostic algorithm for preoperative differentiating uterine sarcoma from leiomyoma through a supervised machine-learning method using multi-parametric MRI. A total of 65 participants with 105 myometrial tumors were included: 84 benign and 21 malignant lesions (belonged to 51 and 14 patients, respectively; based on their postoperative tissue diagnosis). Multi-parametric MRI including T1-, T2-, and diffusion-weighted (DW) sequences with ADC-map, contrast-enhanced images, as well as MR spectroscopy (MRS), was performed for each lesion. Thirteen singular MRI features were extracted from the mentioned sequences. Various combination sets of selective features were fed into a machine classifier (coarse decision-tree) to predict malignant or benign tumors. The accuracy metrics of either singular or combinational models were assessed. Eventually, two diagnostic algorithms, a simple decision-tree and a complex one were proposed using the most accurate models. Our final simple decision-tree obtained accuracy = 96.2%, sensitivity = 100% and specificity = 95%; while the complex tree yielded accuracy, sensitivity and specificity of 100%. To summarise, the complex diagnostic algorithm, compared to the simple one, can differentiate tumors with equal sensitivity, but a higher specificity and accuracy. However, it needs some further time-consuming modalities and difficult imaging calculations. Trading-off costs and benefits in appropriate situations must be determinative.