This Açai contrast agent; iron oxide contrast;

This  works  aims  to assess  images obtained  with administration  of  açai juice  as  compared  to a manufactured17                          standard   iron   oxide   based   contrast   employed   as  negative   oral   contrast   agents   in   Magnetic   Resonance1819                          Cholangiopancreatography  (MRCP),   employing   qualitative   and   quantitative   evaluation.   The   research  was20                          developed with 64 patients submitted to MRCP exams (on 2 days) in a clinic of Curitiba city (Brazil). On the 1st day,21                          a manufactured iron oxide based contrast (A) was offered and on the 2nd  day, açai juice (contrast B) was given to2223                          patients. 2 radiologists (R1 and R2) evaluated the images, classifying them by a score (maximum of 4). In order to24                          have a quantitative assessment, Image J free software was employed generating plots of gray levels against distance2526                          of a chosen area of the bile duct interest region. Evaluating images for contrast A, R1 furnished an average score of27                          3.

52 and R2 of 3.27. For contrast B, R1 provided 3.44 and R2 3.38. Both evaluators considered image quality with28                          contrast A adequate for 62 (96.9%) patients. R1 considered adequate for 62 (96.

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9%) and R2 for 60 (93.8%) patients2930                          when using açai juice. By taking same images for all patients with Image J, a quantitative analysis was obtained,31                          resulting  correlation coefficient  of 0.

986  between  average  curves of contrasts A and B.   Thus,  açai juice is an32                          alternative as contrast agent in MRCP, since a standardized protocol is implemented. Image J was employed as a3334                          new method for quantitative investigation of image quality, presenting good agreement with medical opinion.3536                          Key words: Açai  contrast agent; iron oxide  contrast;  magnetic  resonance  cholangiopancreatography;  image3738                          quality; image J.394041                          INTRODUCTION42                          Magnetic  Resonance  Cholangiopancreatography (MRCP)  exams make  use of a negative contrast  to43                          identify and visualize organs such as pancreas and gallbladder.

In the images, contrast agents can avoid 45   44                          the overlapping  of these organs 1. The procedure is useful for detection  of pancreatitis, cholelithiasis,46                          biliary sludge, pseudo pancreatic cysts, tumors and others. Images acquired by magnetic resonance with47                          natural contrasts are very similar to those acquired with manufactured ones, according to previous work48                          done by other authors 2.49                          For a juice to be effective as contrast agent in MRCP exams, some features are required 3, besides acting50                          to reduce signal intensity  from the stomach  and duodenum and,  improving bile duct and gallbladder51                          views.

Although there are papers about the use of juices as MRCP contrast agents 4, it was not found52                          publications about standardization procedure and administration protocol of the juices 5, 6.53                          Image evaluation is achieved from several ways in clinics and hospitals by means of medical analysis or54                          using some computational tool 7, 8, 9. These can help to identify lesions, tumors or some kind of alteration55                          of  the  organ or tissue being examined.

 Image evaluation can  present inherent limitation due to  the 57   56                          technique employed or analysis made by different personnel and equipment.BrazilianArchives of Biology and TechnologyPage2 of 13  12345                            Since there is a great amount of subjectivity on the assessment of the acquired images by medical teams,6                            depending on the previous  experience of each evaluator, there is an opportunity to explore the use of7                            Image J free software 10  in order to produce a new quantitative analysis of the images and to compare8                            them to medical evaluation. Thus, the main objective of this study was to assess quality of MRCP images,9                            obtained with the administration of açai juice and a manufactured iron oxide based contrast employed as10                          negative oral contrast agents, by means of medical evaluation and with the use of Image J software 10.111213                          MATERIALSAND METHODS14                          Contrast agents1516                          Considering its use on previous works, a natural juice obtained from açai (Euterpe oleracea) pulp was17                          employed as contrast agent, containing approximately 36 grams of carbohydrates per 100g, corresponding18                          to the amount of sugar in the fruit 11. The manufactured iron oxide based contrast was obtained from19                          Guerbet Ltda and used as specified for MCRP exams.

2021                          MRCP exam protocol2223                          As patients would  need a medical report,  the exam  was started (first  day)  after  the ingestion  of the24                          manufactured iron oxide based contrast (referred as A) with the sequence of full abdomen, followed by25                          MRCP. On the second day, after the ingestion of açai juice (referred as contrast B), the MRCP sequence26                          was  also performed. Doctors  supported  the  patients  in the  days of exams,  but  the  type  of contrast27                          administered each day was kept secret. Thus, the study was double-blind and prospective 12.2829                          The images were acquired with a 1.

5T MRI system from General Electric Company (GE), model HDXT30                          with 12 channels,  GE Healthcare Advantage  workstation  running Centricity  DICOM (Digital  Imaging31                          and Communications in Medicine) Viewer version 3.0 software, and were saved in the filing system and32                          communicating images (PACS-Picture Archiving and Communication System) 13,in a clinic of Curitiba33                          city (Brazil).  The usual MRCP acquisition  protocol  was used: localizer  (LOC) in 3 orthogonal  planes34                          (PL) following single-shot (SS), fast spin echo (FSE) in apnea (LOC 3 PL SSFSE Apnea); radial colangio35                          14 and axial lava T1 without fat 15 for the two days of exams.3637                          Patient selection3839                          The selection of patients was made at the Clinics Hospital of Parana Federal University (UFPR), which40                          receives patients from the metropolitan region of Curitiba city (via Health Units). The clinical research41                          was  developed  during a period  of 6 months, in the  outpatient  clinics of non-alcoholic  esteatopathy,42                          alcoholic liver  disease  and  fat  and biliary routes  diseases. The  study  was approved by  the Ethics43                          Committee of Federal University of Technology-Paraná (UTFPR) by number 02.520.512.

0.00005547  and44                          a free and informed consent form (ICF) was released. Patients who agreed to participate received the ICF45                          and appropriate guidance on the MRI examination.4647                          For patient preparation, it was determined 3 hours of absolute fast. On the first day, when the patient48                          arrived at the clinic, he/she was directed to the preparation room, the fasting time was confirmed and the49                          manufactured contrast (A) was fractionated in 2 doses of 100 mL, one dose was given after the patient50                          responded   the   anamnesis,   and  another   was   given   10  minutes   later.   The   anamnesis  contained51                          anthropometric data, history of allergy, use of medicines, pre-existing diseases (as diabetes and hepatitis),52                          surgeries, etc.

In case of a diabetic patient, glucose measurement in blood was performed before and after53                          ingestion of contrasts.  On the second day, the procedure was similar, only changing the contrast, i. e.,54                          administration of açai juice (B) in 2 doses of 100 mL was started.5556                          Patients who participated met the following criteria: age between 18 and 80 years for both genders, need57                          to perform exams of MRCP and present pancreaticobiliary disease and/or alteration in liver ducts 16, 17Page3 of 13BrazilianArchives of Biology and Technology  12345                            being in treatment  or  follow-up in the referred  hospital  and, ingest  the contrast agents orally and6                            accomplish  fasting  of 3 hours  in the 2 days of the exams. Also,  patients  should lie down, not have7                            claustrophobia nor hearing difficulties.89                            Exclusion  criteria involved patients who  could  not  ingest  juice  and/or  contrast  agent,  or had  some10                          difficulty  as: not being able to perform fasting, making use of devices such as pacemakers,  aneurysm11                          clips, stents,  intraocular foreign  bodies, cochlear  implants,  prosthetic/  pins in any region  of the body12                          which could cause artifacts  18.

Also, exclusion criteria included pregnancy or suspected pregnancy.1314                          Medical images analysis15 For   16                          For the analysis of images, there was the collaboration of 2 radiologists identified as R1 and R2, both17                          with large experience in image diagnosis of more than 13 years.1819                          To analyze the effects of contrasts, scores 1-4 were used, having as reference the action of the contrast in20                          places where it must make effect (stomach and duodenum).

Score 1 means that there is a hyper intensity21                          of  the  stomach  and duodenum signals, thus  it  is  not  possible  to evaluate  these structures.  Score 2: Review   22                          evaluation takes place partly when it is possible to visualize the structures. Score 3: the hyper intensity of23                          the signal does not hinder the analysis of structures. Score 4: there is no signal hyper intensity between24                          the stomach and duodenum, which makes clearer the MRCP exam 8.25                          The evaluation of the image quality by doctors followed  the filling of a patient individual  form which26                          contained: image quality classification  for contrasts  A and B as excellent,  good, fair and poor; if the27                          acquired  image for contrasts A and B could replace each other; and if the contrasts were suitable and28                          efficient for issuing a medical report 19.

29                          Also,  a  new quantitative evaluation method  based on Image J free software, 16-bits version,  was30                          employed   9  and it can furnish the intensity of pixels against distance of a chosen area of an image. By31                          taking a section of interest from the image, one can limit the anatomical  region of the structure to be32                          analyzed. After, the selected area (with x and y values)  is transferred to an Excel® file and a plot is33                          produced with gray levels (pixel intensities) against distance (width of the bile duct region for this study)34                          in mm 20.353637                          Statistical analysis3839                          Data analysis of patients was performed with the items in the anamnesis and medical evaluations, in order40                          to assist in verifying the behavior of the variables 21. Subsequently, it was evaluated the concordance of41                          responses of doctors through Kappa 22 statistics, aimed at testing the degree of concordance (reliability42                          and precision), and to assess the values obtained. If ? 0.75, it indicates an excellent result.

Values ? 0.4043                          are considered low or if they become between 0.40 and 0.75 are of median concordance 23.


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