A comparison of ultrasonography and magnetic resonance imaging in the evaluation of temporomandibular joint involvement in rheumatoid arthritis and psoriatic arthritis.

OBJECTIVE: To define the diagnostic value of ultrasonographic (US) examination in comparison with magnetic resonance imaging (MRI) for the assessment of temporomandibular joint (TMJ) involvement in rheumatoid arthritis (RA) and psoriatic arthritis (PsA). METHODS: MRI and US examinations were performed in 33 patients (22 with RA and 11 with PsA). Alterations of the disc, alterations of the condyle and joint effusion were evaluated. RESULTS: Pathological changes of the TMJ were observed by MRI in 24 patients and by US in 31 patients. The sensitivity and specificity of US were calculated in comparison with MRI. The sensitivity was 72.2% and the specificity was 60% in the assessment of pathological changes of the TMJ. The sensitivity was 69.6% with specificity of 30.0% in the assessment of alterations of the disc; the sensitivity was 70.6% with specificity of 75.0% in the assessment of joint effusion. Significant concordance was not observed in the assessment of condylar alterations. CONCLUSIONS: US imaging appears able to detect different pathological changes of the TMJ and may be considered an important diagnostic tool for clinical evaluation of the TMJ in RA and PsA.

A comparison between radiographic and sonographic assessment of hand and wrist bones for the estimation of skeletal age in the child patient.

AIM: The purpose of this study was to examine, with a sonographic investigation, the hand and wrist bones of a group of young patients and to compare the results with those obtained with a classical radiographic assessment. MATERIALS AND METHODS: Some 25 subjects, 9-18 years of age, who presented problems concerning their short stature or precocious puberty, were evaluated. Each subject was examined by a standard radiographic assessment and by a sonographic investigation with real-time imaging. Sonographic examination was performed on the metacarpus-phalanx articulation of the first finger in order to locate the sesamoid bone. Sonographic examination was also performed on the second and third phalanxes of the third finger and on the distal portion of the radius to evaluate the characteristics of growth cartilage in the area. RESULTS AND STATISTICS: In all the cases where a sesamoid bone was present, this was correctly identified by the sonogram, even up to the initial appearance of its ossification nucleus. Sensitivity, specificity, and diagnostic accuracy were all 100%. The capping phenomenon seen in radiographs was not detected by sonographic investigation in any of the cases. Sonographic evaluation of the fertile cartilage of the third finger distal phalanx demonstrated a sensitivity of 89%, a specificity of 100% and a diagnostic accuracy of 92%. Sonographic evaluation of the radius cartilage showed a sensitivity of 95%, a specificity of 100% and a diagnostic accuracy of 96%. CONCLUSION: Sonographic evaluation of hand and wrist bones cannot accurately reproduce the results of the classical radiographic evaluation. However, the sonographic investigation may be useful, when integrated in a radiographic investigation.

[Diagnostic approach to acute laryngeal trauma: role of computerized tomography]. / L'approccio diagnostico ai traumi laringei acuti: ruolo della Tomografia Computerizzata.

Aim of this study was to assess the role of Computed Tomography (CT) in the management of acute laryngeal injuries by reviewing our 5 years' experience. From January, 1991, to November, 1996, sixteen patients with blunt trauma and 2 patients with penetrating injuries of the larynx underwent physical examination, laryngoscopy and CT; 2 of them underwent angiography too. The patients were divided into 3 groups according to Schaefer classification [13], first on the basis of physical examination, CT and laryngoscopy findings. The definitive group and therapy were decided on the basis of final spatial assessment. Physical examination diagnosed the presence and the anatomical level of laryngeal injuries in group I (4 patients); laryngoscopy and CT depicted the type of injury and suggested conservative management in 100% of cases. In group II (10 patients), conservative management was suggested by CT findings in the laryngeal, submucosal soft tissues and fascial plane injuries in 100% of cases. Physical examination findings were correct in 30% of cases, questionable in 30% and incorrect in 30%; the exam was not performed in 10% of cases. Finally, laryngoscopy findings were correct in 60% of cases, incorrect in 20% and not diagnostic in 20%. In group III (2 patients), exposed laryngeal injuries required immediate surgery. In group II, the selective application of CT was useful for assessing the degree of damage in 100% of cases and was helpful in planning conservative management. CT avoided surgery in one patient, showed laryngeal cartilaginous features in 2 patients and 2 pseudoaneurysmal injuries not suspected on the basis of physical examination findings.

Glomerular and tubular effects of contrast media diatrizoate and iopromide.

The aim of this study is to evaluate the nephrotoxicity of two contrast media (CM), with different physicochemical characteristics: diatrizoate (ionic high-osmolar), iopromide (nonionic low-osmolar). Intravenous urography was performed in 34 patients: 17 were examined with diatrizoate and 17 with iopromide, randomly assigned. Different parameters of glomerular and tubular function were measured before and at 6, 24, and 48 h after urography. Both contrast media induced a reversible increase of urine enzymes, which was significantly higher after diatrizoate. In particular, diatrizoate determined a relevant increase of brush border enzymes gamma-glutamyltransferase (GGT) and alkaline phosphatase (ALP) and of cytosolic enzyme lactate dehydrogenase (LDH), while, after iopromide increases of urinary enzymes were less evident and were significant only for GGT and ALP. In addition, diatrizoate affected other tubular functions (clearances of phosphorus and uric acid) and slightly decreased glomerular function in a few patients. In no case did these glomerular and tubular effects have a clinical relevance. In conclusion, the nonionic low-osmolar contrast medium iopromide appeared less nephrotoxic than diatrizoate. The cost-benefit ratio needs further examination.

[The imaging diagnosis of Sjögren's syndrome: echography, sialography and scintigraphy compared in the study of the salivary glands]. / Diagnostica per immagini della sindrome di Sjögren: ecografia, scialografia e scintigrafia a confronto nello studio delle ghiandole salivari.

The aim of the present study was to evaluate the sensitivity and specificity of the ultrasonography, in comparison with other methods of investigation (scintigraphy, sialography, and biopsy), in scanning morphostructural changes in the parotid gland in patient with Sjögren's syndrome. During the period June-October 1994, 34 patients (5 males and 29 females, age ranged between 20 and 88 years) with "sicca syndrome" underwent to echography, scintigraphy, sialography and biopsy. The diagnosis was confirmed or excluded using the European Community Epidemiologic Committee criteria for Sjögren's syndrome. Twenty-two patients out of 34 were affected by Sjögren's syndrome, while the others resulted as control subjects. The ultrasonographic investigation has shown 76.19% of sensitivity and 30.43% of specificity. Even if echography is a non-invasive method, which could be used as preliminary approach for studying the diffused involvement of the parotid gland, at the status of the art, it is not completely reliable for the global evaluation of the morphostructural changes in patients with Sjögren's syndrome, in comparison with the other techniques. Because of the double nature of the gland injury, it appears to be essential the diagnostic integration between echography and sialography.

[Short stature due to a partial idiopathic deficiency of the growth hormone. The role of the TW2 method in assessing treatment with r-hGH]. / Ipostaturalità da deficit idiopatico parziale di ormone della crescita. Il ruolo del metodo TW2 nella valutazione del trattamento con r-hGH.

The Tanner-Whitehouse 2 (TW2) method to assess skeletal maturation (reviewed by Nicoletti for the Italian population) was used to study, from January, 1991, to December, 1994, a series of 26 Italian patients. The patients, 18 men (69.3%) and 8 women (30.7%), came from inhomogeneous family stocks and were all affected with short stature due to partial idiopathic GH deficiency; they were treated with replacement therapy with the biosynthetic recombinant human growth hormone (r-hGH). Each patient underwent 3 wrist and left hand radiographs, the first one made on the basis of medical and endocrinologic assessment. The patients were reexamined after one and two years of treatment with the analysis of stature growth and of the skeletal maturation of hand bones. At one year, the average chronological age of our patients was 12.42 year (range: 9.4-15.2 years), their average bone age was 11.13 years (range: 6.5-14 years) and their average height was 137.81 cm (range: 117-155.5 cm). The patients were then retrospectively examined on the basis of bone maturation and final height, at the end of two years' therapy. At the end of treatment, height was above the third percentile in all patients and therefore within the expected personal target on the basis of genetic stature. The TW2 indexes of bone maturation, after one year of treatment, had increased by 44.84% (range: 27-77%) of the total maturation increase at two years. Moreover, after one year of treatment, average stature increase was 55.81% (range: 42-72%) of the total stature increase at two years. After two years of treatment, TW2 indexes showed an average 55.16% increase in bone maturation (range: 23-73%) of total maturation and average stature increase was 44.19% (range: 28-56%) of the total stature increase. Our results confirmed that skeletal growth and bone maturation are two distinct processes. Particularly, we noted that, while after one year of r-hGH therapy skeletal growth (especially in the long bones) prevails over bone maturation, after two years maturation prevails. In conclusion, our experience confirms the TW2 method as a simple and highly informative method which can be used in any radiologic center.

Radiological findings in a case of Menkes' disease.

Menkes' disease, a neurodegenerative progressive X-linked disorder, was diagnosed in a 4-month-old child. The diagnosis was made on the combination of clinical features with laboratory and radiological findings. The pathogenesis of the skeletal findings in Menkes' disease is as yet unclear. Because of the severity of the prognosis and in order to plan treatment, the correct diagnosis has to be reached quickly. Typical manifestations of the syndrome are likely to develop after 3 months of age, with a pleiotropic appearance. In the present case, on the basis of the clinical investigation the patient underwent retrograde cystourethrography, roentgenographic examination of the skeleton, and magnetic resonance imaging of the brain. On analysis of the magnetic resonance imaging, we detected one-sided involvement of both subcortical and cortical parenchyma resembling a unilateral ischemic lesion such as, to our knowledge, has not yet been reported.

[SPECT in the study of pathology of the temporomandibular joint. The authors' personal experience]. / La SPECT nello studio della patologia dell'articolazione temporo-mandibolare. Esperienza personale.

Symptomatic temporomandibular joint dysfunctions may affect about 25% of the adult population, with a smaller though significant percentage of patients experiencing severe impairment. From 1986 through 1991, 107 patients with severe temporomandibular joint symptoms and with various temporomandibular joint disorders were evaluated with conventional radiology and with closed/open-mouth temporomandibular joint tomograms. Single-photon emission-computed tomography (SPECT) and planar imaging were performed on 32 patients using a rotating gamma camera equipped with a general purpose collimator. Transaxial, coronal and sagittal tomoscintigrams were reconstructed. Increased radiotracer uptake in the temporomandibular joint was regarded as a positive finding, and the intensity of temporomandibular joint activity was compared with that of adjacent calvarium using regions of interest. In the 32 patients submitted to scintigraphy, conventional radiology showed no pathologic patterns, while SPECT showed pathologic findings in 31 patients (97% of cases). The patient with normal temporomandibular joint findings on SPECT exhibited abnormal maxillary isotope uptake, ipsilateral to the symptoms. Our results indicate that SPECT is a simple, noninvasive, inexpensive and very sensitive screening test relative to the internal derangement of the temporomandibular joint. Moreover, it provides information which is not available by means of routine bone scans or X-ray studies. Thus, SPECT appears to be the modality of choice for patients whose clinical findings are equivocal or whose symptoms are unclear, and it can guide treatment strategies and be useful in the follow-up.

[Digital radiology with storage phosphors in cephalometric study in orthodontics]. / La radiologia digitale con fosfori a memoria nello studio cefalometrico nell'ortodonzia.

Conventional radiology is continually modified with the development of digital systems which can be used for several types of radiologic examinations. Our study was aimed at evaluating the advantages of these new technologies in the orthodontic field, where the problems associated with image quality and radiation protection are major especially in young patients; the latter goal is achievable by dramatically reducing radiation dose and by avoiding repeating the exam. In our study, we compared lateral teleradiographs of the skull for cephalometric analysis obtained using conventional and digital diagnostic methods. The preliminary results demonstrated that the two imaging techniques did not differ relative to bone structure representation, even though the digital system provided better visualization of soft tissue structures. Computed radiography also allowed a marked reduction in the number of repeats and reduced radiation dose. The current disadvantages of this imaging method are the high initial cost of the equipment, reduced work rate, and the need of frequent technical assistance.

[The echo-guided percutaneous injection of ethanol: a therapeutic alternative in the "autonomous thyroid nodule". Our experience]. / Iniezione percutanea ecoguidata di etanolo: alternativa terapeutica del "nodulo tiroideo autonomo". Nostra esperienza.

The authors report their experience on the therapeutic value, in terms of efficacy and tolerance, of percutaneous ethanol injection (PEI) in the treatment of autonomous thyroid nodules (ATN). A group of 15 patients, 13 in clinical pretoxicity and 2 in initial thyrotoxicosis, were submitted to fine-needle ethanol injection (95%) performed under US guidance. The amount of injected alcohol was measured on the basis of the volume and diffusion of alcohol itself within the nodule, in the whole of 79 injections given. Follow-up lasted 3-15 months. Thyroid scanning demonstrated a complete or partial recovery of extranodular parenchymal function in 80% and 20% of cases, respectively. In all cases a volume reduction greater than 50% was obtained, with an initial sharp fall, already after the first month, thanks to early alcohol cytotoxicity. In the 2 patients with toxic ATN serum, normal values of free hormones have been observed ever since the third weekly injection. Good tolerance to treatment was observed, and no permanent complications. In agreement with other authors, we believe our experience to show that PEI represents a new therapeutic approach in patients with ATN. PEI will certainly play a preferential role, relative to other conventional therapies, in the management of clinical pretoxic ATN, regarding which no uniform treatment protocol exists yet.

[Comparison of colpocystourethrorectography and transrectal ultrasonography in the assessment of female urinary incontinence]. / Confronto tra colpocistouretrorettografia ed ecografia transrettale nella valutazione dell'incontinenza urinaria femminile.

In order to investigate the diagnostic reliability of transrectal US in the study of female urinary incontinence, the authors compared the static images obtained by means of colpocystourethrorectography with the ones obtained with transrectal US. The study population included 30 patients suffering from urinary incontinence. US images were obtained both at rest and during Valsalva's maneuver, some minutes before cystourethrography and employing part of its preparation (vesical filling with 250 cc of iodine contrast medium and positioning of a metallic bead chain in the urethra). On static images obtained with cystourethrography and transrectal US both at rest and during Valsalva, 4 parameters were evaluated: anterior and posterior vesical angles, urethral axis angle, and distance between symphysis pubis and urethral-vesical junction. As for posterior vesical angle, urethral axis angle, and symphysis-junction distance, the statistical comparison of the results did non demonstrate any significant differences. Anterior vesical angle was not included because it is too difficult to measure by transrectal US. In our experience, transrectal US was capable of yielding accurate information similar to that obtained with colpocystourethrorectography.

[Mammographic control after quadrantectomy and radiation therapy]. / Il controllo mammografico dopo trattamento con quadrantectomia e terapia radiante.

The efficacy of combined surgery and radiation therapy in the treatment of breast cancer has increased the use of mammography in the follow-up to detect early recurrences. The authors report their experience in the follow-up of 43 breast cancers after treatment with local excision, axillary dissection, and irradiation. Mammography was performed at 6.12, and 24 months. The radiological findings were: 38/43 (88.3%) breasts with abnormal mammographic patterns, skin thickening in 36/43 (83.7%) cases, breast retraction in 16/43 (37.2%), architectural distortion in 17/43 (39.5%), increased parenchymal density in 33/43 (76.7%), calcifications in 6/43 (13.9%), and a mass in 10/43 (23.2%) cases. The authors describe histologic changes, corresponding to mammographic findings, and evolution of the treated breasts. Suspicious findings were microcalcifications in one case and a mass in 6 cases (4 of them at 6 months and 2 at 12). Excisional biopsy, performed in the above 7 patients, confirmed recurrence in 4 cases. In 3 cases with negative pathology, where the malignant nature of the lesion could not be demonstrated, we observed: a cluster of microcalcifications undistinguishable from neoplasm in 1 case and spiculated nodules with architectural distortion in the extant 2 cases. Further limitations of mammography were due to radiological density of the breast in one case, and to its minimal size in another--these elements delayed both correct interpretation of mammographic findings and final diagnosis. The low agreement between mammography and histology proved the difficulty of both analysis and evaluation of abnormal post-irradiation breast tissue. The authors, in agreement with literature reports, suggest the schedule for clinical and mammographic follow-up.

Mineral metabolism and calcitriol therapy in idiopathic juvenile osteoporosis.

Idiopathic juvenile osteoporosis is a rare cause of osteoporosis during childhood. We examined four children (three boys and one girl, ranging in age from 2.3 to 12.6 years) with idiopathic juvenile osteoporosis. All of these patients had normal serum calcium, ionized calcium, phosphate, magnesium, 25-hydroxyvitamin D, intact parathyroid hormone, and total and extractable calcitonin levels. 1,25-Dihydroxyvitamin D values were low in three patients and slightly decreased in one. Three children were treated with calcitriol (1,25-dihydroxycholecalciferol) (0.50 micrograms/d in two and 0.25 microgram/d in the other). The fourth patient was not treated because of parental refusal. Therapy reduced the fracture rate. Follow-up at 6 and 12 months showed a significant increase in bone mineralization, which reached normal values in two children after 12 months of treatment. No side effects of calcitriol therapy were observed. The untreated patient did not show an improvement of bone mineralization in the same time.

[Diagnostic reflections on lung lymphangioleiomyomatosis]. / Riflessioni di ordine diagnostico sulla linfangioleiomiomatosi polmonare.

Two cases of histologically proven pulmonary lymphangiomyomatosis were studied by means of an adequate combination of the current imaging modalities. After an anatomical survey of the secondary pulmonary lobule, the authors discuss the pathologic appearance, the pathogenetic factors (mainly hormones), and the diagnostic problems concerning this pathologic condition. Finally, the authors emphasize the decisive role of high-resolution CT (HRCT) in the evaluation of pulmonary lymphangioleiomyomatosis.